(305 ILCS 5/Art. V heading)
(305 ILCS 5/5-1) (from Ch. 23, par. 5-1)
Sec. 5-1. Declaration of purpose. It is the purpose of this Article to
provide a program of essential
medical care and rehabilitative services for persons receiving basic
maintenance grants under this Code and for other persons who are unable,
because of inadequate resources, to meet their essential medical needs.
Preservation of health, alleviation of sickness, and correction of
disabling conditions for persons requiring maintenance support are
essential if they are to have an opportunity to become self-supporting or
to attain a greater capacity for self-care. For persons who are medically
indigent but otherwise able to provide themselves with a livelihood, it is
of special importance to maintain their incentives for continued
independence and preserve their limited resources for ordinary maintenance
needs to prevent their total or substantial dependency.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-1.1) (from Ch. 23, par. 5-1.1)
Sec. 5-1.1. Definitions. The terms defined in this Section
shall have the meanings ascribed to them, except when the
context otherwise requires.
(a) "Nursing facility" means a facility, licensed by the Department of Public Health under the Nursing Home Care Act, that provides nursing facility services within the meaning of Title XIX of
the federal Social Security Act.
(b) "Intermediate care facility for persons with developmental disabilities" or "ICF/DD" means a facility, licensed by the Department of Public Health under the ID/DD Community Care Act, that is an intermediate care facility for the mentally retarded within the meaning of Title XIX
of the federal Social Security Act.
(c) "Standard services" means those services required for
the care of all patients in the facility and shall, as a
minimum, include the following: (1) administration; (2)
dietary (standard); (3) housekeeping; (4) laundry and linen;
(5) maintenance of property and equipment, including utilities;
(6) medical records; (7) training of employees; (8) utilization
review; (9) activities services; (10) social services; (11)
disability services; and all other similar services required
by either the laws of the State of Illinois or one of its
political subdivisions or municipalities or by Title XIX of
the Social Security Act.
(d) "Patient services" means those which vary with the
number of personnel; professional and para-professional
skills of the personnel; specialized equipment, and reflect
the intensity of the medical and psycho-social needs of the
patients. Patient services shall as a minimum include:
(1) physical services; (2) nursing services, including
restorative nursing; (3) medical direction and patient care
planning; (4) health related supportive and habilitative
services and all similar services required by either the
laws of the State of Illinois or one of its political
subdivisions or municipalities or by Title XIX of the
Social Security Act.
(e) "Ancillary services" means those services which
require a specific physician's order and defined as under
the medical assistance program as not being routine in
nature for skilled nursing facilities and ICF/DDs.
Such services generally must be authorized prior to delivery
and payment as provided for under the rules of the Department
of Healthcare and Family Services.
(f) "Capital" means the investment in a facility's assets
for both debt and non-debt funds. Non-debt capital is the
difference between an adjusted replacement value of the assets
and the actual amount of debt capital.
(g) "Profit" means the amount which shall accrue to a
facility as a result of its revenues exceeding its expenses
as determined in accordance with generally accepted accounting
principles.
(h) "Non-institutional services" means those services provided under
paragraph (f) of Section 3 of the Rehabilitation of Persons with Disabilities Act and those services provided under Section 4.02 of the Illinois Act on the Aging.
(i) (Blank).
(j) "Institutionalized person" means an individual who is an inpatient
in an ICF/DD or nursing facility, or who is an inpatient in
a medical
institution receiving a level of care equivalent to that of an ICF/DD or nursing facility, or who is receiving services under
Section 1915(c) of the Social Security Act.
(k) "Institutionalized spouse" means an institutionalized person who is
expected to receive services at the same level of care for at least 30 days
and is married to a spouse who is not an institutionalized person.
(l) "Community spouse" is the spouse of an institutionalized spouse.
(m) "Health Benefits Service Package" means, subject to federal approval, benefits covered by the medical assistance program as determined by the Department by rule for individuals eligible for medical assistance under paragraph 18 of Section 5-2 of this Code.
(n) "Federal poverty level" means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services. These guidelines set poverty levels by family size.
(Source: P.A. 98-104, eff. 7-22-13; 99-143, eff. 7-27-15.)
(305 ILCS 5/5-1.2)
Sec. 5-1.2. Recipient eligibility verification.
(a) The Illinois Department shall initiate a statewide system by which
providers and sites of medical care can electronically verify recipient
eligibility for aid under this Article.
High-volume providers and sites of medical care, as defined by the Illinois
Department by rule, shall be required to participate in the eligibility
verification system.
Every non-high-volume provider and site of medical
care shall be afforded the opportunity to participate in the eligibility
verification system.
The Illinois Department shall provide by rule for
implementation of the system, which may be accomplished in phases over time and
by geographic region, recipient classification, and provider type.
The system shall initially be implemented in, but not limited to, the
following zip codes in Cook County: 60601, 60602, 60603, 60604, 60605, 60606,
60607, 60608, 60609, 60612, and 60616. The system shall be implemented within
6
months after approval by the federal government. The Illinois Department shall
report to the General Assembly by December 31, 1994 on the status of the
Illinois Department's application to the federal government for approval of
this system.
The recipient eligibility verification system may be coordinated with the
Electronic Benefits Transfer system established by Section 11-3.1 of this Code
and compatible with any of the methods for the delivery of medical care and
services authorized by this Article.
The system shall make available to providers the history of claims for
medical services submitted to the Illinois Department for those services
provided to the recipient. The Illinois Department shall develop safeguards to
protect each recipient's health information from misuse or unauthorized
disclosure.
(b) The Illinois Department shall conduct a demonstration project in at
least 2 geographic locations for the purpose of assessing the effectiveness of
a recipient photo identification card in reducing abuses in the provision of
services under this Article. In order to receive medical care, recipients
included in this demonstration project must present a Medicaid card and photo
identification card. The Illinois Department shall apply for any federal
waivers or approvals necessary to conduct this demonstration project. The
demonstration project shall become operational (i) 12 months after the
effective
date of this amendatory Act of 1994 or (ii) after the Illinois Department's
receipt
of all necessary federal waivers and approvals, whichever occurs later, and
shall operate for 12 months.
(c) Effective October 1, 2007, all changes in status of Medicaid recipients
residing in Illinois nursing facilities after initial eligibility for
Medicaid has been established shall be reported to the Department, using an
Internet-based electronic data interchange system, by the nursing facilities,
except for those changes made by personnel of the Department. Changes reported
using the Internet-based electronic data interchange system shall be deemed
valid and shall be used as the basis for future Medicaid payments unless
Department approval of the transaction is required, or until such time as
any review or audit conducted by the State establishes that the
information is incorrect.
(Source: P.A. 95-458, eff. 8-27-07.)
(305 ILCS 5/5-1.3)
Sec. 5-1.3. Payer of last resort. To the extent permissible under federal law, the State may pay for medical services only after payment from all other sources of payment have been exhausted, or after the Department has determined that pursuit of such payment is economically unfeasible. Applicants for, and recipients of, medical assistance under this Code shall disclose to the State all insurance coverage they have. To the extent permissible under federal law, the State shall require vendors of medical services to bill third-party payers for services that may be covered by those third-party payers prior to submission of a request for payment to the State. The Department shall, to the extent permissible under federal law, reject a request for payment of a medical service that should first have been submitted to a third-party payer.
(Source: P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-1.4)
Sec. 5-1.4. Moratorium on eligibility expansions. Beginning on January 25, 2011 (the effective date of Public Act 96-1501), there shall be a 4-year moratorium on the expansion of eligibility through increasing financial eligibility standards, or through increasing income disregards, or through the creation of new programs which would add new categories of eligible individuals under the medical assistance program in addition to those categories covered on January 1, 2011 or above the level of any subsequent reduction in eligibility. This moratorium shall not apply to expansions required as a federal condition of State participation in the medical assistance program or to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds. If the State of Illinois finds that the State has borne a cost related to such an expansion, the unit of local government shall reimburse the State. All federal funds associated with an expansion funded by a unit of local government shall be returned to the local government entity funding the expansion, pursuant to an intergovernmental agreement between the Department of Healthcare and Family Services and the local government entity. Within 10 calendar days of the effective date of this amendatory Act of the 97th General Assembly, the Department of Healthcare and Family Services shall formally advise the Centers for Medicare and Medicaid Services of the passage of this amendatory Act of the 97th General Assembly. The State is prohibited from submitting additional waiver requests that expand or allow for an increase in the classes of persons eligible for medical assistance under this Article to the federal government for its consideration beginning on the 20th calendar day following the effective date of this amendatory Act of the 97th General Assembly until January 25, 2015. This moratorium shall not apply to those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) and 42 U.S.C. 1396a(a)(10)(A)(i)(IX).
(Source: P.A. 97-687, eff. 6-14-12; 98-104, eff. 7-22-13.)
(305 ILCS 5/5-1.5)
Sec. 5-1.5. COVID-19 public health emergency. Notwithstanding any other provision of Articles V, XI, and XII of this Code, the Department may take necessary actions to address the COVID-19 public health emergency to the extent such actions are required, approved, or authorized by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services. Such actions may continue throughout the public health emergency and for up to 12 months after the period ends, and may include, but are not limited to: accepting an applicant's or recipient's attestation of income, incurred medical expenses, residency, and insured status when electronic verification is not available; eliminating resource tests for some eligibility determinations; suspending redeterminations; suspending changes that would adversely affect an applicant's or recipient's eligibility; phone or verbal approval by an applicant to submit an application in lieu of applicant signature; allowing adult presumptive eligibility; allowing presumptive eligibility for children, pregnant women, and adults as often as twice per calendar year; paying for additional services delivered by telehealth; and suspending premium and co-payment requirements.
The Department's authority under this Section shall extend to encompass, incorporate, or effectuate the terms, items, conditions, and other provisions approved, authorized, or required by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, and shall not extend beyond the time of the COVID-19 public health emergency and up to 12 months after the period expires.
Any individual determined eligible for medical assistance under this Code as of or during the COVID-19 public health emergency may be treated as eligible for such medical assistance benefits during the COVID-19 public health emergency, and up to 12 months after the period expires, regardless of whether federally required or whether the individual's eligibility may be State or federally funded, unless the individual requests a voluntary termination of eligibility or ceases to be a resident. This paragraph shall not restrict any determination of medical need or appropriateness for any particular service and shall not require continued coverage of any particular service that may be no longer necessary, appropriate, or otherwise authorized for an individual. Nothing shall prevent the Department from determining and properly establishing an individual's eligibility under a different category of eligibility.
(Source: P.A. 101-649, eff. 7-7-20; 102-43, eff. 7-6-21.)
(305 ILCS 5/5-1.6)
Sec. 5-1.6. Continuous eligibility; ex parte redeterminations.
(a) By July 1, 2022, the Department of Healthcare and Family Services shall seek a State Plan amendment or any federal waivers necessary to make changes to the medical assistance program. The Department shall apply for federal approval to implement 12 months of continuous eligibility for adults participating in the medical assistance program. The Department shall secure federal financial participation in accordance with this Section for expenditures made by the Department in State Fiscal Year 2023 and every State fiscal year thereafter.
(b) By July 1, 2022, the Department of Healthcare and Family Services shall seek a State Plan amendment or any federal waivers or approvals necessary to make changes to the medical assistance redetermination process for people without any income at the time of redetermination. These changes shall seek to allow all people without income to be considered for ex parte redetermination. If there is no non-income related disqualifying information for medical assistance recipients without any income, then a person without any income shall be redetermined ex parte. Within 60 days after receiving federal approval or guidance, the Department of Healthcare and Family Services and the Department of Human Services shall make necessary technical and rule changes to implement changes to the redetermination process. The percentage of medical assistance recipients whose eligibility is renewed through the ex parte redetermination process shall be reported monthly by the Department of Healthcare and Family Services on its website in accordance with subsection (d) of Section 11-5.1 of this Code as well as shared in all Medicaid Advisory Committee meetings and Medicaid Advisory Committee Public Education Subcommittee meetings.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
Sec. 5-2. Classes of persons eligible. Medical assistance under this
Article shall be available to any of the following classes of persons in
respect to whom a plan for coverage has been submitted to the Governor
by the Illinois Department and approved by him. If changes made in this Section 5-2 require federal approval, they shall not take effect until such approval has been received:
In implementing the provisions of Public Act 96-20, the Department is authorized to adopt only those rules necessary, including emergency rules. Nothing in Public Act 96-20 permits the Department to adopt rules or issue a decision that expands eligibility for the FamilyCare Program to a person whose income exceeds 185% of the Federal Poverty Level as determined from time to time by the U.S. Department of Health and Human Services, unless the Department is provided with express statutory authority.
The eligibility of any such person for medical assistance under this
Article is not affected by the payment of any grant under the Senior
Citizens and Persons with Disabilities Property Tax Relief Act or any distributions or items of income described under
subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
The Department shall by rule establish the amounts of
assets to be disregarded in determining eligibility for medical assistance,
which shall at a minimum equal the amounts to be disregarded under the
Federal Supplemental Security Income Program. The amount of assets of a
single person to be disregarded
shall not be less than $2,000, and the amount of assets of a married couple
to be disregarded shall not be less than $3,000.
To the extent permitted under federal law, any person found guilty of a
second violation of Article VIIIA
shall be ineligible for medical assistance under this Article, as provided
in Section 8A-8.
The eligibility of any person for medical assistance under this Article
shall not be affected by the receipt by the person of donations or benefits
from fundraisers held for the person in cases of serious illness,
as long as neither the person nor members of the person's family
have actual control over the donations or benefits or the disbursement
of the donations or benefits.
Notwithstanding any other provision of this Code, if the United States Supreme Court holds Title II, Subtitle A, Section 2001(a) of Public Law 111-148 to be unconstitutional, or if a holding of Public Law 111-148 makes Medicaid eligibility allowed under Section 2001(a) inoperable, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after June 14, 2012 (the effective date of Public Act 97-687), and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible.
Notwithstanding any other provision of this Code, if an Act of Congress that becomes a Public Law eliminates Section 2001(a) of Public Law 111-148, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after June 14, 2012 (the effective date of Public Act 97-687), and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible.
Effective October 1, 2013, the determination of eligibility of persons who qualify under paragraphs 5, 6, 8, 15, 17, and 18 of this Section shall comply with the requirements of 42 U.S.C. 1396a(e)(14) and applicable federal regulations.
The Department of Healthcare and Family Services, the Department of Human Services, and the Illinois health insurance marketplace shall work cooperatively to assist persons who would otherwise lose health benefits as a result of changes made under Public Act 98-104 to transition to other health insurance coverage.
(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; 102-43, eff. 7-6-21; 102-558, eff. 8-20-21; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-2.06)
Sec. 5-2.06. Payment rates; Children's Community-Based Health Care Centers. Beginning January 1, 2020, the Department shall, for eligible individuals, reimburse Children's Community-Based Health Care Centers established in the Alternative Health Care Delivery Act and providing nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting and reuniting families for a maximum of up to 120 days on a per diem basis at the lower of the Children's Community-Based Health Care Center's usual and customary charge to the public or at the Department rate of $950. Payments at the rate set forth in this Section are exempt from the 2.7% rate reduction required under Section 5-5e.
(Source: P.A. 101-10, eff. 6-5-19.)
(305 ILCS 5/5-2.09)
Sec. 5-2.09. Enhanced federal medical assistance percentage. In accordance with Section 9817 of the American Rescue Plan Act of 2021 (Pub. L. 117-2) and corresponding federal guidance, the Department of Healthcare and Family Services shall take appropriate actions to claim an enhanced federal medical assistance percentage (FMAP) provided by Section 9817 of the American Rescue Plan Act of 2021 with respect to expenditures under the State medical assistance program for home and community-based services from April 1, 2021 through March 31, 2022. The Department is authorized to use State funds equivalent to the amount of federal funds attributable to the increased federal medical assistance percentage under Section 9817 of the American Rescue Plan Act of 2021 to implement or supplement the implementation of activities to enhance, expand, or strengthen home and community based services under the State's medical assistance program to the extent permitted by and aligned with the goals of Section 9817 of the American Rescue Plan Act of 2021 through March 31, 2024 or any revised deadline established by the federal government. The use of such funds is subject to compliance with applicable federal requirements and federal approval, including the approval of any necessary State Plan Amendments, Waiver Amendments, or other federally required documents or assurances.
The Department may adopt rules as necessary, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(Source: P.A. 102-16, eff. 6-17-21.)
(305 ILCS 5/5-2.10)
Sec. 5-2.10. Increased accountability for nursing facilities. The Department shall develop a plan for the revitalization of nursing homes licensed under the Nursing Home Care Act and shall report to the Governor and the General Assembly on a recommended course of action, including, but not limited to, the following:
No later than September 30, 2021, the Department shall submit a report to the Governor and the General Assembly, which outlines the steps taken by the Department, including discussions with interested stakeholders and industry representatives, and recommendations for further action by the General Assembly to provide for accountability and to achieve the program objectives outlined in this Section, which shall require action by the General Assembly.
(Source: P.A. 102-16, eff. 6-17-21.)
(305 ILCS 5/5-2a)
Sec. 5-2a. Medicaid State Plan; eligibility determination status. The Department shall conduct an analysis and deliver a report to the General Assembly by January 1, 2012 to evaluate the feasibility of changing Illinois' Medicaid State Plan from 209(b) status to the federal 1634 eligibility determination status for applicable individuals as provided in the Social Security Act. The report shall include a review of the current standard used by the Department, anticipated fiscal implications of converting to 1634 status, anticipated changes in caseloads resulting from a change to 1634 status, and any additional information deemed relevant by the Department to evaluate the feasibility of converting to 1634 status.
(Source: P.A. 97-173, eff. 7-22-11.)
(305 ILCS 5/5-2b)
Sec. 5-2b. Medically fragile and technology dependent children eligibility and program. Notwithstanding any other provision of law except as provided in Section 5-30a, on and after September 1, 2012, subject to federal approval, medical assistance under this Article shall be available to children who qualify as persons with a disability, as defined under the federal Supplemental Security Income program and who are medically fragile and technology dependent. The program shall allow eligible children to receive the medical assistance provided under this Article in the community and must maximize, to the fullest extent permissible under federal law, federal reimbursement and family cost-sharing, including co-pays, premiums, or any other family contributions, except that the Department shall be permitted to incentivize the utilization of selected services through the use of cost-sharing adjustments. The Department shall establish the policies, procedures, standards, services, and criteria for this program by rule.
(Source: P.A. 100-990, eff. 1-1-19.)
(305 ILCS 5/5-2.01)
Sec. 5-2.01. Medicaid accountability through transparency program.
(a) Internet-based transparency program. The Director of the Department of Healthcare and Family Services shall be authorized to implement a program under which the Director shall make available through the Department's public Internet website information on medical claims reimbursed under the State's medical assistance program insofar as such information has been de-identified in accordance with regulations promulgated pursuant to the Illinois Health Insurance Portability and Accountability Act. In implementing the program, the Director shall ensure the following:
(b) Use of contractor. For purposes of implementing the program under subsection (a) of this Section and ensuring the information made available through the program is periodically updated, the Director may select and enter into a contract with a public or private entity meeting the criteria and qualifications the Director determines appropriate.
(c) Annual Reports. Not later than 12 months after the effective date of this amendatory Act of the 96th General Assembly and annually thereafter, the Director shall submit to the General Assembly a report on the status of the program authorized under subsection (a). The report shall include details including, but not limited to, the estimated or actual costs of developing and maintaining the reporting system, the actual or potential benefit or adverse consequences associated with the system, and, if applicable, the extent to which information made available through the program is accessed and the extent to which comments received under paragraph (4) of subsection (a) of this Section were used to improve the utility of the program.
(Source: P.A. 96-941, eff. 6-25-10.)
(305 ILCS 5/5-2.03)
Sec. 5-2.03. Presumptive eligibility. Beginning on the effective date of this amendatory Act of the 96th General Assembly and except where federal law requires presumptive eligibility, no adult may be presumed eligible for medical assistance under this Code and the Department may not cover any service rendered to an adult unless the adult has completed an application for benefits, all required verifications have been received, and the Department or its designee has found the adult eligible for the date on which that service was provided. Nothing in this Section shall apply to pregnant women or to persons enrolled under the medical assistance program due to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds.
(Source: P.A. 96-1501, eff. 1-25-11; 97-687, eff. 6-14-12.)
(305 ILCS 5/5-2.05)
Sec. 5-2.05. Children with disabilities.
(a) The Department of Healthcare and Family Services, in conjunction with the Department of Human Services,
may offer, to children with developmental
disabilities or children with severe mental illness or severe emotional disorders who
otherwise would not qualify for medical assistance under this Article due to
family income, home-based and community-based services instead of institutional
placement, as allowed under paragraph 7 of Section 5-2.
(b) The Department of Healthcare and Family Services, in conjunction with the Department of
Human Services and the Division of Specialized Care for Children, University of
Illinois-Chicago, shall submit a bi-annual
report to the Governor and the General Assembly no
later than January 1 of every even-numbered year, beginning in 2008, regarding the status of existing services offered
under paragraph 7
of Section 5-2. This report shall include, but not be limited to, the following
information:
(Source: P.A. 95-331, eff. 8-21-07; 95-622, eff. 9-17-07.)
(305 ILCS 5/5-2.07)
Sec. 5-2.07. Use of Medicaid spend-down. No later than July 1, 2007, subject to federal approval of a State Medicaid Plan amendment, which shall be sought by the Department of Healthcare and Family Services or its successor agency, persons described in item 2(a) of Section 5-2, who fail to qualify for basic maintenance under Article III of this Code on the basis of need because of excess income or assets, or both, may establish eligibility for medical assistance by paying the amount of their monthly spend-down under this Article (as described in 42 CFR 435.831) to the Department of Healthcare and Family Services or its successor agency or by having a third party pay that amount to the Department on their behalf. A person who uses Medicaid spend-down to qualify for medical assistance shall be provided up to 6 consecutive months to submit and have medical receipts and bills processed by the Department as evidence of payment of the person's monthly spend-down amount before becoming ineligible for medical assistance under this Section.
(Source: P.A. 102-74, eff. 7-9-21.)
(305 ILCS 5/5-2.08)
Sec. 5-2.08. Spousal caregiver demonstration.
(a) The Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall develop a demonstration project within the Home Services Program under which a spouse may be reimbursed for providing care to his or her spouse, who is eligible for services through the Home Services Program and who meets the criteria for this demonstration project. The demonstration project shall operate in selected counties and be limited to serving no more than 100 unduplicated persons in a State fiscal year.
The components of the demonstration project shall include the following:
(b) By July 1, 2009, the Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall begin development of the demonstration project. The Department of Human Services shall provide an interim report on or before March 1, 2010 to the Governor and the General Assembly that includes the progress on the development of the demonstration project and implementation timelines of the demonstration project and the criteria for the demonstration project.
(c) The Department of Human Services shall report findings and recommendations by March 1, 2011 to the Governor and the General Assembly. The report shall include an explanation of the manner in which each demonstration project component listed in paragraphs (1) through (10) of subsection (a) is addressed. In addition, the report shall include (i) the estimated number of clients statewide who could utilize services and (ii) an analysis of the fiscal impact per client on the Department's new and existing costs under the Home Services Program.
(Source: P.A. 96-351, eff. 8-13-09.)
(305 ILCS 5/5-2.1) (from Ch. 23, par. 5-2.1)
Sec. 5-2.1.
Property transfers.
(a) To the extent required under federal law, a person shall not make or
have made a voluntary or involuntary assignment or transfer of any legal or
equitable interests in real property or in personal property, whether vested,
contingent or inchoate, for less than fair market value. A person's interest in
real or personal property includes all income and assets to which the person is
entitled or to which the person would be entitled if the person had not taken
action to avoid receiving the interest.
(b) (Blank).
(c) (Blank).
(d) (Blank).
(e) (Blank).
(Source: P.A. 92-84, eff. 7-1-02.)
(305 ILCS 5/5-2.1a)
Sec. 5-2.1a. Treatment of trust amounts. To the extent required by
federal
law, the Department of Healthcare and Family Services shall provide by rule for the consideration of
trusts and similar legal instruments or devices established by a person in the
Illinois Department's determination of the person's eligibility for and the
amount of assistance provided under this Article.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5-2.1d)
Sec. 5-2.1d. Retroactive eligibility. An applicant for medical assistance may be eligible for up to 3 months prior to the date of application if the person would have been eligible for medical assistance at the time he or she received the services if he or she had applied, regardless of whether the individual is alive when the application for medical assistance is made. In determining financial eligibility for medical assistance for retroactive months, the Department shall consider the amount of income and resources and exemptions available to a person as of the first day of each of the backdated months for which eligibility is sought.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-2.2) (from Ch. 23, par. 5-2.2)
Sec. 5-2.2.
Cooperation in establishing support obligation.
A
parent or other person having custody of the child or a spouse who fails or
refuses to comply with the requirements of Title XIX of the federal Social
Security Act, and the regulations duly promulgated thereunder, regarding
establishment and enforcement of the child or spousal support obligation
shall be ineligible for medical assistance and shall remain ineligible for
medical assistance for as long as the failure or refusal persists.
In addition to any other definition of failure or refusal to comply
with the requirements of Title XIX of the federal Social Security Act, in
the case of failure to attend court hearings, the parent or other person
can show cooperation by attending a court hearing or, if a court hearing
cannot be scheduled within 30 days following the court hearing that was
missed, by signing a statement that the parent or other person is now
willing to cooperate in the child support enforcement process and will
appear at any later scheduled court date. The parent or other person can
show cooperation by signing such a statement only once. If failure to
attend the court hearing or other failure to cooperate results in the case
being dismissed, such a statement may be signed after 2 months.
No denial or termination of medical assistance pursuant to this Section
shall commence during pregnancy of the parent or other person having
custody of the child or for 30 days after the termination of such pregnancy.
The termination of medical assistance may commence thereafter if the
Illinois Department determines that the failure or refusal to comply with
this Section persists. Postponement of denial or termination of medical
assistance during pregnancy under this paragraph shall be effective only to
the extent it does not conflict with federal law or regulation.
(Source: P.A. 85-1155.)
(305 ILCS 5/5-2.3)
Sec. 5-2.3.
Notice of rights concerning institutionalization.
The
Illinois Department shall prepare a notice to be given to every applicant for
and recipient of medical assistance under this Article when the applicant or
recipient, or the spouse of the applicant or recipient, or a person for whom
the applicant or recipient is the primary caretaker, becomes an
institutionalized person. The notice shall fully and completely inform the
institutionalized person (and that person's spouse or primary caretaker, if
applicable) of each individual's rights and obligations under this Code with
respect to that institutionalization.
(Source: P.A. 88-162.)
(305 ILCS 5/5-2.4)
Sec. 5-2.4. (Repealed).
(Source: P.A. 95-248, eff. 8-17-07. Repealed by P.A. 97-48, eff. 6-28-11.)
(305 ILCS 5/5-3) (from Ch. 23, par. 5-3)
Sec. 5-3. Residence.) Any person who has established his residence
in this State and lives therein, including any person who is a migrant
worker, may qualify for medical assistance. A person who, while
temporarily in this State, suffers injury or illness endangering his
life and health and necessitating emergency care, may also qualify.
Temporary absence from the State shall not disqualify a person from
maintaining his eligibility under this Article.
As used in this Section, "migrant worker" means any person residing
temporarily and employed in Illinois who moves seasonally from one
place to another for the purpose of employment in agricultural
activities, including the planting, raising or harvesting of any
agricultural or horticultural commodities and the handling, packing or
processing of such commodities on the farm where produced or at the
point of first processing, in animal husbandry, or in other activities connected
with the care of animals. Dependents of such person shall be
considered eligible if they are living with the person during his or her
temporary residence and employment in Illinois.
In order to be eligible for medical assistance under this section,
each migrant worker shall show proof of citizenship or legal immigration status.
(Source: P.A. 102-1030, eff. 5-27-22.)
(305 ILCS 5/5-4) (from Ch. 23, par. 5-4)
Sec. 5-4. Amount and nature of medical assistance.
(a) The amount and nature of
medical assistance shall be determined in accordance
with the standards, rules, and regulations of the Department of Healthcare and Family Services, with due regard to the requirements and conditions in each case,
including contributions available from legally responsible
relatives. However, the amount and nature of such medical assistance shall
not be affected by the payment of any grant under the Senior Citizens and
Persons with Disabilities Property Tax Relief Act or any
distributions or items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
The amount and nature of medical assistance shall not be affected by the
receipt of donations or benefits from fundraisers in cases of serious
illness, as long as neither the person nor members of the person's family
have actual control over the donations or benefits or the disbursement of
the donations or benefits.
In determining the income and resources available to the institutionalized
spouse and to the community spouse, the Department of Healthcare and Family Services
shall follow the procedures established by federal law. If an institutionalized spouse or community spouse refuses to comply with the requirements of Title XIX of the federal Social Security Act and the regulations duly promulgated thereunder by failing to provide the total value of assets, including income and resources, to the extent either the institutionalized spouse or community spouse has an ownership interest in them pursuant to 42 U.S.C. 1396r-5, such refusal may result in the institutionalized spouse being denied eligibility and continuing to remain ineligible for the medical assistance program based on failure to cooperate.
Subject to federal approval, beginning January 1, 2023, the community spouse resource allowance shall be established and maintained as follows: a base amount of $109,560 plus an additional amount of $2,784 added to the base amount each year for a period of 10 years commencing with calendar year 2024 through calendar year 2034. In addition to the base amount and the additional amount shall be any increase each year from the prior year to the maximum resource allowance permitted under Section 1924(f)(2)(A)(ii)(II) of the Social Security Act. Subject to federal approval, beginning January 1, 2034 the community spouse resource allowance shall be established and maintained at the maximum amount permitted under Section 1924(f)(2)(A)(ii)(II) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing. Subject to federal approval, beginning January 1, 2023 the monthly maintenance allowance for the community spouse shall be
established and maintained at the maximum amount permitted pursuant to Section
1924(d)(3)(C) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater. Subject
to the approval of the Secretary of the United States Department of Health and
Human Services, the provisions of this Section shall be extended to persons who
but for the provision of home or community-based services under Section
4.02 of the Illinois Act on the Aging, would require the level of care provided
in an institution, as is provided for in federal law.
(b) Spousal support for institutionalized spouses receiving medical assistance.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-4.1) (from Ch. 23, par. 5-4.1)
Sec. 5-4.1. Co-payments. The Department may by rule provide that recipients under any Article of this Code shall pay a federally approved fee as a co-payment for services. No
co-payment requirement can exist
for renal dialysis, radiation therapy, cancer chemotherapy, or insulin, and
other products necessary on a recurring basis, the absence of which would
be life threatening, or where co-payment expenditures for required services
and/or medications for chronic diseases that the Illinois Department shall
by rule designate shall cause an extensive financial burden on the
recipient, and provided no co-payment shall exist for emergency room
encounters which are for medical emergencies. The Department shall seek approval of a State plan amendment that allows pharmacies to refuse to dispense drugs in circumstances where the recipient does not pay the required co-payment. Co-payments may not exceed $10 for emergency room use for a non-emergency situation as defined by the Department by rule and subject to federal approval.
(Source: P.A. 101-209, eff. 8-5-19.)
(305 ILCS 5/5-4.2)
Sec. 5-4.2. Ambulance services payments.
