Article V - Medical Assistance

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(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 5/5-2) (from Ch. 23, par. 5-2) Sec. 5-2. Classes of Persons Eligible. Medical assistance under this Article shall be available to any of the following classes of persons in respect to whom a plan for coverage has been submitted to the Governor by the Illinois Department and approved by him. If changes made in this Section 5-2 require federal approval, they shall not take effect until such approval has been received: 1. Recipients of basic maintenance grants under

Articles III and IV.

2. Beginning January 1, 2014, persons otherwise

eligible for basic maintenance under Article III, excluding any eligibility requirements that are inconsistent with any federal law or federal regulation, as interpreted by the U.S. Department of Health and Human Services, but who fail to qualify thereunder on the basis of need, and who have insufficient income and resources to meet the costs of necessary medical care, including but not limited to the following:

(a) All persons otherwise eligible for basic

maintenance under Article III but who fail to qualify under that Article on the basis of need and who meet either of the following requirements:

(i) their income, as determined by the

Illinois Department in accordance with any federal requirements, is equal to or less than 100% of the federal poverty level; or

(ii) their income, after the deduction of

costs incurred for medical care and for other types of remedial care, is equal to or less than 100% of the federal poverty level.

(b) (Blank). 3. (Blank). 4. Persons not eligible under any of the preceding

paragraphs who fall sick, are injured, or die, not having sufficient money, property or other resources to meet the costs of necessary medical care or funeral and burial expenses.

5.(a) Beginning January 1, 2020, women during

pregnancy and during the 12-month period beginning on the last day of the pregnancy, together with their infants, whose income is at or below 200% of the federal poverty level. Until September 30, 2019, or sooner if the maintenance of effort requirements under the Patient Protection and Affordable Care Act are eliminated or may be waived before then, women during pregnancy and during the 12-month period beginning on the last day of the pregnancy, whose countable monthly income, after the deduction of costs incurred for medical care and for other types of remedial care as specified in administrative rule, is equal to or less than the Medical Assistance-No Grant(C) (MANG(C)) Income Standard in effect on April 1, 2013 as set forth in administrative rule.

(b) The plan for coverage shall provide ambulatory

prenatal care to pregnant women during a presumptive eligibility period and establish an income eligibility standard that is equal to 200% of the federal poverty level, provided that costs incurred for medical care are not taken into account in determining such income eligibility.

demonstration in at least one county that will provide medical assistance to pregnant women, together with their infants and children up to one year of age, where the income eligibility standard is set up to 185% of the nonfarm income official poverty line, as defined by the federal Office of Management and Budget. The Illinois Department shall seek and obtain necessary authorization provided under federal law to implement such a demonstration. Such demonstration may establish resource standards that are not more restrictive than those established under Article IV of this Code.

6. (a) Children younger than age 19 when countable

income is at or below 133% of the federal poverty level. Until September 30, 2019, or sooner if the maintenance of effort requirements under the Patient Protection and Affordable Care Act are eliminated or may be waived before then, children younger than age 19 whose countable monthly income, after the deduction of costs incurred for medical care and for other types of remedial care as specified in administrative rule, is equal to or less than the Medical Assistance-No Grant(C) (MANG(C)) Income Standard in effect on April 1, 2013 as set forth in administrative rule.

(b) Children and youth who are under temporary

custody or guardianship of the Department of Children and Family Services or who receive financial assistance in support of an adoption or guardianship placement from the Department of Children and Family Services.

7. (Blank). 8. As required under federal law, persons who are

eligible for Transitional Medical Assistance as a result of an increase in earnings or child or spousal support received. The plan for coverage for this class of persons shall:

(a) extend the medical assistance coverage to the

extent required by federal law; and

(b) offer persons who have initially received 6

months of the coverage provided in paragraph (a) above, the option of receiving an additional 6 months of coverage, subject to the following:

(i) such coverage shall be pursuant to

provisions of the federal Social Security Act;

(ii) such coverage shall include all services

covered under Illinois' State Medicaid Plan;

(iii) no premium shall be charged for such

coverage; and

(iv) such coverage shall be suspended in the

event of a person's failure without good cause to file in a timely fashion reports required for this coverage under the Social Security Act and coverage shall be reinstated upon the filing of such reports if the person remains otherwise eligible.

9. Persons with acquired immunodeficiency syndrome

(AIDS) or with AIDS-related conditions with respect to whom there has been a determination that but for home or community-based services such individuals would require the level of care provided in an inpatient hospital, skilled nursing facility or intermediate care facility the cost of which is reimbursed under this Article. Assistance shall be provided to such persons to the maximum extent permitted under Title XIX of the Federal Social Security Act.

10. Participants in the long-term care insurance

partnership program established under the Illinois Long-Term Care Partnership Program Act who meet the qualifications for protection of resources described in Section 15 of that Act.

11. Persons with disabilities who are employed and

eligible for Medicaid, pursuant to Section 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, subject to federal approval, persons with a medically improved disability who are employed and eligible for Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of the Social Security Act, as provided by the Illinois Department by rule. In establishing eligibility standards under this paragraph 11, the Department shall, subject to federal approval:

(a) set the income eligibility standard at not

lower than 350% of the federal poverty level;

(b) exempt retirement accounts that the person

cannot access without penalty before the age of 59 1/2, and medical savings accounts established pursuant to 26 U.S.C. 220;

those assets accumulated during periods of eligibility under this paragraph 11; and

(d) continue to apply subparagraphs (b) and (c)

in determining the eligibility of the person under this Article even if the person loses eligibility under this paragraph 11.

12. Subject to federal approval, persons who are

eligible for medical assistance coverage under applicable provisions of the federal Social Security Act and the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000. Those eligible persons are defined to include, but not be limited to, the following persons:

(1) persons who have been screened for breast or

cervical cancer under the U.S. Centers for Disease Control and Prevention Breast and Cervical Cancer Program established under Title XV of the federal Public Health Services Act in accordance with the requirements of Section 1504 of that Act as administered by the Illinois Department of Public Health; and

(2) persons whose screenings under the above

program were funded in whole or in part by funds appropriated to the Illinois Department of Public Health for breast or cervical cancer screening.

"Medical assistance" under this paragraph 12 shall be

identical to the benefits provided under the State's approved plan under Title XIX of the Social Security Act. The Department must request federal approval of the coverage under this paragraph 12 within 30 days after the effective date of this amendatory Act of the 92nd General Assembly.

In addition to the persons who are eligible for

medical assistance pursuant to subparagraphs (1) and (2) of this paragraph 12, and to be paid from funds appropriated to the Department for its medical programs, any uninsured person as defined by the Department in rules residing in Illinois who is younger than 65 years of age, who has been screened for breast and cervical cancer in accordance with standards and procedures adopted by the Department of Public Health for screening, and who is referred to the Department by the Department of Public Health as being in need of treatment for breast or cervical cancer is eligible for medical assistance benefits that are consistent with the benefits provided to those persons described in subparagraphs (1) and (2). Medical assistance coverage for the persons who are eligible under the preceding sentence is not dependent on federal approval, but federal moneys may be used to pay for services provided under that coverage upon federal approval.

13. Subject to appropriation and to federal approval,

persons living with HIV/AIDS who are not otherwise eligible under this Article and who qualify for services covered under Section 5-5.04 as provided by the Illinois Department by rule.

14. Subject to the availability of funds for this

purpose, the Department may provide coverage under this Article to persons who reside in Illinois who are not eligible under any of the preceding paragraphs and who meet the income guidelines of paragraph 2(a) of this Section and (i) have an application for asylum pending before the federal Department of Homeland Security or on appeal before a court of competent jurisdiction and are represented either by counsel or by an advocate accredited by the federal Department of Homeland Security and employed by a not-for-profit organization in regard to that application or appeal, or (ii) are receiving services through a federally funded torture treatment center. Medical coverage under this paragraph 14 may be provided for up to 24 continuous months from the initial eligibility date so long as an individual continues to satisfy the criteria of this paragraph 14. If an individual has an appeal pending regarding an application for asylum before the Department of Homeland Security, eligibility under this paragraph 14 may be extended until a final decision is rendered on the appeal. The Department may adopt rules governing the implementation of this paragraph 14.

15. Family Care Eligibility.(a) On and after July 1, 2012, a parent or other

caretaker relative who is 19 years of age or older when countable income is at or below 133% of the federal poverty level. A person may not spend down to become eligible under this paragraph 15.

(b) Eligibility shall be reviewed annually.(c) (Blank).(d) (Blank).(e) (Blank).(f) (Blank).(g) (Blank).(h) (Blank).(i) Following termination of an individual's

coverage under this paragraph 15, the individual must be determined eligible before the person can be re-enrolled.