(a) For
ambulance
services provided to a recipient of aid under this Article on or after
January 1, 1993, the Illinois Department shall reimburse ambulance service
providers at rates calculated in accordance with this Section. It is the intent
of the General Assembly to provide adequate reimbursement for ambulance
services so as to ensure adequate access to services for recipients of aid
under this Article and to provide appropriate incentives to ambulance service
providers to provide services in an efficient and cost-effective manner. Thus,
it is the intent of the General Assembly that the Illinois Department implement
a reimbursement system for ambulance services that, to the extent practicable
and subject to the availability of funds appropriated by the General Assembly
for this purpose, is consistent with the payment principles of Medicare. To
ensure uniformity between the payment principles of Medicare and Medicaid, the
Illinois Department shall follow, to the extent necessary and practicable and
subject to the availability of funds appropriated by the General Assembly for
this purpose, the statutes, laws, regulations, policies, procedures,
principles, definitions, guidelines, and manuals used to determine the amounts
paid to ambulance service providers under Title XVIII of the Social Security
Act (Medicare).
(b) For ambulance services provided to a recipient of aid under this Article
on or after January 1, 1996, the Illinois Department shall reimburse ambulance
service providers based upon the actual distance traveled if a natural
disaster, weather conditions, road repairs, or traffic congestion necessitates
the use of a
route other than the most direct route.
(c) For purposes of this Section, "ambulance services" includes medical
transportation services provided by means of an ambulance, medi-car, service
car, or
taxi.
(c-1) For purposes of this Section, "ground ambulance service" means medical transportation services that are described as ground ambulance services by the Centers for Medicare and Medicaid Services and provided in a vehicle that is licensed as an ambulance by the Illinois Department of Public Health pursuant to the Emergency Medical Services (EMS) Systems Act.
(c-2) For purposes of this Section, "ground ambulance service provider" means a vehicle service provider as described in the Emergency Medical Services (EMS) Systems Act that operates licensed ambulances for the purpose of providing emergency ambulance services, or non-emergency ambulance services, or both. For purposes of this Section, this includes both ambulance providers and ambulance suppliers as described by the Centers for Medicare and Medicaid Services.
(c-3) For purposes of this Section, "medi-car" means transportation services provided to a patient who is confined to a wheelchair and requires the use of a hydraulic or electric lift or ramp and wheelchair lockdown when the patient's condition does not require medical observation, medical supervision, medical equipment, the administration of medications, or the administration of oxygen.
(c-4) For purposes of this Section, "service car" means transportation services provided to a patient by a passenger vehicle where that patient does not require the specialized modes described in subsection (c-1) or (c-3).
(d) This Section does not prohibit separate billing by ambulance service
providers for oxygen furnished while providing advanced life support
services.
(e) Beginning with services rendered on or after July 1, 2008, all providers of non-emergency medi-car and service car transportation must certify that the driver and employee attendant, as applicable, have completed a safety program approved by the Department to protect both the patient and the driver, prior to transporting a patient.
The provider must maintain this certification in its records. The provider shall produce such documentation upon demand by the Department or its representative. Failure to produce documentation of such training shall result in recovery of any payments made by the Department for services rendered by a non-certified driver or employee attendant. Medi-car and service car providers must maintain legible documentation in their records of the driver and, as applicable, employee attendant that actually transported the patient. Providers must recertify all drivers and employee attendants every 3 years.
If they meet the established training components set forth by the Department, providers of non-emergency medi-car and service car transportation that are either directly or through an affiliated company licensed by the Department of Public Health shall be approved by the Department to have in-house safety programs for training their own staff.
Notwithstanding the requirements above, any public transportation provider of medi-car and service car transportation that receives federal funding under 49 U.S.C. 5307 and 5311 need not certify its drivers and employee attendants under this Section, since safety training is already federally mandated.
(f) With respect to any policy or program administered by the Department or its agent regarding approval of non-emergency medical transportation by ground ambulance service providers, including, but not limited to, the Non-Emergency Transportation Services Prior Approval Program (NETSPAP), the Department shall establish by rule a process by which ground ambulance service providers of non-emergency medical transportation may appeal any decision by the Department or its agent for which no denial was received prior to the time of transport that either (i) denies a request for approval for payment of non-emergency transportation by means of ground ambulance service or (ii) grants a request for approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than the ground ambulance service provider would have received as compensation for the level of service requested. The rule shall be filed by December 15, 2012 and shall provide that, for any decision rendered by the Department or its agent on or after the date the rule takes effect, the ground ambulance service provider shall have 60 days from the date the decision is received to file an appeal. The rule established by the Department shall be, insofar as is practical, consistent with the Illinois Administrative Procedure Act. The Director's decision on an appeal under this Section shall be a final administrative decision subject to review under the Administrative Review Law.
(f-5) Beginning 90 days after July 20, 2012 (the effective date of Public Act 97-842), (i) no denial of a request for approval for payment of non-emergency transportation by means of ground ambulance service, and (ii) no approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than would have been received at the level of service submitted by the ground ambulance service provider, may be issued by the Department or its agent unless the Department has submitted the criteria for determining the appropriateness of the transport for first notice publication in the Illinois Register pursuant to Section 5-40 of the Illinois Administrative Procedure Act.
(f-6) Within 90 days after the effective date of this amendatory Act of the 102nd General Assembly and subject to federal approval, the Department shall file rules to allow for the approval of ground ambulance services when the sole purpose of the transport is for the navigation of stairs or the assisting or lifting of a patient at a medical facility or during a medical appointment in instances where the Department or a contracted Medicaid managed care organization or their transportation broker is unable to secure transportation through any other transportation provider.
(f-7) For non-emergency ground ambulance claims properly denied under Department policy at the time the claim is filed due to failure to submit a valid Medical Certification for Non-Emergency Ambulance on and after December 15, 2012 and prior to January 1, 2021, the Department shall allot $2,000,000 to a pool to reimburse such claims if the provider proves medical necessity for the service by other means. Providers must submit any such denied claims for which they seek compensation to the Department no later than December 31, 2021 along with documentation of medical necessity. No later than May 31, 2022, the Department shall determine for which claims medical necessity was established. Such claims for which medical necessity was established shall be paid at the rate in effect at the time of the service, provided the $2,000,000 is sufficient to pay at those rates. If the pool is not sufficient, claims shall be paid at a uniform percentage of the applicable rate such that the pool of $2,000,000 is exhausted. The appeal process described in subsection (f) shall not be applicable to the Department's determinations made in accordance with this subsection.
(g) Whenever a patient covered by a medical assistance program under this Code or by another medical program administered by the Department, including a patient covered under the State's Medicaid managed care program, is being transported from a facility and requires non-emergency transportation including ground ambulance, medi-car, or service car transportation, a Physician Certification Statement as described in this Section shall be required for each patient. Facilities shall develop procedures for a licensed medical professional to provide a written and signed Physician Certification Statement. The Physician Certification Statement shall specify the level of transportation services needed and complete a medical certification establishing the criteria for approval of non-emergency ambulance transportation, as published by the Department of Healthcare and Family Services, that is met by the patient. This certification shall be completed prior to ordering the transportation service and prior to patient discharge. The Physician Certification Statement is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome. If the ground ambulance provider, medi-car provider, or service car provider is unable to obtain the required Physician Certification Statement within 10 calendar days following the date of the service, the ground ambulance provider, medi-car provider, or service car provider must document its attempt to obtain the requested certification and may then submit the claim for payment. Acceptable documentation includes a signed return receipt from the U.S. Postal Service, facsimile receipt, email receipt, or other similar service that evidences that the ground ambulance provider, medi-car provider, or service car provider attempted to obtain the required Physician Certification Statement.
The medical certification specifying the level and type of non-emergency transportation needed shall be in the form of the Physician Certification Statement on a standardized form prescribed by the Department of Healthcare and Family Services. Within 75 days after July 27, 2018 (the effective date of Public Act 100-646), the Department of Healthcare and Family Services shall develop a standardized form of the Physician Certification Statement specifying the level and type of transportation services needed in consultation with the Department of Public Health, Medicaid managed care organizations, a statewide association representing ambulance providers, a statewide association representing hospitals, 3 statewide associations representing nursing homes, and other stakeholders. The Physician Certification Statement shall include, but is not limited to, the criteria necessary to demonstrate medical necessity for the level of transport needed as required by (i) the Department of Healthcare and Family Services and (ii) the federal Centers for Medicare and Medicaid Services as outlined in the Centers for Medicare and Medicaid Services' Medicare Benefit Policy Manual, Pub. 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician Certification Statement shall satisfy the obligations of hospitals under Section 6.22 of the Hospital Licensing Act and nursing homes under Section 2-217 of the Nursing Home Care Act. Implementation and acceptance of the Physician Certification Statement shall take place no later than 90 days after the issuance of the Physician Certification Statement by the Department of Healthcare and Family Services.
Pursuant to subsection (E) of Section 12-4.25 of this Code, the Department is entitled to recover overpayments paid to a provider or vendor, including, but not limited to, from the discharging physician, the discharging facility, and the ground ambulance service provider, in instances where a non-emergency ground ambulance service is rendered as the result of improper or false certification.
Beginning October 1, 2018, the Department of Healthcare and Family Services shall collect data from Medicaid managed care organizations and transportation brokers, including the Department's NETSPAP broker, regarding denials and appeals related to the missing or incomplete Physician Certification Statement forms and overall compliance with this subsection. The Department of Healthcare and Family Services shall publish quarterly results on its website within 15 days following the end of each quarter.
(h) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(i) On and after July 1, 2018, the Department shall increase the base rate of reimbursement for both base charges and mileage charges for ground ambulance service providers for medical transportation services provided by means of a ground ambulance to a level not lower than 112% of the base rate in effect as of June 30, 2018.
(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20; 102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-4.20)
Sec. 5-4.20. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.21)
Sec. 5-4.21. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.22)
Sec. 5-4.22. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.23)
Sec. 5-4.23. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.24)
Sec. 5-4.24. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.25)
Sec. 5-4.25. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.26)
Sec. 5-4.26. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.27)
Sec. 5-4.27. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.28)
Sec. 5-4.28. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.29)
Sec. 5-4.29. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.30)
Sec. 5-4.30. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.31)
Sec. 5-4.31. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.32)
Sec. 5-4.32. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.33)
Sec. 5-4.33. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.34)
Sec. 5-4.34. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.35)
Sec. 5-4.35. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.36)
Sec. 5-4.36. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.37)
Sec. 5-4.37. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.38)
Sec. 5-4.38. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.39)
Sec. 5-4.39. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
(Text of Section from P.A. 102-813)
Sec. 5-5. Medical services. The Illinois Department, by rule, shall
determine the quantity and quality of and the rate of reimbursement for the
medical assistance for which
payment will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient hospital
services; (2) outpatient hospital services; (3) other laboratory and
X-ray services; (4) skilled nursing home services; (5) physicians'
services whether furnished in the office, the patient's home, a
hospital, a skilled nursing home, or elsewhere; (6) medical care, or any
other type of remedial care furnished by licensed practitioners; (7)
home health care services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related
services; (12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in the diseases of the eye,
or by an optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary; (15) medical
treatment of sexual assault survivors, as defined in
Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for
injuries sustained as a result of the sexual assault, including
examinations and laboratory tests to discover evidence which may be used in
criminal proceedings arising from the sexual assault; (16) the
diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17)
any other medical care, and any other type of remedial care recognized
under the laws of this State. The term "any other type of remedial care" shall
include nursing care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a comprehensive
tobacco use cessation program that includes purchasing prescription drugs or
prescription medical devices approved by the Food and Drug Administration shall
be covered under the medical assistance
program under this Article for persons who are otherwise eligible for
assistance under this Article.
Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval.
Notwithstanding any other provision of this Code, the Illinois
Department may not require, as a condition of payment for any laboratory
test authorized under this Article, that a physician's handwritten signature
appear on the laboratory test order form. The Illinois Department may,
however, impose other appropriate requirements regarding laboratory test
order documentation.
Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to
persons
eligible for assistance under this Article who are participating in
education, training or employment programs operated by the Department of Human
Services as successor to the Department of Public Aid:
On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession.
On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program.
Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department.
The Illinois Department, by rule, may distinguish and classify the
medical services to be provided only in accordance with the classes of
persons designated in Section 5-2.
The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
The Illinois Department shall authorize the provision of, and shall
authorize payment for, screening by low-dose mammography for the presence of
occult breast cancer for individuals 35 years of age or older who are eligible
for medical assistance under this Article, as follows:
The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223).
All screenings
shall
include a physical breast exam, instruction on self-examination and
information regarding the frequency of self-examination and its value as a
preventative tool.
For purposes of this Section:
"Diagnostic
mammogram" means a mammogram obtained using diagnostic mammography.
"Diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.
"Low-dose mammography" means
the x-ray examination of the breast using equipment dedicated specifically
for mammography, including the x-ray tube, filter, compression device,
and image receptor, with an average radiation exposure delivery
of less than one rad per breast for 2 views of an average size breast.
The term also includes digital mammography and includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph.
On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology.
On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography.
The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography.
On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program.
The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment.
Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph.
The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation.
The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit.
On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department.
Any medical or health care provider shall immediately recommend, to
any pregnant individual who is being provided prenatal services and is suspected
of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services
shall assure coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the Illinois Medicaid
Program in conjunction with the Department of Human Services.
All medical providers providing medical assistance to pregnant individuals
under this Code shall receive information from the Department on the
availability of services under any
program providing case management services for addicted individuals,
including information on appropriate referrals for other social services
that may be needed by addicted individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the Departments of Human
Services (as successor to the Department of Alcoholism and Substance
Abuse) and Public Health, through a public awareness campaign, may
provide information concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs directed at
reducing the number of drug-affected infants born to recipients of medical
assistance.
Neither the Department of Healthcare and Family Services nor the Department of Human
Services shall sanction the recipient solely on the basis of the recipient's
substance abuse.
The Illinois Department shall establish such regulations governing
the dispensing of health services under this Article as it shall deem
appropriate. The Department
should
seek the advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of providing regular
advice on policy and administrative matters, information dissemination and
educational activities for medical and health care providers, and
consistency in procedures to the Illinois Department.
The Illinois Department may develop and contract with Partnerships of
medical providers to arrange medical services for persons eligible under
Section 5-2 of this Code. Implementation of this Section may be by
demonstration projects in certain geographic areas. The Partnership shall
be represented by a sponsor organization. The Department, by rule, shall
develop qualifications for sponsors of Partnerships. Nothing in this
Section shall be construed to require that the sponsor organization be a
medical organization.
The sponsor must negotiate formal written contracts with medical
providers for physician services, inpatient and outpatient hospital care,
home health services, treatment for alcoholism and substance abuse, and
other services determined necessary by the Illinois Department by rule for
delivery by Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse medical services
delivered by Partnership providers to clients in target areas according to
provisions of this Article and the Illinois Health Finance Reform Act,
except that:
Medical providers shall be required to meet certain qualifications to
participate in Partnerships to ensure the delivery of high quality medical
services. These qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for participation in the
medical assistance program. Partnership sponsors may prescribe reasonable
additional qualifications for participation by medical providers, only with
the prior written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of practitioners,
hospitals, and other providers of medical services by clients.
In order to ensure patient freedom of choice, the Illinois Department shall
immediately promulgate all rules and take all other necessary actions so that
provided services may be accessed from therapeutically certified optometrists
to the full extent of the Illinois Optometric Practice Act of 1987 without
discriminating between service providers.
The Department shall apply for a waiver from the United States Health
Care Financing Administration to allow for the implementation of
Partnerships under this Section.
The Illinois Department shall require health care providers to maintain
records that document the medical care and services provided to recipients
of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall
require health care providers to make available, when authorized by the
patient, in writing, the medical records in a timely fashion to other
health care providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of medical services
shall be required to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope, details and
receipt of the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations promulgated by
the Illinois Department. The rules and regulations shall require that proof
of the receipt of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany each claim
for reimbursement submitted by the dispenser of such medical services.
No such claims for reimbursement shall be approved for payment by the Illinois
Department without such proof of receipt, unless the Illinois Department
shall have put into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed adequate by
the Illinois Department to assure that such drugs, dentures, prosthetic
devices and eyeglasses for which payment is being made are actually being
received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a
current list of acquisition costs for all prosthetic devices and any
other items recognized as medical equipment and supplies reimbursable under
this Article and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be updated no
less frequently than every 30 days as required by Section 5-5.12.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of medical
services, other than an individual practitioner or group of practitioners,
desiring to participate in the Medical Assistance program
established under this Article to disclose all financial, beneficial,
ownership, equity, surety or other interests in any and all firms,
corporations, partnerships, associations, business enterprises, joint
ventures, agencies, institutions or other legal entities providing any
form of health care services in this State under this Article.
The Illinois Department may require that all dispensers of medical
services desiring to participate in the medical assistance program
established under this Article disclose, under such terms and conditions as
the Illinois Department may by rule establish, all inquiries from clients
and attorneys regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens for the
Illinois Department.
Enrollment of a vendor
shall be
subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may
terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance
program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the
Department's hearing process.
However, a disenrolled vendor may reapply without penalty.
The Department has the discretion to limit the conditional enrollment period for vendors based upon 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:
For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September
1, 2014, admission documents, including all prescreening
information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
The Illinois Department shall establish policies, procedures,
standards and criteria by rule for the acquisition, repair and replacement
of orthotic and prosthetic devices and durable medical equipment. Such
rules shall provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of
durable medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of the
recipient's needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and
use alternative or substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized for such
recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs.
The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement.
In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations.
The Department shall execute, relative to the nursing home prescreening
project, written inter-agency agreements with the Department of Human
Services and the Department on Aging, to effect the following: (i) intake
procedures and common eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and development of
non-institutional services in areas of the State where they are not currently
available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in cooperation
with other State Departments and agencies and in compliance with
applicable federal laws and regulations, appropriate and effective
systems of health care evaluation and programs for monitoring of
utilization of health care services and facilities, as it affects
persons eligible for medical assistance under this Code.
The Illinois Department shall report annually to the General Assembly,
no later than the second Friday in April of 1979 and each year
thereafter, in regard to:
The period covered by each report shall be the 3 years ending on the June
30 prior to the report. The report shall include suggested legislation
for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied
by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional
copies
with the State Government Report Distribution Center for the General
Assembly as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
Because kidney transplantation can be an appropriate, cost-effective
alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee for service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria,
(2) prior authorization mandate, or (3) lifetime restriction limit
mandate.
On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration.
Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection.
A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal
Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws.
Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative
Care Act.
(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20; 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22.)
(Text of Section from P.A. 102-1018)
Sec. 5-5. Medical services. The Illinois Department, by rule, shall
determine the quantity and quality of and the rate of reimbursement for the
medical assistance for which
payment will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient hospital
services; (2) outpatient hospital services; (3) other laboratory and
X-ray services; (4) skilled nursing home services; (5) physicians'
services whether furnished in the office, the patient's home, a
hospital, a skilled nursing home, or elsewhere; (6) medical care, or any
other type of remedial care furnished by licensed practitioners; (7)
home health care services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related
services; (12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in the diseases of the eye,
or by an optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary; (15) medical
treatment of sexual assault survivors, as defined in
Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for
injuries sustained as a result of the sexual assault, including
examinations and laboratory tests to discover evidence which may be used in
criminal proceedings arising from the sexual assault; (16) the
diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17)
any other medical care, and any other type of remedial care recognized
under the laws of this State. The term "any other type of remedial care" shall
include nursing care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a comprehensive
tobacco use cessation program that includes purchasing prescription drugs or
prescription medical devices approved by the Food and Drug Administration shall
be covered under the medical assistance
program under this Article for persons who are otherwise eligible for
assistance under this Article.
Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval.
Notwithstanding any other provision of this Code, the Illinois
Department may not require, as a condition of payment for any laboratory
test authorized under this Article, that a physician's handwritten signature
appear on the laboratory test order form. The Illinois Department may,
however, impose other appropriate requirements regarding laboratory test
order documentation.
Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to
persons
eligible for assistance under this Article who are participating in
education, training or employment programs operated by the Department of Human
Services as successor to the Department of Public Aid:
On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession.
On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program.
Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department.
The Illinois Department, by rule, may distinguish and classify the
medical services to be provided only in accordance with the classes of
persons designated in Section 5-2.
The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
The Illinois Department shall authorize the provision of, and shall
authorize payment for, screening by low-dose mammography for the presence of
occult breast cancer for individuals 35 years of age or older who are eligible
for medical assistance under this Article, as follows:
The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223).
All screenings
shall
include a physical breast exam, instruction on self-examination and
information regarding the frequency of self-examination and its value as a
preventative tool.
For purposes of this Section:
"Diagnostic
mammogram" means a mammogram obtained using diagnostic mammography.
"Diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.
"Low-dose mammography" means
the x-ray examination of the breast using equipment dedicated specifically
for mammography, including the x-ray tube, filter, compression device,
and image receptor, with an average radiation exposure delivery
of less than one rad per breast for 2 views of an average size breast.
The term also includes digital mammography and includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph.
On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology.
On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography and, after the effective date of this amendatory Act of the 102nd General Assembly, breast tomosynthesis.
The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography.
On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program.
The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment.
Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph.
The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation.
The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit.
The Department shall provide coverage and reimbursement for a human papillomavirus (HPV) vaccine that is approved for marketing by the federal Food and Drug Administration for all persons between the ages of 9 and 45 and persons of the age of 46 and above who have been diagnosed with cervical dysplasia with a high risk of recurrence or progression. The Department shall disallow any preauthorization requirements for the administration of the human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department.
Any medical or health care provider shall immediately recommend, to
any pregnant individual who is being provided prenatal services and is suspected
of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services
shall assure coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the Illinois Medicaid
Program in conjunction with the Department of Human Services.
All medical providers providing medical assistance to pregnant individuals
under this Code shall receive information from the Department on the
availability of services under any
program providing case management services for addicted individuals,
including information on appropriate referrals for other social services
that may be needed by addicted individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the Departments of Human
Services (as successor to the Department of Alcoholism and Substance
Abuse) and Public Health, through a public awareness campaign, may
provide information concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs directed at
reducing the number of drug-affected infants born to recipients of medical
assistance.
Neither the Department of Healthcare and Family Services nor the Department of Human
Services shall sanction the recipient solely on the basis of the recipient's
substance abuse.
The Illinois Department shall establish such regulations governing
the dispensing of health services under this Article as it shall deem
appropriate. The Department
should
seek the advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of providing regular
advice on policy and administrative matters, information dissemination and
educational activities for medical and health care providers, and
consistency in procedures to the Illinois Department.
The Illinois Department may develop and contract with Partnerships of
medical providers to arrange medical services for persons eligible under
Section 5-2 of this Code. Implementation of this Section may be by
demonstration projects in certain geographic areas. The Partnership shall
be represented by a sponsor organization. The Department, by rule, shall
develop qualifications for sponsors of Partnerships. Nothing in this
Section shall be construed to require that the sponsor organization be a
medical organization.
The sponsor must negotiate formal written contracts with medical
providers for physician services, inpatient and outpatient hospital care,
home health services, treatment for alcoholism and substance abuse, and
other services determined necessary by the Illinois Department by rule for
delivery by Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse medical services
delivered by Partnership providers to clients in target areas according to
provisions of this Article and the Illinois Health Finance Reform Act,
except that:
Medical providers shall be required to meet certain qualifications to
participate in Partnerships to ensure the delivery of high quality medical
services. These qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for participation in the
medical assistance program. Partnership sponsors may prescribe reasonable
additional qualifications for participation by medical providers, only with
the prior written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of practitioners,
hospitals, and other providers of medical services by clients.
In order to ensure patient freedom of choice, the Illinois Department shall
immediately promulgate all rules and take all other necessary actions so that
provided services may be accessed from therapeutically certified optometrists
to the full extent of the Illinois Optometric Practice Act of 1987 without
discriminating between service providers.
The Department shall apply for a waiver from the United States Health
Care Financing Administration to allow for the implementation of
Partnerships under this Section.
The Illinois Department shall require health care providers to maintain
records that document the medical care and services provided to recipients
of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall
require health care providers to make available, when authorized by the
patient, in writing, the medical records in a timely fashion to other
health care providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of medical services
shall be required to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope, details and
receipt of the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations promulgated by
the Illinois Department. The rules and regulations shall require that proof
of the receipt of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany each claim
for reimbursement submitted by the dispenser of such medical services.
No such claims for reimbursement shall be approved for payment by the Illinois
Department without such proof of receipt, unless the Illinois Department
shall have put into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed adequate by
the Illinois Department to assure that such drugs, dentures, prosthetic
devices and eyeglasses for which payment is being made are actually being
received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a
current list of acquisition costs for all prosthetic devices and any
other items recognized as medical equipment and supplies reimbursable under
this Article and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be updated no
less frequently than every 30 days as required by Section 5-5.12.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of medical
services, other than an individual practitioner or group of practitioners,
desiring to participate in the Medical Assistance program
established under this Article to disclose all financial, beneficial,
ownership, equity, surety or other interests in any and all firms,
corporations, partnerships, associations, business enterprises, joint
ventures, agencies, institutions or other legal entities providing any
form of health care services in this State under this Article.
The Illinois Department may require that all dispensers of medical
services desiring to participate in the medical assistance program
established under this Article disclose, under such terms and conditions as
the Illinois Department may by rule establish, all inquiries from clients
and attorneys regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens for the
Illinois Department.
Enrollment of a vendor
shall be
subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may
terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance
program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the
Department's hearing process.
However, a disenrolled vendor may reapply without penalty.
The Department has the discretion to limit the conditional enrollment period for vendors based upon 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:
For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September
1, 2014, admission documents, including all prescreening
information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
The Illinois Department shall establish policies, procedures,
standards and criteria by rule for the acquisition, repair and replacement
of orthotic and prosthetic devices and durable medical equipment. Such
rules shall provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of
durable medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of the
recipient's needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and
use alternative or substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized for such
recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs.
The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement.
In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations.
The Department shall execute, relative to the nursing home prescreening
project, written inter-agency agreements with the Department of Human
Services and the Department on Aging, to effect the following: (i) intake
procedures and common eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and development of
non-institutional services in areas of the State where they are not currently
available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in cooperation
with other State Departments and agencies and in compliance with
applicable federal laws and regulations, appropriate and effective
systems of health care evaluation and programs for monitoring of
utilization of health care services and facilities, as it affects
persons eligible for medical assistance under this Code.
The Illinois Department shall report annually to the General Assembly,
no later than the second Friday in April of 1979 and each year
thereafter, in regard to:
The period covered by each report shall be the 3 years ending on the June
30 prior to the report. The report shall include suggested legislation
for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied
by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional
copies
with the State Government Report Distribution Center for the General
Assembly as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
Because kidney transplantation can be an appropriate, cost-effective
alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee for service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria,
(2) prior authorization mandate, or (3) lifetime restriction limit
mandate.
On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration.
Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection.
A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal
Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws.
Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative
Care Act.
(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20; 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-1018, eff. 1-1-23.)
(Text of Section from P.A. 102-1037)
Sec. 5-5. Medical services. The Illinois Department, by rule, shall
determine the quantity and quality of and the rate of reimbursement for the
medical assistance for which
payment will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient hospital
services; (2) outpatient hospital services; (3) other laboratory and
X-ray services; (4) skilled nursing home services; (5) physicians'
services whether furnished in the office, the patient's home, a
hospital, a skilled nursing home, or elsewhere; (6) medical care, or any
other type of remedial care furnished by licensed practitioners; (7)
home health care services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related
services; (12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in the diseases of the eye,
or by an optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary; (15) medical
treatment of sexual assault survivors, as defined in
Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for
injuries sustained as a result of the sexual assault, including
examinations and laboratory tests to discover evidence which may be used in
criminal proceedings arising from the sexual assault; (16) the
diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17)
any other medical care, and any other type of remedial care recognized
under the laws of this State. The term "any other type of remedial care" shall
include nursing care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a comprehensive
tobacco use cessation program that includes purchasing prescription drugs or
prescription medical devices approved by the Food and Drug Administration shall
be covered under the medical assistance
program under this Article for persons who are otherwise eligible for
assistance under this Article.
Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval.
Notwithstanding any other provision of this Code, the Illinois
Department may not require, as a condition of payment for any laboratory
test authorized under this Article, that a physician's handwritten signature
appear on the laboratory test order form. The Illinois Department may,
however, impose other appropriate requirements regarding laboratory test
order documentation.
Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to
persons
eligible for assistance under this Article who are participating in
education, training or employment programs operated by the Department of Human
Services as successor to the Department of Public Aid:
On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession.
On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program.
Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department.
The Illinois Department, by rule, may distinguish and classify the
medical services to be provided only in accordance with the classes of
persons designated in Section 5-2.
The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
The Illinois Department shall authorize the provision of, and shall
authorize payment for, screening by low-dose mammography for the presence of
occult breast cancer for individuals 35 years of age or older who are eligible
for medical assistance under this Article, as follows:
The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223).
All screenings
shall
include a physical breast exam, instruction on self-examination and
information regarding the frequency of self-examination and its value as a
preventative tool.
For purposes of this Section:
"Diagnostic
mammogram" means a mammogram obtained using diagnostic mammography.
"Diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.
"Low-dose mammography" means
the x-ray examination of the breast using equipment dedicated specifically
for mammography, including the x-ray tube, filter, compression device,
and image receptor, with an average radiation exposure delivery
of less than one rad per breast for 2 views of an average size breast.
The term also includes digital mammography and includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph.
On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology.
On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography.
The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography.
On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program.
The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment.
Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph.
The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation.
The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit.
On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department.
Any medical or health care provider shall immediately recommend, to
any pregnant individual who is being provided prenatal services and is suspected
of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services
shall assure coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the Illinois Medicaid
Program in conjunction with the Department of Human Services.
All medical providers providing medical assistance to pregnant individuals
under this Code shall receive information from the Department on the
availability of services under any
program providing case management services for addicted individuals,
including information on appropriate referrals for other social services
that may be needed by addicted individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the Departments of Human
Services (as successor to the Department of Alcoholism and Substance
Abuse) and Public Health, through a public awareness campaign, may
provide information concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs directed at
reducing the number of drug-affected infants born to recipients of medical
assistance.
Neither the Department of Healthcare and Family Services nor the Department of Human
Services shall sanction the recipient solely on the basis of the recipient's
substance abuse.
The Illinois Department shall establish such regulations governing
the dispensing of health services under this Article as it shall deem
appropriate. The Department
should
seek the advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of providing regular
advice on policy and administrative matters, information dissemination and
educational activities for medical and health care providers, and
consistency in procedures to the Illinois Department.
The Illinois Department may develop and contract with Partnerships of
medical providers to arrange medical services for persons eligible under
Section 5-2 of this Code. Implementation of this Section may be by
demonstration projects in certain geographic areas. The Partnership shall
be represented by a sponsor organization. The Department, by rule, shall
develop qualifications for sponsors of Partnerships. Nothing in this
Section shall be construed to require that the sponsor organization be a
medical organization.
The sponsor must negotiate formal written contracts with medical
providers for physician services, inpatient and outpatient hospital care,
home health services, treatment for alcoholism and substance abuse, and
other services determined necessary by the Illinois Department by rule for
delivery by Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse medical services
delivered by Partnership providers to clients in target areas according to
provisions of this Article and the Illinois Health Finance Reform Act,
except that:
Medical providers shall be required to meet certain qualifications to
participate in Partnerships to ensure the delivery of high quality medical
services. These qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for participation in the
medical assistance program. Partnership sponsors may prescribe reasonable
additional qualifications for participation by medical providers, only with
the prior written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of practitioners,
hospitals, and other providers of medical services by clients.
In order to ensure patient freedom of choice, the Illinois Department shall
immediately promulgate all rules and take all other necessary actions so that
provided services may be accessed from therapeutically certified optometrists
to the full extent of the Illinois Optometric Practice Act of 1987 without
discriminating between service providers.
The Department shall apply for a waiver from the United States Health
Care Financing Administration to allow for the implementation of
Partnerships under this Section.
The Illinois Department shall require health care providers to maintain
records that document the medical care and services provided to recipients
of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall
require health care providers to make available, when authorized by the
patient, in writing, the medical records in a timely fashion to other
health care providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of medical services
shall be required to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope, details and
receipt of the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations promulgated by
the Illinois Department. The rules and regulations shall require that proof
of the receipt of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany each claim
for reimbursement submitted by the dispenser of such medical services.
No such claims for reimbursement shall be approved for payment by the Illinois
Department without such proof of receipt, unless the Illinois Department
shall have put into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed adequate by
the Illinois Department to assure that such drugs, dentures, prosthetic
devices and eyeglasses for which payment is being made are actually being
received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a
current list of acquisition costs for all prosthetic devices and any
other items recognized as medical equipment and supplies reimbursable under
this Article and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be updated no
less frequently than every 30 days as required by Section 5-5.12.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of medical
services, other than an individual practitioner or group of practitioners,
desiring to participate in the Medical Assistance program
established under this Article to disclose all financial, beneficial,
ownership, equity, surety or other interests in any and all firms,
corporations, partnerships, associations, business enterprises, joint
ventures, agencies, institutions or other legal entities providing any
form of health care services in this State under this Article.
The Illinois Department may require that all dispensers of medical
services desiring to participate in the medical assistance program
established under this Article disclose, under such terms and conditions as
the Illinois Department may by rule establish, all inquiries from clients
and attorneys regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens for the
Illinois Department.
Enrollment of a vendor
shall be
subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may
terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance
program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the
Department's hearing process.
However, a disenrolled vendor may reapply without penalty.
The Department has the discretion to limit the conditional enrollment period for vendors based upon 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:
For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September
1, 2014, admission documents, including all prescreening
information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
The Illinois Department shall establish policies, procedures,
standards and criteria by rule for the acquisition, repair and replacement
of orthotic and prosthetic devices and durable medical equipment. Such
rules shall provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of
durable medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of the
recipient's needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and
use alternative or substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized for such
recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs.
The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement.
In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations.
The Department shall execute, relative to the nursing home prescreening
project, written inter-agency agreements with the Department of Human
Services and the Department on Aging, to effect the following: (i) intake
procedures and common eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and development of
non-institutional services in areas of the State where they are not currently
available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in cooperation
with other State Departments and agencies and in compliance with
applicable federal laws and regulations, appropriate and effective
systems of health care evaluation and programs for monitoring of
utilization of health care services and facilities, as it affects
persons eligible for medical assistance under this Code.
The Illinois Department shall report annually to the General Assembly,
no later than the second Friday in April of 1979 and each year
thereafter, in regard to:
The period covered by each report shall be the 3 years ending on the June
30 prior to the report. The report shall include suggested legislation
for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied
by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional
copies
with the State Government Report Distribution Center for the General
Assembly as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
Because kidney transplantation can be an appropriate, cost-effective
alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee for service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria,
(2) prior authorization mandate, or (3) lifetime restriction limit
mandate.
On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration.
Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection.
A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal
Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws.
Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative
Care Act.
Notwithstanding any other provision of this Code, within 12 months after the effective date of this amendatory Act of the 102nd General Assembly and subject to federal approval, acupuncture services performed by an acupuncturist licensed under the Acupuncture Practice Act who is acting within the scope of his or her license shall be covered under the medical assistance program. The Department shall apply for any federal waiver or State Plan amendment, if required, to implement this paragraph. The Department may adopt any rules, including standards and criteria, necessary to implement this paragraph.
(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20; 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-1037, eff. 6-2-22.)
(Text of Section from P.A. 102-1038)
Sec. 5-5. Medical services. The Illinois Department, by rule, shall
determine the quantity and quality of and the rate of reimbursement for the
medical assistance for which
payment will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient hospital
services; (2) outpatient hospital services; (3) other laboratory and
X-ray services; (4) skilled nursing home services; (5) physicians'
services whether furnished in the office, the patient's home, a
hospital, a skilled nursing home, or elsewhere; (6) medical care, or any
other type of remedial care furnished by licensed practitioners; (7)
home health care services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant individuals, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related
services; (12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in the diseases of the eye,
or by an optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary; (15) medical
treatment of sexual assault survivors, as defined in
Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for
injuries sustained as a result of the sexual assault, including
examinations and laboratory tests to discover evidence which may be used in
criminal proceedings arising from the sexual assault; (16) the
diagnosis and treatment of sickle cell anemia; (16.5) services performed by a chiropractic physician licensed under the Medical Practice Act of 1987 and acting within the scope of his or her license, including, but not limited to, chiropractic manipulative treatment; and (17)
any other medical care, and any other type of remedial care recognized
under the laws of this State. The term "any other type of remedial care" shall
include nursing care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a comprehensive
tobacco use cessation program that includes purchasing prescription drugs or
prescription medical devices approved by the Food and Drug Administration shall
be covered under the medical assistance
program under this Article for persons who are otherwise eligible for
assistance under this Article.
Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Section, all tobacco cessation medications approved by the United States Food and Drug Administration and all individual and group tobacco cessation counseling services and telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline shall be covered under the medical assistance program for persons who are otherwise eligible for assistance under this Article. The Department shall comply with all federal requirements necessary to obtain federal financial participation, as specified in 42 CFR 433.15(b)(7), for telephone-based counseling services provided through the Illinois Tobacco Quitline, including, but not limited to: (i) entering into a memorandum of understanding or interagency agreement with the Department of Public Health, as administrator of the Illinois Tobacco Quitline; and (ii) developing a cost allocation plan for Medicaid-allowable Illinois Tobacco Quitline services in accordance with 45 CFR 95.507. The Department shall submit the memorandum of understanding or interagency agreement, the cost allocation plan, and all other necessary documentation to the Centers for Medicare and Medicaid Services for review and approval. Coverage under this paragraph shall be contingent upon federal approval.
Notwithstanding any other provision of this Code, the Illinois
Department may not require, as a condition of payment for any laboratory
test authorized under this Article, that a physician's handwritten signature
appear on the laboratory test order form. The Illinois Department may,
however, impose other appropriate requirements regarding laboratory test
order documentation.
Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to
persons
eligible for assistance under this Article who are participating in
education, training or employment programs operated by the Department of Human
Services as successor to the Department of Public Aid:
On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession.
On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program.
Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare and Family Services shall administer and regulate a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. The Department shall establish, by rule, guidelines for participation by providers and set requirements for follow-up referral care based on the requirements established in the Dental Office Reference Manual published by the Department that establishes the requirements for dentists participating in the All Kids Dental School Program. Every effort shall be made by the Department when developing the program requirements to consider the different geographic differences of both urban and rural areas of the State for initial treatment and necessary follow-up care. No provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Nothing in this paragraph shall be construed to limit or preempt a home rule unit's or school district's authority to establish, change, or administer a school-based dental program in addition to, or independent of, the school-based dental program administered by the Department.
The Illinois Department, by rule, may distinguish and classify the
medical services to be provided only in accordance with the classes of
persons designated in Section 5-2.
The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
The Illinois Department shall authorize the provision of, and shall
authorize payment for, screening by low-dose mammography for the presence of
occult breast cancer for individuals 35 years of age or older who are eligible
for medical assistance under this Article, as follows:
The Department shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this paragraph; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223).
All screenings
shall
include a physical breast exam, instruction on self-examination and
information regarding the frequency of self-examination and its value as a
preventative tool.
For purposes of this Section:
"Diagnostic
mammogram" means a mammogram obtained using diagnostic mammography.
"Diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.
"Low-dose mammography" means
the x-ray examination of the breast using equipment dedicated specifically
for mammography, including the x-ray tube, filter, compression device,
and image receptor, with an average radiation exposure delivery
of less than one rad per breast for 2 views of an average size breast.
The term also includes digital mammography and includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph.
On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology.
On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography.
The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography.
On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program.
The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment.
Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph.
The Department shall establish a methodology to remind individuals who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation.
The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit.
On or after July 1, 2022, individuals who are otherwise eligible for medical assistance under this Article shall receive coverage for perinatal depression screenings for the 12-month period beginning on the last day of their pregnancy. Medical assistance coverage under this paragraph shall be conditioned on the use of a screening instrument approved by the Department.
Any medical or health care provider shall immediately recommend, to
any pregnant individual who is being provided prenatal services and is suspected
of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services
shall assure coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the Illinois Medicaid
Program in conjunction with the Department of Human Services.
All medical providers providing medical assistance to pregnant individuals
under this Code shall receive information from the Department on the
availability of services under any
program providing case management services for addicted individuals,
including information on appropriate referrals for other social services
that may be needed by addicted individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the Departments of Human
Services (as successor to the Department of Alcoholism and Substance
Abuse) and Public Health, through a public awareness campaign, may
provide information concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs directed at
reducing the number of drug-affected infants born to recipients of medical
assistance.
Neither the Department of Healthcare and Family Services nor the Department of Human
Services shall sanction the recipient solely on the basis of the recipient's
substance abuse.
The Illinois Department shall establish such regulations governing
the dispensing of health services under this Article as it shall deem
appropriate. The Department
should
seek the advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of providing regular
advice on policy and administrative matters, information dissemination and
educational activities for medical and health care providers, and
consistency in procedures to the Illinois Department.
The Illinois Department may develop and contract with Partnerships of
medical providers to arrange medical services for persons eligible under
Section 5-2 of this Code. Implementation of this Section may be by
demonstration projects in certain geographic areas. The Partnership shall
be represented by a sponsor organization. The Department, by rule, shall
develop qualifications for sponsors of Partnerships. Nothing in this
Section shall be construed to require that the sponsor organization be a
medical organization.
The sponsor must negotiate formal written contracts with medical
providers for physician services, inpatient and outpatient hospital care,
home health services, treatment for alcoholism and substance abuse, and
other services determined necessary by the Illinois Department by rule for
delivery by Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse medical services
delivered by Partnership providers to clients in target areas according to
provisions of this Article and the Illinois Health Finance Reform Act,
except that:
Medical providers shall be required to meet certain qualifications to
participate in Partnerships to ensure the delivery of high quality medical
services. These qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for participation in the
medical assistance program. Partnership sponsors may prescribe reasonable
additional qualifications for participation by medical providers, only with
the prior written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of practitioners,
hospitals, and other providers of medical services by clients.
In order to ensure patient freedom of choice, the Illinois Department shall
immediately promulgate all rules and take all other necessary actions so that
provided services may be accessed from therapeutically certified optometrists
to the full extent of the Illinois Optometric Practice Act of 1987 without
discriminating between service providers.
The Department shall apply for a waiver from the United States Health
Care Financing Administration to allow for the implementation of
Partnerships under this Section.
The Illinois Department shall require health care providers to maintain
records that document the medical care and services provided to recipients
of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall
require health care providers to make available, when authorized by the
patient, in writing, the medical records in a timely fashion to other
health care providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of medical services
shall be required to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope, details and
receipt of the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations promulgated by
the Illinois Department. The rules and regulations shall require that proof
of the receipt of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany each claim
for reimbursement submitted by the dispenser of such medical services.
No such claims for reimbursement shall be approved for payment by the Illinois
Department without such proof of receipt, unless the Illinois Department
shall have put into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed adequate by
the Illinois Department to assure that such drugs, dentures, prosthetic
devices and eyeglasses for which payment is being made are actually being
received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a
current list of acquisition costs for all prosthetic devices and any
other items recognized as medical equipment and supplies reimbursable under
this Article and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be updated no
less frequently than every 30 days as required by Section 5-5.12.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of medical
services, other than an individual practitioner or group of practitioners,
desiring to participate in the Medical Assistance program
established under this Article to disclose all financial, beneficial,
ownership, equity, surety or other interests in any and all firms,
corporations, partnerships, associations, business enterprises, joint
ventures, agencies, institutions or other legal entities providing any
form of health care services in this State under this Article.
The Illinois Department may require that all dispensers of medical
services desiring to participate in the medical assistance program
established under this Article disclose, under such terms and conditions as
the Illinois Department may by rule establish, all inquiries from clients
and attorneys regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens for the
Illinois Department.
Enrollment of a vendor
shall be
subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may
terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance
program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the
Department's hearing process.
However, a disenrolled vendor may reapply without penalty.
The Department has the discretion to limit the conditional enrollment period for vendors based upon 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:
For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
In the case of long term care facilities, within 120 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September
1, 2014, admission documents, including all prescreening
information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including, but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
The Illinois Department shall establish policies, procedures,
standards and criteria by rule for the acquisition, repair and replacement
of orthotic and prosthetic devices and durable medical equipment. Such
rules shall provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of
durable medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of the
recipient's needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and
use alternative or substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized for such
recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs.
The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement.
In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of the same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations.
The Department shall execute, relative to the nursing home prescreening
project, written inter-agency agreements with the Department of Human
Services and the Department on Aging, to effect the following: (i) intake
procedures and common eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and development of
non-institutional services in areas of the State where they are not currently
available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in cooperation
with other State Departments and agencies and in compliance with
applicable federal laws and regulations, appropriate and effective
systems of health care evaluation and programs for monitoring of
utilization of health care services and facilities, as it affects
persons eligible for medical assistance under this Code.
The Illinois Department shall report annually to the General Assembly,
no later than the second Friday in April of 1979 and each year
thereafter, in regard to:
The period covered by each report shall be the 3 years ending on the June
30 prior to the report. The report shall include suggested legislation
for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied
by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional
copies
with the State Government Report Distribution Center for the General
Assembly as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
Because kidney transplantation can be an appropriate, cost-effective
alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee for service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria,
(2) prior authorization mandate, or (3) lifetime restriction limit
mandate.
On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees or hospital fees related to the dispensing, distribution, and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration. The Department shall not impose a copayment on the coverage provided for naloxone hydrochloride under the medical assistance program.
Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection.
A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal
Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date of Public Act 102-665), the Department shall seek federal approval of a State Plan amendment to expand coverage for family planning services that includes presumptive eligibility to individuals whose income is at or below 208% of the federal poverty level. Coverage under this Section shall be effective beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare and Medicaid Services of a Title XIX State Plan amendment electing the Program of All-Inclusive Care for the Elderly (PACE) as a State Medicaid option, as provided for by Subtitle I (commencing with Section 4801) of Title IV of the Balanced Budget Act of 1997 (Public Law 105-33) and Part 460 (commencing with Section 460.2) of Subchapter E of Title 42 of the Code of Federal Regulations, PACE program services shall become a covered benefit of the medical assistance program, subject to criteria established in accordance with all applicable laws.
Notwithstanding any other provision of this Code, community-based pediatric palliative care from a trained interdisciplinary team shall be covered under the medical assistance program as provided in Section 15 of the Pediatric Palliative
Care Act.
(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20; 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-1038, eff. 1-1-23.)
(305 ILCS 5/5-5.01) (from Ch. 23, par. 5-5.01)
Sec. 5-5.01. The Department of Healthcare and Family Services may establish and implement
a pilot project for determining the feasibility of authorizing medical
assistance payments for the costs of diagnosis and treatment of Alzheimer's
disease.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program.
(a) The
Department shall establish and provide oversight for a program of supportive living facilities that seek to promote
resident independence, dignity, respect, and well-being in the most
cost-effective manner.
A supportive living facility is (i) a free-standing facility or (ii) a distinct
physical and operational entity within a mixed-use building that meets the criteria established in subsection (d). A supportive
living facility integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents their own
separate, private, and distinct living units.
Sites for the operation of the program
shall be selected by the Department based upon criteria
that may include the need for services in a geographic area, the
availability of funding, and the site's ability to meet the standards.
(b) Beginning July 1, 2014, subject to federal approval, the Medicaid rates for supportive living facilities shall be equal to the supportive living facility Medicaid rate effective on June 30, 2014 increased by 8.85%.
Once the assessment imposed at Article V-G of this Code is determined to be a permissible tax under Title XIX of the Social Security Act, the Department shall increase the Medicaid rates for supportive living facilities effective on July 1, 2014 by 9.09%. The Department shall apply this increase retroactively to coincide with the imposition of the assessment in Article V-G of this Code in accordance with the approval for federal financial participation by the Centers for Medicare and Medicaid Services.
The Medicaid rates for supportive living facilities effective on July 1, 2017 must be equal to the rates in effect for supportive living facilities on June 30, 2017 increased by 2.8%.
The Medicaid rates for supportive living facilities effective on July 1, 2018 must be equal to the rates in effect for supportive living facilities on June 30, 2018.
Subject to federal approval, the Medicaid rates for supportive living services on and after July 1, 2019 must be at least 54.3% of the average total nursing facility services per diem for the geographic areas defined by the Department while maintaining the rate differential for dementia care and must be updated whenever the total nursing facility service per diems are updated. Beginning July 1, 2022, upon the implementation of the Patient Driven Payment Model, Medicaid rates for supportive living services must be at least 54.3% of the average total nursing services per diem rate for the geographic areas. For purposes of this provision, the average total nursing services per diem rate shall include all add-ons for nursing facilities for the geographic area provided for in Section 5-5.2. The rate differential for dementia care must be maintained in these rates and the rates shall be updated whenever nursing facility per diem rates are updated.
(c) The Department may adopt rules to implement this Section. Rules that
establish or modify the services, standards, and conditions for participation
in the program shall be adopted by the Department in consultation
with the Department on Aging, the Department of Rehabilitation Services, and
the Department of Mental Health and Developmental Disabilities (or their
successor agencies).
(d) Subject to federal approval by the Centers for Medicare and Medicaid Services, the Department shall accept for consideration of certification under the program any application for a site or building where distinct parts of the site or building are designated for purposes other than the provision of supportive living services, but only if:
(e) Facilities or distinct parts of facilities which are selected as supportive
living facilities and are in good standing with the Department's rules are
exempt from the provisions of the Nursing Home Care Act and the Illinois Health
Facilities Planning Act.
(f) Section 9817 of the American Rescue Plan Act of 2021 (Public Law 117-2) authorizes a 10% enhanced federal medical assistance percentage for supportive living services for a 12-month period from April 1, 2021 through March 31, 2022. Subject to federal approval, including the approval of any necessary waiver amendments or other federally required documents or assurances, for a 12-month period the Department must pay a supplemental $26 per diem rate to all supportive living facilities with the additional federal financial participation funds that result from the enhanced federal medical assistance percentage from April 1, 2021 through March 31, 2022. The Department may issue parameters around how the supplemental payment should be spent, including quality improvement activities. The Department may alter the form, methods, or timeframes concerning the supplemental per diem rate to comply with any subsequent changes to federal law, changes made by guidance issued by the federal Centers for Medicare and Medicaid Services, or other changes necessary to receive the enhanced federal medical assistance percentage.
(Source: P.A. 101-10, eff. 6-5-19; 102-43, eff. 7-6-21; 102-699, eff. 4-19-22.)
(305 ILCS 5/5-5.01b)
Sec. 5-5.01b. Certified Nursing Assistant Intern Program.
(a) The Department shall establish or approve a Certified Nursing Assistant Intern Program to address the increasing need for trained health care workers for the supporting living facilities program established under Section 5-5.01a. Upon successful completion of the classroom education and on-the-job training requirements of the Program under this Section, an individual may provide, at a facility certified under this Act, the patient and resident care services determined under the Program and may perform the procedures listed under subsection (d).
(b) In order to qualify as a certified nursing assistant intern, an individual shall successfully complete at least 8 hours of classroom education on the services and procedures listed under subsection (d). The classroom education shall be:
(c) In order to qualify as a certified nursing assistant intern, an individual shall successfully complete at least 24 hours of on-the-job training in the services and procedures determined under the Program and listed under subsection (d), as follows:
(d) A certified nursing assistant intern shall receive classroom and on-the-job training on how to provide the patient or resident care services and procedures, as determined under the Program, that are required of a certified nursing assistant's performance skills, including, but not limited to, all of the following:
(e) A certified nursing assistant intern may not perform any of the following on a resident:
(f) A certified nursing assistant intern may only provide the patient or resident care services and perform the procedures that he or she is deemed qualified to perform that are listed under subsection (d). A certified nursing assistant intern may not provide the procedures excluded under subsection (e).
(g) A certified nursing assistant intern shall report to a facility's charge nurse or nursing supervisor and may only be assigned duties authorized in this Section by a supervising nurse.
(h) A facility shall notify its certified and licensed staff members, in writing, that a certified nursing assistant intern may only provide the services and perform the procedures listed under subsection (d). The notification shall detail which duties may be delegated to a certified nursing assistant intern.
(i) If a facility learns that a certified nursing assistant intern is performing work outside of the scope of the Program's training, the facility shall:
(j) The Program is subject to the Health Care Worker Background Check Act and the Health Care Worker Background Check Code under 77 Ill. Adm. Code 955. Program participants and personnel shall be included on the Health Care Worker Registry.
(k) A Program participant who has completed the training required under paragraph (5) of subsection (a) of Section 3-206 of the Nursing Home Care Act, has completed the Program from April 21, 2020 through September 18, 2020, and has shown competency in all of the performance skills listed under subsection (d) shall be considered a certified nursing assistant intern.
(l) The requirement under subsection (b) of Section 395.400 of Title 77 of the Illinois Administrative Code that a student must pass a BNATP written competency examination within 12 months after the completion of the BNATP does not apply to a certified nursing assistant intern under this Section. However, upon a Program participant's enrollment in a certified nursing assistant course, the requirement under subsection (b) of Section 395.400 of Title 77 of the Illinois Administrative Code that a student pass a BNATP written competency examination within 12 months after completion of the BNATP program applies.
(m) A certified nursing assistant intern shall enroll in a certified nursing assistant program within 6 months after completing his or her certified nursing assistant intern training under the Program. The individual may continue to work as a certified nursing assistant intern during his or her certified nursing assistant training. If the scope of work for a nurse assistant in training pursuant to 77 Ill. Adm. Code 300.660 is broader in scope than the work permitted to be performed by a certified nursing assistant intern, then the certified nursing assistant intern enrolled in certified nursing assistant training may perform the work allowed under 77. Ill. Adm. Code 300.660. The individual shall receive one hour of credit for every hour employed as a certified nursing assistant intern or as a temporary nurse assistant, not to exceed 30 hours of credit, subject to the approval of an accredited certified nursing assistant training program.
(n) A facility that seeks to train and employ a certified nursing assistant intern at the facility must:
(o) A facility that does not meet the requirements of subsection (n) shall cease its new employment training, education, or onboarding of any employee under the Program. The facility may resume its new employment training, education, or onboarding of an employee under the Program once the Department determines that the facility is in compliance with subsection (n).
(p) To study the effectiveness of the Program, the Department shall collect data from participating facilities and publish a report on the extent to which the Program brought individuals into continuing employment as certified nursing assistants in long-term care. Data collected from facilities shall include, but shall not be limited to, the number of certified nursing assistants employed, the number of persons who began participation in the Program, the number of persons who successfully completed the Program, and the number of persons who continue employment in a long-term care service or facility. The report shall be published no later than 6 months after the Program end date determined under subsection (r). A facility participating in the Program shall, twice annually, submit data under this subsection in a manner and time determined by the Department. Failure to submit data under this subsection shall result in suspension of the facility's Program.
(q) The Department may adopt emergency rules in accordance with Section 5-45.22 of the Illinois Administrative Procedure Act.
(r) The Program shall end upon the termination of the Secretary of Health and Human Services' public health emergency declaration for COVID-19 or 3 years after the date that the Program becomes operational, whichever occurs later.
(s) This Section is inoperative 18 months after the Program end date determined under subsection (r).
(Source: P.A. 102-1037, eff. 6-2-22.)
(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:
(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:
(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:
(d) Supplemental adjustment payments. In addition to the adjustment
payments described in paragraph (c), hospitals as defined in clauses
(1) through (6) of paragraph (b), excluding county hospitals (as defined in
subsection (c) of Section 15-1 of this Code) and a hospital organized under the
University of Illinois Hospital Act, shall be paid supplemental inpatient
adjustment payments of $60 per day. For purposes of Title XIX of the federal
Social Security Act, these supplemental adjustment payments shall not be
classified as adjustment payments to disproportionate share hospitals.
(e) The inpatient adjustment payments described in paragraphs (c) and (d)
shall be increased on October 1, 1993 and annually thereafter by a percentage
equal to the lesser of (i) the increase in the DRI hospital cost index for the
most recent 12 month period for which data are available, or (ii) the
percentage increase in the statewide average hospital payment rate over the
previous year's statewide average hospital payment rate. The sum of the
inpatient adjustment payments under paragraphs (c) and (d) to a hospital, other
than a county hospital (as defined in subsection (c) of Section 15-1 of this
Code) or a hospital organized under the University of Illinois Hospital Act,
however, shall not exceed $275 per day; that limit shall be increased on
October 1, 1993 and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most recent 12-month
period for which data are available or (ii) the percentage increase in the
statewide average hospital payment rate over the previous year's statewide
average hospital payment rate.
(f) Children's hospital inpatient adjustment payments. For children's
hospitals, as defined in clause (5) of paragraph (b), the adjustment payments
required pursuant to paragraphs (c) and (d) shall be multiplied by 2.0.
(g) County hospital inpatient adjustment payments. For county hospitals,
as defined in subsection (c) of Section 15-1 of this Code, there shall be an
adjustment payment as determined by rules issued by the Illinois Department.
(h) For the purposes of this Section the following terms shall be defined
as follows:
(i) Inpatient adjustment payment limit. In order to meet the limits
of Public Law 102-234 and Public Law 103-66, the
Illinois Department shall by rule adjust
disproportionate share adjustment payments.
(j) University of Illinois Hospital inpatient adjustment payments. For
hospitals organized under the University of Illinois Hospital Act, there shall
be an adjustment payment as determined by rules adopted by the Illinois
Department.
(k) The Illinois Department may by rule establish criteria for and develop
methodologies for adjustment payments to hospitals participating under this
Article.
(l) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(m) The Department shall establish a cost-based reimbursement methodology for determining payments to hospitals for approved graduate medical education (GME) programs for dates of service on and after July 1, 2018.
(305 ILCS 5/5-5.03)
Sec. 5-5.03.
Trauma center adjustment.
(a) For inpatient admissions on or after October 1, 1992 for trauma
injuries as defined in the Emergency Medical Services (EMS) Systems Act, in
addition to any other payments made under this Code, the Illinois Department
shall make adjustment payments, in an amount calculated under subsection (b) of
this Section, to hospitals located in the State of Illinois that are recognized
as Level I trauma centers (adult or pediatric) and to certain Level II trauma
centers as determined by the Illinois Department.
(b) Trauma center adjustment calculation.
(c) Definitions. As used in this Section, unless the context requires
otherwise:
"Trauma center adjustment year" means, beginning October 1, 1992, the 12
month period beginning on October 1 of the year and ending September 30 of
the following year.
"Trauma center base year" means State Fiscal Year 1991 for trauma center
adjustment payments calculated for the October 1, 1992 trauma center
adjustment year, State Fiscal Year 1992 for trauma center adjustment payments
calculated for the October 1, 1993 trauma center adjustment year, and so on
for each succeeding State Fiscal Year for trauma center adjustment payments
calculated for the trauma center adjustment year beginning October 1 of
that State Fiscal Year.
(Source: P.A. 87-1229.)
(305 ILCS 5/5-5.04)
Sec. 5-5.04. Persons living with HIV/AIDS. The Department of Public Aid may seek federal approval to expand access to health care for persons living with HIV/AIDS. Implementation of this Section is subject to appropriation.
(Source: P.A. 94-629, eff. 1-1-06.)
(305 ILCS 5/5-5.4k)
Sec. 5-5.4k. Payments for long-acting injectable medications for mental health or substance use disorders. Notwithstanding any other provision of this Code, effective for dates of service on and after January 1, 2022, the medical assistance program shall separately reimburse at the prevailing fee schedule, for long-acting injectable medications administered for mental health or substance use disorder in the hospital inpatient setting, and which are compliant with the prior authorization requirements of this Section. The Department, in consultation with a statewide association representing a majority of hospitals and Managed Care Organizations shall implement, by rule, reimbursement policy and prior authorization criteria for the use of long-acting injectable medications administered in the hospital inpatient setting for the treatment of mental health disorders.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-5.05)
Sec. 5-5.05. Hospitals; psychiatric services.
(a) On and after 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:
For purposes of this Section, "inpatient psychiatric services" means those services provided to patients who are in need of short-term acute inpatient hospitalization for active treatment of an emotional or mental disorder.
(b-5) Notwithstanding any other provision of this Section, and subject to appropriation, the inpatient, per diem rate to be paid to all safety-net hospitals for inpatient psychiatric services on and after January 1, 2021 shall be at least $630.
(b-10) Notwithstanding any other provision of this Section, effective with dates of service on and after January 1, 2022, any general acute care hospital with more than 9,500 inpatient psychiatric Medicaid days in any calendar year shall be paid the inpatient per diem rate of no less than $630.
(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. 102-4, eff. 4-27-21; 102-674, eff. 11-30-21.)
(305 ILCS 5/5-5.05a)
Sec. 5-5.05a. Reimbursement rates; community mental health centers. Notwithstanding the provisions of any other law,
reimbursement rates, including enhanced payment rates and rate
add-ons, for psychiatric and behavioral health services
provided in or by community mental health centers licensed or
certified by the Department of Human Services shall not be
lower than the rates for such services in effect on November 1,
2017. The Department of Healthcare and Family Services shall
apply for any waiver or State Plan amendment, if required, to
implement the reimbursement rates established in this Section.
Implementation of the reimbursement rates shall be contingent
on federal approval.
(Source: P.A. 100-587, eff. 6-4-18.)
(305 ILCS 5/5-5.05b)
Sec. 5-5.05b. Access to psychiatric treatment. Effective July 1, 2019, or as soon thereafter as practical and subject to federal approval, the Department shall allocate an amount of up to $40,000,000 to enhance access psychiatric treatment, including both reimbursement rates to individual physicians board certified in psychiatry as well as community mental health centers and other relevant providers.
(Source: P.A. 101-10, eff. 6-5-19.)
(305 ILCS 5/5-5.05c)
Sec. 5-5.05c. Access to physician services. The Department shall increase rates of reimbursement for physician services to as close to 60% of Medicare rates in effect as of January 1, 2020 utilizing the rates of Illinois Locality 99 facility rates.
(Source: P.A. 101-650, eff. 7-7-20.)
(305 ILCS 5/5-5.05d)
Sec. 5-5.05d. Academic detailing for behavioral health providers. The Department shall develop, in collaboration with associations representing behavioral health providers, a program designed to provide behavioral health providers and providers in academic medical settings who need assistance in caring for patients with severe mental illness or a developmental disability under the medical assistance program with academic detailing and clinical consultation over the phone from a qualified provider on how to best care for the patient. The Department shall include the phone number on its website and notify providers that the service is available. The Department may create an in-person option if adequate staff is available. To the extent practicable, the Department shall build upon this service to address worker shortages and the availability of specialty services.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.05e)
Sec. 5-5.05e. Tracking availability of beds for withdrawal management services. The Department of Human Services shall track, or contract with an organization to track, the availability of beds for withdrawal management services that are licensed by the Department and are available to medical assistance beneficiaries. The Department of Human Services shall update the tracking daily and publish the availability of beds online or in another public format.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.05f)
Sec. 5-5.05f. Medicaid coverage for peer recovery support services. On or before January 1, 2023, the Department shall seek approval from the federal Centers for Medicare and Medicaid Services to cover peer recovery support services under the medical assistance program when rendered by certified peer support specialists for the purposes of supporting the recovery of individuals receiving substance use disorder treatment. As used in this Section, "certified peer support specialist" means an individual who:
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.05g)
Sec. 5-5.05g. Alignment of substance use prevention and recovery and mental health policy. The Department and the Department of Human Services shall collaborate to review coverage and billing requirements for substance use prevention and recovery and mental health services with the goal of identifying disparities and streamlining coverage and billing requirements to reduce the administrative burden for providers and medical assistance beneficiaries.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.06)
Sec. 5-5.06. Dental home initiative. The Department, in cooperation with the dental community and other affected organizations such as Head Start, shall work to develop and promote the concept of a dental home for children covered under this Article. Included in this dental home outreach should be an effort to ensure an ongoing relationship between the patient and the dentist with an effort to provide comprehensive, coordinated, oral health care so that all children covered under this Article have access to preventative and restorative oral health care.