16. Subject to appropriation, uninsured persons who

are not otherwise eligible under this Section who have been certified and referred by the Department of Public Health as having been screened and found to need diagnostic evaluation or treatment, or both diagnostic evaluation and treatment, for prostate or testicular cancer. For the purposes of this paragraph 16, uninsured persons are those who do not have creditable coverage, as defined under the Health Insurance Portability and Accountability Act, or have otherwise exhausted any insurance benefits they may have had, for prostate or testicular cancer diagnostic evaluation or treatment, or both diagnostic evaluation and treatment. To be eligible, a person must furnish a Social Security number. A person's assets are exempt from consideration in determining eligibility under this paragraph 16. Such persons shall be eligible for medical assistance under this paragraph 16 for so long as they need treatment for the cancer. A person shall be considered to need treatment if, in the opinion of the person's treating physician, the person requires therapy directed toward cure or palliation of prostate or testicular cancer, including recurrent metastatic cancer that is a known or presumed complication of prostate or testicular cancer and complications resulting from the treatment modalities themselves. Persons who require only routine monitoring services are not considered to need treatment. "Medical assistance" under this paragraph 16 shall be identical to the benefits provided under the State's approved plan under Title XIX of the Social Security Act. Notwithstanding any other provision of law, the Department (i) does not have a claim against the estate of a deceased recipient of services under this paragraph 16 and (ii) does not have a lien against any homestead property or other legal or equitable real property interest owned by a recipient of services under this paragraph 16.

17. Persons who, pursuant to a waiver approved by

the Secretary of the U.S. Department of Health and Human Services, are eligible for medical assistance under Title XIX or XXI of the federal Social Security Act. Notwithstanding any other provision of this Code and consistent with the terms of the approved waiver, the Illinois Department, may by rule:

(a) Limit the geographic areas in which

the waiver program operates.

(b) Determine the scope, quantity, duration, and

quality, and the rate and method of reimbursement, of the medical services to be provided, which may differ from those for other classes of persons eligible for assistance under this Article.

choice of providers.

18. Beginning January 1, 2014, persons aged 19 or

older, but younger than 65, who are not otherwise eligible for medical assistance under this Section 5-2, who qualify for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) and applicable federal regulations, and who have income at or below 133% of the federal poverty level plus 5% for the applicable family size as determined pursuant to 42 U.S.C. 1396a(e)(14) and applicable federal regulations. Persons eligible for medical assistance under this paragraph 18 shall receive coverage for the Health Benefits Service Package as that term is defined in subsection (m) of Section 5-1.1 of this Code. If Illinois' federal medical assistance percentage (FMAP) is reduced below 90% for persons eligible for medical assistance under this paragraph 18, eligibility under this paragraph 18 shall cease no later than the end of the third month following the month in which the reduction in FMAP takes effect.

19. Beginning January 1, 2014, as required under 42

U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18 and younger than age 26 who are not otherwise eligible for medical assistance under paragraphs (1) through (17) of this Section who (i) were in foster care under the responsibility of the State on the date of attaining age 18 or on the date of attaining age 21 when a court has continued wardship for good cause as provided in Section 2-31 of the Juvenile Court Act of 1987 and (ii) received medical assistance under the Illinois Title XIX State Plan or waiver of such plan while in foster care.

20. Beginning January 1, 2018, persons who are

foreign-born victims of human trafficking, torture, or other serious crimes as defined in Section 2-19 of this Code and their derivative family members if such persons: (i) reside in Illinois; (ii) are not eligible under any of the preceding paragraphs; (iii) meet the income guidelines of subparagraph (a) of paragraph 2; and (iv) meet the nonfinancial eligibility requirements of Sections 16-2, 16-3, and 16-5 of this Code. The Department may extend medical assistance for persons who are foreign-born victims of human trafficking, torture, or other serious crimes whose medical assistance would be terminated pursuant to subsection (b) of Section 16-5 if the Department determines that the person, during the year of initial eligibility (1) experienced a health crisis, (2) has been unable, after reasonable attempts, to obtain necessary information from a third party, or (3) has other extenuating circumstances that prevented the person from completing his or her application for status. The Department may adopt any rules necessary to implement the provisions of this paragraph.

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 the effective date of this amendatory Act of the 97th General Assembly, 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 the effective date of this amendatory Act of the 97th General Assembly, 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 this amendatory Act of the 98th General Assembly to transition to other health insurance coverage. (Source: P.A. 101-10, eff. 6-5-19.)

(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 5/5-2a) 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:(1) The information made so available shall be in a

format that is easily accessible, useable, and understandable to the public, including individuals interested in improving the quality of care provided to individuals eligible for items and services under this Article, researchers, health care providers, and individuals interested in reducing the prevalence of waste and fraud under this Article.

(2) The information made so available shall be as

current as deemed practical by the Director and shall be updated at least once per calendar quarter.

(3) The information made so available shall be

aggregated to a level to ensure patient confidentiality, but shall, to the extent feasible, allow for posting of information by provider or vendor name and county, number of individuals served, total patient visits, payment for bills submitted, average cost for bills submitted, adjustments to payments, and total amounts paid.

(4) The Director periodically solicits comments from

a sampling of individuals who access the information through the program on how to best improve the utility of the program.

(b) Use of contractor. For purposes of implementing the program under subsection (a) of this Section and ensuring the information made available through the program is periodically updated, the Director may select and enter into a contract with a public or private entity meeting the criteria and qualifications the Director determines appropriate.(c) Annual Reports. Not later than 12 months after the effective date of this amendatory Act of the 96th General Assembly and annually thereafter, the Director shall submit to the General Assembly a report on the status of the program authorized under subsection (a). The report shall include details including, but not limited to, the estimated or actual costs of developing and maintaining the reporting system, the actual or potential benefit or adverse consequences associated with the system, and, if applicable, the extent to which information made available through the program is accessed and the extent to which comments received under paragraph (4) of subsection (a) of this Section were used to improve the utility of the program. (Source: P.A. 96-941, eff. 6-25-10.)

(305 ILCS 5/5-2.03) Sec. 5-2.03. Presumptive eligibility. Beginning on the effective date of this amendatory Act of the 96th General Assembly and except where federal law requires presumptive eligibility, no adult may be presumed eligible for medical assistance under this Code and the Department may not cover any service rendered to an adult unless the adult has completed an application for benefits, all required verifications have been received, and the Department or its designee has found the adult eligible for the date on which that service was provided. Nothing in this Section shall apply to pregnant women or to persons enrolled under the medical assistance program due to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds. (Source: P.A. 96-1501, eff. 1-25-11; 97-687, eff. 6-14-12.)

(305 ILCS 5/5-2.05) Sec. 5-2.05. Children with disabilities. (a) The Department of Healthcare and Family Services, in conjunction with the Department of Human Services, may offer, to children with developmental disabilities or children with severe mental illness or severe emotional disorders who otherwise would not qualify for medical assistance under this Article due to family income, home-based and community-based services instead of institutional placement, as allowed under paragraph 7 of Section 5-2. (b) The Department of Healthcare and Family Services, in conjunction with the Department of Human Services and the Division of Specialized Care for Children, University of Illinois-Chicago, shall submit a bi-annual report to the Governor and the General Assembly no later than January 1 of every even-numbered year, beginning in 2008, regarding the status of existing services offered under paragraph 7 of Section 5-2. This report shall include, but not be limited to, the following information: (1) The number of persons who currently receive these

services.

(2) The nature, scope, and cost of services. (3) The comparative cost of providing those services

in a hospital, skilled nursing facility, or intermediate care facility.

(4) The funding sources for the provision of

services, including federal financial participation.

(5) The qualifications, skills, and availability of

caregivers for children receiving services.

(6) The number of children who have aged out of the

services offered under paragraph 7 of Section 5-2 during the 2 years immediately preceding the report.

(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. (Source: P.A. 94-847, eff. 1-1-07.)

(305 ILCS 5/5-2.08) Sec. 5-2.08. Spousal caregiver demonstration.(a) The Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall develop a demonstration project within the Home Services Program under which a spouse may be reimbursed for providing care to his or her spouse, who is eligible for services through the Home Services Program and who meets the criteria for this demonstration project. The demonstration project shall operate in selected counties and be limited to serving no more than 100 unduplicated persons in a State fiscal year.The components of the demonstration project shall include the following:(1) Authorization for a spouse to be reimbursed for

care provided to his or her otherwise eligible spouse through the Home Services Program.

(2) The development of specific criteria for the

provision of services under the demonstration project. Criteria applicable to a spousal caregiver shall include, but need not be limited to, (i) a limitation on the total hours of a spousal caregiver's outside employment plus hours of providing care to his or her eligible spouse to ensure that the complete plan of care is delivered to the eligible spouse and (ii) limitations on a spousal caregiver's participation in the demonstration project if the caregiver has a known history of spousal abuse, neglect, or exploitation.

(3) The determination of the personal care or similar

services for which payment may be made. Spousal caregivers shall be paid at the Personal Assistant level of care and pay rate. In those instances in which the eligible spouse requires specialized services (for example, services provided by a certified nursing assistant (CNA), licensed practical nurse (LPN), or registered nurse (RN)) and the spousal caregiver has the corresponding certification or licensure, the spousal caregiver shall be paid the higher rate for the specialized services only. The specialized services the eligible spouse is authorized to receive shall be defined and approved in the services plan.

(4) The method for determining that the amount of

personal care or similar services provided by the spouse is "extraordinary care" that exceeds the ordinary care that would be provided to a spouse without a disability.

(5) Limitations on the number of hours of personal

services that will be reimbursed.

(6) Utilization of the Determination of Need

evaluation and other comprehensive assessment tools as criteria for determining eligibility and developing service plans under the demonstration project.

(7) Determination of how or whether the provision of

personal care by the spouse is in the best interest of his or her spouse, who is an eligible participant in the demonstration project.

(8) Use of procedures that ensure that payments are

made for services rendered.

(9) Assurances that all other criteria of the

demonstration project are met.

(10) Measurement of participant experiences.(11) Monthly in-home monitoring of the health and

safety of the eligible spouse.

(12) Documentation of the marital relationship for

participation in the demonstration project.

(13) Assurances that the eligible spouse is capable

of communicating his or her needs.

(14) Enrollment of an alternative care provider to

ensure that there is no disruption of care to the eligible spouse.

(15) Assurances that the spousal caregiver is

emotionally, physically, and cognitively able to provide the necessary care to the eligible spouse.

(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 alien status. (Source: P.A. 81-746.)

(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, the community spouse resource allowance shall be established and maintained at the higher of $109,560 or the minimum level permitted pursuant to Section 1924(f)(2) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater. The monthly maintenance allowance for the community spouse shall be established and maintained at the higher of $2,739 per month or the minimum level permitted pursuant to Section 1924(d)(3) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater. Subject to the approval of the Secretary of the United States Department of Health and Human Services, the provisions of this Section shall be extended to persons who but for the provision of home or community-based services under Section 4.02 of the Illinois Act on the Aging, would require the level of care provided in an institution, as is provided for in federal law. (b) Spousal support for institutionalized spouses receiving medical assistance.(i) The Department may seek support for an

institutionalized spouse, who has assigned his or her right of support from his or her spouse to the State, from the resources and income available to the community spouse.

(ii) The Department may bring an action in the

circuit court to establish support orders or itself establish administrative support orders by any means and procedures authorized in this Code, as applicable, except that the standard and regulations for determining ability to support in Section 10-3 shall not limit the amount of support that may be ordered.

(iii) Proceedings may be initiated to obtain support,

or for the recovery of aid granted during the period such support was not provided, or both, for the obtainment of support and the recovery of the aid provided. Proceedings for the recovery of aid may be taken separately or they may be consolidated with actions to obtain support. Such proceedings may be brought in the name of the person or persons requiring support or may be brought in the name of the Department, as the case requires.

(iv) The orders for the payment of moneys for the

support of the person shall be just and equitable and may direct payment thereof for such period or periods of time as the circumstances require, including support for a period before the date the order for support is entered. In no event shall the orders reduce the community spouse resource allowance below the level established in subsection (a) of this Section or an amount set after a fair hearing, whichever is greater, or reduce the monthly maintenance allowance for the community spouse below the level permitted pursuant to subsection (a) of this Section.

(Source: P.A. 98-104, eff. 7-22-13; 99-143, eff. 7-27-15.)

(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) (from Ch. 23, par. 5-4.2) Sec. 5-4.2. Ambulance services payments. (a) For ambulance services provided to a recipient of aid under this Article on or after January 1, 1993, the Illinois Department shall reimburse ambulance service providers at rates calculated in accordance with this Section. It is the intent of the General Assembly to provide adequate reimbursement for ambulance services so as to ensure adequate access to services for recipients of aid under this Article and to provide appropriate incentives to ambulance service providers to provide services in an efficient and cost-effective manner. Thus, it is the intent of the General Assembly that the Illinois Department implement a reimbursement system for ambulance services that, to the extent practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, is consistent with the payment principles of Medicare. To ensure uniformity between the payment principles of Medicare and Medicaid, the Illinois Department shall follow, to the extent necessary and practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, the statutes, laws, regulations, policies, procedures, principles, definitions, guidelines, and manuals used to determine the amounts paid to ambulance service providers under Title XVIII of the Social Security Act (Medicare). (b) For ambulance services provided to a recipient of aid under this Article on or after January 1, 1996, the Illinois Department shall reimburse ambulance service providers based upon the actual distance traveled if a natural disaster, weather conditions, road repairs, or traffic congestion necessitates the use of a route other than the most direct route. (c) For purposes of this Section, "ambulance services" includes medical transportation services provided by means of an ambulance, medi-car, service car, or taxi. (c-1) For purposes of this Section, "ground ambulance service" means medical transportation services that are described as ground ambulance services by the Centers for Medicare and Medicaid Services and provided in a vehicle that is licensed as an ambulance by the Illinois Department of Public Health pursuant to the Emergency Medical Services (EMS) Systems Act.(c-2) For purposes of this Section, "ground ambulance service provider" means a vehicle service provider as described in the Emergency Medical Services (EMS) Systems Act that operates licensed ambulances for the purpose of providing emergency ambulance services, or non-emergency ambulance services, or both. For purposes of this Section, this includes both ambulance providers and ambulance suppliers as described by the Centers for Medicare and Medicaid Services.(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. 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. (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.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. 100-587, eff. 6-4-18; 100-646, eff. 7-27-18; 101-81, eff. 7-12-19.)

(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. 101-209)Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant women, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, 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; 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 Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the

supervision of a dentist; and

(2) eyeglasses prescribed by a physician skilled in

the diseases of the eye, or by an optometrist, whichever the person may select.

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. The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2. The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary. The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for women 35 years of age or older who are eligible for medical assistance under this Article, as follows:(A) A baseline mammogram for women 35 to 39 years of

age.

(B) An annual mammogram for women 40 years of age or

older.

medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.

(D) A comprehensive ultrasound screening and MRI of

an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches.

(E) A screening MRI when medically necessary, as

determined by a physician licensed to practice medicine in all of its branches.

All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section, "low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis. As used in this Section, the term "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 women who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall 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.Any medical or health care provider shall immediately recommend, to any pregnant woman 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 women under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted women, including information on appropriate referrals for other social services that may be needed by addicted women in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of her substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and

providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.

(2) The Department may elect to consider and

negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.

(3) Persons receiving medical services through

Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.

Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department. Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section. The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after 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:(1) In the case of a provider whose enrollment is in

process by the Illinois Department, the 180-day period shall not begin until the date on the written notice from the Illinois Department that the provider enrollment is complete.

(2) In the case of errors attributable to the

Illinois Department or any of its claims processing intermediaries which result in an inability to receive, process, or adjudicate a claim, the 180-day period shall not begin until the provider has been notified of the error.

(3) In the case of a provider for whom the Illinois

Department initiates the monthly billing process.

(4) In the case of a provider operated by a unit of

local government with a population exceeding 3,000,000 when local government funds finance federal participation for claims payments.

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 45 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 same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations. The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted. The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code. The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to: (a) actual statistics and trends in utilization of

medical services by public aid recipients;

(b) actual statistics and trends in the provision of

the various medical services by medical vendors;

those rate structures for the various medical vendors; and

(d) efforts at utilization review and control by the

Illinois Department.

The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The 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 related to the dispensing 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. (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19.) (Text of Section from P.A. 101-580) Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant women, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, 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; 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 Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation. Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses. On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid: (1) dental services provided by or under the

supervision of a dentist; and

(2) eyeglasses prescribed by a physician skilled in

the diseases of the eye, or by an optometrist, whichever the person may select.

age.

(B) An annual mammogram for women 40 years of age or

older.

(D) A comprehensive ultrasound screening and MRI of

an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.

(E) A screening MRI when medically necessary, as

determined by a physician licensed to practice medicine in all of its branches.

(F) A diagnostic mammogram when medically necessary,

as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.