(Source: P.A. 97-283, eff. 8-9-11.)
(305 ILCS 5/5-5.06a)
Sec. 5-5.06a. Increased funding for dental services. Beginning January 1, 2022, the amount allocated to fund rates for dental services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $10,000,000.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-5.06b)
Sec. 5-5.06b. Dental services. On and after July 1, 2021, dental services provided to adults and children under the medical assistance program may be established and paid at no less than the rates published by the Department and effective January 1, 2020 for all local health departments as the fee schedule for children and adult recipients but shall include the following dental procedures and amounts: D0140 $19.12, D0150 $24.84, D0220 $6.61, D0230 $4.48, D0272 $11.09, D0274 $19.94, D1110 $48.38, D2140 $36.40, D2150 $56.82, D2391 $36.40, D2392 $56.82, D5110 $444.09, D5120 $444.09, D7140 $46.16, D7210 $67.73.
(Source: P.A. 102-16, eff. 6-17-21.)
(305 ILCS 5/5-5.06c)
Sec. 5-5.06c. Access to prenatal and postpartum care. To ensure access to high quality prenatal and postpartum care and to promote continuity of care for pregnant individuals, the Department shall increase the rate for prenatal and postpartum visits to no less than the rate for an adult well visit, including any applicable add-ons, beginning on January 1, 2023. Bundled rates that include prenatal or postpartum visits shall incorporate this increased rate, beginning on January 1, 2023.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.06d)
Sec. 5-5.06d. External cephalic version rate. To encourage provider use of external cephalic versions and decrease the rates of caesarean sections in Illinois, the Department shall evaluate the rate for external cephalic versions and increase the rate by an amount determined by the Department to promote safer birthing options for pregnant individuals, beginning on January 1, 2023.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.06e)
Sec. 5-5.06e. Increased funding for dental services. Beginning January 1, 2023, the amount allocated to fund rates for dental services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $10,000,000.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.07)
Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem rate. The Department of Children and Family Services shall pay the DCFS per diem rate for inpatient psychiatric stay at a free-standing psychiatric hospital or a hospital with a pediatric or adolescent inpatient psychiatric unit effective the 11th day when a child is in the hospital beyond medical necessity, and the parent or caregiver has denied the child access to the home and has refused or failed to make provisions for another living arrangement for the child or the child's discharge is being delayed due to a pending inquiry or investigation by the Department of Children and Family Services. If any portion of a hospital stay is reimbursed under this Section, the hospital stay shall not be eligible for payment under the provisions of Section 14-13 of this Code.
(Source: Reenacted by P.A. 101-15, eff. 6-14-19; reenacted by P.A. 101-209, eff. 8-5-19; P.A. 101-655, eff. 3-12-21; 102-201, eff. 7-30-21; 102-558, eff. 8-20-21; 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.7b)
Sec. 5-5.7b. Pandemic related stability payments to ambulance service providers in response to COVID-19.
(a) Definitions. As used in this Section:
"Ambulance Services Industry" means the industry that is comprised of "Qualifying Ground Ambulance Service Providers", as defined in this Section.
"Qualifying Ground Ambulance Service Provider" means a "vehicle service provider," as that term is defined in Section 3.85 of the Emergency Medical Services (EMS) Systems Act, which operates licensed ambulances for the purpose of providing emergency, non-emergency ambulance services, or both emergency and non-emergency ambulance services. The term "Qualifying Ground Ambulance Service Provider" is limited to ambulance and EMS agencies that are privately held and nonprofit organizations headquartered within the State and licensed by the Department of Public Health as of March 12, 2020.
"Eligible worker" means a staff member of a Qualifying Ground Ambulance Service Provider engaged in "essential work", as defined by Section 9901 of the ARPA and related federal guidance, and (1) whose total pay is below 150% of the average annual wage for all occupations in the worker's county of residence, as defined by the BLS Occupational Employment and Wage Statistics or (2) is not exempt from the federal Fair Labor Standards Act overtime provisions.
(b) Purpose. The Department may receive federal funds under the authority of legislation passed in response to the Coronavirus epidemic, including, but not limited to, the American Rescue Plan Act of 2021, P.L. 117-2 (the "ARPA"). Upon receipt or availability of such State or federal funds, and subject to appropriations for their use, the Department shall establish and administer programs for purposes allowable under Section 9901 of the ARPA to provide financial assistance to Qualifying Ground Ambulance Service Providers for premium pay for eligible workers, to provide reimbursement for eligible expenditures, and to provide support following the negative economic impact of the COVID-19 public health emergency on the Ambulance Services Industry. Financial assistance may include, but is not limited to, grants, expense reimbursements, or subsidies.
(b-1) By December 31, 2022, the Department shall obtain appropriate documentation from Qualifying Ground Ambulance Service Providers to ascertain an accurate count of the number of licensed vehicles available to serve enrollees in the State's medical assistance programs, which shall be known as the "total eligible vehicles". By February 28, 2023, Qualifying Ground Ambulance Service Providers shall be initially notified of their eligible award, which shall be the product of (i) the total amount of funds allocated under this Section and (ii) a quotient, the numerator of which is the number of licensed ground ambulance vehicles of an individual Qualifying Ground Ambulance Service Provider and the denominator of which is the total eligible vehicles. After March 31, 2024, any unobligated funds shall be reallocated pro rata to the remaining Qualifying Ground Ambulance Service Providers that are able to prove up eligible expenses in excess of their initial award amount until all such appropriated funds are exhausted.
Providers shall indicate to the Department what portion of their award they wish to allocate under the purposes outlined under paragraphs (d), (e), or (f), if applicable, of this Section.
(c) Non-Emergency Service Certification. To be eligible for funding under this Section, a Qualifying Ground Ambulance Service Provider that provides non-emergency services to institutional residents must certify whether or not it is able to provide non-emergency ambulance services to individuals enrolled in the State's Medical Assistance Program and residing in non-institutional settings for at least one year following the receipt of funding pursuant to this amendatory Act of the 102nd General Assembly. Certification indicating that a provider has such an ability does not mean that a provider is required to accept any or all requested transports.
(d) Premium Pay Initiative. Subject to paragraph (c) of this Section, the Department shall establish a Premium Pay Initiative to distribute awards to each Qualifying Ground Ambulance Service Provider for the purpose of providing premium pay to eligible workers.
(e) COVID-19 Response Support Initiative. Subject to paragraph (c) of this Section and based on an application filed by a Qualifying Ground Ambulance Service Provider, the Department shall establish the Ground Ambulance COVID-19 Response Support Initiative. The purpose of the award shall be to reimburse Qualifying Ground Ambulance Service Providers for eligible expenses under Section 9901 of the ARPA related to the public health impacts of the COVID-19 public health emergency, including, but not limited to: (i) costs incurred due to the COVID-19 public health emergency; (ii) costs related to vaccination programs, including vaccine incentives; (iii) costs related to COVID-19 testing; (iv) costs related to COVID-19 prevention and treatment equipment; (v) expenses for medical supplies; (vi) expenses for personal protective equipment; (vii) costs related to isolation and quarantine; (viii) costs for ventilation system installation and improvement; (ix) costs related to other emergency response equipment, such as ground ambulances, ventilators, cardiac monitoring equipment, defibrillation equipment, pacing equipment, ambulance stretchers, and radio equipment; and (x) other emergency medical response expenses.
(f) Ambulance Industry Recovery Program. If the Department designates the Ambulance Services Industry as an "impacted industry", as defined by the ARPA and related federal guidance, the Department shall establish the Ambulance Industry Recovery Grant Program, to provide aid to Qualifying Ground Ambulance Service Providers that experienced staffing losses due to the COVID-19 public health emergency.
(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23.)
(305 ILCS 5/5-5.08)
Sec. 5-5.08. Dialysis center funding. Notwithstanding any other provision of law, the add-on Medicaid payments to hospitals and freestanding chronic dialysis centers established under 89 Illinois Administrative Code 148.140(g)(4) for dates of service July 1, 2013 through June 30, 2015 is restored and in effect for dates of service on and after July 1, 2015 with no end date for such payments.
(Source: P.A. 100-23, eff. 7-6-17.)
(305 ILCS 5/5-5.1) (from Ch. 23, par. 5-5.1)
Sec. 5-5.1. Grouping of facilities. The Department of Healthcare and Family Services shall, for purposes of payment, provide for
groupings of nursing facilities. Factors to be considered
in grouping facilities may include, but are not limited to,
size, age, patient mix, percentage of Medicaid funded residents, or geographical area.
The groupings developed under this Section shall be
considered in determining reasonable cost reimbursement
formulas. However, this Section shall not preclude the
Department from recognizing and evaluating the cost of
capital on a facility-by-facility basis.
A resident of a nursing facility whose application for long term care benefits is awaiting final action shall be included in the calculation as a Medicaid funded resident.
(Source: P.A. 99-684, eff. 1-1-17.)
(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) (Blank).
(c-1) Notwithstanding any other provisions of this Code, the methodologies for reimbursement of nursing services as provided under this Article shall no longer be applicable for bills payable for nursing services rendered on or after a new reimbursement system based on the Patient Driven Payment Model (PDPM) has been fully operationalized, which shall take effect for services provided on or after the implementation of the PDPM reimbursement system begins. For the purposes of this amendatory Act of the 102nd General Assembly, the implementation date of the PDPM reimbursement system and all related provisions shall be July 1, 2022 if the following conditions are met: (i) the Centers for Medicare and Medicaid Services has approved corresponding changes in the reimbursement system and bed assessment; and (ii) the Department has filed rules to implement these changes no later than June 1, 2022. Failure of the Department to file rules to implement the changes provided in this amendatory Act of the 102nd General Assembly no later than June 1, 2022 shall result in the implementation date being delayed to October 1, 2022.
(d) The new nursing services reimbursement methodology utilizing the Patient Driven Payment Model, which shall be referred to as the PDPM reimbursement system, taking effect July 1, 2022, upon federal approval by the Centers for Medicare and Medicaid Services, shall be based on the following:
(d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate.
(e) Beginning July 1, 2014, the Department shall allocate funding in the amount up to $10,000,000 for per diem add-ons to the RUGS methodology for dates of service on and after July 1, 2014:
(e-1) (Blank).
(e-2) For dates of services beginning January 1, 2014 and ending September 30, 2023, the RUG-IV nursing component per diem for a nursing home shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index, and the regional wage adjustor. For dates of service beginning July 1, 2022 and ending September 30, 2023, the Medicaid access adjustment described in subsection (e-3) shall be added to the product.
(e-3) A Medicaid Access Adjustment of $4 adjusted for the facility average PDPM case mix index calculated quarterly shall be added to the statewide PDPM nursing per diem for all facilities with annual Medicaid bed days of at least 70% of all occupied bed days adjusted quarterly. For each new calendar year and for the 6-month period beginning July 1, 2022, the percentage of a facility's occupied bed days comprised of Medicaid bed days shall be determined by the Department quarterly. For dates of service beginning January 1, 2023, the Medicaid Access Adjustment shall be increased to $4.75. This subsection shall be inoperative on and after January 1, 2028.
(f) (Blank).
(g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows:
(h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall have the nursing, socio-developmental, capital, and support components of their reimbursement rate effective May 1, 2011 reduced in total by 2.7%.
(i) On and after July 1, 2014, the reimbursement rates for the support component of the nursing facility rate for facilities licensed under the Nursing Home Care Act as skilled or intermediate care facilities shall be the rate in effect on June 30, 2014 increased by 8.17%.
(j) Notwithstanding any other provision of law, subject to federal approval, effective July 1, 2019, sufficient funds shall be allocated for changes to rates for facilities licensed under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities for dates of services on and after July 1, 2019: (i) to establish, through June 30, 2022 a per diem add-on to the direct care per diem rate not to exceed $70,000,000 annually in the aggregate taking into account federal matching funds for the purpose of addressing the facility's unique staffing needs, adjusted quarterly and distributed by a weighted formula based on Medicaid bed days on the last day of the second quarter preceding the quarter for which the rate is being adjusted. Beginning July 1, 2022, the annual $70,000,000 described in the preceding sentence shall be dedicated to the variable per diem add-on for staffing under paragraph (6) of subsection (d); and (ii) in an amount not to exceed $170,000,000 annually in the aggregate taking into account federal matching funds to permit the support component of the nursing facility rate to be updated as follows:
(k) During the first quarter of State Fiscal Year 2020, the Department of Healthcare of Family Services must convene a technical advisory group consisting of members of all trade associations representing Illinois skilled nursing providers to discuss changes necessary with federal implementation of Medicare's Patient-Driven Payment Model. Implementation of Medicare's Patient-Driven Payment Model shall, by September 1, 2020, end the collection of the MDS data that is necessary to maintain the current RUG-IV Medicaid payment methodology. The technical advisory group must consider a revised reimbursement methodology that takes into account transparency, accountability, actual staffing as reported under the federally required Payroll Based Journal system, changes to the minimum wage, adequacy in coverage of the cost of care, and a quality component that rewards quality improvements.
(l) The Department shall establish per diem add-on payments to improve the quality of care delivered by facilities, including:
(m) The Department shall work with nursing facility industry representatives to design policies and procedures to permit facilities to address the integrity of data from federal reporting sites used by the Department in setting facility rates.
(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19; 102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23.)
(305 ILCS 5/5-5.3) (from Ch. 23, par. 5-5.3)
Sec. 5-5.3. Conditions of Payment - Prospective Rates -
Accounting Principles. This amendatory Act establishes certain
conditions for the Department of Healthcare and Family Services in instituting
rates for the care of recipients of medical assistance in
nursing facilities and ICF/DDs.
Such conditions shall assure a method under which the payment
for nursing facility and ICF/DD services provided
to recipients under the Medical Assistance Program shall be
on a reasonable cost related basis, which is prospectively
determined at least annually by the Department of Public Aid (now Healthcare and Family Services).
The annually established payment rate shall take effect on July 1 in 1984
and subsequent years. There shall be no rate increase during calendar year
1983 and the first six months of calendar year 1984.
The determination of the payment shall be made on the
basis of generally accepted accounting principles that
shall take into account the actual costs to the facility
of providing nursing facility and ICF/DD services
to recipients under the medical assistance program.
The resultant total rate for a specified type of service
shall be an amount which shall have been determined to be
adequate to reimburse allowable costs of a facility that
is economically and efficiently operated. The Department
shall establish an effective date for each facility or group
of facilities after which rates shall be paid on a reasonable
cost related basis which shall be no sooner than the effective
date of this amendatory Act of 1977.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)
Sec. 5-5.4. Standards of Payment - Department of Healthcare and Family Services.
The Department of Healthcare and Family Services shall develop standards of payment of
nursing facility and ICF/DD services in facilities providing such services
under this Article which:
(1) Provide for the determination of a facility's payment
for nursing facility or ICF/DD services on a prospective basis.
The amount of the payment rate for all nursing facilities certified by the
Department of Public Health under the ID/DD Community Care Act or the Nursing Home Care Act as Intermediate
Care for the Developmentally Disabled facilities, Long Term Care for Under Age
22 facilities, Skilled Nursing facilities, or Intermediate Care facilities
under the
medical assistance program shall be prospectively established annually on the
basis of historical, financial, and statistical data reflecting actual costs
from prior years, which shall be applied to the current rate year and updated
for inflation, except that the capital cost element for newly constructed
facilities shall be based upon projected budgets. The annually established
payment rate shall take effect on July 1 in 1984 and subsequent years. No rate
increase and no
update for inflation shall be provided on or after July 1, 1994, unless specifically provided for in this
Section.
The changes made by Public Act 93-841
extending the duration of the prohibition against a rate increase or update for inflation are effective retroactive to July 1, 2004.
For facilities licensed by the Department of Public Health under the Nursing
Home Care Act as Intermediate Care for the Developmentally Disabled facilities
or Long Term Care for Under Age 22 facilities, the rates taking effect on July
1, 1998 shall include an increase of 3%. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as Skilled Nursing
facilities or Intermediate Care facilities, the rates taking effect on July 1,
1998 shall include an increase of 3% plus $1.10 per resident-day, as defined by
the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2006 shall include an increase of 3%.
For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2009 shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive staff. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities the rates taking effect within 30 days after July 6, 2017 (the effective date of Public Act 100-23) shall include an increase sufficient to provide a $0.75 per hour wage increase for non-executive staff. The Department shall adopt rules, including emergency rules under subsection (y) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, the rates taking effect within 30 days after the effective date of this amendatory Act of the 100th General Assembly shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff. The Department shall adopt rules, including emergency rules under subsection (bb) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on July 1, 1999 shall include an increase of 1.6% plus $3.00 per
resident-day, as defined by the Department. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as Skilled Nursing
facilities or Intermediate Care facilities, the rates taking effect on July 1,
1999 shall include an increase of 1.6% and, for services provided on or after
October 1, 1999, shall be increased by $4.00 per resident-day, as defined by
the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on July 1, 2000 shall include an increase of 2.5% per resident-day,
as defined by the Department. For facilities licensed by the Department of
Public Health under the Nursing Home Care Act as Skilled Nursing facilities or
Intermediate Care facilities, the rates taking effect on July 1, 2000 shall
include an increase of 2.5% per resident-day, as defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as skilled nursing facilities or intermediate care
facilities, a new payment methodology must be implemented for the nursing
component of the rate effective July 1, 2003. The Department of Public Aid
(now Healthcare and Family Services) shall develop the new payment methodology using the Minimum Data Set
(MDS) as the instrument to collect information concerning nursing home
resident condition necessary to compute the rate. The Department
shall develop the new payment methodology to meet the unique needs of
Illinois nursing home residents while remaining subject to the appropriations
provided by the General Assembly.
A transition period from the payment methodology in effect on June 30, 2003
to the payment methodology in effect on July 1, 2003 shall be provided for a
period not exceeding 3 years and 184 days after implementation of the new payment
methodology as follows:
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:
Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the support component of the rates taking effect on January 1, 2008 shall be computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on April 1, 2002 shall include a statewide increase of 2.0%, as
defined by the Department.
This increase terminates on July 1, 2002;
beginning July 1, 2002 these rates are reduced to the level of the rates
in effect on March 31, 2002, as defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as skilled nursing facilities or intermediate care
facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports
on file with the Department of Public Aid no later than April 1, 2000,
updated for inflation to January 1, 2001. For rates effective July 1, 2001
only, rates shall be the greater of the rate computed for July 1, 2001
or the rate effective on June 30, 2001.
Notwithstanding any other provision of this Section, for facilities
licensed by the Department of Public Health under the Nursing Home Care Act
as skilled nursing facilities or intermediate care facilities, the Illinois
Department shall determine by rule the rates taking effect on July 1, 2002,
which shall be 5.9% less than the rates in effect on June 30, 2002.
Notwithstanding any other provision of this Section, for facilities
licensed by the Department of Public Health under the Nursing Home Care Act as
skilled nursing
facilities or intermediate care facilities, if the payment methodologies required under Section 5A-12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take
effect only upon approval and
implementation of the payment methodologies required under Section 5A-12.
Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004.
Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2009, the per diem support component of the rates effective on January 1, 2008, computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006, shall be increased to the amount that would have been derived using standard Department of Healthcare and Family Services methods, procedures, and inflators.
Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as intermediate care facilities that are federally defined as Institutions for Mental Disease, or facilities licensed by the Department of Public Health under the Specialized Mental Health Rehabilitation Act of 2013, a socio-development component rate equal to 6.6% of the facility's nursing component rate as of January 1, 2006 shall be established and paid effective July 1, 2006. The socio-development component of the rate shall be increased by a factor of 2.53 on the first day of the month that begins at least 45 days after January 11, 2008 (the effective date of Public Act 95-707). As of August 1, 2008, the socio-development component rate shall be equal to 6.6% of the facility's nursing component rate as of January 1, 2006, multiplied by a factor of 3.53. For services provided on or after April 1, 2011, or the first day of the month that begins at least 45 days after 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 $4,000,000 of the funds
collected from the assessment established by Section 5B-2 of this Code for such payments. For
the purpose of this Section, "exceptional needs" means, but need not be limited to, ventilator care and traumatic brain injury care. The enhanced payments for exceptional need residents under this paragraph are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.
Beginning January 1, 2014 the methodologies for reimbursement of nursing facility services as provided under this Section 5-5.4 shall no longer be applicable for services provided on or after January 1, 2014.
No payment increase under this Section for the MDS methodology, exceptional care residents, or the socio-development component rate established by Public Act 96-1530 of the 96th General Assembly and funded by the assessment imposed under Section 5B-2 of this Code shall be due and payable until after the Department notifies the long-term care providers, in writing, that the payment methodologies to long-term care providers required under this Section have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and the waivers under 42 CFR 433.68 for the assessment imposed by this Section, if necessary, have been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. Upon notification to the Department of approval of the payment methodologies required under this Section and the waivers granted under 42 CFR 433.68, all increased payments otherwise due under this Section prior to the date of notification shall be due and payable within 90 days of the date federal approval is received.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect for services delivered on or after August 1, 2019 shall be increased by 3.5% over the rates in effect on June 30, 2019. The Department shall adopt rules, including emergency rules under subsection (ii) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect on the latter of the approval date of the State Plan Amendment for these facilities or the Waiver Amendment for the home and community-based services settings shall include an increase sufficient to provide a $0.26 per hour wage increase to the base wage for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of
this Section, including wage increases for direct care staff.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, the rates taking effect for the services delivered on or after July 1, 2020 shall include an increase sufficient to provide a $1.00 per hour wage increase for non-executive staff. For services delivered on or after January 1, 2021, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, shall include an increase sufficient to provide a $0.50 per hour increase for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after July 1, 2021, shall include an increase sufficient to provide a $0.50 per hour increase for aides in the rate methodology. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after January 1, 2022 shall include an increase sufficient to provide a $1.00 per hour increase for aides in the rate methodology. In addition, for residential services delivered on or after January 1, 2022 such rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD facilities and under the MC/DD Act as MC/DD facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for services delivered on or after January 1, 2023, shall include a $1.00 per hour wage increase for all direct support personnel and all other frontline personnel who are not subject to the Bureau of Labor Statistics' average wage increases, who work in residential and community day services settings, with at least $0.50 of those funds to be provided as a direct increase to all aide base wages, with the remaining $0.50 to be used flexibly for base wage increases to the rate methodology for aides. In addition, for residential services delivered on or after January 1, 2023 the rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as determined by the Department. Also, for services delivered on or after January 1, 2023, the rates will include adjustments to employment-related expenses as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(Source: P.A. 101-10, eff. 6-5-19; 101-636, eff. 6-10-20; 102-16, eff. 6-17-21; 102-699, eff. 4-19-22.)
(305 ILCS 5/5-5.4a)
Sec. 5-5.4a. (Repealed).
(Source: P.A. 96-1530, eff. 2-16-11. Repealed by P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4b)
Sec. 5-5.4b.
Publicly owned or publicly operated nursing facilities.
The
Illinois
Department may by rule establish alternative reimbursement methodologies for
nursing facilities that are owned or operated by a county, a township,
a municipality, a hospital district, or any other local government in
Illinois.
(Source: P.A. 93-20, eff. 6-20-03.)
(305 ILCS 5/5-5.4c)
Sec. 5-5.4c. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4d)
Sec. 5-5.4d. MDS payment methodology; quarterly rate adjustments.
(a) On and after July 1, 2009, and until April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be calculated and adjusted quarterly. The Department of Healthcare and Family Services may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section. For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare.
(b) On April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be frozen to allow the Department of Healthcare and Family Services to develop a rate methodology based on a federally mandated long term care data collection system. The rates in effect prior to and through the quarter ending March 31, 2011, shall continue to be subject to follow-up audits and retroactive rate adjustments pursuant to administrative rules of the Department for reviews of accuracy and resident assessment information. The reimbursement methodology for a Class I Institution for Mental Diseases shall also be frozen pending review of a federally mandated long term care data collection system.
(Source: P.A. 96-743, eff. 8-25-09; 96-959, eff. 7-1-10.)
(305 ILCS 5/5-5.4e)
Sec. 5-5.4e. Nursing facilities; ventilator rates. On and after October 1, 2009, the Department of Healthcare and Family Services shall adopt rules to provide medical assistance reimbursement under this Article for the care of persons on ventilators in skilled nursing facilities licensed under the Nursing Home Care Act and certified to participate under the medical assistance program. Accordingly, necessary amendments to the rules implementing the Minimum Data Set (MDS) payment methodology shall also be made to provide a separate per diem ventilator rate based on days of service. The Department may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section. For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 96-743, eff. 8-25-09; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4f)
Sec. 5-5.4f. Intermediate care facilities for persons with developmental disabilities quality workforce initiative.
(a) Legislative intent. Individuals with developmental disabilities who live in community-based settings rely on direct support staff for a variety of supports and services essential to the ability to reach their full potential. A stable, well-trained direct support workforce is critical to the well-being of these individuals. State and national studies have documented high rates of turnover among direct support workers and confirmed that improvements in wages can help reduce turnover and develop a more stable and committed workforce. This Section would increase the wages and benefits for direct care workers supporting individuals with developmental disabilities and provide accountability by ensuring that additional resources go directly to these workers.
(b) Reimbursement. Notwithstanding any provision of Section 5-5.4, in order to attract and retain a stable, qualified, and healthy workforce, beginning July 1, 2010, the Department of Healthcare and Family Services may reimburse an individual intermediate care facility for persons with developmental disabilities for spending incurred to provide improved wages and benefits to its employees serving the individuals residing in the facility. Reimbursement shall be based upon patient days reported in the facility's most recent cost report. Subject to available appropriations, this reimbursement shall be made according to the following criteria:
(c) Audit. Reimbursement under this Section is subject to audit by the Department and shall be reduced or eliminated in the case of any facility that does not honor its commitment to increase spending to improve the wages and benefits of its employees or that decreases such spending.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-5.4g)
Sec. 5-5.4g. Minimum Data Set (MDS) Compliance Review; preliminary findings. The Department shall establish by rule a procedure for sharing preliminary Minimum Data Set (MDS) Compliance Review findings with nursing facilities prior to completion of the on-site review. The procedure shall include, but not be limited to, notification to a nursing facility of specific areas of missing documentation required under 89 Ill. Adm. Code 147.75 and the federally mandated resident assessment instrument as specified in 42 CFR 483.20 likely to be determined deficient upon conclusion of the Department's quality assurance review process. Prior to the conclusion of the on-site review, the facility shall be given the opportunity to address the specific areas of missing documentation. A facility disputing any rate change may submit an appeal request pursuant to provisions established at 89 Ill. Adm. Code 140.830. An appeal hearing may be requested if the facility believes that the basis for reducing the facility's MDS rate was in error. The facility may not offer any additional documentation during the appeal hearing, but may identify documentation provided during the on-site review that may support a specific area of documentation deemed deficient by the Department.
(Source: P.A. 96-1317, eff. 7-27-10; 97-333, eff. 8-12-11.)
(305 ILCS 5/5-5.4h)
Sec. 5-5.4h. Medicaid reimbursement for medically complex for the developmentally disabled facilities licensed under the MC/DD Act.
(a) Facilities licensed as medically complex for the developmentally disabled facilities that serve severely and chronically ill patients shall have a specific reimbursement system designed to recognize the characteristics and needs of the patients they serve.
(b) For dates of services starting July 1, 2013 and until a new reimbursement system is designed, medically complex for the developmentally disabled facilities that meet the following criteria:
(c) Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting July 1, 2014 through March 31, 2019, medically complex for the developmentally disabled facilities which meet the criteria in subsection (b) of this Section shall receive a per diem rate for clinically complex residents of $304. Clinically complex residents on a ventilator shall receive a per diem rate of $669. Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting April 1, 2019, medically complex for the developmentally disabled facilities must be reimbursed an exceptional care per diem rate, instead of the base rate, for services to residents with complex or extensive medical needs. Exceptional care per diem rates must be paid for the conditions or services specified under subsection (f) at the following per diem rates: Tier 1 $326, Tier 2 $546, and Tier 3 $735.
(d) For residents on a ventilator pursuant to subsection (c) or subsection (f), facilities shall have a policy documenting their method of routine assessment of a resident's weaning potential with interventions implemented noted in the resident's medical record.
(e) For services provided prior to April 1, 2019 and for the purposes of this Section, a resident is considered clinically complex if the resident requires at least one of the following medical services:
(f) Complex or extensive medical needs for exceptional care reimbursement. The conditions and services used for the purposes of this Section have the same meanings as ascribed to those conditions and services under the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) and specified in the most recent manual. Instead of submitting minimum data set assessments to the Department, medically complex for the developmentally disabled facilities must document within each resident's medical record the conditions or services using the minimum data set documentation standards and requirements to qualify for exceptional care reimbursement.
(g) For dates of services starting April 1, 2019, reimbursement calculations and direct payment for services provided by medically complex for the developmentally disabled facilities are the responsibility of the Department of Healthcare and Family Services instead of the Department of Human Services. Appropriations for medically complex for the developmentally disabled facilities must be shifted from the Department of Human Services to the Department of Healthcare and Family Services. Nothing in this Section prohibits the Department of Healthcare and Family Services from paying more than the rates specified in this Section. The rates in this Section must be interpreted as a minimum amount. Any reimbursement increases applied to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to medically complex for the developmentally disabled facilities.
(h) The Department of Healthcare and Family Services shall pay the rates in effect on March 31, 2019 until the changes made to this Section by this amendatory Act of the 100th General Assembly have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
(i) The Department of Healthcare and Family Services may adopt rules as allowed by the Illinois Administrative Procedure Act to implement this Section; however, the requirements of this Section must be implemented by the Department of Healthcare and Family Services even if the Department of Healthcare and Family Services has not adopted rules by the implementation date of April 1, 2019.
(Source: P.A. 100-646, eff. 7-27-18.)
(305 ILCS 5/5-5.4i)
Sec. 5-5.4i. Rates and reimbursements.
(a) Within 30 days after July 6, 2017 (the effective date of Public Act 100-23), the Department shall increase rates and reimbursements to fund a minimum of a $0.75 per hour wage increase for front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff working in community-based provider organizations serving individuals with developmental disabilities. The Department shall adopt rules, including emergency rules under subsection (y) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(b) Within 30 days after June 4, 2018 (the effective date of Public Act 100-587), the Department shall increase rates and reimbursements to fund a minimum of a $0.50 per hour wage increase for front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff working in community-based provider organizations serving individuals with developmental disabilities. The Department shall adopt rules, including emergency rules under subsection (bb) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(c) Within 30 days after the effective date of this amendatory Act of the 101st General Assembly, subject to federal approval, the Department shall increase rates and reimbursements in effect on June 30, 2019 for community-based providers for persons with Developmental Disabilities by 3.5%. The Department shall adopt rules, including emergency rules under subsection (ii) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.
(Source: P.A. 100-23, eff. 7-6-17; 100-587, eff. 6-4-18; 101-10, eff. 6-5-19.)