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 women who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall 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.Any medical or health care provider shall immediately recommend, to any pregnant woman 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 women under this Code shall receive information from the Department on the availability of services under any program providing case management services for addicted women, including information on appropriate referrals for other social services that may be needed by addicted women in addition to treatment for addiction. The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance. Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of her substance abuse. The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department. The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization. The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that: (1) Physicians participating in a Partnership and

providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.

(2) The Department may elect to consider and

negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.

(3) Persons receiving medical services through

Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.

process by the Illinois Department, the 180-day period shall not begin until the date on the written notice from the Illinois Department that the provider enrollment is complete.

(2) In the case of errors attributable to the

(3) In the case of a provider for whom the Illinois

Department initiates the monthly billing process.

(4) In the case of a provider operated by a unit of

local government with a population exceeding 3,000,000 when local government funds finance federal participation for claims payments.

medical services by public aid recipients;

(b) actual statistics and trends in the provision of

the various medical services by medical vendors;

those rate structures for the various medical vendors; and

(d) efforts at utilization review and control by the

Illinois Department.

(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%. 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. (c) The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies). (d) Subject to federal approval by the Centers for Medicare and Medicaid Services, the Department shall accept for consideration of certification under the program any application for a site or building where distinct parts of the site or building are designated for purposes other than the provision of supportive living services, but only if: (1) those distinct parts of the site or building are

not designated for the purpose of providing assisted living services as required under the Assisted Living and Shared Housing Act;

(2) those distinct parts of the site or building are

completely separate from the part of the building used for the provision of supportive living program services, including separate entrances;

(3) those distinct parts of the site or building do

not share any common spaces with the part of the building used for the provision of supportive living program services; and

(4) those distinct parts of the site or building do

not share staffing with the part of the building used for the provision of supportive living program services.

(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. (Source: P.A. 100-23, eff. 7-6-17; 100-583, eff. 4-6-18; 100-587, eff. 6-4-18; 101-10, eff. 6-5-19.)

(305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02) Sec. 5-5.02. Hospital reimbursements. (a) Reimbursement to hospitals; July 1, 1992 through September 30, 1992. Notwithstanding any other provisions of this Code or the Illinois Department's Rules promulgated under the Illinois Administrative Procedure Act, reimbursement to hospitals for services provided during the period July 1, 1992 through September 30, 1992, shall be as follows: (1) For inpatient hospital services rendered, or if

applicable, for inpatient hospital discharges occurring, on or after July 1, 1992 and on or before September 30, 1992, the Illinois Department shall reimburse hospitals for inpatient services under the reimbursement methodologies in effect for each hospital, and at the inpatient payment rate calculated for each hospital, as of June 30, 1992. For purposes of this paragraph, "reimbursement methodologies" means all reimbursement methodologies that pertain to the provision of inpatient hospital services, including, but not limited to, any adjustments for disproportionate share, targeted access, critical care access and uncompensated care, as defined by the Illinois Department on June 30, 1992.

(2) For the purpose of calculating the inpatient

payment rate for each hospital eligible to receive quarterly adjustment payments for targeted access and critical care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period July 1, 1992 through September 30, 1992, shall be 25% of the annual adjustment payments calculated for each eligible hospital, as of June 30, 1992. The Illinois Department shall determine by rule the adjustment payments for targeted access and critical care beginning October 1, 1992.

(3) For the purpose of calculating the inpatient

payment rate for each hospital eligible to receive quarterly adjustment payments for uncompensated care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period August 1, 1992 through September 30, 1992, shall be one-sixth of the total uncompensated care adjustment payments calculated for each eligible hospital for the uncompensated care rate year, as defined by the Illinois Department, ending on July 31, 1992. The Illinois Department shall determine by rule the adjustment payments for uncompensated care beginning October 1, 1992.

(b) Inpatient payments. For inpatient services provided on or after October 1, 1993, in addition to rates paid for hospital inpatient services pursuant to the Illinois Health Finance Reform Act, as now or hereafter amended, or the Illinois Department's prospective reimbursement methodology, or any other methodology used by the Illinois Department for inpatient services, the Illinois Department shall make adjustment payments, in an amount calculated pursuant to the methodology described in paragraph (c) of this Section, to hospitals that the Illinois Department determines satisfy any one of the following requirements: (1) Hospitals that are described in Section 1923 of

the federal Social Security Act, as now or hereafter amended, except that for rate year 2015 and after a hospital described in Section 1923(b)(1)(B) of the federal Social Security Act and qualified for the payments described in subsection (c) of this Section for rate year 2014 provided the hospital continues to meet the description in Section 1923(b)(1)(B) in the current determination year; or

(2) Illinois hospitals that have a Medicaid inpatient

utilization rate which is at least one-half a standard deviation above the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department; or

(3) Illinois hospitals that on July 1, 1991 had a

Medicaid inpatient utilization rate, as defined in paragraph (h) of this Section, that was at least the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department and which were located in a planning area with one-third or fewer excess beds as determined by the Health Facilities and Services Review Board, and that, as of June 30, 1992, were located in a federally designated Health Manpower Shortage Area; or

(4) Illinois hospitals that: (A) have a Medicaid inpatient utilization rate

that is at least equal to the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department; and

(B) also have a Medicaid obstetrical inpatient

utilization rate that is at least one standard deviation above the mean Medicaid obstetrical inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department for obstetrical services; or

(5) Any children's hospital, which means a hospital

devoted exclusively to caring for children. A hospital which includes a facility devoted exclusively to caring for children shall be considered a children's hospital to the degree that the hospital's Medicaid care is provided to children if either (i) the facility devoted exclusively to caring for children is separately licensed as a hospital by a municipality prior to February 28, 2013; (ii) the hospital has been designated by the State as a Level III perinatal care facility, has a Medicaid Inpatient Utilization rate greater than 55% for the rate year 2003 disproportionate share determination, and has more than 10,000 qualified children days as defined by the Department in rulemaking; (iii) the hospital has been designated as a Perinatal Level III center by the State as of December 1, 2017, is a Pediatric Critical Care Center designated by the State as of December 1, 2017 and has a 2017 Medicaid inpatient utilization rate equal to or greater than 45%; or (iv) the hospital has been designated as a Perinatal Level II center by the State as of December 1, 2017, has a 2017 Medicaid Inpatient Utilization Rate greater than 70%, and has at least 10 pediatric beds as listed on the IDPH 2015 calendar year hospital profile.

(c) Inpatient adjustment payments. The adjustment payments required by paragraph (b) shall be calculated based upon the hospital's Medicaid inpatient utilization rate as follows: (1) hospitals with a Medicaid inpatient utilization

rate below the mean shall receive a per day adjustment payment equal to $25;

(2) hospitals with a Medicaid inpatient utilization

rate that is equal to or greater than the mean Medicaid inpatient utilization rate but less than one standard deviation above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $25 plus $1 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds the mean Medicaid inpatient utilization rate;

(3) hospitals with a Medicaid inpatient utilization

rate that is equal to or greater than one standard deviation above the mean Medicaid inpatient utilization rate but less than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $40 plus $7 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds one standard deviation above the mean Medicaid inpatient utilization rate; and

(4) hospitals with a Medicaid inpatient utilization

rate that is equal to or greater than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $90 plus $2 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds 1.5 standard deviations above the mean Medicaid inpatient utilization rate.

(d) Supplemental adjustment payments. In addition to the adjustment payments described in paragraph (c), hospitals as defined in clauses (1) through (5) of paragraph (b), excluding county hospitals (as defined in subsection (c) of Section 15-1 of this Code) and a hospital organized under the University of Illinois Hospital Act, shall be paid supplemental inpatient adjustment payments of $60 per day. For purposes of Title XIX of the federal Social Security Act, these supplemental adjustment payments shall not be classified as adjustment payments to disproportionate share hospitals. (e) The inpatient adjustment payments described in paragraphs (c) and (d) shall be increased on October 1, 1993 and annually thereafter by a percentage equal to the lesser of (i) the increase in the DRI hospital cost index for the most recent 12 month period for which data are available, or (ii) the percentage increase in the statewide average hospital payment rate over the previous year's statewide average hospital payment rate. The sum of the inpatient adjustment payments under paragraphs (c) and (d) to a hospital, other than a county hospital (as defined in subsection (c) of Section 15-1 of this Code) or a hospital organized under the University of Illinois Hospital Act, however, shall not exceed $275 per day; that limit shall be increased on October 1, 1993 and annually thereafter by a percentage equal to the lesser of (i) the increase in the DRI hospital cost index for the most recent 12-month period for which data are available or (ii) the percentage increase in the statewide average hospital payment rate over the previous year's statewide average hospital payment rate. (f) Children's hospital inpatient adjustment payments. For children's hospitals, as defined in clause (5) of paragraph (b), the adjustment payments required pursuant to paragraphs (c) and (d) shall be multiplied by 2.0. (g) County hospital inpatient adjustment payments. For county hospitals, as defined in subsection (c) of Section 15-1 of this Code, there shall be an adjustment payment as determined by rules issued by the Illinois Department. (h) For the purposes of this Section the following terms shall be defined as follows: (1) "Medicaid inpatient utilization rate" means a

fraction, the numerator of which is the number of a hospital's inpatient days provided in a given 12-month period to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act, and the denominator of which is the total number of the hospital's inpatient days in that same period.