(305 ILCS 5/5-5.4j)
Sec. 5-5.4j. ID/DD targeted Medicaid rate enhancement. Within 30 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall increase the Medicaid per diem rate by $21.15 for facilities with more than 16 beds licensed by the Department of Public Health under the ID/DD Community Care Act located in the Department of Public Health's Planning Area 7-B.
(Source: P.A. 100-587, eff. 6-4-18.)
(305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5)
Sec. 5-5.5. Elements of Payment Rate.
(a) The Department of Healthcare and Family Services shall develop a prospective method for
determining payment rates for nursing facility and ICF/DD
services in nursing facilities composed of the following cost elements:
(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:
(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. 96-1123, eff. 1-1-11; 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.5a) (from Ch. 23, par. 5-5.5a)
Sec. 5-5.5a. Kosher kitchen and food service.
(a) The Department of Healthcare and Family Services may develop in its rate structure for
nursing facilities an accommodation
for fully kosher kitchen and food service operations, rabbinically
approved or certified on an annual basis for a facility in which the only
kitchen or all kitchens are fully kosher (a fully kosher facility).
Beginning in the fiscal year after the fiscal year when this amendatory Act
of 1990 becomes effective, the rate structure may provide for an additional
payment to such facility not to exceed 50 cents per resident per day if 60%
or more of the residents in the facility request kosher foods or food
products prepared in accordance with Jewish religious dietary requirements
for religious purposes in a fully kosher facility. Based upon food cost
reports of the Illinois Department of Agriculture regarding kosher and
non-kosher food available in the various regions of the State, this rate
structure may be periodically adjusted by the Department but may not exceed
the maximum authorized under this subsection (a).
(b) The Department shall by rule determine how a facility with a fully
kosher kitchen and food service may be determined to be eligible and apply
for the rate accommodation specified in subsection (a).
(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.6) (from Ch. 23, par. 5-5.6)
Sec. 5-5.6.
Federal Requirements.
All reimbursement
rates established pursuant to this Act must be consistent
with the criteria for nursing facility reimbursement
established by the Federal government for approval of
matching funds under Title XIX of the Federal
Social Security Act.
(Source: P.A. 80-1142.)
(305 ILCS 5/5-5.6a)
Sec. 5-5.6a. (Repealed).
(Source: P.A. 85-1440. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.6b) (from Ch. 23, par. 5-5.6b)
Sec. 5-5.6b. Prohibition against double payment. If any resident of a
nursing facility or ICF/DD is admitted to such
facility on the basis that the charges for such resident's care will be
paid from private funds, and the source of payment for such care thereafter
changes from private funds to payments under this Article, the facility
shall, upon receiving the first such payment under this Article, notify the
Illinois Department of such source of private funds for such recipient and
repay to the source of private funds any amounts received from such source
as payment for care for which payment also was made under this Article.
Private funds shall not include third party resources such as
insurance or Medicare benefits or payments made by responsible relatives.
(Source: P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.7) (from Ch. 23, par. 5-5.7)
Sec. 5-5.7. Cost reports - audits. The Department of Healthcare and Family Services shall
work with the Department of Public Health to use cost report information
currently being collected under provisions of the Nursing Home Care
Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, and the MC/DD Act. The Department of Healthcare and Family Services may, in conjunction with the Department of Public Health,
develop in accordance with generally accepted accounting principles a
uniform chart of accounts which each facility providing services under the
medical assistance program shall adopt, after a reasonable period.
Facilities licensed under the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act
and providers of adult developmental training services certified by the
Department of Human Services pursuant to
Section 15.2 of the Mental Health and Developmental Disabilities Administrative
Act which provide
services to clients eligible for
medical assistance under this Article are responsible for submitting the
required annual cost report to the Department of Healthcare and Family Services.
The Department of Healthcare and Family Services
shall audit the financial and statistical
records of each provider participating in the medical assistance program
as a nursing facility, a specialized mental health rehabilitation facility, or an ICF/DD over a 3 year period,
beginning with the close of the first cost reporting year. Following the
end of this 3-year term, audits of the financial and statistical records
will be performed each year in at least 20% of the facilities participating
in the medical assistance program with at least 10% being selected on a
random sample basis, and the remainder selected on the basis of exceptional
profiles. All audits shall be conducted in accordance with generally accepted
auditing standards.
The Department of Healthcare and Family Services
shall establish prospective payment rates
for categories or levels of services within each licensure class, in order to more appropriately recognize the
individual needs of patients in nursing facilities.
The Department of Healthcare and Family Services
shall provide, during the process of
establishing the payment rate for nursing facility, specialized mental health rehabilitation facility, or ICF/DD
services, or when a substantial change in rates is proposed, an opportunity
for public review and comment on the proposed rates prior to their becoming
effective.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
(305 ILCS 5/5-5.7a)
Sec. 5-5.7a. Pandemic related stability payments for health care providers. Notwithstanding other provisions of law, and in accordance with the Illinois Emergency Management Agency, the Department of Healthcare and Family Services shall develop a process to distribute pandemic related stability payments, from federal sources dedicated for such purposes, to health care providers that are providing care to recipients under the Medical Assistance Program. For provider types serving residents who are recipients of medical assistance under this Code and are funded by other State agencies, the Department will coordinate the distribution process of the pandemic related stability payments. Federal sources dedicated to pandemic related payments include, but are not limited to, funds distributed to the State of Illinois from the Coronavirus Relief Fund pursuant to the Coronavirus Aid, Relief, and Economic Security Act ("CARES Act") and from the Coronavirus State Fiscal Recovery Fund pursuant to Section 9901 of the American Rescue Plan Act of 2021, that are appropriated to the Department during Fiscal Years 2020, 2021, and 2022 for purposes permitted by those federal laws and related federal guidance.
(305 ILCS 5/5-5.8) (from Ch. 23, par. 5-5.8)
Sec. 5-5.8. Report on nursing home reimbursement. The Illinois
Department shall report annually to the General Assembly, no later than the
first Monday in April of 1982, and each year thereafter, in regard to:
The requirement for reporting to the General Assembly shall be satisfied
by filing copies of the report
as required by Section 3.1 of the General Assembly Organization Act, and filing such
additional copies with the State Government Report Distribution Center for
the General Assembly as is required under paragraph (t) of Section 7 of the
State Library Act.
(Source: P.A. 102-1035, eff. 5-31-22.)
(305 ILCS 5/5-5.8a)
Sec. 5-5.8a. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 96-1123, eff. 1-1-11.)
(305 ILCS 5/5-5.8b) (from Ch. 23, par. 5-5.8b)
Sec. 5-5.8b. Payment to Campus Facilities. There is hereby established
a separate payment category for campus facilities. A "campus facility" is
defined as an entity which consists of a long term care facility (or group
of facilities if the facilities are on the same contiguous parcel of real
estate) which meets all of the following criteria as of May 1,
1987: the
entity provides care for both children and adults; residents of the entity
reside in three or more separate buildings with congregate and small group
living arrangements on a single campus; the entity provides three or more
separate licensed levels of care; the entity (or a part of the entity) is
enrolled with the Department of Healthcare and Family Services as a provider of long term care
services and receives payments from that Department; the
entity (or a part of the entity) receives funding from the Department of
Human
Services; and the entity (or a part of
the entity) holds a current license as a child care institution issued by
the Department of Children and Family Services.
The Department of Healthcare and Family Services, the Department of Human Services, and the Department of Children and Family
Services shall develop jointly a rate methodology or methodologies for
campus facilities. Such methodology or methodologies may establish a
single rate to be paid by all the agencies, or a separate rate to be paid
by each agency, or separate components to be paid to
different parts of the campus facility. All campus facilities shall
receive the same rate of payment for similar services. Any methodology
developed pursuant to this section shall take into account the actual costs
to the facility of providing services to residents, and shall be adequate
to reimburse the allowable costs of a campus facility which is economically
and efficiently operated. Any methodology shall be established on the
basis of historical, financial, and statistical data submitted by campus
facilities, and shall take into account the actual costs incurred by campus
facilities in providing services, and in meeting licensing and
certification standards imposed and prescribed by the State of Illinois,
any of its political subdivisions or municipalities and by the United
States Department of Health and Human Services. Rates may be established
on a prospective or retrospective basis. Any methodology shall provide
reimbursement for appropriate payment elements, including the following:
standard services, patient services, real estate taxes, and capital costs.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.09)
Sec. 5-5.09. Mental health professionals; veterans.
(a) The General Assembly is proud of and grateful to members of all branches of the United States Armed Forces. The General Assembly recognizes that returning veterans may have unique and specific needs that are better understood and addressed by persons with military exposure. The Department of Healthcare and Family Services shall seek federal approval of an amendment to the Illinois Title XIX State Plan for the purpose of allowing a person who has completed a psychiatric training certification program from any branch of the United States Armed Forces and who has at least one year of experience in a mental health setting to be recognized as a mental health professional.
(b) Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department of Healthcare and Family Services, in collaboration with all necessary partners including the Department of Human Services, shall adopt within 180 days after the date upon which federal approval is received any necessary rules that would allow a person who has completed a psychiatric training certification program from any branch of the United States Armed Forces and who has at least one year of experience in a mental health setting to be recognized as a mental health professional for purposes of programs authorized or funded by the Department of Healthcare and Family Services under the standards of practice as authorized by the Department.
(Source: P.A. 100-908, eff. 1-1-19.)
(305 ILCS 5/5-5.10)
Sec. 5-5.10. Value-based purchasing.
(a) The Department of Healthcare and Family Services, and, as appropriate, divisions within the Department of Human Services, shall confer with stakeholders to discuss development of alternative value-based payment models that move away from fee-for-service and reward health outcomes and improved quality and provide flexibility in how providers meet the needs of the individuals they serve. Stakeholders include providers, managed care organizations, and community-based and advocacy organizations. The approaches explored may be different for different types of services.
(b) The Department of Healthcare and Family Services and the Department of Human Services shall initiate discussions with mental health providers, substance abuse providers, managed care organizations, advocacy groups for individuals with behavioral health issues, and others, as appropriate, no later than July 1, 2019. A model for value-based purchasing for behavioral health providers shall be presented to the General Assembly by January 31, 2020. In developing this model, the Department of Healthcare and Family Services shall develop projections of the funding necessary for the model.
(Source: P.A. 101-209, eff. 8-5-19.)
(305 ILCS 5/5-5.11)
Sec. 5-5.11. (Repealed).
(Source: P.A. 83-748. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
Sec. 5-5.12. Pharmacy payments.
(a) Every request submitted by a pharmacy for reimbursement under this
Article for prescription drugs provided to a recipient of aid under this
Article shall include the name of the prescriber or an acceptable
identification number as established by the Department.
(b) Pharmacies providing prescription drugs under
this Article shall be reimbursed at a rate which shall include
a professional dispensing fee as determined by the Illinois
Department, plus the current acquisition cost of the prescription
drug dispensed. The Illinois Department shall update its
information on the acquisition costs of all prescription drugs
no less frequently than every 30 days. However, the Illinois
Department may set the rate of reimbursement for the acquisition
cost, by rule, at a percentage of the current average wholesale
acquisition cost.
(c) (Blank).
(d) The Department shall review utilization of narcotic medications in the medical assistance program and impose utilization controls that protect against abuse.
(e) When making determinations as to which drugs shall be on a prior approval list, the Department shall include as part of the analysis for this determination, the degree to which a drug may affect individuals in different ways based on factors including the gender of the person taking the medication.
(f) The Department shall cooperate with the Department of Public Health and the Department of Human Services Division of Mental Health in identifying psychotropic medications that, when given in a particular form, manner, duration, or frequency (including "as needed") in a dosage, or in conjunction with other psychotropic medications to a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act or the MC/DD Act, may constitute a chemical restraint or an "unnecessary drug" as defined by the Nursing Home Care Act or Titles XVIII and XIX of the Social Security Act and the implementing rules and regulations. The Department shall require prior approval for any such medication prescribed for a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act or the MC/DD Act, that appears to be a chemical restraint or an unnecessary drug. The Department shall consult with the Department of Human Services Division of Mental Health in developing a protocol and criteria for deciding whether to grant such prior approval.
(g) The Department may by rule provide for reimbursement of the dispensing of a 90-day supply of a generic or brand name, non-narcotic maintenance medication in circumstances where it is cost effective.
(g-5) On and after July 1, 2012, the Department may require the dispensing of drugs to nursing home residents be in a 7-day supply or other amount less than a 31-day supply. The Department shall pay only one dispensing fee per 31-day supply.
(h) Effective July 1, 2011, the Department shall discontinue coverage of select over-the-counter drugs, including analgesics and cough and cold and allergy medications.
(h-5) On and after July 1, 2012, the Department shall impose utilization controls, including, but not limited to, prior approval on specialty drugs, oncolytic drugs, drugs for the treatment of HIV or AIDS, immunosuppressant drugs, and biological products in order to maximize savings on these drugs. The Department may adjust payment methodologies for non-pharmacy billed drugs in order to incentivize the selection of lower-cost drugs. For drugs for the treatment of AIDS, the Department shall take into consideration the potential for non-adherence by certain populations, and shall develop protocols with organizations or providers primarily serving those with HIV/AIDS, as long as such measures intend to maintain cost neutrality with other utilization management controls such as prior approval.
For hemophilia, the Department shall develop a program of utilization review and control which may include, in the discretion of the Department, prior approvals. The Department may impose special standards on providers that dispense blood factors which shall include, in the discretion of the Department, staff training and education; patient outreach and education; case management; in-home patient assessments; assay management; maintenance of stock; emergency dispensing timeframes; data collection and reporting; dispensing of supplies related to blood factor infusions; cold chain management and packaging practices; care coordination; product recalls; and emergency clinical consultation. The Department may require patients to receive a comprehensive examination annually at an appropriate provider in order to be eligible to continue to receive blood factor.
(i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(j) On and after July 1, 2012, the Department shall impose limitations on prescription drugs such that the Department shall not provide reimbursement for more than 4 prescriptions, including 3 brand name prescriptions, for distinct drugs in a 30-day period, unless prior approval is received for all prescriptions in excess of the 4-prescription limit. Drugs in the following therapeutic classes shall not be subject to prior approval as a result of the 4-prescription limit: immunosuppressant drugs, oncolytic drugs, anti-retroviral drugs, and, on or after July 1, 2014, antipsychotic drugs. On or after July 1, 2014, the Department may exempt children with complex medical needs enrolled in a care coordination entity contracted with the Department to solely coordinate care for such children, if the Department determines that the entity has a comprehensive drug reconciliation program.
(k) No medication therapy management program implemented by the Department shall be contrary to the provisions of the Pharmacy Practice Act.
(l) Any provider enrolled with the Department that bills the Department for outpatient drugs and is eligible to enroll in the federal Drug Pricing Program under Section 340B of the federal Public Health Service Act shall enroll in that program. No entity participating in the federal Drug Pricing Program under Section 340B of the federal Public Health Service Act may exclude fee-for-service Medicaid from their participation in that program, however, entities defined in Section 1905(l)(2)(B) of the Social Security Act are excluded from this requirement. This subsection does not apply to outpatient drugs billed to Medicaid managed care organizations.
(Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)
(305 ILCS 5/5-5.12a)
Sec. 5-5.12a.
Title XIX waiver; pharmacy assistance program.
The
Illinois Department may seek a waiver of otherwise applicable requirements
of Title XIX of the federal Social Security Act in order to claim federal
financial participation for a pharmacy assistance program for persons aged
65 and over with income levels at or less than 250% of the federal poverty
level. The Illinois Department may provide by rule for all other requirements
of the program, including cost sharing, as permitted by an approved waiver and
without regard to any provision of this Code to the contrary. The benefits may
be no more restrictive than the Pharmacy Assistance Program in effect on May
31, 2001. Benefits provided under the waiver are subject to appropriation.
The Illinois Department may not implement the waiver until cost neutrality is
demonstrated for the State relative to the final Pharmacy Assistance Program
appropriation for the fiscal year beginning July 1, 2001. Implementation of
the waiver shall terminate on June 30, 2007.
(Source: P.A. 92-10, eff. 6-11-01.)
(305 ILCS 5/5-5.12b)
Sec. 5-5.12b. Critical access care pharmacy program.
(a) As used in this Section:
"Critical access care pharmacy" means an Illinois-based brick and mortar pharmacy that is located in a county with fewer than 50,000 residents and that owns fewer than 10 pharmacies.
"Critical access care pharmacy program payment" means the number of individual prescriptions a critical access care pharmacy fills during that quarter multiplied by the lesser of the individual payment amount or the dispensing reimbursement rate made by the Department under the medical assistance program as of April 1, 2018.
"Individual payment amount" means the dividend of 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter.
(b) Subject to appropriations, the Department shall establish a critical access care pharmacy program to ensure the sustainability of critical access pharmacies throughout the State of Illinois.
(c) The critical access care pharmacy program shall not exceed $10,000,000 annually and individual payment amounts per prescription shall not exceed the dispensing rate that the Department would have reimbursed under the Medical Assistance Program as of April 1, 2018.
(d) Quarterly, the Department shall determine the number of prescriptions filled by critical access care pharmacies reimbursed by Medicaid managed care organizations utilizing encounter data available to the Department. The Department shall determine the individual payment amount per prescription by dividing 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. If the individual payment amount per prescription as calculated using quarterly prescription amounts exceeds the reimbursement rate under the medical assistance program as of April 1, 2018, then the individual payment amount per prescription shall be the dispensing reimbursement rate under the medical assistance program as of April 1, 2018.
(e) Quarterly, the Department shall distribute to critical access care pharmacies a critical access care pharmacy program payment. The first payment shall be calculated utilizing the encounter data from the last quarter of State fiscal year 2018.
(f) The Department may adopt rules permitting an Illinois-based brick and mortar pharmacy that owns fewer than 10 pharmacies to receive critical access care pharmacy program payments in the same manner as a critical access care pharmacy, regardless of whether the pharmacy is located in a county with a population of less than 50,000.
(Source: P.A. 100-587, eff. 6-4-18.)
(305 ILCS 5/5-5.12c)
Sec. 5-5.12c. Managed care organization uniform electronic prior authorization form; prescription benefits.
(a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.
(b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, a managed care organization that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits.
(c) On or before July 1, 2020, the Department of Healthcare and Family Services shall develop a uniform electronic prior authorization form that shall be used by managed care organizations. Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits, and every managed care organization shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits.
(d) The Department of Healthcare and Family Services shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director of Healthcare and Family Services: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents managed care organizations, from at least one public meeting.
(e) The Department of Healthcare and Family Services, in development of the uniform electronic prior authorization form, shall take into consideration the following:
(f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, a managed care organization fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours, then the prior authorization request shall be deemed to have been granted.
(Source: P.A. 101-463, eff. 1-1-20.)
(305 ILCS 5/5-5.12d)
Sec. 5-5.12d. Coverage for patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis provided by a pharmacist.
(a) Subject to approval by the federal Centers for Medicare and Medicaid Services, the medical assistance program, including both the fee-for-service and managed care medical assistance programs established under this Article, shall cover patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation.
(b) The Department shall establish a fee schedule for patient care services provided by a pharmacist under Sections 43 and 43.5 of the Pharmacy Practice Act and shall be covered and reimbursed at no less than 85% of the rate that the services are reimbursed when provided by a physician.
(c) The rate of reimbursement for patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation shall be at 85% of the fee schedule for physician services by the medical assistance program.
(d) A pharmacist must be enrolled in the medical assistance program as an ordering and referring provider prior to providing patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation that is submitted by a pharmacy or pharmacist provider for reimbursement pursuant to this Section.
(e) The Department shall apply for any necessary federal waivers or approvals to implement this Section by January 1, 2023.
(f) This Section does not restrict or prohibit any services currently provided by pharmacists as authorized by law, including, but not limited to, pharmacist services provided under this Code or authorized under the Illinois Title XIX State Plan.
(g) The Department shall submit to the Joint Committee on Administrative Rules administrative rules for this Section as soon as practicable but no later than 6 months after federal approval is received.
(Source: P.A. 102-103, eff. 1-1-22; 102-813, eff. 5-13-22; 102-1051, eff. 1-1-23.)
(305 ILCS 5/5-5.12e)
Sec. 5-5.12e. Managed care organization prior authorization of health care services.
(a) As used in this Section, "health care service" has the meaning given to that term in the Prior Authorization Reform Act.
(b) Notwithstanding any other provision of law to the contrary, all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act.
(Source: P.A. 102-409, eff. 1-1-22; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-5.13) (from Ch. 23, par. 5-5.13)
Sec. 5-5.13.
The Illinois Department shall establish procedures for the
expedited review, for purposes of inclusion in the Illinois Public Aid
formulary, of any drug for the treatment of acquired immunodeficiency syndrome
(AIDS) which the federal Food and Drug Administration has indicated is subject
to a treatment investigational new drug application.
(Source: P.A. 88-85.)
(305 ILCS 5/5-5.14)
Sec. 5-5.14.
(Repealed).
(Source: Repealed by P.A. 88-85.)
(305 ILCS 5/5-5.14.5)
Sec. 5-5.14.5. Treatment; substance use disorder and mental health. The Department shall consult with stakeholders and General Assembly members for input on a plan to develop enhanced Medicaid rates for substance use disorder treatment and mental health treatment in underserved communities. The Department shall present the plan to General Assembly members within 3 months of the effective date of this amendatory Act of the 101st General Assembly, which will specifically address ensuring access to treatment in provider deserts. Within 4 months of the effective date of this amendatory Act of the 101st General Assembly, the Department shall submit a State plan amendment to create medical assistance enhanced rates to enhance access to those to community mental health services and substance abuse services for underserved communities.
Subject to federal approval, the Department shall create medical assistance enhanced rates for community mental health services and substance abuse providers for underserved communities to enhance access to those communities.
(Source: P.A. 101-10, eff. 6-5-19.)
(305 ILCS 5/5-5.15)
Sec. 5-5.15. (Repealed).
(Source: P.A. 83-1509. Repealed by P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-5.16) (from Ch. 23, par. 5-5.16)
Sec. 5-5.16.
(Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)
(305 ILCS 5/5-5.17) (from Ch. 23, par. 5-5.17)
Sec. 5-5.17. Separate reimbursement rate. The Illinois Department may
by rule establish a separate reimbursement rate to be paid to long term
care facilities for adult developmental training services as defined in
Section 15.2 of the Mental Health and Developmental Disabilities Administrative
Act which are provided to
residents of such facilities who have intellectual disabilities and who receive aid under this Article. Any such
reimbursement shall be based upon cost reports submitted by the providers
of such services and shall be paid by the long term care facility to the
provider within such time as the Illinois Department shall prescribe by
rule, but in no case less than 3 business days after receipt of the
reimbursement by such facility from the Illinois Department. The Illinois
Department may impose a penalty upon a facility which does not make payment
to the provider of adult developmental training services within the time so
prescribed, up to the amount of payment not made to the provider.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-5.18)
Sec. 5-5.18.
Diagnosis accompanying request for reimbursement.
Every
request submitted by a physician for reimbursement under this Article for
services provided to a recipient of aid under this Article shall include the
physician's diagnosis of the recipient's illness or other condition requiring
those services. The diagnosis shall be either written out or expressed in a
code approved by the Illinois Department.
(Source: P.A. 88-554, eff. 7-26-94.)
(305 ILCS 5/5-5.19)
Sec. 5-5.19.
Reimbursement request records.
The Illinois Department shall
file all requests for reimbursement for medical services provided under this
Article
according to both (i) the name of the service provider and (ii) the name of the
recipient of aid under this Article to whom the medical services were
provided.
(Source: P.A. 88-554, eff. 7-26-94.)
(305 ILCS 5/5-5.20)
Sec. 5-5.20. Clinic payments. For services provided by federally
qualified health centers as defined in Section 1905 (l)(2)(B) of the federal
Social Security Act, on or after April 1, 1989, and as long as required by
federal law, the Illinois Department shall
reimburse those health centers for those services according to a prospective
cost-reimbursement methodology.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.21)
Sec. 5-5.21. (Repealed).
(Source: P.A. 89-415, eff. 1-1-96. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.22)
Sec. 5-5.22. (Repealed).
(Source: P.A. 92-725, eff. 7-25-02. Repealed by P.A. 94-838, eff. 6-6-06.)
(305 ILCS 5/5-5.23)
Sec. 5-5.23. Children's mental health services.
(a) The Department of Healthcare and Family Services, by rule, shall require the screening and
assessment of
a child prior to any Medicaid-funded admission to an inpatient hospital for
psychiatric
services to be funded by Medicaid. The screening and assessment shall include a
determination of the appropriateness and availability of out-patient support
services
for necessary treatment. The Department, by rule, shall establish methods and
standards of payment for the screening, assessment, and necessary alternative
support
services.
(b) The Department of Healthcare and Family Services, to the extent allowable under federal law,
shall secure federal financial participation for Individual Care Grant
expenditures made
by the Department of Healthcare and Family Services for the Medicaid optional service
authorized under
Section 1905(h) of the federal Social Security Act, pursuant to the provisions
of Section
7.1 of the Mental Health and Developmental Disabilities Administrative Act. The
Department of Healthcare and Family Services may exercise the
authority under this Section as is necessary to administer
Individual Care Grants as authorized under Section 7.1 of the
Mental Health and Developmental Disabilities Administrative
Act.
(c) The Department of Healthcare and Family Services shall work collaboratively with the Department of Children and Family
Services and the Division of Mental Health of the Department of
Human Services to implement subsections (a) and (b).
(d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(e) All rights, powers, duties, and responsibilities currently exercised by the Department of Human Services related to the Individual Care Grant program are transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services to be completed and implemented within 6 months after the effective date of this amendatory Act of the 99th General Assembly. For the purposes of the Successor Agency Act, the Department of Healthcare and Family Services is declared to be the successor agency of the Department of Human Services, but only with respect to the functions of the Department of Human Services that are transferred to the Department of Healthcare and Family Services under this amendatory Act of the 99th General Assembly.
(f) (Blank).
(g) Family Support Program. The Department of Healthcare and Family Services shall restructure the Family Support Program, formerly known as the Individual Care Grant program, to enable early treatment of youth, emerging adults, and transition-age adults with a serious mental illness or serious emotional disturbance.
(h) Eligibility for the Family Support Program. Eligibility criteria established under 89 Ill.
Adm. Code 139 for the Family Support Program shall include the following:
(i) Notification of Family Support Program and Specialized Family Support Program services.
(j) Workgroup to develop a plan for improving access to substance use treatment. The Department of Healthcare and Family Services and the Department of Human Services' Division of Substance Use Prevention and Recovery shall co-lead a working group that includes Family Support Program providers, family support organizations, and other stakeholders over a 12-month period beginning in the first quarter of calendar year 2020 to develop a plan for increasing access to substance use treatment services for youth, emerging adults, and transition-age adults who are eligible for Family Support Program services.
(k) Appropriation. Implementation of this Section shall be limited by the State's annual appropriation to the Family Support Program. Spending within the Family Support Program appropriation shall be further limited for the new Family Support Program services to be developed accordingly:
(l) Exhausting third party insurance coverage first.
(m) Service authorization. A youth, emerging adult, or transition-age adult enrolled in the Family Support Program or the Specialized Family Support Program shall be eligible to receive a mental health treatment service covered by the applicable program if the medical necessity criteria established by the Department of Healthcare and Family Services are met.
(n) Streamlined application. The Department of Healthcare and Family Services shall revise the Family Support Program applications and the application process to reflect the changes made to this Section by this amendatory Act of the 101st General Assembly within 8 months after the adoption of any amendments to 89 Ill.
Adm. Code 139.
(o) Study of reimbursement policies during planned and unplanned absences of youth and emerging adults in Family Support Program residential treatment settings. The Department of Healthcare and Family Services shall undertake a study of those standards of the Department of Children and Family Services and other states for reimbursement of residential treatment during planned and unplanned absences to determine if reimbursing residential providers for such unplanned absences positively impacts the availability of residential treatment for youth and emerging adults. The Department of Healthcare and Family Services shall begin the study on July 1, 2019 and shall report its findings and the results of the study to the General Assembly, along with any recommendations for or against adopting a similar policy, by December 31, 2020.
(p) Public awareness and educational campaign for all relevant providers. The Department of Healthcare and Family Services shall engage in a public awareness campaign to educate hospitals with psychiatric units, crisis response providers such as Screening, Assessment and Support Services providers and Comprehensive Community Based Youth Services agencies, schools, and other community institutions and providers across Illinois on the changes made by this amendatory Act of the 101st General Assembly to the Family Support Program. The Department of Healthcare and Family Services shall produce written materials geared for the appropriate target audience, develop webinars, and conduct outreach visits over a 12-month period beginning after implementation of the changes made to this Section by this amendatory Act of the 101st General Assembly.
(q) Maximizing federal matching funds for the Family Support Program and the Specialized Family Support Program. The Department of Healthcare and Family Services, as the sole Medicaid State agency, shall seek approval from the federal Centers for Medicare and Medicaid Services within 12 months after the effective date of this amendatory Act of the 101st General Assembly to draw additional federal Medicaid matching funds for individuals served under the Family Support Program or the Specialized Family Support Program who are not covered by the Department's medical assistance programs. The Department of Children and Family Services, as the State agency responsible for administering federal funds pursuant to Title IV-E of the Social Security Act, shall submit a State Plan to the federal government within 12 months after the effective date of this amendatory Act of the 101st General Assembly to maximize the use of federal Title IV-E prevention funds through the federal Family First Prevention Services Act, to provide mental health and substance use disorder treatment services and supports, including, but not limited to, the provision of short-term crisis and transition beds post-hospitalization for youth who are at imminent risk of entering Illinois' youth welfare system solely due to the inability to access mental health or substance use treatment services.
(r) Outcomes and data reported annually to the General Assembly. Beginning in 2021, the Department of Healthcare and Family Services shall submit an annual report to the General Assembly that includes the following information with respect to the time period covered by the report:
(s) Rulemaking authority. Unless a timeline is otherwise specified in a subsection, if amendments to 89 Ill. Adm. Code 139 are needed for implementation of this Section, such amendments shall be filed by the Department of Healthcare and Family Services within one year after the effective date of this amendatory Act of the 101st General Assembly.
(Source: P.A. 101-461, eff. 1-1-20; 101-616, eff. 12-20-19.)
(305 ILCS 5/5-5.24)
Sec. 5-5.24. Prenatal and perinatal care.
(a) The Department of
Healthcare and Family Services may provide reimbursement under this Article for all prenatal and
perinatal health care services that are provided for the purpose of preventing
low-birthweight infants, reducing the need for neonatal intensive care hospital
services, and promoting perinatal and maternal health. These services may include
comprehensive risk assessments for pregnant individuals, individuals with infants, and
infants, lactation counseling, nutrition counseling, childbirth support,
psychosocial counseling, treatment and prevention of periodontal disease, language translation, nurse home visitation, and
other support
services
that have been proven to improve birth and maternal health outcomes.
The Department
shall
maximize the use of preventive prenatal and perinatal health care services
consistent with
federal statutes, rules, and regulations.
The Department of Public Aid (now Department of Healthcare and Family Services)
shall develop a plan for prenatal and perinatal preventive
health care and
shall present the plan to the General Assembly by January 1, 2004.
On or before January 1, 2006 and
every 2 years
thereafter, the Department shall report to the General Assembly concerning the
effectiveness of prenatal and perinatal health care services reimbursed under
this Section
in preventing low-birthweight infants and reducing the need for neonatal
intensive care
hospital services. Each such report shall include an evaluation of how the
ratio of
expenditures for treating
low-birthweight infants compared with the investment in promoting healthy
births and
infants in local community areas throughout Illinois relates to healthy infant
development
in those areas.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(b)(1) As used in this subsection:
"Affiliated provider" means a provider who is enrolled in the medical assistance program and has an active contract with a managed care organization.