(2) "Mean Medicaid inpatient utilization rate" means

the total number of Medicaid inpatient days provided by all Illinois Medicaid-participating hospitals divided by the total number of inpatient days provided by those same hospitals.

(3) "Medicaid obstetrical inpatient utilization rate"

means the ratio of Medicaid obstetrical inpatient days to total Medicaid inpatient days for all Illinois hospitals receiving Medicaid payments from the Illinois Department.

(i) Inpatient adjustment payment limit. In order to meet the limits of Public Law 102-234 and Public Law 103-66, the Illinois Department shall by rule adjust disproportionate share adjustment payments. (j) University of Illinois Hospital inpatient adjustment payments. For hospitals organized under the University of Illinois Hospital Act, there shall be an adjustment payment as determined by rules adopted by the Illinois Department. (k) The Illinois Department may by rule establish criteria for and develop methodologies for adjustment payments to hospitals participating under this Article. (l) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (m) The Department shall establish a cost-based reimbursement methodology for determining payments to hospitals for approved graduate medical education (GME) programs for dates of service on and after July 1, 2018.(1) As used in this subsection, "hospitals" means the

University of Illinois Hospital as defined in the University of Illinois Hospital Act and a county hospital in a county of over 3,000,000 inhabitants.

(2) An amendment to the Illinois Title XIX State Plan

defining GME shall maximize reimbursement, shall not be limited to the education programs or special patient care payments allowed under Medicare, and shall include:

(A) inpatient days;(B) outpatient days;(C) direct costs;(D) indirect costs;(E) managed care days;(F) all stages of medical training and education

including students, interns, residents, and fellows with no caps on the number of persons who may qualify; and

(G) patient care payments related to the

complexities of treating Medicaid enrollees including clinical and social determinants of health.

(3) The Department shall make all GME payments

directly to hospitals including such costs in support of clients enrolled in Medicaid managed care entities.

(4) The Department shall promptly take all actions

necessary for reimbursement to be effective for dates of service on and after July 1, 2018 including publishing all appropriate public notices, amendments to the Illinois Title XIX State Plan, and adoption of administrative rules if necessary.

(5) As used in this subsection, "managed care days"

means costs associated with services rendered to enrollees of Medicaid managed care entities. "Medicaid managed care entities" means any entity which contracts with the Department to provide services paid for on a capitated basis. "Medicaid managed care entities" includes a managed care organization and a managed care community network.

(6) All payments under this Section are contingent

upon federal approval of changes to the Illinois Title XIX State Plan, if that approval is required.

(7) The Department may adopt rules necessary to

implement Public Act 100-581 through the use of emergency rulemaking in accordance with subsection (aa) of Section 5-45 of the Illinois Administrative Procedure Act. For purposes of that Act, the General Assembly finds that the adoption of rules to implement Public Act 100-581 is deemed an emergency and necessary for the public interest, safety, and welfare.

(Source: P.A. 100-580, eff. 3-12-18; 100-581, eff. 3-12-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-5.03) Sec. 5-5.03. Trauma center adjustment. (a) For inpatient admissions on or after October 1, 1992 for trauma injuries as defined in the Emergency Medical Services (EMS) Systems Act, in addition to any other payments made under this Code, the Illinois Department shall make adjustment payments, in an amount calculated under subsection (b) of this Section, to hospitals located in the State of Illinois that are recognized as Level I trauma centers (adult or pediatric) and to certain Level II trauma centers as determined by the Illinois Department. (b) Trauma center adjustment calculation. (1) The funds used to make trauma center adjustment

payments to qualifying trauma centers shall consist of:

(A) At least 50% of the amount of moneys

deposited each State fiscal year into the Trauma Center Fund created in the State treasury; and

(B) All federal matching funds received by the

Illinois Department as a result of expenditures made by the Illinois Department as required by this Section.

(2) The trauma center adjustment payments shall be

made to qualifying trauma centers on a quarterly basis. In determining the payment methodology for trauma center adjustment payments, the Illinois Department shall divide the available funds from the Trauma Center Fund for each quarter by the total number of the Medicaid trauma admissions as determined by the Illinois Department for the same quarter of the Trauma Center base year. The result of that calculation shall be the amount of the quarterly trauma center adjustment payment to be paid to qualifying trauma centers.

(3) Disbursements from the Trauma Center Fund shall

be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.

(4) Trauma center adjustment payments shall not be

treated as payments for hospital services under Title XIX of the Social Security Act for purposes of the calculation of the intergovernmental transfer provided for in Section 15-3(a) of the Code.

(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 5/5-5.05) Sec. 5-5.05. Hospitals; psychiatric services.(a) On and after July 1, 2008, the inpatient, per diem rate to be paid to a hospital for inpatient psychiatric services shall be $363.77.(b) For purposes of this Section, "hospital" means the following:(1) Advocate Christ Hospital, Oak Lawn, Illinois.(2) Barnes-Jewish Hospital, St. Louis, Missouri.(3) BroMenn Healthcare, Bloomington, Illinois.(4) Jackson Park Hospital, Chicago, Illinois.(5) Katherine Shaw Bethea Hospital, Dixon, Illinois.(6) Lawrence County Memorial Hospital, Lawrenceville,

Illinois.

(7) Advocate Lutheran General Hospital, Park Ridge,

Illinois.

(8) Mercy Hospital and Medical Center, Chicago,

Illinois.

(9) Methodist Medical Center of Illinois, Peoria,

Illinois.

(10) Provena United Samaritans Medical Center,

Danville, Illinois.

(11) Rockford Memorial Hospital, Rockford, Illinois.(12) Sarah Bush Lincoln Health Center, Mattoon,

Illinois.

(13) Provena Covenant Medical Center, Urbana,

Illinois.

(14) Rush-Presbyterian-St. Luke's Medical Center,

Chicago, Illinois.

(15) Mt. Sinai Hospital, Chicago, Illinois.(16) Gateway Regional Medical Center, Granite City,

Illinois.

(17) St. Mary of Nazareth Hospital, Chicago, Illinois.(18) Provena St. Mary's Hospital, Kankakee, Illinois.(19) St. Mary's Hospital, Decatur, Illinois.(20) Memorial Hospital, Belleville, Illinois.(21) Swedish Covenant Hospital, Chicago, Illinois.(22) Trinity Medical Center, Rock Island, Illinois.(23) St. Elizabeth Hospital, Chicago, Illinois.(24) Richland Memorial Hospital, Olney, Illinois.(25) St. Elizabeth's Hospital, Belleville, Illinois.(26) Samaritan Health System, Clinton, Iowa.(27) St. John's Hospital, Springfield, Illinois.(28) St. Mary's Hospital, Centralia, Illinois.(29) Loretto Hospital, Chicago, Illinois.(30) Kenneth Hall Regional Hospital, East St. Louis,

Illinois.

(31) Hinsdale Hospital, Hinsdale, Illinois.(32) Pekin Hospital, Pekin, Illinois.(33) University of Chicago Medical Center, Chicago,

Illinois.

(34) St. Anthony's Health Center, Alton, Illinois.(35) OSF St. Francis Medical Center, Peoria, Illinois.(36) Memorial Medical Center, Springfield, Illinois.(37) A hospital with a distinct part unit for

psychiatric services that begins operating on or after July 1, 2008.

For purposes of this Section, "inpatient psychiatric services" means those services provided to patients who are in need of short-term acute inpatient hospitalization for active treatment of an emotional or mental disorder.(c) No rules shall be promulgated to implement this Section. For purposes of this Section, "rules" is given the meaning contained in Section 1-70 of the Illinois Administrative Procedure Act.(d) This Section shall not be in effect during any period of time that the State has in place a fully operational hospital assessment plan that has been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. (e) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12.)

(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 5/5-5.06) 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 5/5-5.07) (Text of Section from P.A. 101-15)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 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. This Section is inoperative on and after July 1, 2019. (Source: P.A. 100-646, eff. 7-27-18; 100-1181, eff. 3-8-19; reenacted by P.A. 101-15, eff. 6-14-19.) (Text of Section from P.A. 101-209)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 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. This Section is inoperative on and after July 1, 2020. (Source: P.A. 100-646, eff. 7-27-18; 100-1181, eff. 3-8-19; reenacted by P.A. 101-209, eff. 8-5-19.)