"Non-affiliated provider" means a provider who is enrolled in the medical assistance program but does not have a contract with an MCO.
"Preventive prenatal and perinatal health care services" means services described in subsection (a) including the following non-emergent diagnostic and ancillary services:
(2) In order to maximize the accessibility of preventive prenatal and perinatal health care services, the Department of Healthcare and Family Services shall amend its managed care contracts such that an MCO must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid under the Illinois Medicaid fee-for-service program methodology for such services, including all policy adjusters, including, but not limited to, Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates, unless a different rate was agreed upon by the health plan and the non-affiliated provider.
(3) In cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the requirements under paragraph (2) shall not apply if the services were not emergency services, as defined in Section 5-30.1, and:
(305 ILCS 5/5-5.25)
Sec. 5-5.25. Access to behavioral health, medical, and epilepsy treatment services.
(a) The General Assembly finds that providing access to behavioral health, medical, and epilepsy treatment services in a timely manner will improve the quality of life for persons suffering from illness and will contain health care costs by avoiding the need for more costly inpatient hospitalization.
(b) The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in
Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. The Department, by rule, shall establish: (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.
(c) The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services' Division of Alcoholism and Substance Abuse.
(d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 101-81, eff. 7-12-19; 102-207, eff. 7-30-21.)
(305 ILCS 5/5-5.26)
Sec. 5-5.26. Multiple sclerosis; home services; waiver. The Department of Healthcare and Family Services shall apply for a waiver of federal law and regulations to the extent necessary to claim federal financial participation for medical assistance for services provided under the Department of Human Services' Home Services Program for persons with multiple sclerosis who are (i) over 60 years of age, and (ii) have assets not exceeding $17,500. In determining whether a person's assets meet this requirement, the Department must disregard retirement assets up to a total of $500,000 and disregard all life insurance assets.
(Source: P.A. 95-744, eff. 7-18-08.)
(305 ILCS 5/5-5.27)
Sec. 5-5.27. Coverage for clinical trials.
(a) The medical assistance program shall provide coverage for routine care costs that are incurred in the course of an approved clinical trial if the medical assistance program would provide coverage for the same routine care costs not incurred in a clinical trial. "Routine care cost" shall be defined by the Department by rule.
(b) The coverage that must be provided under this Section is subject to the terms, conditions, restrictions, exclusions, and limitations that apply generally under the medical assistance program, including terms, conditions, restrictions, exclusions, or limitations that apply to health care services rendered by participating providers and nonparticipating providers.
(c) Implementation of this Section shall be contingent upon federal approval. Upon receipt of federal approval, if required, the Department shall adopt any rules necessary to implement this Section.
(d) As used in this Section:
"Approved clinical trial" means a phase I, II, III, or IV clinical trial involving the prevention, detection, or treatment of cancer or any other life-threatening disease or condition if one or more of the following conditions apply:
"Care method" means the use of a particular drug or device in a particular manner.
"Life-threatening disease or condition" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(Source: P.A. 101-649, eff. 7-7-20.)
(305 ILCS 5/5-5a) (from Ch. 23, par. 5-5a)
Sec. 5-5a. Waiver for home and community-based services. The Department
shall apply for a waiver from the United States Health Care Financing
Administration to allow payment for home and community-based services under
this Article.
The Department, in cooperation with the Department on Aging, the Department
of Human Services and any other relevant State, local or
federal
government agency, may establish a nursing home pre-screening program to
determine whether the applicant, eligible for medical assistance under this
Article, may use home and community-based services as a reasonable,
lower-cost alternative form of care. For the purpose of this Section,
"home and community-based services" may include, but are not limited to,
those services provided under subsection (f) of Section 3 of the Rehabilitation of Persons with Disabilities Act and Section 4 of the Illinois Act on the Aging.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-5b) (from Ch. 23, par. 5-5b)
Sec. 5-5b.
Payment Reductions.
(a) Notwithstanding any other Section in this Code establishing a
methodology for determining payment rates or dispensing fees for
non-institutional services provided under this Code, the Illinois
Department is authorized to reduce those payment rates or dispensing fees
with due regard for and subject to budgetary limitations to the extent
permitted by federal law.
(b) The Illinois Department may implement this Section as added by
this amendatory Act of 1991 through the use of emergency rules in
accordance with the provisions of Section 5.02 of the Illinois
Administrative Procedure Act. For purposes of the Illinois Administrative
Procedure Act, the adoption of rules to implement this Section as added by
this amendatory Act of 1991 shall be deemed an emergency
and necessary for the public interest, safety and welfare.
(Source: P.A. 87-14.)
(305 ILCS 5/5-5b.1)
Sec. 5-5b.1. Reimbursement rates; Fiscal Year 2015 reductions.
(a) Except as provided in subsection (b), notwithstanding any other provision of this Code to the contrary, and subject to rescission if not federally approved, providers of the following services shall have their reimbursement rates or dispensing fees reduced for the remainder of State fiscal year 2015 by an amount equivalent to a 2.25% reduction in appropriations from the General Revenue Fund for the medical assistance program for the full fiscal year:
(b) No provider shall be exempt from the rate reductions authorized under this Section, except that, rates or payments, or the portion thereof, paid to a provider that is operated by a unit of local government that provides the non-federal share of such services shall not be reduced as provided in this Section.
(c) To the extent practical and subject to rescission if not federally approved, the reductions required under this Section must be applied uniformly among and within each group, class, subgroup, or category of providers listed in this Section.
(d) In order to provide for the expeditious and timely implementation of the provisions of this Section, emergency rules to implement any provision of this Section may be adopted by the Department in accordance with subsection (s) of Section 5-45 of the Illinois Administrative Procedure Act.
(Source: P.A. 99-2, eff. 3-26-15.)
(305 ILCS 5/5-5c)
Sec. 5-5c.
Waiver for home and community-based services for traumatic
brain injury (TBI) patients. The Department shall apply for a waiver from the
United States Health Care Financing Administration to allow payment for home
and community-based services under this Article for traumatic brain injury
patients.
The Department shall submit a Home and Community-Based
Services TBI
Waiver request to the United States Health Care Financing
Administration by January 1, 1998. The waiver shall be requested pursuant to
Section
1915(c) of the Social Security Act. The Department shall request a waiver of
Section 1902(a)(10)(B) of the Social Security Act in order to target home and
community-based services to individuals with a traumatic brain injury meeting
the Medicaid eligibility criteria set forth in appendices to the Prototype
Waiver request.
Under the waiver, the Department, in cooperation with the
Department of Human Services and any other relevant State, local, or federal
government agency, may establish a nursing facility pre-screening program to
determine whether an applicant who is eligible for medical assistance under
this Article and has a traumatic brain injury may use home and community-based
services as a reasonable, lower-cost alternative form of care. If a waiver
request has not been submitted by
January 1,
1998 the Department shall submit the TBI Prototype Waiver request to the
United States Health Care Financing Administration.
(Source: P.A. 90-335, eff. 8-8-97.)
(305 ILCS 5/5-5d)
Sec. 5-5d. Enhanced transition and follow-up services. The Department of Healthcare and Family Services shall apply for any necessary waivers pursuant to Section 1915(c) of the Social Security Act to facilitate the transition from one residential setting to another and follow-up services. Nothing in this Section shall be construed as limiting current similar programs by the Department of Human Services or the Department on Aging.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-5e)
Sec. 5-5e. Adjusted rates of reimbursement.
(a) Rates or payments for services in effect on June 30, 2012 shall be adjusted and
services shall be affected as required by any other provision of Public Act 97-689. In addition, the Department shall do the following:
(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:
(c) Any assessment imposed by this Code shall continue and nothing in this Section shall be construed to cause it to cease.
(d) Notwithstanding any other provision of this Code to the contrary, subject to federal approval under Title XIX of the Social Security Act, for dates of service on and after July 1, 2014, rates or payments for services provided for the purpose of transitioning children from a hospital to home placement or other appropriate setting by a children's community-based health care center authorized under the Alternative Health Care Delivery Act shall be $683 per day.
(e) (Blank).
(f) (Blank).
(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; 102-16, eff. 6-17-21; 102-687, eff. 12-17-21.)
(305 ILCS 5/5-5e.1)
Sec. 5-5e.1. Safety-Net Hospitals.
(a) A Safety-Net Hospital is an Illinois hospital that:
(b) Definitions. As used in this Section:
(c) Beginning July 1, 2012 and ending on December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2011 or October 1, 2012 shall be a Safety-Net Hospital.
(c-5) Beginning July 1, 2020 and ending on December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2020 and was designated a federal rural referral center under 42 CFR 412.96 as of October 1, 2020 shall be a Safety-Net Hospital.
(d) No later than August 15 preceding the rate year, each hospital shall submit the OBRA form to the Department. Prior to October 1, the Department shall notify each hospital whether it has qualified as a Safety-Net Hospital.
(e) The Department may promulgate rules in order to implement this Section.
(f) Nothing in this Section shall be construed as limiting the ability of the Department to include the Safety-Net Hospitals in the hospital rate reform mandated by Section 14-11 of this Code and implemented under Section 14-12 of this Code and by administrative rulemaking.
(Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21; 102-886, eff. 5-17-22.)
(305 ILCS 5/5-5e.2)
Sec. 5-5e.2. Academic medical centers and major teaching hospital status.
(a) Hospitals dedicated to medical research and medical education shall be classified each State fiscal year in 3 tiers based on specific criteria:
(b) All hospitals seeking to qualify for Tier I, Tier II, or Tier III recognition must annually submit a report to the Department with supporting documentation and attesting to meeting the requirements in this Section. Such reporting must also describe each hospital's education and research activities for the preceding year.
(Source: P.A. 98-104, eff. 7-22-13.)
(305 ILCS 5/5-5f)
Sec. 5-5f. Elimination and limitations of medical assistance services. Notwithstanding any other provision of this Code to the contrary, on and after July 1, 2012:
(305 ILCS 5/5-5g)
Sec. 5-5g. Long-term care patient; resident status. Long-term care providers shall submit all changes in resident status, including, but not limited to, death, discharge, changes in patient credit, third party liability, and Medicare coverage, to the Department through the Medical Electronic Data Interchange System, the Recipient Eligibility Verification System, or the Electronic Data Interchange System established under 89 Ill. Adm. Code 140.55(b) in compliance with the schedule below:
(Source: P.A. 100-665, eff. 8-2-18.)
(305 ILCS 5/5-5h)
Sec. 5-5h. Long-term acute care hospital base rates.
(a) The base per diem rate paid to long-term acute care hospitals for Medicaid services on and after January 1, 2020 must be $60 more than the base rate in effect on June 30, 2019.
(b) Nothing in this Section shall change the rates authorized under Section 5A-12.6 or the Long-Term Acute Care Hospital Quality Improvement Transfer Program Act.
(Source: P.A. 101-10, eff. 6-5-19.)
(305 ILCS 5/5-6) (from Ch. 23, par. 5-6)
Sec. 5-6. Obligations incurred prior to death of a recipient. Obligations incurred but not paid for at the time of a recipient's death
for services authorized under Section 5-5, including medical and other
care in facilities as defined in the Nursing Home Care
Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act, or in like facilities
not required to be licensed under that Act, may be paid, subject to the
rules and regulations of the Illinois Department, after the death of the recipient.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
(305 ILCS 5/5-7) (from Ch. 23, par. 5-7)
Sec. 5-7.
(Repealed).
(Source: P.A. 81-487. Repealed by P.A. 93-20, eff. 6-20-03.)
(305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
Sec. 5-8. Practitioners. In supplying medical assistance, the Illinois
Department may provide for the legally authorized services of (i) persons
licensed under the Medical Practice Act of 1987, as amended, except as
hereafter in this Section stated, whether under a
general or limited license, (ii) persons licensed under the Nurse Practice Act as advanced practice registered nurses, regardless of whether or not the persons have written collaborative agreements, (iii) persons licensed or registered
under
other laws of this State to provide dental, medical, pharmaceutical,
optometric, podiatric, or nursing services, or other remedial care
recognized under State law, (iv) persons licensed under other laws of
this State as a clinical social worker, and (v) persons licensed under other laws of this State as physician assistants. The Department shall adopt rules, no later than 90 days after January 1, 2017 (the effective date of Public Act 99-621), for the legally authorized services of persons licensed under other laws of this State as a clinical social worker.
The Department shall provide for the legally authorized services of persons licensed under the Professional Counselor and Clinical Professional Counselor Licensing and Practice Act as clinical professional counselors and for the legally
authorized services of persons licensed under the Marriage and
Family Therapy Licensing Act as marriage and family
therapists. The
utilization of the services of persons engaged in the treatment or care of
the sick, which persons are not required to be licensed or registered under
the laws of this State, is not prohibited by this Section.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
Sec. 5-9. Choice of medical dispensers. Applicants and recipients shall
be entitled to free choice of those qualified practitioners, hospitals,
nursing homes, and other dispensers of medical services meeting the
requirements and complying with the rules and regulations of the Illinois
Department. However, the Director of Healthcare and Family Services may, after providing
reasonable notice and opportunity for hearing, deny, suspend or terminate
any otherwise qualified person, firm, corporation, association, agency,
institution, or other legal entity, from participation as a vendor of goods
or services under the medical assistance program authorized by this Article
if the Director finds such vendor of medical services in violation of this
Act or the policy or rules and regulations issued pursuant to this Act.
(Source: P.A. 100-538, eff. 1-1-18.)
(305 ILCS 5/5-10) (from Ch. 23, par. 5-10)
Sec. 5-10.
Entitlement to Social Services.
Persons receiving medical
assistance shall be entitled to receive, under Article IX and the Illinois
Act on the Aging, such
rehabilitative, training or other social services as are appropriate to their
condition.
(Source: P.A. 92-651, eff. 7-11-02.)
(305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
Sec. 5-11. Co-operative arrangements; contracts with other State
agencies, health care and rehabilitation organizations, and fiscal
intermediaries.
(a) The Illinois Department may enter into co-operative arrangements
with
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services to
the end that there may be maximum utilization of such services in the
provision of medical assistance.
The Illinois Department shall, not later than June 30, 1993, enter into
one or more co-operative arrangements with the Department of Mental Health
and Developmental Disabilities providing that the Department of Mental
Health and Developmental Disabilities will be responsible for administering
or supervising all programs for services to persons in community care
facilities for persons with developmental disabilities, including but not
limited to intermediate care facilities, that are supported by State funds or
by funding under Title XIX of the federal Social Security Act. The
responsibilities of the Department of Mental Health and Developmental
Disabilities under these agreements are transferred to the Department of
Human Services as provided in the Department of Human Services Act.
The Department may also contract with such State health and
rehabilitation agencies and other public or private health care and
rehabilitation organizations to act for it in supplying designated medical
services to persons eligible therefor under this Article. Any contracts
with health services or health maintenance organizations shall be
restricted to organizations which have been certified as being in
compliance with standards promulgated pursuant to the laws of this State
governing the establishment and operation of health services or health
maintenance organizations. The Department shall renegotiate the contracts with health maintenance organizations and managed care community
networks that took effect August 1, 2003, so as to produce $70,000,000 savings to the Department net of resulting increases to the fee-for-service program for State fiscal year 2006. The Department may also contract with insurance
companies or other corporate entities serving as fiscal intermediaries in
this State for the Federal Government in respect to Medicare payments under
Title XVIII of the Federal Social Security Act to act for the Department in
paying medical care suppliers. The provisions of Section 9 of "An Act in
relation to State finance", approved June 10, 1919, as amended,
notwithstanding, such contracts with State agencies, other health care and
rehabilitation organizations, or fiscal intermediaries may provide for
advance payments.
(b) For purposes of this subsection (b), "managed care community
network" means an entity, other than a health maintenance organization, that
is owned, operated, or governed by providers of health care services within
this State and that provides or arranges primary, secondary, and tertiary
managed health care services under contract with the Illinois Department
exclusively to persons participating in programs administered by the Illinois
Department.
The Illinois Department may certify managed care community
networks, including managed care community networks owned, operated, managed,
or
governed by State-funded medical schools, as risk-bearing entities eligible to
contract with the Illinois Department as Medicaid managed care
organizations. The Illinois Department may contract with those managed
care community networks to furnish health care services to or arrange those
services for individuals participating in programs administered by the Illinois
Department. The rates for those provider-sponsored organizations may be
determined on a prepaid, capitated basis. A managed care community
network may choose to contract with the Illinois Department to provide only
pediatric
health care services.
The
Illinois Department shall by rule adopt the criteria, standards, and procedures
by
which a managed care community network may be permitted to contract with
the Illinois Department and shall consult with the Department of Insurance in
adopting these rules.
A county provider as defined in Section 15-1 of this Code may
contract with the Illinois Department to provide primary, secondary, or
tertiary managed health care services as a managed care
community network without the need to establish a separate entity and shall
be deemed a managed care community network for purposes of this Code
only to the extent it provides services to participating individuals. A county
provider is entitled to contract with the Illinois Department with respect to
any contracting region located in whole or in part within the county. A
county provider is not required to accept enrollees who do not reside within
the county.
In order
to (i) accelerate and facilitate the development of integrated health care in
contracting areas outside counties with populations in excess of 3,000,000 and
counties adjacent to those counties and (ii) maintain and sustain the high
quality of education and residency programs coordinated and associated with
local area hospitals, the Illinois Department may develop and implement a
demonstration program from managed care community networks owned, operated,
managed, or
governed by State-funded medical schools. The Illinois Department shall
prescribe by rule the criteria, standards, and procedures for effecting this
demonstration program.
A managed care community network that
contracts with the Illinois Department to furnish health care services to or
arrange those services for enrollees participating in programs administered by
the Illinois Department shall do all of the following:
The Illinois Department shall contract with an entity or entities to provide
external peer-based quality assurance review for the managed health care
programs administered by the Illinois Department. The entity shall meet all federal requirements for an external quality review organization.
Each managed care community network must demonstrate its ability to
bear the financial risk of serving individuals under this program.
The Illinois Department shall by rule adopt standards for assessing the
solvency and financial soundness of each managed care community network.
Any solvency and financial standards adopted for managed care community
networks
shall be no more restrictive than the solvency and financial standards adopted
under
Section 1856(a) of the Social Security Act for provider-sponsored
organizations under Part C of Title XVIII of the Social Security Act.
The Illinois
Department may implement the amendatory changes to this
Code made by this amendatory Act of 1998 through the use of emergency
rules in accordance with Section 5-45 of the Illinois Administrative Procedure
Act. For purposes of that Act, the adoption of rules to implement these
changes is deemed an emergency and necessary for the public interest,
safety, and welfare.
(c) Not later than June 30, 1996, the Illinois Department shall
enter into one or more cooperative arrangements with the Department of Public
Health for the purpose of developing a single survey for
nursing facilities, including but not limited to facilities funded under Title
XVIII or Title XIX of the federal Social Security Act or both, which shall be
administered and conducted solely by the Department of Public Health.
The Departments shall test the single survey process on a pilot basis, with
both the Departments of Public Aid and Public Health represented on the
consolidated survey team. The pilot will sunset June 30, 1997. After June 30,
1997, unless otherwise determined by the Governor, a single survey shall be
implemented by the Department of Public Health which would not preclude staff
from the Department of Healthcare and Family Services (formerly Department of Public Aid) from going on-site to nursing facilities to
perform necessary audits and reviews which shall not replicate the single State
agency survey required by this Act. This Section shall not apply to community
or intermediate care facilities for persons with developmental disabilities.
(d) Nothing in this Code in any way limits or otherwise impairs the
authority or power of the Illinois Department to enter into a negotiated
contract pursuant to this Section with a managed care community network or
a health maintenance organization, as defined in the Health Maintenance
Organization Act, that provides for
termination or nonrenewal of the contract without cause, upon notice as
provided in the contract, and without a hearing.
(Source: P.A. 95-331, eff. 8-21-07; 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-11.1)
Sec. 5-11.1. Cooperative arrangements; contracts. The Illinois Department
may enter into cooperative
arrangements with
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services to
maximize utilization of these services in the provision of medical assistance.
The Illinois Department shall, not later than June 30, 1994, enter into
one or more cooperative arrangements with the Department of Mental Health
and Developmental Disabilities providing that the Department of Mental
Health and Developmental Disabilities will be responsible for administering
or supervising all programs for services to persons in community care
facilities for persons with mental illness, including but not limited to
intermediate care facilities, that are supported by State funds or by funding
under Title XIX of the federal Social Security Act.
The responsibilities of the Department of Mental Health and Developmental
Disabilities under these agreements are transferred to the Department of
Human Services as provided in the Department of Human Services Act.
The Department may also contract with State health and rehabilitation
agencies and other public or private health care and rehabilitation
organizations to act for it in supplying designated medical services to persons
eligible under this Section. Any contracts with health services or health
maintenance organizations shall be restricted to organizations which have been
certified as being in compliance with standards promulgated under the laws of
this State governing the establishment and operation of health services or
health maintenance organizations. The Department may also contract with
insurance companies or other corporate entities serving as fiscal
intermediaries in this State for the federal government in respect to Medicare
payments under Title XVIII of the federal Social Security Act to act for the
Department in paying medical care suppliers. Nothing in this Section shall be
construed to abrogate any existing doctor/patient relationships with
Department of Healthcare and Family Services recipients or the free choice of clients or their
guardians to select a physician to provide medical care. The provisions of
Section 9 of the State Finance Act notwithstanding, such contracts with State
agencies, other health care and rehabilitation organizations, or fiscal
intermediaries may provide for advance payments.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-11a)
Sec. 5-11a. Health Benefit Information Systems.
(a) It is the intent of the General Assembly to support unified electronic systems initiatives that will improve management of information related to medical assistance programs. This will include improved management capabilities and new systems for Eligibility, Verification, and Enrollment (EVE) that will simplify and increase efficiencies in and access to the medical assistance programs and ensure program integrity. The Department of Healthcare and Family Services, in coordination with the Department of Human Services and other appropriate state agencies, shall develop a plan by July 1, 2011, that will:
(b) The Department of Healthcare and Family Services shall continue to plan for and implement a new Medicaid Management Information System (MMIS) and upgrade the capabilities of the MMIS data warehouse. Upgrades shall include, among other things, enhanced capabilities in data analysis including the ability to identify risk factors that could impact the treatment and resulting quality of care, and tools that perform predictive analytics on data applying to newborns, women with high risk pregnancies, and other populations served by the Department.
(c) The Department of Healthcare and Family Services shall report in its annual Medical Assistance program report each April through April, 2015 on the progress and implementation of this plan.
(Source: P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-12) (from Ch. 23, par. 5-12)
Sec. 5-12.
Funeral and burial.
Upon the death of a recipient who
qualified under class 2, 3 or 4 of Section 5-2, if his estate is
insufficient to pay his funeral and burial expenses and if no other
resources, including assistance from legally responsible relatives, are
available for such purposes, there shall be paid, in accordance with the
standards, rules and regulations of the Illinois Department of Human
Services, such reasonable amounts as may be necessary to meet the costs of
the funeral, burial space, and cemetery charges, or to reimburse any person not
financially responsible for the deceased who has voluntarily made
expenditures for such costs.
(Source: P.A. 92-651, eff. 7-11-02.)
(305 ILCS 5/5-13) (from Ch. 23, par. 5-13)
Sec. 5-13. Claim against estate of recipients. To the extent permitted under
the federal Social Security Act, the amount expended under this Article (1) for
a person of any age who is an inpatient in a nursing facility, an intermediate
care facility for persons with intellectual disabilities, or other medical institution, or (2)
for a person aged 55 or more, shall be a claim against the person's
estate or a claim against the estate of the person's spouse,
regardless of the order of death, but no recovery may
be had thereon until after the death of the surviving spouse, if any, and then
only at such time when there is no surviving child who is under age 21, or
blind, or is a child with a permanent total disability. This Section, however, shall not
bar recovery at the death of the person of amounts of medical assistance paid
to or in his behalf to which he was not entitled; provided that such
recovery shall not be enforced against any real estate while it is occupied
as a homestead by the surviving spouse or other dependent, if no claims by
other creditors have been filed against the estate, or if such claims have
been filed, they remain dormant for failure of prosecution or failure of
the claimant to compel administration of the estate for the purpose of
payment. The term "estate", as used in this Section, with respect to a
deceased person, means all real and personal property and other assets included
within the person's estate, as that term is used in the Probate Act of 1975;
however, in the case of a deceased person who has received (or is entitled to
receive) benefits under a long-term care insurance policy in connection with
which assets or resources are disregarded to the extent that payments are made
or because the deceased person received (or was entitled to receive) benefits
under a long-term care insurance policy, "estate" also includes any
other real and personal property and other assets in which the deceased person
had any legal title or interest at the time of his or her death (to the extent
of that interest), including assets conveyed to a survivor, heir, or assignee
of the deceased person through joint tenancy, tenancy in common, survivorship,
life estate, living trust, or other arrangement. The term "homestead", as used
in this Section, means the dwelling house and contiguous real estate occupied
by a surviving spouse or relative, as defined by the rules and regulations of
the Illinois Department, regardless of the value of the property.
A claim arising under this Section against assets conveyed to a survivor,
heir, or assignee of the deceased person through joint tenancy, tenancy in
common, survivorship, life estate, living trust, or other arrangement is not
effective until the claim is recorded or filed in the manner provided for a
notice of lien in Section 3-10.2. The claim is subject to the same
requirements and conditions to which liens on real property interests are
subject under Sections 3-10.1 through 3-10.10. A claim arising under this
Section attaches to interests owned or subsequently acquired by the estate of a
recipient or the estate of a recipient's surviving spouse.
The transfer or conveyance of any real or personal property of the estate
as
defined in this Section shall be subject to the fraudulent transfer conditions
that apply to real property in Section 3-11 of this Code.
The provisions of this Section shall not affect the validity of claims
against estates for medical assistance provided prior to January 1, 1966 to
aged or blind persons or persons with disabilities receiving aid under Articles V, VII and
VII-A of the 1949 Code.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-13.1)
Sec. 5-13.1. Cost-effectiveness waiver, hardship waivers, and making information about waivers more accessible.
(a) It is the intent of the General Assembly to ease the burden of liens and estate recovery for correctly paid benefits for participants, applicants, and their families and heirs, and to make information about waivers more widely available.
(b) The Department shall waive estate recovery under Sections 3-9 and 5-13 where recovery would not be cost-effective, would work an undue hardship, or for any other just reason, and shall make information about waivers and estate recovery easily accessible.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-13.2)
Sec. 5-13.2.
Notice of claim for payment or against estate.
If the Illinois Department determines, more than 120 days after a person
becomes an institutionalized person, that (i) the institutionalized person, the
institutionalized person's spouse, or any other person is required under this
Code to reimburse the Illinois Department for any part of the amount of medical
assistance provided under this Article to or on behalf of the institutionalized
person or (ii) the institutionalized person's estate is liable for any amount
of medical assistance provided to or on behalf of the institutionalized person,
the Illinois Department shall not make any claim for payment of that amount on
demand, but rather shall establish, in cooperation with the institutionalized
person (and that person's spouse or primary caretaker, if applicable), a
schedule for payment of the amount owed to the Illinois Department.
(Source: P.A. 88-162; 88-670, eff. 12-2-94.)
(305 ILCS 5/5-13.5)
Sec. 5-13.5. (Repealed).
(Source: P.A. 88-670, eff. 12-2-94. Repealed by P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-14) (from Ch. 23, par. 5-14)
Sec. 5-14.
Exemption for Townships.
Nothing in this Article shall be
construed as requiring townships to provide, in whole or in part, medical
assistance to persons who are not residents of the State of Illinois.
In all instances under this Article where medical aid or assistance to
a person who is not a resident of this State would otherwise be in whole
or in part, the responsibility of a township, the Illinois Department shall
be responsible for such aid or assistance.
The Illinois Department shall, by rule or regulation, insure that provision
of such aid or assistance to a non-resident is identical to the uniform
standard of eligibility established by the Illinois Department.
(Source: P.A. 81-519.)
(305 ILCS 5/5-15) (from Ch. 23, par. 5-15)
Sec. 5-15. (a) The Illinois Department is authorized to contract
with community based organizations serving low income communities for a
three year period to demonstrate how and the extent to which preventive
health programs can decrease utilization of medical care services and/or
improve health status.
(b) As used in this Section (1) a community based organization is an
organization established as a not-for-profit corporation under laws of the
State of Illinois which serves a defined geographic community and is
governed by members of that community; and (2) a preventive health program
is any program, service or intervention the purpose of which is to
identify, resolve, or ameliorate problems which contribute to the
utilization of medical services.
(c) The Illinois Department is authorized, for evaluation purposes, to
release names of recipients and other pertinent identification and medical
utilization information to the community organizations under contract.
(d) Contractors shall maintain strict confidentiality of information
released by the Illinois Department by following guidelines established by
the Illinois Department, which shall require that recipients sign a release
for any further use or disclosure of such information.
(Source: P.A. 93-632, eff. 2-1-04.)
(305 ILCS 5/5-15.5)
Sec. 5-15.5.
Preventive physical examinations; demonstration program.
(a) The Illinois Department may establish and implement a demonstration
program of preventive physical examinations over a 3-year period commencing on
January 1, 1994, for persons receiving assistance under Article IV of this
Code and persons eligible for assistance under this Article who are otherwise
eligible for assistance under Article IV but who fail to qualify for cash
assistance under Article IV on the basis of need. Notwithstanding any other
provision of this Section, however, persons who are pregnant or who are less
than 21 years of age shall not be eligible to participate in the demonstration
program. The demonstration program may be implemented for recipients in at
least 2 counties, one with a population of not more than 650,000 as determined
by the 1990 federal census, and one with a population of not more than 100,000
as determined by the 1990 federal census. The Illinois Department may
establish by rule the nature and scope of the preventive physical examinations
required under this Section, except that the services may include, as
appropriate, blood pressure reading, complete blood test appropriate to the
population and risk factors, family planning, nutrition counselling, smoking
evaluation, temperature, urinalysis, chest x-ray, tuberculosis screening, and
appropriate referrals.
(b) Participation in the demonstration program shall be voluntary, and
eligible recipients shall not be subject to sanctions for refusing or failing
to submit to a preventive physical examination or any portion of such an
examination. The Illinois Department may by rule limit each eligible recipient
to one examination during the demonstration period.
(c) For the purpose of carrying out its responsibilities under this Section,
the Illinois Department is authorized to enter into cooperative arrangements
with for-profit and non-profit medical clinics and hospitals, local health
departments, and other providers of medical services. The Illinois Department
of Public Health shall cooperate in the development and establishment of this
demonstration program. During the period of the demonstration program, the
Illinois Department of Public Aid shall study the cost benefit of providing
preventive physical examinations to the targeted group of recipients of public
aid.
(d) Implementation of the demonstration program shall be contingent on the
receipt of all necessary federal waivers.
(Source: P.A. 88-396.)
(305 ILCS 5/5-16) (from Ch. 23, par. 5-16)
Sec. 5-16.
Managed Care.
The Illinois Department may develop and implement
a Primary Care Sponsor System consistent with the provisions of this Section.
The purpose of this managed care delivery system shall be to contain the costs
of providing medical care to Medicaid recipients by having one provider
responsible for managing all aspects of a recipient's medical care. This
managed care system shall have the following characteristics:
The Illinois Department shall seek and obtain necessary authorization
provided under federal law to implement such a program including the waiver of
any federal regulations.