(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) (Text of Section from P.A. 101-10)Sec. 5-5.2. Payment. (a) All nursing facilities that are grouped pursuant to Section 5-5.1 of this Act shall receive the same rate of payment for similar services. (b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the long-term care providers. (c) Notwithstanding any other provisions of this Code, 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 Resource Utilization Groups (RUGs) has been fully operationalized, which shall take effect for services provided on or after January 1, 2014. (d) The new nursing services reimbursement methodology utilizing RUG-IV 48 grouper model, which shall be referred to as the RUGs reimbursement system, taking effect January 1, 2014, shall be based on the following: (1) The methodology shall be resident-driven,

facility-specific, and cost-based.

(2) Costs shall be annually rebased and case mix

index quarterly updated. The nursing services methodology will be assigned to the Medicaid enrolled residents on record as of 30 days prior to the beginning of the rate period in the Department's Medicaid Management Information System (MMIS) as present on the last day of the second quarter preceding the rate period based upon the Assessment Reference Date of the Minimum Data Set (MDS).

(3) Regional wage adjustors based on the Health

Service Areas (HSA) groupings and adjusters in effect on April 30, 2012 shall be included.

(4) Case mix index shall be assigned to each

resident class based on the Centers for Medicare and Medicaid Services staff time measurement study in effect on July 1, 2013, utilizing an index maximization approach.

(5) The pool of funds available for distribution by

case mix and the base facility rate shall be determined using the formula contained in subsection (d-1).

(d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate. (1) Base rate spending pool shall be: (A) The base year resident days which are

calculated by multiplying the number of Medicaid residents in each nursing home as indicated in the MDS data defined in paragraph (4) by 365.

(B) Each facility's nursing component per diem

in effect on July 1, 2012 shall be multiplied by subsection (A).

subparagraph (A) and subparagraph (B) to adjust for the exclusion of nursing homes defined in paragraph (5).

(2) For each nursing home with Medicaid residents as

indicated by the MDS data defined in paragraph (4), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each home this calculation is the product of:

(A) Base year resident days as calculated in

subparagraph (A) of paragraph (1).

(B) The nursing home's regional wage adjustor

based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.

number of Medicaid residents as indicated by the MDS data defined in paragraph (4) multiplied by the associated case weight for the RUG-IV 48 grouper model using standard RUG-IV procedures for index maximization.

(D) The sum of the products calculated for each

nursing home in subparagraphs (A) through (C) above shall be the base year case mix, rate adjusted weighted days.

(3) The Statewide RUG-IV nursing base per diem rate:(A) on January 1, 2014 shall be the quotient of

the paragraph (1) divided by the sum calculated under subparagraph (D) of paragraph (2); and

(B) on and after July 1, 2014, shall be the

amount calculated under subparagraph (A) of this paragraph (3) plus $1.76.

(4) Minimum Data Set (MDS) comprehensive assessments

for Medicaid residents on the last day of the quarter used to establish the base rate.

(5) Nursing facilities designated as of July 1, 2012

by the Department as "Institutions for Mental Disease" shall be excluded from all calculations under this subsection. The data from these facilities shall not be used in the computations described in paragraphs (1) through (4) above to establish the base 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:(1) $0.63 for each resident who scores in I4200

Alzheimer's Disease or I4800 non-Alzheimer's Dementia.

(2) $2.67 for each resident who scores either a "1"

or "2" in any items S1200A through S1200I and also scores in RUG groups PA1, PA2, BA1, or BA2.

(e-1) (Blank).(e-2) For dates of services beginning January 1, 2014, 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. Transition rates for services provided between January 1, 2014 and December 31, 2014 shall be as follows:(1) The transition RUG-IV per diem nursing rate for

nursing homes whose rate calculated in this subsection (e-2) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:

(A) The nursing component rate in effect July

1, 2012; plus

(B) The difference of the RUG-IV nursing

component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.88.

(2) The transition RUG-IV per diem nursing rate for

nursing homes whose rate calculated in this subsection (e-2) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:

(A) The nursing component rate in effect July

1, 2012; plus

(B) The difference of the RUG-IV nursing

component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.13.

(f) Notwithstanding any other provision of this Code, on and after July 1, 2012, reimbursement rates associated with the nursing or support components of the current nursing facility rate methodology shall not increase beyond the level effective May 1, 2011 until a new reimbursement system based on the RUGs IV 48 grouper model has been fully operationalized.(g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows:(1) Individual nursing rates for residents classified

in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter ending March 31, 2012 shall be reduced by 10%;

(2) Individual nursing rates for residents classified

in all other RUG IV groups shall be reduced by 1.0%;

(3) Facility rates for the capital and support

components shall be reduced by 1.7%.

(h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act 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 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; and (ii) in an amount not to exceed $170,000,000 annually in the aggregate taking into account federal matching funds to permit the support component of the nursing facility rate to be updated as follows:(1) 80%, or $136,000,000, of the funds shall be used

to update each facility's rate in effect on June 30, 2019 using the most recent cost reports on file, which have had a limited review conducted by the Department of Healthcare and Family Services and will not hold up enacting the rate increase, with the Department of Healthcare and Family Services and taking into account subsection (i).

(2) After completing the calculation in paragraph

(1), any facility whose rate is less than the rate in effect on June 30, 2019 shall have its rate restored to the rate in effect on June 30, 2019 from the 20% of the funds set aside.

(3) The remainder of the 20%, or $34,000,000, shall

be used to increase each facility's rate by an equal percentage.

To implement item (i) in this subsection, facilities shall file quarterly reports documenting compliance with its annually approved staffing plan, which shall permit compliance with Section 3-202.05 of the Nursing Home Care Act. A facility that fails to meet the benchmarks and dates contained in the plan may have its add-on adjusted in the quarter following the quarterly review. Nothing in this Section shall limit the ability of the facility to appeal a ruling of non-compliance and a subsequent reduction to the add-on. Funds adjusted for noncompliance shall be maintained in the Long-Term Care Provider Fund and accounted for separately. At the end of each fiscal year, these funds shall be made available to facilities for special staffing projects. In order to provide for the expeditious and timely implementation of the provisions of this amendatory Act of the 101st General Assembly, emergency rules to implement any provision of this amendatory Act of the 101st General Assembly may be adopted in accordance with this subsection by the agency charged with administering that provision or initiative. The agency shall simultaneously file emergency rules and permanent rules to ensure that there is no interruption in administrative guidance. The 150-day limitation of the effective period of emergency rules does not apply to rules adopted under this subsection, and the effective period may continue through June 30, 2021. The 24-month limitation on the adoption of emergency rules does not apply to rules adopted under this subsection. The adoption of emergency rules authorized by this subsection is deemed to be necessary for the public interest, safety, and welfare. (Source: P.A. 101-10, eff. 6-5-19.) (Text of Section from P.A. 101-348) Sec. 5-5.2. Payment. (a) All nursing facilities that are grouped pursuant to Section 5-5.1 of this Act shall receive the same rate of payment for similar services. (b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the long-term care providers. (c) Notwithstanding any other provisions of this Code, 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 Resource Utilization Groups (RUGs) has been fully operationalized, which shall take effect for services provided on or after January 1, 2014. (d) The new nursing services reimbursement methodology utilizing RUG-IV 48 grouper model, which shall be referred to as the RUGs reimbursement system, taking effect January 1, 2014, shall be based on the following: (1) The methodology shall be resident-driven,

facility-specific, and cost-based.

(2) Costs shall be annually rebased and case mix

(3) Regional wage adjustors based on the Health

Service Areas (HSA) groupings and adjusters in effect on April 30, 2012 shall be included.

(4) Case mix index shall be assigned to each

resident class based on the Centers for Medicare and Medicaid Services staff time measurement study in effect on July 1, 2013, utilizing an index maximization approach.

(5) The pool of funds available for distribution by

case mix and the base facility rate shall be determined using the formula contained in subsection (d-1).

(d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate. (1) Base rate spending pool shall be: (A) The base year resident days which are

calculated by multiplying the number of Medicaid residents in each nursing home as indicated in the MDS data defined in paragraph (4) by 365.

(B) Each facility's nursing component per diem

in effect on July 1, 2012 shall be multiplied by subsection (A).

subparagraph (A) and subparagraph (B) to adjust for the exclusion of nursing homes defined in paragraph (5).

(2) For each nursing home with Medicaid residents as

indicated by the MDS data defined in paragraph (4), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each home this calculation is the product of:

(A) Base year resident days as calculated in

subparagraph (A) of paragraph (1).

(B) The nursing home's regional wage adjustor

based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.