The Illinois Department may implement the amendatory changes to
this Section made by this amendatory Act of 1991 through the use of emergency
rules in accordance with the provisions of Section 5.02 of the Illinois
Administrative Procedure Act. For purposes of the Illinois Administrative
Procedure Act, the adoption of rules to implement the amendatory changes to
this Section made by this amendatory Act of 1991 shall be deemed an emergency
and necessary for the public interest, safety and welfare.
The Illinois Department may establish a managed care system demonstration
program, on a limited basis, as described in this Section. The demonstration
program shall terminate on June 30, 1997. Within 30 days after the end of each
year of the demonstration program's operation, the Illinois Department shall
report to the Governor and the General Assembly concerning the operation of the
demonstration program.
(Source: P.A. 87-14; 88-490.)
(305 ILCS 5/5-16.1) (from Ch. 23, par. 5-16.1)
Sec. 5-16.1. Case Management Services. The Illinois Department may
develop, implement and evaluate a Case Management Services Program which
provides services consistent with the provisions of this Section, and the
Inter-Agency Agreement between the Department of Healthcare and Family Services (formerly Department of Public Aid) and the
Department of Public Health, for a targeted population on a less than
Statewide basis in the State of Illinois. The purpose of this Case
Management Services Program shall be to assist eligible participants in
gaining access to needed medical, social, educational and other services
thereby reducing the likelihood of long-term welfare dependency. The Case
Management Services Program shall have the following characteristics:
The Illinois Department shall take any necessary steps to obtain
authorization or waiver under federal law to implement a Case Management
Services Program. Participation shall be voluntary for the provider and
the recipient.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-16.2)
Sec. 5-16.2.
Long range plan for case management.
The Illinois Department
shall develop a long range plan for the implementation of case management
services, as defined in Section 5-16.1 of this Act, throughout Illinois. The
long range plan shall include: (i) a geographic overview of the State and the
proportion, as determined by the Department of Public Aid and the Department of
Public Health records, of Medicaid eligible pregnant or parenting girls under
17 years of age at the time of the initial assessment; (ii) identification of
high proportion areas; (iii) goals for reducing the likelihood of long-term
welfare dependency; (iv) the time frames for accomplishing the identified
goals; and (v) specific recommendations for administrative or legislative
policies and programs necessary to complete the identified goals. The long
range plan shall take into consideration other resources currently serving the
identified population. The long range plan shall be completed no later than
July 1, 1994, and provided to the Governor and the General Assembly in the form
of a written report.
(Source: P.A. 88-70.)
(305 ILCS 5/5-16.3)
Sec. 5-16.3.
(Repealed).
(Source: P.A. 90-742, eff. 8-13-98. Repealed by P.A. 92-370, eff. 8-15-01.)
(305 ILCS 5/5-16.4)
Sec. 5-16.4. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 99-933, eff. 1-27-17.)
(305 ILCS 5/5-16.5)
Sec. 5-16.5.
Expedited payments.
(a) (Blank).
(b) In a county with a population of 3,000,000 or more, a managed care
community network shall receive expedited payment of its capitated
reimbursement for each of its managed care enrollees if both of the following
criteria are met:
(c) For counties whose population is less than 3,000,000, the Illinois
Department shall establish by rule the terms and conditions under which a
managed care community network shall receive expedited payment, including a
determination of the qualifying percentage criteria for
disproportionate share hospitals and managed care enrollees
within a network receiving services at disproportionate share hospitals or
their affiliated sites.
(Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95.)
(305 ILCS 5/5-16.6)
Sec. 5-16.6.
Provider compliance with certain requirements.
The Illinois
Department shall inquire of appropriate State agencies concerning the status of
all providers' compliance with State income tax requirements, child support
payments in accordance with Article X of this Code, and educational loans
guaranteed by the Illinois State Scholarship Commission. The Illinois
Department may suspend from participation in the medical assistance program,
after reasonable notice and opportunity for a hearing in accordance with
Section
12-4.25 of this Code, those providers not in compliance with
these
requirements, unless payment arrangements acceptable to the appropriate State
agency are made.
(Source: P.A. 90-655, eff. 7-30-98.)
(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. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-16.7a)
Sec. 5-16.7a. Reimbursement for epidural anesthesia services.
In addition to other procedures authorized by the
Department under this Code, the
Department shall provide reimbursement to medical providers for epidural
anesthesia services when ordered by the attending practitioner at the time of
delivery.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-16.8)
Sec. 5-16.8. Required health benefits. The medical assistance program
shall
(i) provide the post-mastectomy care benefits required to be covered by a policy of
accident and health insurance under Section 356t and the coverage required
under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, and 356z.60 of the Illinois
Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois
Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.
The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.
(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff. 1-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
(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. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-16.10)
Sec. 5-16.10.
Managed care entities; marketing.
A managed health care entity
providing services under this Article V
may not engage in door-to-door
marketing activities or marketing activities at an office of the Illinois
Department or a county department in order to enroll
recipients
in the entity's health
care
delivery system. The Department shall adopt rules defining "marketing
activities" prohibited by this Section.
Before a managed health care entity
providing services under this Article V
may market its health care delivery
system
to recipients,
the Illinois Department must approve a marketing plan submitted
by the entity to the Illinois Department. The Illinois Department shall adopt
guidelines for approving marketing plans submitted by managed health care
entities under this Section. Besides prohibiting door-to-door marketing
activities and marketing activities at public aid offices, the guidelines shall
include at least the following:
The Inspector General appointed under Section 12-13.1 may conduct
investigations to determine whether the marketing practices of managed health
care entities
providing services under this Article V
comply with
the guidelines.
(Source: P.A. 90-538, eff. 12-1-97.)
(305 ILCS 5/5-16.11)
Sec. 5-16.11.
Uniform standards applied to managed care entities.
Any
managed care entity providing services under this Code shall use a pharmacy
formulary that is no more restrictive than the Illinois Department's
pharmaceutical program.
(Source: P.A. 92-370, eff. 8-15-01.)
(305 ILCS 5/5-16.12)
Sec. 5-16.12.
Managed Care Reform and Patient Rights Act.
The medical
assistance
program and other programs administered by the Department are subject to the
provisions of the Managed Care Reform and Patient Rights Act.
The
Department may adopt rules
to
implement those provisions. These rules shall require compliance with
that Act in
the medical assistance managed care programs and other programs administered by
the Department. The medical assistance
fee-for-service program is not subject to the provisions of the Managed Care
Reform and Patient Rights Act.
Nothing in the Managed Care Reform and Patient Rights Act shall be
construed to mean that the Department is a health care plan as defined in that
Act simply because the Department enters into contractual relationships with
health care plans.
(Source: P.A. 91-617, eff. 1-1-00.)
(305 ILCS 5/5-16.13)
Sec. 5-16.13. (Repealed).
(Source: P.A. 93-674, eff. 6-10-04. Repealed internally, eff. 12-31-04.)
(305 ILCS 5/5-17) (from Ch. 23, par. 5-17)
Sec. 5-17. Programs to improve access to hospital care.
(a) (1) The General Assembly finds:
(b) The Illinois Department shall require hospitals certified to
participate in the federal Medicaid program to:
(c) From the effective date of this amendatory Act of 1992 until July
1, 1992, nothing in this Section 5-17 shall be construed as creating a
private right of action on behalf of any individual.
(d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-18) (from Ch. 23, par. 5-18)
Sec. 5-18.
(Repealed).
(Source: P.A. 87-895. Repealed by P.A. 92-275, eff. 8-7-01.)
(305 ILCS 5/5-18.5)
Sec. 5-18.5. Perinatal doula and evidence-based home visiting services.
(a) As used in this Section:
"Home visiting" means a voluntary, evidence-based strategy used to support pregnant people, infants, and young children and their caregivers to promote infant, child, and maternal health, to foster educational development and school readiness, and to help prevent child abuse and neglect. Home visitors are trained professionals whose visits and activities focus on promoting strong parent-child attachment to foster healthy child development.
"Perinatal doula" means a trained provider who provides regular, voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period.
"Perinatal doula training" means any doula training that focuses on providing support throughout the prenatal, labor and delivery, or postpartum period, and reflects the type of doula care that the doula seeks to provide.
(b) Notwithstanding any other provision of this Article, perinatal doula services and evidence-based home visiting services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. Perinatal doula services include regular visits beginning in the prenatal period and continuing into the postnatal period, inclusive of continuous support during labor and delivery, that support healthy pregnancies and positive birth outcomes. Perinatal doula services may be embedded in an existing program, such as evidence-based home visiting. Perinatal doula services provided during the prenatal period may be provided weekly, services provided during the labor and delivery period may be provided for the entire duration of labor and the time immediately following birth, and services provided during the postpartum period may be provided up to 12 months postpartum.
(b-5) Notwithstanding any other provision of this Article, beginning January 1, 2023, licensed certified professional midwife services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. The Department shall consult with midwives on reimbursement rates for midwifery services.
(c) The Department of Healthcare and Family Services shall adopt rules to administer this Section. In this rulemaking, the Department shall consider the expertise of and consult with doula program experts, doula training providers, practicing doulas, and home visiting experts, along with State agencies implementing perinatal doula services and relevant bodies under the Illinois Early Learning Council. This body of experts shall inform the Department on the credentials necessary for perinatal doula and home visiting services to be eligible for Medicaid reimbursement and the rate of reimbursement for home visiting and perinatal doula services in the prenatal, labor and delivery, and postpartum periods. Every 2 years, the Department shall assess the rates of reimbursement for perinatal doula and home visiting services and adjust rates accordingly.
(d) The Department shall seek such State plan amendments or waivers as may be necessary to implement this Section and shall secure federal financial participation for expenditures made by the Department in accordance with this Section.
(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-18.10)
Sec. 5-18.10. Reimbursement for postpartum visits.
(a) In this Section:
"Certified lactation counselor" means a health care professional in lactation counseling who has demonstrated the necessary skills, knowledge, and attitudes to provide clinical breastfeeding counseling and management support to families who are thinking about breastfeeding or who have questions or problems during the course of breastfeeding.
"Certified nurse midwife" means a person who exceeds the competencies for a midwife contained in the Essential Competencies for Midwifery Practice, published by the International Confederation of Midwives, and who qualifies as an advanced practice registered nurse.
"Community health worker" means a frontline public health worker who is a trusted member or has an unusually close understanding of the community served. This trusting relationship enables the community health worker to serve as a liaison, link, and intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
"International board-certified lactation consultant" means a health care professional who is certified by the International Board of Lactation Consultant Examiners and specializes in the clinical management of breastfeeding.
"Medical caseworker" means a health care professional who assists in the planning, coordination, monitoring, and evaluation of medical services for a patient with emphasis on quality of care, continuity of services, and affordability.
"Perinatal doula" means a trained provider of regular and voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period.
"Public health nurse" means a registered nurse who promotes and protects the health of populations using knowledge from nursing, social, and public health sciences.
(b) The Illinois Department shall establish a medical assistance program to cover a universal postpartum visit within the first 3 weeks after childbirth and a comprehensive visit within 4 to 12 weeks postpartum for persons who are otherwise eligible for medical assistance under this Article. In addition, postpartum care services rendered by perinatal doulas, certified lactation counselors, international board-certified lactation consultants, public health nurses, certified nurse midwives, community health workers, and medical caseworkers shall be covered under the medical assistance program.
(Source: P.A. 102-665, eff. 10-8-21.)
(305 ILCS 5/5-19) (from Ch. 23, par. 5-19)
Sec. 5-19. Healthy Kids Program.
(a) Any child under the age of 21 eligible to receive Medical Assistance
from the Illinois Department under Article V of this Code shall be eligible
for Early and Periodic Screening, Diagnosis and Treatment services provided
by the Healthy Kids Program of the Illinois Department under the Social
Security Act, 42 U.S.C. 1396d(r).
(b) Enrollment of Children in Medicaid. The Illinois Department shall
provide for receipt and initial processing of applications for Medical
Assistance for all pregnant women and children under the age of 21 at
locations in addition to those used for processing applications for cash
assistance, including disproportionate share hospitals, federally qualified
health centers and other sites as selected by the Illinois Department.
(c) Healthy Kids Examinations. The Illinois Department shall consider
any examination of a child eligible for the Healthy Kids services provided
by a medical provider meeting the requirements and complying with the rules
and regulations of the Illinois Department to be reimbursed as a Healthy
Kids examination.
(d) Medical Screening Examinations.
(e) Minimum Screening Protocols For Periodic Health Screening
Examinations. Health Screening Examinations must include the following
services:
(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.
(h) Data Collection. The Illinois Department shall collect data in a
usable form to track utilization of Healthy Kids screening examinations by
children eligible for Healthy Kids services, including but not limited to
data showing screening examinations and immunizations received, a summary
of follow-up treatment received by children eligible for Healthy Kids
services and the number of children receiving dental, hearing and vision
services.
(i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(j) To ensure full access to the benefits set forth in this
Section, on and after January 1, 2022, the Illinois Department
shall ensure that provider and hospital reimbursements for
immunization as required under this Section are no lower than
70% of the median regional maximum administration fee for the State of Illinois as established
by the U.S. Department of Health and Human Services' Centers
for Medicare and Medicaid Services.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-20)
Sec. 5-20. Electronic health care card. By December 31, 1994, the
Illinois Department may develop and implement by rule an electronic health
information system to process claims electronically and to electronically store
Medicare and Medicaid patient records, medical histories, and billing
information. The Illinois Department may issue each Medicare and Medicaid
recipient a health card containing electronically coded information that will
access the system, verify their Medicare or Medicaid status, and display how
much the patient must pay in deductibles or copayments for a medical procedure.
The Illinois Department may also develop safeguards to protect recipients'
health information from misuse or unauthorized disclosure.
On or before July 1, 2011, the Department shall cease issuing monthly MediPlan cards and shall instead issue permanent or semi-permanent member cards to individuals enrolled for medical assistance. Furthermore, the Department may employ any reasonable means by which providers may verify an individual's eligibility for medical assistance in place of MediPlan cards.
(Source: P.A. 96-940, eff. 1-1-11.)
(305 ILCS 5/5-21)
Sec. 5-21. Immunization. By July 1, 1994, the Illinois Department shall,
in cooperation with the Department of Public Health, establish and implement a
pilot program that will provide immunization services for children on a walk-in
basis at local public aid offices. The Director shall determine the number and
location of the local public aid offices that will participate in the pilot
program. The Illinois Department shall submit a report on the effectiveness
of the program to the General Assembly on or before December 31, 1995.
The Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Human Services, in
cooperation with the Department of Public Health, shall continue to implement
the pilot program after the effective date of this amendatory Act of 1996.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-22)
Sec. 5-22. (Repealed).
(Source: P.A. 90-655, eff. 7-30-98. Repealed by P.A. 96-1123, eff. 1-1-11.)
(305 ILCS 5/5-23)
Sec. 5-23.
(Repealed).
(Source: P.A. 92-581, eff. 6-26-02. Repealed internally, eff. 7-1-03.)
(305 ILCS 5/5-24)
Sec. 5-24. (Repealed).
(Source: P.A. 97-689, eff. 6-14-12. Repealed internally, eff. 1-1-14.)
(305 ILCS 5/5-25)
Sec. 5-25. Pediatric asthma initiative.
(a) During fiscal year 2006, the Department of Public Aid shall evaluate current standards of treatment of asthma for its beneficiaries. The review may include state-of-the-art programs in asthma disease management as well as evidence-based best practices for the early diagnosis, treatment, and control of asthma, particularly in children. The Department's review may include asthma disease management as one component of a comprehensive disease management model. The Department shall consult with the Department of Public Health and other State agencies, advocates, and providers in conducting this review. The Department's review shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The review shall also assess the available methods of implementing and funding asthma disease management and treatment within the Medicaid program.
(b) After completing the review under subsection (a), the Department of Public Aid shall develop a pilot asthma disease management program. The pilot program shall be targeted to an area or areas with the highest prevalence of asthma.
The Department shall consult with the Department of Public Health and other State agencies, federal health agencies, experts in asthma and immunology, providers, and consumers in developing the pilot program. The pilot program shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The pilot program shall be subject to specific appropriations or budget savings derived from the program due to reduced asthma-related hospitalizations or emergency room visits.
(Source: P.A. 94-328, eff. 7-26-05.)
(305 ILCS 5/5-26)
Sec. 5-26. Federal Family Opportunity Act.
(a) As used in this Section, "the federal Act" means the federal Family Opportunity Act, enacted as part of the Deficit Reduction Act of 2005.
(b) Subject to appropriations for program administration and services, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall implement the Medical Assistance provisions of the federal Act as soon as possible after the effective date of this amendatory Act of the 95th General Assembly.
(c) As soon as possible after the effective date of this amendatory Act of the 95th General Assembly, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall take all necessary and appropriate steps to try to secure (i) any available federal funds for a demonstration project regarding home and community-based alternatives to psychiatric residential treatment facilities for children, as authorized by the federal Act, and (ii) the location in Illinois of a family-to-family health information center, as authorized by the federal Act.
(Source: P.A. 97-48, eff. 6-28-11.)
(305 ILCS 5/5-27)
Sec. 5-27. (Repealed).
(Source: P.A. 96-1372, eff. 7-29-10. Repealed internally, eff. 1-1-11.)
(305 ILCS 5/5-28)
Sec. 5-28. Community transition resources. The Department of Healthcare and Family Services, in collaboration with all relevant agencies, shall develop a Community Transition Plan to allow nursing facility residents who are determined to be appropriate for transition to the community to access or acquire resources to support the transition. These strategies may include, but need not be limited to, enhancement of the Community Home Maintenance Allowance, retention of income from work, and incorporation of community transition services into existing home and community-based waiver programs.
(Source: P.A. 96-1372, eff. 7-29-10.)
(305 ILCS 5/5-29)
Sec. 5-29. Income Limits and Parental Responsibility. In light of the unprecedented fiscal crisis confronting the State, it is the intent of the General Assembly to explore whether the income limits and income counting methods established for children under the Covering ALL KIDS Health Insurance Act, pursuant to this amendatory Act of the 96th General Assembly, should apply to medical assistance programs available to children made eligible under the Illinois Public Aid Code, including through home and community based services waiver programs authorized under Section 1915(c) of the Social Security Act, where parental income is currently not considered in determining a child's eligibility for medical assistance. The Department of Healthcare and Family Services is hereby directed, with the participation of the Department of Human Services and stakeholders, to conduct an analysis of these programs to determine parental cost sharing opportunities, how these opportunities may impact the children currently in the programs, waivers and on the waiting list, and any other factors which may increase efficiencies and decrease State costs. The Department is further directed to review how services under these programs and waivers may be provided by the use of a combination of skilled, unskilled, and uncompensated care and to advise as to what revisions to the Nurse Practice Act, and Acts regulating other relevant professions, are necessary to accomplish this combination of care. The Department shall submit a written analysis on the children's programs and waivers as part of the Department's annual Medicaid reports due to the General Assembly in 2011 and 2012.
(Source: P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-30)
Sec. 5-30. Care coordination.
(a) At least 50% of recipients eligible for comprehensive medical benefits in all medical assistance programs or other health benefit programs administered by the Department, including the Children's Health Insurance Program Act and the Covering ALL KIDS Health Insurance Act, shall be enrolled in a care coordination program by no later than January 1, 2015. For purposes of this Section, "coordinated care" or "care coordination" means delivery systems where recipients will receive their care from providers who participate under contract in integrated delivery systems that are responsible for providing or arranging the majority of care, including primary care physician services, referrals from primary care physicians, diagnostic and treatment services, behavioral health services, in-patient and outpatient hospital services, dental services, and rehabilitation and long-term care services. The Department shall designate or contract for such integrated delivery systems (i) to ensure enrollees have a choice of systems and of primary care providers within such systems; (ii) to ensure that enrollees receive quality care in a culturally and linguistically appropriate manner; and (iii) to ensure that coordinated care programs meet the diverse needs of enrollees with developmental, mental health, physical, and age-related disabilities.
(b) Payment for such coordinated care shall be based on arrangements where the State pays for performance related to health care outcomes, the use of evidence-based practices, the use of primary care delivered through comprehensive medical homes, the use of electronic medical records, and the appropriate exchange of health information electronically made either on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements.
(c) To qualify for compliance with this Section, the 50% goal shall be achieved by enrolling medical assistance enrollees from each medical assistance enrollment category, including parents, children, seniors, and people with disabilities to the extent that current State Medicaid payment laws would not limit federal matching funds for recipients in care coordination programs. In addition, services must be more comprehensively defined and more risk shall be assumed than in the Department's primary care case management program as of January 25, 2011 (the effective date of Public Act 96-1501).
(d) The Department shall report to the General Assembly in a separate part of its annual medical assistance program report, beginning April, 2012 until April, 2016, on the progress and implementation of the care coordination program initiatives established by the provisions of Public Act 96-1501. The Department shall include in its April 2011 report a full analysis of federal laws or regulations regarding upper payment limitations to providers and the necessary revisions or adjustments in rate methodologies and payments to providers under this Code that would be necessary to implement coordinated care with full financial risk by a party other than the Department.
(e) Integrated Care Program for individuals with chronic mental health conditions.
(f) A hospital that is located in a county of the State in which the Department mandates some or all of the beneficiaries of the Medical Assistance Program residing in the county to enroll in a Care Coordination Program, as set forth in Section 5-30 of this Code, shall not be eligible for any non-claims based payments not mandated by Article V-A of this Code for which it would otherwise be qualified to receive, unless the hospital is a Coordinated Care Participating Hospital no later than 60 days after June 14, 2012 (the effective date of Public Act 97-689) or 60 days after the first mandatory enrollment of a beneficiary in a Coordinated Care program. For purposes of this subsection, "Coordinated Care Participating Hospital" means a hospital that meets one of the following criteria:
As used in this subsection (f), "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis.
(g) No later than August 1, 2013, the Department shall issue a purchase of care solicitation for Accountable Care Entities (ACE) to serve any children and parents or caretaker relatives of children eligible for medical assistance under this Article. An ACE may be a single corporate structure or a network of providers organized through contractual relationships with a single corporate entity. The solicitation shall require that:
The Department shall allow potential ACE entities 5 months from the date of the posting of the solicitation to submit proposals. After the solicitation is released, in addition to the MCO rate development data available on the Department's website, subject to federal and State confidentiality and privacy laws and regulations, the Department shall provide 2 years of de-identified summary service data on the targeted population, split between children and adults, showing the historical type and volume of services received and the cost of those services to those potential bidders that sign a data use agreement. The Department may add up to 2 non-state government employees with expertise in creating integrated delivery systems to its review team for the purchase of care solicitation described in this subsection. Any such individuals must sign a no-conflict disclosure and confidentiality agreement and agree to act in accordance with all applicable State laws.
During the first 2 years of an ACE's operation, the Department shall provide claims data to the ACE on its enrollees on a periodic basis no less frequently than monthly.
Nothing in this subsection shall be construed to limit the Department's mandate to enroll 50% of its beneficiaries into care coordination systems by January 1, 2015, using all available care coordination delivery systems, including Care Coordination Entities (CCE), MCCNs, or MCOs, nor be construed to affect the current CCEs, MCCNs, and MCOs selected to serve seniors and persons with disabilities prior to that date.
Nothing in this subsection precludes the Department from considering future proposals for new ACEs or expansion of existing ACEs at the discretion of the Department.
(h) Department contracts with MCOs and other entities reimbursed by risk based capitation shall have a minimum medical loss ratio of 85%, shall require the entity to establish an appeals and grievances process for consumers and providers, and shall require the entity to provide a quality assurance and utilization review program. Entities contracted with the Department to coordinate healthcare regardless of risk shall be measured utilizing the same quality metrics. The quality metrics may be population specific. Any contracted entity serving at least 5,000 seniors or people with disabilities or 15,000 individuals in other populations covered by the Medical Assistance Program that has been receiving full-risk capitation for a year shall be accredited by a national accreditation organization authorized by the Department within 2 years after the date it is eligible to become accredited. The requirements of this subsection shall apply to contracts with MCOs entered into or renewed or extended after June 1, 2013.
(h-5) The Department shall monitor and enforce compliance by MCOs with agreements they have entered into with providers on issues that include, but are not limited to, timeliness of payment, payment rates, and processes for obtaining prior approval. The Department may impose sanctions on MCOs for violating provisions of those agreements that include, but are not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. As used in this subsection (h-5), "MCO" has the meaning ascribed to that term in Section 5-30.1 of this Code.
(i) Unless otherwise required by federal law, Medicaid Managed Care Entities and their respective business associates shall not disclose, directly or indirectly, including by sending a bill or explanation of benefits, information concerning the sensitive health services received by enrollees of the Medicaid Managed Care Entity to any person other than covered entities and business associates, which may receive, use, and further disclose such information solely for the purposes permitted under applicable federal and State laws and regulations if such use and further disclosure satisfies all applicable requirements of such laws and regulations. The Medicaid Managed Care Entity or its respective business associates may disclose information concerning the sensitive health services if the enrollee who received the sensitive health services requests the information from the Medicaid Managed Care Entity or its respective business associates and authorized the sending of a bill or explanation of benefits. Communications including, but not limited to, statements of care received or appointment reminders either directly or indirectly to the enrollee from the health care provider, health care professional, and care coordinators, remain permissible. Medicaid Managed Care Entities or their respective business associates may communicate directly with their enrollees regarding care coordination activities for those enrollees.
For the purposes of this subsection, the term "Medicaid Managed Care Entity" includes Care Coordination Entities, Accountable Care Entities, Managed Care Organizations, and Managed Care Community Networks.
For purposes of this subsection, the term "sensitive health services" means mental health services, substance abuse treatment services, reproductive health services, family planning services, services for sexually transmitted infections and sexually transmitted diseases, and services for sexual assault or domestic abuse. Services include prevention, screening, consultation, examination, treatment, or follow-up.
For purposes of this subsection, "business associate", "covered entity", "disclosure", and "use" have the meanings ascribed to those terms in 45 CFR 160.103.
Nothing in this subsection shall be construed to relieve a Medicaid Managed Care Entity or the Department of any duty to report incidents of sexually transmitted infections to the Department of Public Health or to the local board of health in accordance with regulations adopted under a statute or ordinance or to report incidents of sexually transmitted infections as necessary to comply with the requirements under Section 5 of the Abused and Neglected Child Reporting Act or as otherwise required by State or federal law.
The Department shall create policy in order to implement the requirements in this subsection.
(j) Managed Care Entities (MCEs), including MCOs and all other care coordination organizations, shall develop and maintain a written language access policy that sets forth the standards, guidelines, and operational plan to ensure language appropriate services and that is consistent with the standard of meaningful access for populations with limited English proficiency. The language access policy shall describe how the MCEs will provide all of the following required services:
(k) The Department shall actively monitor the contractual relationship between Managed Care Organizations (MCOs) and any dental administrator contracted by an MCO to provide dental services. The Department shall adopt appropriate dental Healthcare Effectiveness Data and Information Set (HEDIS) measures and shall include the Annual Dental Visit (ADV) HEDIS measure in its Health Plan Comparison Tool and Illinois Medicaid Plan Report Card that is available on the Department's website for enrolled individuals.
The Department shall collect from each MCO specific information about the types of contracted, broad-based care coordination occurring between the MCO and any dental administrator, including, but not limited to, pregnant women and diabetic patients in need of oral care.
(Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff. 6-4-18.)
(305 ILCS 5/5-30.1)
Sec. 5-30.1. Managed care protections.
(a) As used in this Section:
"Managed care organization" or "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis.
"Emergency services" include:
(b) As provided by Section 5-16.12, managed care organizations are subject to the provisions of the Managed Care Reform and Patient Rights Act.
(c) An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid fee-for-service program methodology, including all policy adjusters, including but not limited to Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates.
(d) An MCO shall pay for all post-stabilization services as a covered service in any of the following situations:
(e) The following requirements apply to MCOs in determining payment for all emergency services:
(f) Network adequacy and transparency.
(g) Timely payment of claims.
(g-5) Recognizing that the rapid transformation of the Illinois Medicaid program may have unintended operational challenges for both payers and providers:
If the fee-for-service system is ultimately determined to have been responsible for coverage on the date of service, the Department shall provide for an extended period for claims submission outside the standard timely filing requirements.
(g-6) MCO Performance Metrics Report.
(g-7) MCO claims processing and performance analysis. In order to monitor MCO payments to hospital providers, pursuant to Public Act 100-580, the Department shall post an analysis of MCO claims processing and payment performance on its website every 6 months. Such analysis shall include a review and evaluation of a representative sample of hospital claims that are rejected and denied for clean and unclean claims and the top 5 reasons for such actions and timeliness of claims adjudication, which identifies the percentage of claims adjudicated within 30, 60, 90, and over 90 days, and the dollar amounts associated with those claims.
(g-8) Dispute resolution process. The Department shall maintain a provider complaint portal through which a provider can submit to the Department unresolved disputes with an MCO. An unresolved dispute means an MCO's decision that denies in whole or in part a claim for reimbursement to a provider for health care services rendered by the provider to an enrollee of the MCO with which the provider disagrees. Disputes shall not be submitted to the portal until the provider has availed itself of the MCO's internal dispute resolution process. Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the Department of Healthcare and Family Services' complaint portal no sooner than 30 days after submitting to the MCO's internal process and not later than 30 days after the unsatisfactory resolution of the internal MCO process or 60 days after submitting the dispute to the MCO internal process. Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy. Within 10 business days of receipt of a complaint, the Department shall present such disputes to the appropriate MCO, which shall then have 30 days to issue its written proposal to resolve the dispute. The Department may grant one 30-day extension of this time frame to one of the parties to resolve the dispute. If the dispute remains unresolved at the end of this time frame or the provider is not satisfied with the MCO's written proposal to resolve the dispute, the provider may, within 30 days, request the Department to review the dispute and make a final determination. Within 30 days of the request for Department review of the dispute, both the provider and the MCO shall present all relevant information to the Department for resolution and make individuals with knowledge of the issues available to the Department for further inquiry if needed. Within 30 days of receiving the relevant information on the dispute, or the lapse of the period for submitting such information, the Department shall issue a written decision on the dispute based on contractual terms between the provider and the MCO, contractual terms between the MCO and the Department of Healthcare and Family Services and applicable Medicaid policy. The decision of the Department shall be final. By January 1, 2020, the Department shall establish by rule further details of this dispute resolution process. Disputes between MCOs and providers presented to the Department for resolution are not contested cases, as defined in Section 1-30 of the Illinois Administrative Procedure Act, conferring any right to an administrative hearing.
(g-9)(1) The Department shall publish annually on its website a report on the calculation of each managed care organization's medical loss ratio showing the following:
(2) The medical loss ratio shall be calculated consistent with federal law and regulation following a claims runout period determined by the Department.
(g-10)(1) "Liability effective date" means the date on which an MCO becomes responsible for payment for medically necessary and covered services rendered by a provider to one of its enrollees in accordance with the contract terms between the MCO and the provider. The liability effective date shall be the later of:
(2) The standardized roster form may be submitted to the MCO at the same time that the provider submits an enrollment application to the Department through IMPACT.
(3) By October 1, 2019, the Department shall require all MCOs to update their provider directory with information for new practitioners of existing contracted providers within 30 days of receipt of a complete and accurate standardized roster template in the format approved by the Department provided that the provider is effective in the Department's provider enrollment subsystem within the IMPACT system. Such provider directory shall be readily accessible for purposes of selecting an approved health care provider and comply with all other federal and State requirements.
(g-11) The Department shall work with relevant stakeholders on the development of operational guidelines to enhance and improve operational performance of Illinois' Medicaid managed care program, including, but not limited to, improving provider billing practices, reducing claim rejections and inappropriate payment denials, and standardizing processes, procedures, definitions, and response timelines, with the goal of reducing provider and MCO administrative burdens and conflict. The Department shall include a report on the progress of these program improvements and other topics in its Fiscal Year 2020 annual report to the General Assembly.