(D) The sum of the products calculated for each

nursing home in subparagraphs (A) through (C) above shall be the base year case mix, rate adjusted weighted days.

(3) The Statewide RUG-IV nursing base per diem rate:(A) on January 1, 2014 shall be the quotient of

the paragraph (1) divided by the sum calculated under subparagraph (D) of paragraph (2); and

(B) on and after July 1, 2014, shall be the

amount calculated under subparagraph (A) of this paragraph (3) plus $1.76.

(4) Minimum Data Set (MDS) comprehensive assessments

for Medicaid residents on the last day of the quarter used to establish the base rate.

(5) Nursing facilities designated as of July 1, 2012

Alzheimer's Disease or I4800 non-Alzheimer's Dementia.

(2) $2.67 for each resident who scores either a "1"

or "2" in any items S1200A through S1200I and also scores in RUG groups PA1, PA2, BA1, or BA2.

nursing homes whose rate calculated in this subsection (e-2) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:

(A) The nursing component rate in effect July

1, 2012; plus

(B) The difference of the RUG-IV nursing

component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.88.

(2) The transition RUG-IV per diem nursing rate for

nursing homes whose rate calculated in this subsection (e-2) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:

(A) The nursing component rate in effect July

1, 2012; plus

(B) The difference of the RUG-IV nursing

component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.13.

in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter ending March 31, 2012 shall be reduced by 10%;

(2) Individual nursing rates for residents classified

in all other RUG IV groups shall be reduced by 1.0%;

(3) Facility rates for the capital and support

components shall be reduced by 1.7%.

(h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act 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) 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. (Source: P.A. 101-348, eff. 8-9-19.)

(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: (A) For a facility that would receive a lower nursing

component rate per patient day under the new system than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be held at the level in effect on the date immediately preceding the date that the Department implements the new payment methodology until a higher nursing component rate of reimbursement is achieved by that facility.

(B) For a facility that would receive a higher

nursing component rate per patient day under the payment methodology in effect on July 1, 2003 than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be adjusted.

nursing component rate per patient day for the facility shall be adjusted subject to appropriations provided by the General Assembly.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on March 1, 2001 shall include a statewide increase of 7.85%, as defined by the Department. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, except facilities participating in the Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, the numerator of the ratio used by the Department of Healthcare and Family Services to compute the rate payable under this Section using the Minimum Data Set (MDS) methodology shall incorporate the following annual amounts as the additional funds appropriated to the Department specifically to pay for rates based on the MDS nursing component methodology in excess of the funding in effect on December 31, 2006:(i) For rates taking effect January 1, 2007,

$60,000,000.

(ii) For rates taking effect January 1, 2008,

$110,000,000.

(iii) For rates taking effect January 1, 2009,

$194,000,000.

(iv) For rates taking effect April 1, 2011, or the

first day of the month that begins at least 45 days after the effective date of this amendatory Act of the 96th General Assembly, $416,500,000 or an amount as may be necessary to complete the transition to the MDS methodology for the nursing component of the rate. Increased payments under this item (iv) are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.

Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the support component of the rates taking effect on January 1, 2008 shall be computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on April 1, 2002 shall include a statewide increase of 2.0%, as defined by the Department. This increase terminates on July 1, 2002; beginning July 1, 2002 these rates are reduced to the level of the rates in effect on March 31, 2002, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports on file with the Department of Public Aid no later than April 1, 2000, updated for inflation to January 1, 2001. For rates effective July 1, 2001 only, rates shall be the greater of the rate computed for July 1, 2001 or the rate effective on June 30, 2001. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the Illinois Department shall determine by rule the rates taking effect on July 1, 2002, which shall be 5.9% less than the rates in effect on June 30, 2002. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, if the payment methodologies required under Section 5A-12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take effect only upon approval and implementation of the payment methodologies required under Section 5A-12. Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004. Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2009, the per diem support component of the rates effective on January 1, 2008, computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006, shall be increased to the amount that would have been derived using standard Department of Healthcare and Family Services methods, procedures, and inflators. Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as intermediate care facilities that are federally defined as Institutions for Mental Disease, or facilities licensed by the Department of Public Health under the Specialized Mental Health Rehabilitation 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. (Source: P.A. 100-23, eff. 7-6-17; 100-587, eff. 6-4-18; 101-10, eff. 6-5-19.)

(305 ILCS 5/5-5.4a) 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:(1) The Department shall reimburse the facility to

compensate for spending on improved wages and benefits for its eligible employees. Eligible employees include employees engaged in direct care work.

(2) In order to qualify for reimbursement under

this Section, a facility must submit to the Department, before January 1 of each year, documentation of a written, legally binding commitment to increase spending for the purpose of providing improved wages and benefits to its eligible employees during the next year. The commitment must be binding as to both existing and future staff. The commitment must include a method of enforcing the commitment that is available to the employees or their representative and is expeditious, uses a neutral decision-maker, and is economical for the employees. The Department must also receive documentation of the facility's provision of written notice of the commitment and the availability of the enforcement mechanism to the employees or their representative.

(3) Reimbursement shall be based on the amount of

increased spending to be incurred by the facility for improving wages and benefits that exceeds the spending reported in the cost report currently used by the Department. Reimbursement shall be calculated as follows: the per diem equivalent of the quarterly difference between the cost to provide improved wages and benefits for covered eligible employees as identified in the legally binding commitment and the previous period cost of wages and benefits as reported in the cost report currently used by the Department, subject to the limitations identified in paragraph (2) of this subsection. In no event shall the per diem increase be in excess of $5.00 for any 12 month period for an intermediate care facility for persons with developmental disabilities with more than 16 beds, or in excess of $6.00 for any 12 month period for an intermediate care facility for persons with developmental disabilities with 16 beds or less.

(4) Any intermediate care facility for persons with

developmental disabilities is eligible to receive reimbursement under this Section. A facility's eligibility to receive reimbursement shall continue as long as the facility maintains eligibility under paragraph (2) of this subsection and the reimbursement program continues to exist.

(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: (1) serve exceptional care patients; and (2) have 30% or more of their patients receiving

ventilator care;

shall receive Medicaid reimbursement on a 30-day expedited schedule. (c) Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting July 1, 2014 through March 31, 2019, medically complex for the developmentally disabled facilities which meet the criteria in subsection (b) of this Section shall receive a per diem rate for clinically complex residents of $304. Clinically complex residents on a ventilator shall receive a per diem rate of $669. Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting April 1, 2019, medically complex for the developmentally disabled facilities must be reimbursed an exceptional care per diem rate, instead of the base rate, for services to residents with complex or extensive medical needs. Exceptional care per diem rates must be paid for the conditions or services specified under subsection (f) at the following per diem rates: Tier 1 $326, Tier 2 $546, and Tier 3 $735. (d) For residents on a ventilator pursuant to subsection (c) or subsection (f), facilities shall have a policy documenting their method of routine assessment of a resident's weaning potential with interventions implemented noted in the resident's medical record. (e) For services provided prior to April 1, 2019 and for the purposes of this Section, a resident is considered clinically complex if the resident requires at least one of the following medical services: (1) Tracheostomy care with dependence on mechanical

ventilation for a minimum of 6 hours each day.

(2) Tracheostomy care requiring suctioning at least

every 6 hours, room air mist or oxygen as needed, and dependence on one of the treatment procedures listed under paragraph (4) excluding the procedure listed in subparagraph (A) of paragraph (4).

(3) Total parenteral nutrition or other intravenous

nutritional support and one of the treatment procedures listed under paragraph (4).

(4) The following treatment procedures apply to the

conditions in paragraphs (2) and (3) of this subsection:

(A) Intermittent suctioning at least every 8

hours and room air mist or oxygen as needed.

(B) Continuous intravenous therapy including

administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent via a peripheral or central line, without continuous infusion.

least 4 exchanges every 24 hours.

(D) Tube feeding via nasogastric or gastrostomy

tube.

(E) Other medical technologies required

continuously, which in the opinion of the attending physician require the services of a professional nurse.

(f) Complex or extensive medical needs for exceptional care reimbursement. The conditions and services used for the purposes of this Section have the same meanings as ascribed to those conditions and services under the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) and specified in the most recent manual. Instead of submitting minimum data set assessments to the Department, medically complex for the developmentally disabled facilities must document within each resident's medical record the conditions or services using the minimum data set documentation standards and requirements to qualify for exceptional care reimbursement.(1) Tier 1 reimbursement is for residents who are

receiving at least 51% of their caloric intake via a feeding tube.

(2) Tier 2 reimbursement is for residents who are

receiving tracheostomy care without a ventilator.