(g-12) Notwithstanding any other provision of law, if the
Department or an MCO requires submission of a claim for payment
in a non-electronic format, a provider shall always be afforded
a period of no less than 90 business days, as a correction
period, following any notification of rejection by either the
Department or the MCO to correct errors or omissions in the
original submission.
Under no circumstances, either by an MCO or under the
State's fee-for-service system, shall a provider be denied
payment for failure to comply with any timely submission
requirements under this Code or under any existing contract,
unless the non-electronic format claim submission occurs after
the initial 180 days following the latest date of service on
the claim, or after the 90 business days correction period
following notification to the provider of rejection or denial
of payment.
(h) The Department shall not expand mandatory MCO enrollment into new counties beyond those counties already designated by the Department as of June 1, 2014 for the individuals whose eligibility for medical assistance is not the seniors or people with disabilities population until the Department provides an opportunity for accountable care entities and MCOs to participate in such newly designated counties.
(i) The requirements of this Section apply to contracts with accountable care entities and MCOs entered into, amended, or renewed after June 16, 2014 (the effective date of Public Act 98-651).
(j) Health care information released to managed care organizations. A health care provider shall release to a Medicaid managed care organization, upon request, and subject to the Health Insurance Portability and Accountability Act of 1996 and any other law applicable to the release of health information, the health care information of the MCO's enrollee, if the enrollee has completed and signed a general release form that grants to the health care provider permission to release the recipient's health care information to the recipient's insurance carrier.
(k) The Department of Healthcare and Family Services, managed care organizations, a statewide organization representing hospitals, and a statewide organization representing safety-net hospitals shall explore ways to support billing departments in safety-net hospitals.
(l) The requirements of this Section added by Public Act 102-4 shall apply to
services provided on or after the first day of the month that
begins 60 days after April 27, 2021 (the effective date of Public Act 102-4).
(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21; 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-30.2)
Sec. 5-30.2. Monthly reports; managed care enrollment.
(a) As used in this Section, "Medicaid Managed Care Entity" means a Managed Care Organization (MCO), a Managed Care Community Network (MCCN), an Accountable Care Entity (ACE), or a Care Coordination Entity (CCE) contracted by the Department.
(b) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of persons in the State's medical assistance program. In addition, as soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of recipients of medical assistance into a Medicaid Managed Care Entity contracted by the Department. As soon as practical if the data is reasonably available, but no later than January 1, 2017, the monthly reports shall include all of the following information for the medical assistance program generally and, separately, for each Medicaid Managed Care Entity contracted by the Department:
(c) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website detailing the percentage of persons enrolled in each Medicaid Managed Care Entity that was assigned using an auto-assignment algorithm. This percentage should also report the type of enrollee who was assigned using an auto-assignment algorithm, including, but not limited to, persons enrolled in the medical assistance program in each of the groups listed in subsection (b) of this Section.
(d) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include data on the 2 most recently available months and data comparing the most recently available month to that month in the prior year.
(e) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include a breakdown of language preference for enrollees by English, Spanish, and the next 4 most commonly used languages.
(f) The Department must annually publish on its website each Medicaid Managed Care Entity's quality metrics outcomes and must make public an independent annual quality review report on the State's Medicaid managed care delivery system.
(Source: P.A. 99-86, eff. 7-21-15.)
(305 ILCS 5/5-30.3)
Sec. 5-30.3. Empowering meaningful patient choice in Medicaid Managed Care.
(a) Definitions. As used in this Section:
"Client enrollment services broker" means a vendor the Department contracts with to carry out activities related to Medicaid recipients' enrollment, disenrollment, and renewal with Medicaid Managed Care Entities.
"Composite domains" means the synthesized categories reflecting the standardized quality performance measures included in the consumer quality comparison tool. At a minimum, these composite domains shall display Medicaid Managed Care Entities' individual Plan performance on standardized quality, timeliness, and access measures.
"Consumer quality comparison tool" means an online and paper tool developed by the Department with input from interested stakeholders reflecting the performance of Medicaid Managed Care Entity Plans on standardized quality performance measures. This tool shall be designed in a consumer-friendly and easily understandable format.
"Covered services" means those health care services to which a covered person is entitled to under the terms of the Medicaid Managed Care Entity Plan.
"Facilities" includes, but is not limited to, federally qualified health centers, skilled nursing facilities, and rehabilitation centers.
"Hospitals" includes, but is not limited to, acute care, rehabilitation, children's, and cancer hospitals.
"Integrated provider directory" means a searchable database bringing together network data from multiple Medicaid Managed Care Entities that is available through client enrollment services.
"Medicaid eligibility redetermination" means the process by which the eligibility of a Medicaid recipient is reviewed by the Department to determine if the recipient's medical benefits will continue, be modified, or terminated.
"Medicaid Managed Care Entity" has the same meaning as defined in Section 5-30.2 of this Code.
(b) Provider directory transparency.
(c) Formulary transparency.
(d) Grievances and appeals. The Department shall display prominently on its website consumer-oriented information describing how a Medicaid enrollee can file a complaint or grievance, request a fair hearing for any adverse action taken by the Department or a Medicaid Managed Care Entity, and access free legal assistance or other assistance made available by the State for Medicaid enrollees to pursue an action.
(e) Medicaid redetermination information.
The Department shall require the client enrollment services broker to display prominently on the client enrollment services broker's website a description of where a Medicaid enrollee can access information regarding the Medicaid redetermination process.
(f) Medicaid care coordination information. The client enrollment services broker shall display prominently on its website, in an easily understandable format, consumer-oriented information regarding the role of care coordination services within Medicaid Managed Care. Such information shall include, but shall not be limited to:
(g) Consumer quality comparison tool.
(h)
The Department may adopt rules and take any other appropriate action necessary to implement its responsibilities under this Section.
(Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.4)
Sec. 5-30.4. Provider inquiry portal. The Department shall establish, no later than January 1, 2018, a web-based portal to accept inquiries and requests for assistance from managed care organizations under contract with the State and providers under contract with managed care organizations to provide direct care.
(Source: P.A. 99-719, eff. 1-1-17; 100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.5)
Sec. 5-30.5. Managed care; automatic assignment. The
Department shall, within a reasonable period of time after
relevant data from managed care entities has been collected and
analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and
implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes
into account quality scores and other operational proficiency
criteria developed, defined, and adopted by the Department, to
automatically assign Medicaid enrollees served under the
Family Health Plan and the Integrated Care Program and those
Medicaid enrollees eligible for medical assistance pursuant to
the Patient Protection and Affordable Care Act (Public Law 111-148) into managed care entities, including Accountable
Care Entities, Managed Care Community Networks, and Managed
Care Organizations. The quality metrics used shall be
measurable for all entities. The algorithm shall not use the
quality and proficiency metrics to reassign enrollees out of
any plan in which they are enrolled at the time and shall only
be used if the client has not voluntarily selected a primary
care physician and a managed care entity or care coordination
entity. Clients shall have one opportunity within 90 calendar
days after auto-assignment by algorithm to select a different
managed care entity. The algorithm developed and implemented
shall favor assignment into managed care entities with the
highest quality scores and levels of compliance with the
operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists.
(Source: P.A. 99-898, eff. 1-1-17; 100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.6)
Sec. 5-30.6. Managed care organization contracts procurement requirement. Beginning on March 12, 2018 (the effective date of Public Act 100-580), any new contract between the Department and a managed care organization as defined in Section 5-30.1 shall be procured in accordance with the Illinois Procurement Code.
(a) Application.
(b) In the event any provision of this Section or of the Illinois Procurement Code is inconsistent with applicable federal law or would have the effect of foreclosing the use, potential use, or receipt of federal financial participation, the applicable federal law or funding condition shall prevail, but only to the extent of such inconsistency.
(Source: P.A. 100-580, eff. 3-12-18; 101-81, eff. 7-12-19.)
(305 ILCS 5/5-30.7)
Sec. 5-30.7. Encounter data guidelines; provider fee schedule.
(a) No later than 60 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall publish on its website comprehensive written guidance on the submission of encounter data by managed care organizations. This information shall be updated and published as needed, but at least quarterly. The Department shall inform providers and managed care organizations of any updates via provider notices.
(b) The Department shall publish on its website provider fee schedules on both a portable document format (PDF) and EXCEL format. The portable document format shall serve as the ultimate source if there is a discrepancy.
(Source: P.A. 100-580, eff. 3-12-18.)
(305 ILCS 5/5-30.8)
Sec. 5-30.8. Managed care organization rate transparency.
(a) For the establishment of managed care
organization (MCO) capitation base rate payments from the State,
including, but not limited to: (i) hospital fee schedule
reforms and updates, (ii) rates related to a single
State-mandated preferred drug list, (iii) rate updates related
to the State's preferred drug list, (iv) inclusion of coverage
for children with special needs, (v) inclusion of coverage for
children within the child welfare system, (vi) annual MCO
capitation rates, and (vii) any retroactive provider fee
schedule adjustments or other changes required by legislation
or other actions, the Department of Healthcare and Family
Services shall implement a capitation base rate setting process beginning
on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following
elements of transparency:
(b) For the development of capitation base rates for new capitation rate years:
(c) For the development of capitation base rates reflecting policy changes:
(d) For the development of capitation base rates for retroactive policy or
fee schedule changes:
(e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.
(Source: P.A. 100-646, eff. 7-27-18; 101-81, eff. 7-12-19.)
(305 ILCS 5/5-30.9)
Sec. 5-30.9. Disenrollment requirements; managed care organization. Disenrollment of a Medicaid enrollee from a managed care organization under contract with the Department shall be in accordance with the requirements of 42 CFR 438.56 whenever a contract is terminated between a Medicaid managed care health plan and a primary care provider that results in a disruption to the Medicaid enrollee's provider-beneficiary relationship.
(Source: P.A. 100-950, eff. 8-19-18; 101-81, eff. 7-12-19.)
(305 ILCS 5/5-30.10)
Sec. 5-30.10. Electronic report submission. To preserve the quality of data and ensure productive oversight of Medicaid managed care organizations, all regular reports required, either by contract or statute, to be collected by the Department from managed care organizations shall be collected through a secure electronic format and medium as designated by the Department. The Department shall consider concerns raised by the contractor about potential burdens associated with producing the report. Ad hoc reports may be collected in alternative manners.
(Source: P.A. 100-1105, eff. 8-27-18; 101-81, eff. 7-12-19.)
(305 ILCS 5/5-30.11)
Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when ordered by: (1) a physician licensed to practice medicine in all its branches and rendered by a licensed or certified health care professional with expertise in applied behavior analysis; or (2) when evaluated and treated by a behavior analyst licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019.
(Source: P.A. 101-10, eff. 6-5-19; 102-558, eff. 8-20-21; 102-953, eff. 5-27-22.)
(305 ILCS 5/5-30.12)
Sec. 5-30.12. Managed care claim rejection and denial management.
(a) In order to provide greater transparency to managed care organizations (MCOs) and providers, the Department shall explore the availability of and, if reasonably available, procure technology that, for all electronic claims, with the exception of direct data entry claims, meets the following needs:
(b) If the Department chooses to implement front end edits or customized responses to claims submissions, the MCOs and other stakeholders shall be consulted prior to implementation and providers shall be notified of edits at least 30 days prior to their effective date.
(c) Neither the technology nor MCO policy shall require providers to submit claims through a process other than the pipeline. MCOs may request supplemental information needed for adjudication which cannot be contained in the claim file to be submitted separately to the MCOs.
(d) The technology shall allow the Department to fully analyze and report on MCO claims processing and payment performance by provider type.
(Source: P.A. 101-209, eff. 8-5-19.)
(305 ILCS 5/5-30.13)
Sec. 5-30.13. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information:
The Department shall publish the reports on its website and shall maintain each report on its website for 5 years. In May of 2020 and every May thereafter, the Department shall hold 2 annual public workshops, one in Chicago and one in Springfield. The workshops shall include each Medicaid managed care health plan and shall be open to vendor communities to discuss the submitted plans and to seek to connect vendors with the Medicaid managed care health plans.
(Source: P.A. 101-209, eff. 8-5-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5-30.14)
Sec. 5-30.14. Medicaid managed care organizations; preferred drug lists.
(a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy, and community-based organizations, providers, and entities with expertise in drug formulary development.
(b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website. Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls.
(c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall:
All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act.
(2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation:
One non-voting clinician recommended by an association of Medicaid managed care health plans shall serve a term of 3 years on the Board without compensation.
Organizations interested in nominating non-voting clinicians to advise the Board may submit requests to participate to the Illinois Department.
A licensed physician recommended by the Rare Disease Commission who is a rare disease specialist and possesses scientific knowledge and medical training with respect to rare diseases and is familiar with drug and biological products and treatment shall be notified in advance to attend an Illinois Drug and Therapeutics Advisory Board meeting when a drug or biological product is scheduled to be reviewed in order to advise and make recommendations on drugs or biological products.
(d) The Illinois Department shall adopt rules, to be in place no later than January 1, 2020, for the purpose of establishing and maintaining the Board.
(Source: P.A. 101-62, eff. 7-12-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5-30.16)
Sec. 5-30.16. Medicaid Business Opportunity Commission.
(a) The Medicaid Business Opportunity Commission is
created within the Department of Healthcare and Family Services
to develop a program to support and grow minority, women, and persons with disability owned businesses.
(b) The Commission shall consist of the following members:
(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d) The members of the Commission shall receive no compensation for their services as members of the Commission.
(e) The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission.
(f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(g) The Commission shall:
(h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program.
(i) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
(305 ILCS 5/5-30.17)
Sec. 5-30.17. Medicaid Managed Care Oversight Commission.
(a) The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program.
(b) The Commission shall consist of the following members:
(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d) The members of the Commission shall receive no compensation for their services as members of the Commission.
(e) The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(f) The Commission shall:
(f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding processing.
(g) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
(305 ILCS 5/5-30a)
Sec. 5-30a. Exemptions from managed care enrollment; children. Notwithstanding any other provision of law, the Department shall not require any of the following children to enroll in or transition to the State's managed care medical assistance program:
Any children who meet the criteria under paragraph (1) or (2) and who are enrolled in the State's managed care medical assistance program on or before the effective date of this amendatory Act of the 100th General Assembly shall be given the option to disenroll from the State's managed care medical assistance program and receive medical assistance coverage under the State's traditional fee-for-service program.
(Source: P.A. 100-990, eff. 1-1-19.)
(305 ILCS 5/5-30b)
Sec. 5-30b. Exemptions from managed care; ground ambulance services. Notwithstanding any other provision of law, beginning on the effective date of this amendatory Act of the 102nd General Assembly, the Department shall exempt ground ambulance services as described in subsections (c-1) and (c-2) of Section 5-4.2. These services shall continue to be paid under the State's traditional fee-for-service program.
(Source: P.A. 102-661, eff. 1-1-22.)
(305 ILCS 5/5-30d)
Sec. 5-30d. Increased funding for transportation services. Beginning no later than January 1, 2023 and subject to federal approval, the amount allocated to fund rates for medi-car, service car, and attendant services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $24,000,000.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-31)
Sec. 5-31. Medicaid Research and Education Support Fund.
(a) There is created in the State treasury the Medicaid Research and Education Support 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, donations, and grants from private and public colleges and universities and disbursing moneys only for the following purposes, notwithstanding any other provision of law, for making payments to hospitals as required under Section 5-32 of this Code and any amounts which are reimbursable to the federal government for payments from this Fund which are required to be paid by State warrant.
Disbursements from the Fund shall be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.
(c) The Fund shall consist of the following:
(d) Interfund transfers from the Medicaid Research and Education Support Fund are prohibited.
(Source: P.A. 98-104, eff. 7-22-13.)
(305 ILCS 5/5-32)
Sec. 5-32. Medicaid research and education enhancement payments.
(a) The Department shall make Medicaid enhancement payments to Tier I and Tier II academic medical centers as defined in Section 5-5e.2 of this Code identified as primary affiliates by any university or college that makes a donation to the Medicaid Research and Education Support Fund.
(b) By April 30 of each year, a university or college that intends to make a donation to the Medicaid Research and Education Support Fund for the upcoming State fiscal year must notify the Department of this intent and identify a primary Tier I or Tier II academic medical center as defined in Section 5-5e.2 of this Code.
(c) Only Tier I and Tier II academic medical centers as defined in Section 5-5e.2 of this Code identified by a university or college as required under subsection (b) of this Section are eligible to receive payments under this Section.
(d) Reimbursement methodology. The Department shall develop a reimbursement methodology consistent with this Section for distribution of moneys from the funds in a manner that would allow distributions from these funds to be matchable under Title XIX of the Social Security Act. The Department may enhance payment rates to any combination of Medicaid inpatient or outpatient Medicaid services. The Department may enhance Medicaid physician services for physicians employed by Tier I or Tier II academic medical centers as defined in Section 5-5e.2 of this Code qualified to receive payment under this Section if the Department and the Tier I or Tier II academic medical centers as defined in Section 5-5e.2 of this Code agree prior to the start of the State fiscal year for which payments are made. The Department shall promulgate rules necessary to make these distributions matchable.
(e) The Department of Healthcare and Family Services must submit a State Medicaid Plan Amendment to the Centers for Medicare and Medicaid Services to implement the payments under this Section within 60 days of the effective date of this amendatory Act of the 98th General Assembly.
(f) Reimbursements or payments by the State. Nothing in this Section may be used to reduce reimbursements or payments by the State to a hospital under any other Act.
(Source: P.A. 98-104, eff. 7-22-13.)
(305 ILCS 5/5-33)
Sec. 5-33. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)
(305 ILCS 5/5-34)
Sec. 5-34. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)
(305 ILCS 5/5-35)
Sec. 5-35. Personal needs allowance. For a person who is a resident in a facility licensed under the ID/DD Community Care Act, the Community-Integrated Living Arrangements Licensure and Certification Act, the Specialized Mental Health Rehabilitation Act of 2013, or the MC/DD Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the State shall pay an amount in addition to the minimum monthly personal needs allowance authorized under Section 1902(q) of Title XIX of the Social Security Act (42 U.S.C. 1396(q)) so that the person's total monthly personal needs allowance from both State and federal sources equals $60.
(Source: P.A. 100-23, eff. 7-6-17.)
(305 ILCS 5/5-36)
Sec. 5-36. Pharmacy benefits.
(a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law.
(2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies:
(b) The provisions of this Section shall not apply to outpatient pharmacy services provided by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b or any pharmacy owned by or contracted with the covered entity. A Medicaid managed care organization shall, either directly or through a pharmacy benefit manager, administer and reimburse outpatient pharmacy claims submitted by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b, its owned pharmacies, and contracted pharmacies in accordance with the contractual agreements the Medicaid managed care organization or its pharmacy benefit manager has with such facilities and pharmacies and in accordance with subsection (h-5).
(b-5) Any pharmacy benefit manager that contracts with a Medicaid managed care organization to administer and reimburse pharmacy claims as provided in this Section must be registered with the Director of Insurance in accordance with Section 513b2 of the Illinois Insurance Code.
(c) On at least an annual basis, the Director of the Department of Healthcare and Family Services shall submit a report beginning no later than one year after January 1, 2020 (the effective date of Public Act 101-452) that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section.
(d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department.
(e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information:
(f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made
available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value. The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable.
(g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification. As used in this Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies.
(h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider:
(h-5) Unless required by law, a Medicaid managed care organization or pharmacy benefit manager administering or managing benefits on behalf of a Medicaid managed care organization shall not refuse to contract with a 340B entity or 340B pharmacy for refusing to accept less favorable payment terms or reimbursement methodologies when compared to similarly situated non-340B entities and shall not include in a contract with a 340B entity or 340B pharmacy a provision that:
A provision that violates this subsection in any contract between a Medicaid managed care organization or its pharmacy benefit manager and a 340B entity entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
In this subsection (h-5):
"340B entity" means a covered entity as defined in 42 U.S.C. 256b(a)(4) authorized to participate in the 340B drug discount program.
"340B pharmacy" means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
(i) Nothing in this Section shall be construed to prohibit a pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy provider as for a pharmacy owned, controlled, or otherwise associated with the pharmacy benefit manager.
(j) A pharmacy benefit manager shall establish and implement a process for the resolution of disputes arising out of this Section, which shall be approved by the Department.
(k) The Department shall adopt rules establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.
(Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)
(305 ILCS 5/5-36.1)
Sec. 5-36.1. Earned income for residents of community-integrated living arrangements.
(a) Beginning no later than July 1, 2021, residents of facilities licensed under the Community-Integrated Living Arrangements Licensure and Certification Act who are determined to be eligible for medical assistance under this Code and who are enrolled in the State's home and community-based services waiver program for adults with developmental disabilities shall retain all earned income from employment or community day services activities.
(b) No portion of earned income shall be applied toward the facilities rate reimbursement methodology. The Department of Human Services shall ensure the rates of payments paid to facilities under the Code are held harmless.
(Source: P.A. 102-343, eff. 8-13-21.)
(305 ILCS 5/5-36.5)
Sec. 5-36.5. Education on mental health and substance use treatment services for children and young adults. The Department of Healthcare and Family Services shall develop a layman's guide to the mental health and substance use treatment services available in Illinois through the Medical Assistance Program and through the Family Support Program, or other publicly funded programs, similar to what Massachusetts developed, to help families understand what services are available to them when they have a child in need of treatment or support. The guide shall be in easy-to-understand language, be prominently available on the Department of Healthcare and Family Services' website, and be part of a statewide communications campaign to ensure families are aware of Family Support Program services. It shall briefly explain the service and whether it is covered by the Medical Assistance Program, the Family Support Program, or any other public funding source. Within one year after January 1, 2020 (the effective date of Public Act 101-461), the Department of Healthcare and Family Services shall complete this guide, have it available on its website, and launch the communications campaign.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.)
(305 ILCS 5/5-37)
Sec. 5-37. Billing mechanism for preventive mental health services delivered to children.
(a) The General Assembly finds:
(b) Consistent with the existing policy of the Department of Healthcare and Family Services and the federal Early and Periodic Screening, Diagnostic and Treatment requirement, within 3 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services shall convene a working group that includes children's mental health providers to receive input on recommendations to develop a medically appropriate and practical solution that enables mental health providers and professionals to deliver and receive reimbursement for medically necessary mental health services provided to a Medicaid-eligible child under age 21 that has a mental health need but does not have a mental health diagnosis in order to prevent the development of a serious mental health condition. The working group shall ensure that the recommended solution works in practice and does not deter clinicians from delivering prevention and early treatment to children with mental health needs but who do not have a diagnosed mental illness. The Department of Healthcare and Family Services shall meet with this working group at least 4 times prior to finalizing the solution to enable and allow for mental health services for a child without a mental health diagnosis for purposes of prevention and early treatment when recommended by a licensed practitioner of the healing arts. If the Department of Healthcare and Family Services determines that an Illinois Title XIX State Plan amendment is necessary to implement this Section, the State Plan amendment shall be filed with the federal Centers for Medicare and Medicaid Services by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly. If rulemaking is required to implement this Section, the rule shall be filed by the Department of Healthcare and Family Services with the Joint Committee on Administrative Rules by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly, or if federal approval is required, within 6 months after federal approval. If federal approval is required but not granted, this Section shall become inoperative.
(Source: P.A. 101-461, eff. 1-1-20.)
(305 ILCS 5/5-38)
Sec. 5-38. Alignment of children's mental health treatment systems. The Governor's Office shall establish, convene, and lead a working group that includes the Director of Healthcare and Family Services, the Secretary of Human Services, the Director of Public Health, the Director of Children and Family Services, the Director of Juvenile Justice, the State Superintendent of Education, and the appropriate agency staff who will be responsible for implementation or oversight of reforms to children's behavioral health services. The working group shall meet at least quarterly to foster interagency collaboration and work toward the goal of aligning services and programs to begin to create a coordinated children's behavioral health system consistent with system of care principles that spans across State agencies, rather than separate siloed systems with different requirements, rates, and administrative processes and standards.
(Source: P.A. 101-461, eff. 1-1-20.)
(305 ILCS 5/5-39)
Sec. 5-39. Behavioral health services for children; diagnostic assessment system. Beginning on July 1, 2022, if it is necessary to provide a diagnostic code for behavioral health services for children ages 5 and under, providers shall utilize a developmentally appropriate and age-appropriate diagnostic assessment system, such as the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC:0-5), for diagnosis and treatment planning. If necessary for billing purposes, the provider, managed care organization, or Department shall utilize the existing crosswalk tool to convert the developmentally appropriate and age-appropriate diagnosis code to the relevant code available in the State system.
By no later than January 1, 2022, the Department shall make recommendations to the General Assembly on the resources needed to integrate developmentally appropriate and age-appropriate diagnostic codes into the State system.
(Source: P.A. 101-654, eff. 3-8-21.)
(305 ILCS 5/5-40)
Sec. 5-40. Human breast milk coverage.
(a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
(c) Notwithstanding any other provision of this Act,
pasteurized donated human breast milk, which may include human
milk fortifiers if indicated by a prescribing licensed medical
practitioner, shall be covered under a health plan for persons
who are otherwise eligible for coverage under this Act if the
covered person is a child 12 months of age or older, a licensed
medical practitioner prescribes the milk for the covered
person, and all of the following conditions are met:
(Source: P.A. 101-511, eff. 1-1-20.)
(305 ILCS 5/5-41)
Sec. 5-41. Inpatient hospitalization for opioid-related overdose or withdrawal patients. Due to the disproportionately high opioid-related fatality rates among African Americans in under-resourced communities in Illinois, the lack of community resources, the comorbidities experienced by these patients, and the high rate of hospital inpatient recidivism associated with this population when improperly treated, the Department shall ensure that patients, whether enrolled under the Medical Assistance Fee For Service program or enrolled with a Medicaid Managed Care Organization, experiencing opioid-related overdose or withdrawal are admitted on an inpatient status and the provider shall be reimbursed accordingly, when deemed medically necessary, as determined by either the patient's primary care physician, or the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents, using criteria established by the American Society of Addiction Medicine. If it is determined by the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents, that a patient does not meet medical necessity criteria for the admission, then the patient may be treated via observation and the provider shall seek reimbursement accordingly. Nothing in this Section shall diminish the requirements of a provider to document medical necessity in the patient's record.
(Source: P.A. 102-43, eff. 7-6-21; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-42)
Sec. 5-42. Tobacco cessation coverage; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for all tobacco cessation medications approved by the United States Food and Drug Administration, all individual and group tobacco cessation counseling services, and all telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline. The Department may adopt any rules necessary to implement this Section.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-43)
Sec. 5-43. Supports Waiver Program for Young Adults with Developmental Disabilities.
(a) The Department of Human Services' Division of Developmental Disabilities, in partnership with the Department of Healthcare and Family Services and stakeholders, shall study the development and implementation of a supports waiver program for young adults with developmental disabilities. The Division shall explore the following components of a supports waiver program to determine what is most appropriate:
(b) The Department of Human Services and the Department of Healthcare and Family Services are authorized to adopt and implement any rules necessary to study the supports waiver program.
(c) Subject to appropriation, no later than January 1, 2024, the Department of Healthcare and Family Services shall apply to the federal Centers for Medicare and Medicaid Services for a supports waiver for young adults with developmental disabilities utilizing the information learned from the study under subsection (a).
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-44)
Sec. 5-44. Screening, Brief Intervention, and Referral to Treatment. As used in this Section, "SBIRT" means a comprehensive, integrated, public health approach to the delivery of early intervention and treatment
services for persons who are at risk of developing substance use disorders or have substance use disorders including, but not limited to, an addiction to alcohol, opioids,
tobacco, or cannabis.
SBIRT services include all of the following:
SBIRT services may include, but are not limited to, the following settings and programs: primary care centers, hospital emergency rooms, hospital in-patient units,
trauma centers, community behavioral health programs, and other community settings that provide opportunities for early intervention with at-risk substance users before more severe
consequences occur.
The Department of Healthcare and Family Services shall develop and seek federal approval of a SBIRT benefit for which
qualified providers shall be reimbursed under the medical assistance program.
In conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, the Department of Healthcare and
Family Services may develop a methodology and reimbursement rate for SBIRT services provided by qualified providers in approved
settings.
For opioid specific SBIRT services provided in a hospital emergency department, the Department of Healthcare and
Family Services shall develop a bundled reimbursement
methodology and rate for a package of opioid treatment services, which include initiation of medication for the treatment of opioid use disorder in
the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services when necessary. This
package of opioid related services shall be billed on a separate claim and shall be reimbursed outside of the Enhanced Ambulatory Patient
Grouping system.
(Source: P.A. 102-598, eff. 1-1-22; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-45)
(Text of Section from P.A. 102-699)
Sec. 5-45. Reimbursement rates; substance use disorder
treatment providers and facilities. Beginning on July 1, 2022,
the Department of Human Services' Division of Substance Use
Prevention and Recovery in conjunction with the Department of
Healthcare and Family Services, shall provide for an increase
in reimbursement rates by way of an increase to existing rates of
47% for all community-based substance use disorder treatment
services, including, but not limited to, all of the following:
No existing or future reimbursement rates or add-ons shall be
reduced or changed to address the rate increase proposed under this Section.
The Department of Healthcare and Family Services shall immediately,
no later than 3 months following the effective date of this amendatory Act of the 102nd General Assembly,
submit any necessary application to the federal Centers for Medicare
and Medicaid Services for a waiver or State Plan amendment to implement the requirements of this Section.
Beginning in State Fiscal year 2023, and every State fiscal year thereafter,
reimbursement rates for those community-based substance use disorder
treatment services shall be adjusted upward by an amount equal
to the Consumer Price Index-U from the previous year, not to
exceed 2% in any State fiscal year. If there is a decrease in
the Consumer Price Index-U, rates shall remain unchanged for
that State fiscal year. The Department of Human Services shall adopt rules,
including emergency rules under Section 5-45.1 of the Illinois
Administrative Procedure Act, to implement the provisions of
this Section.
As used in this Section, "consumer price index-u"
means the index published by the Bureau of Labor Statistics of
the United States Department of Labor that measures the average
change in prices of goods and services purchased by all urban
consumers, United States city average, all items, 1982-84 =
100.
(Source: P.A. 102-699, eff. 4-19-22.)
(Text of Section from P.A. 102-886)
Sec. 5-45. General acute care hospitals. A general acute care hospital is authorized to file a notice with the Department of Public Health and the Health Facilities and Services Review Board to establish an acute mental illness category of service in accordance with the Illinois Health Facilities Planning Act and add authorized acute mental illness beds if the following conditions are met:
(Source: P.A. 102-886, eff. 5-17-22.)
Structure Illinois Compiled Statutes
305 ILCS 5/ - Illinois Public Aid Code.
Article I - Public Purpose - Short Title - Prior Statute - Construction
Article III - Aid To The Aged, Blind Or Disabled
Article IV - Temporary Assistance For Needy Families
Article V - Medical Assistance
Article V-A - Hospital Provider Funding
Article V-B - Long-Term Care Provider Funding
Article V-C - Care Provider Funding For Persons With A Developmental Disability
Article V-D - Exemption of Rural Hospitals (Repealed)
Article V-E - Nursing Home License Fee
Article V-G - Supportive Living Facility Funding
Article V-H - Managed Care Organization Provider Assessment
Article VI - General Assistance
Article VIIIA - Public Assistance Fraud
Article IX - Other Social Services
Article IXA - Education, Training And Employment Program For Recipients Under Article IV
Article X - Determination And Enforcement Of Support Responsibility Of Relatives
Article XIII - Purpose--Repeal--Savings; Provisions--Partial Invalidity-- Effective Date
Article XIV - Hospital Services Trust Fund