(3) Tier 3 reimbursement is for residents who are

receiving tracheostomy care and ventilator care.

(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: (1) Standard Services, with the cost of this

component being determined by taking into account the actual costs to the facilities of these services subject to cost ceilings to be defined in the Department's rules.

(2) Resident Services, with the cost of this

component being determined by taking into account the actual costs, needs and utilization of these services, as derived from an assessment of the resident needs in the nursing facilities.

(3) Ancillary Services, with the payment rate being

developed for each individual type of service. Payment shall be made only when authorized under procedures developed by the Department of Healthcare and Family Services.

(4) Nurse's Aide Training, with the cost of this

component being determined by taking into account the actual cost to the facilities of such training.

(5) Real Estate Taxes, with the cost of this

component being determined by taking into account the figures contained in the most currently available cost reports (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1984 and June 30, 1985, and with the cost of this component being determined by taking into account the actual 1983 taxes for which the nursing homes were assessed (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1985 and June 30, 1986.

(b) In developing a prospective method for determining payment rates for nursing facility and ICF/DD services in nursing facilities and ICF/DDs, the Department of Healthcare and Family Services shall consider the following cost elements: (1) Reasonable capital cost determined by utilizing

incurred interest rate and the current value of the investment, including land, utilizing composite rates, or by utilizing such other reasonable cost related methods determined by the Department. However, beginning with the rate reimbursement period effective July 1, 1987, the Department shall be prohibited from establishing, including, and implementing any depreciation factor in calculating the capital cost element.

(2) Profit, with the actual amount being produced and

accruing to the providers in the form of a return on their total investment, on the basis of their ability to economically and efficiently deliver a type of service. The method of payment may assure the opportunity for a profit, but shall not guarantee or establish a specific amount as a cost.

(c) The Illinois Department may implement the amendatory changes to this Section made by this amendatory Act of 1991 through the use of emergency rules in accordance with the provisions of Section 5.02 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the adoption of rules to implement the amendatory changes to this Section made by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare. (d) No later than January 1, 2001, the Department of Public Aid shall file with the Joint Committee on Administrative Rules, pursuant to the Illinois Administrative Procedure Act, a proposed rule, or a proposed amendment to an existing rule, regarding payment for appropriate services, including assessment, care planning, discharge planning, and treatment provided by nursing facilities to residents who have a serious mental illness. (e) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 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 5/5-5.8) (from Ch. 23, par. 5-5.8) Sec. 5-5.8. Report on nursing home reimbursement. The Illinois Department shall report annually to the General Assembly, no later than the first Monday in April of 1982, and each year thereafter, in regard to: (a) the rate structure used by the Illinois

Department to reimburse nursing facilities;

(b) changes in the rate structure for reimbursing

nursing facilities;

reimbursing nursing facilities;

(d) the availability of beds in nursing facilities

for public aid recipients; and

(e) the number of closings of nursing facilities, and

the reasons for those closings.

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. 100-1148, eff. 12-10-18.)

(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 Services Act shall enroll in that program. No entity participating in the federal Drug Pricing Program under Section 340B of the federal Public Health Services Act may exclude Medicaid from their participation in that program, although the Department may exclude entities defined in Section 1905(l)(2)(B) of the Social Security Act from this requirement. (Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 99-180, eff. 7-29-15.)

(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) (This Section may contain text from a Public Act with a delayed effective date)Sec. 5-5.12c. Managed care organization uniform electronic prior authorization form; prescription benefits. (a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.(b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, a managed care organization that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits. (c) On or before July 1, 2020, the Department of Healthcare and Family Services shall develop a uniform electronic prior authorization form that shall be used by managed care organizations. Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits, and every managed care organization shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits. (d) The Department of Healthcare and Family Services shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director of Healthcare and Family Services: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents managed care organizations, from at least one public meeting. (e) The Department of Healthcare and Family Services, in development of the uniform electronic prior authorization form, shall take into consideration the following: (1) existing prior authorization forms established by

the federal Centers for Medicare and Medicaid Services and the Department of Healthcare and Family Services; and

(2) national standards pertaining to electronic prior

authorization.

(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 5/5-5.13) (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) (Text of Section before amendment by P.A. 101-461) Sec. 5-5.23. Children's mental health services. (a) The Department of Healthcare and Family Services, by rule, shall require the screening and assessment of a child prior to any Medicaid-funded admission to an inpatient hospital for psychiatric services to be funded by Medicaid. The screening and assessment shall include a determination of the appropriateness and availability of out-patient support services for necessary treatment. The Department, by rule, shall establish methods and standards of payment for the screening, assessment, and necessary alternative support services. (b) The Department of Healthcare and Family Services, to the extent allowable under federal law, shall secure federal financial participation for Individual Care Grant expenditures made by the Department of Healthcare and Family Services for the Medicaid optional service authorized under Section 1905(h) of the federal Social Security Act, pursuant to the provisions of Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act. The Department of Healthcare and Family Services may exercise the authority under this Section as is necessary to administer Individual Care Grants as authorized under Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act. (c) The Department of Healthcare and Family Services shall work collaboratively with the Department of Children and Family Services and the Division of Mental Health of the Department of Human Services to implement subsections (a) and (b). (d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (e) All rights, powers, duties, and responsibilities currently exercised by the Department of Human Services related to the Individual Care Grant program are transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services to be completed and implemented within 6 months after the effective date of this amendatory Act of the 99th General Assembly. For the purposes of the Successor Agency Act, the Department of Healthcare and Family Services is declared to be the successor agency of the Department of Human Services, but only with respect to the functions of the Department of Human Services that are transferred to the Department of Healthcare and Family Services under this amendatory Act of the 99th General Assembly.(1) Each act done by the Department of Healthcare and

Family Services in exercise of the transferred powers, duties, rights, and responsibilities shall have the same legal effect as if done by the Department of Human Services or its offices.

(2) Any rules of the Department of Human Services

that relate to the functions and programs transferred by this amendatory Act of the 99th General Assembly that are in full force on the effective date of this amendatory Act of the 99th General Assembly shall become the rules of the Department of Healthcare and Family Services. All rules transferred under this amendatory Act of the 99th General Assembly are hereby amended such that the term "Department" shall be defined as the Department of Healthcare and Family Services and all references to the "Secretary" shall be changed to the "Director of Healthcare and Family Services or his or her designee". As soon as practicable hereafter, the Department of Healthcare and Family Services shall revise and clarify the rules to reflect the transfer of rights, powers, duties, and responsibilities affected by this amendatory Act of the 99th General Assembly, using the procedures for recodification of rules available under the Illinois Administrative Procedure Act, except that existing title, part, and section numbering for the affected rules may be retained. The Department of Healthcare and Family Services, consistent with its authority to do so as granted by this amendatory Act of the 99th General Assembly, shall propose and adopt any other rules under the Illinois Administrative Procedure Act as necessary to administer the Individual Care Grant program. These rules may include, but are not limited to, the application process and eligibility requirements for recipients.

(3) All unexpended appropriations and balances and

other funds available for use in connection with any functions of the Individual Care Grant program shall be transferred for the use of the Department of Healthcare and Family Services to operate the Individual Care Grant program. Unexpended balances shall be expended only for the purpose for which the appropriation was originally made. The Department of Healthcare and Family Services shall exercise all rights, powers, duties, and responsibilities for operation of the Individual Care Grant program.

(4) Existing personnel and positions of the

Department of Human Services pertaining to the administration of the Individual Care Grant program shall be 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. The status and rights of Department of Human Services employees engaged in the performance of the functions of the Individual Care Grant program shall not be affected by this amendatory Act of the 99th General Assembly. The rights of the employees, the State of Illinois, and its agencies under the Personnel Code and applicable collective bargaining agreements or under any pension, retirement, or annuity plan shall not be affected by this amendatory Act of the 99th General Assembly. All transferred employees who are members of collective bargaining units shall retain their seniority, continuous service, salary, and accrued benefits.

(5) All books, records, papers, documents, property

(real and personal), contracts, and pending business pertaining to the powers, duties, rights, and responsibilities related to the functions of the Individual Care Grant program, including, but not limited to, material in electronic or magnetic format and necessary computer hardware and software, shall be delivered to the Department of Healthcare and Family Services; provided, however, that the delivery of this information shall not violate any applicable confidentiality constraints.

(6) Whenever reports or notices are now required to

be made or given or papers or documents furnished or served by any person to or upon the Department of Human Services in connection with any of the functions transferred by this amendatory Act of the 99th General Assembly, the same shall be made, given, furnished, or served in the same manner to or upon the Department of Healthcare and Family Services.

(7) This amendatory Act of the 99th General Assembly

shall not affect any act done, ratified, or canceled or any right occurring or established or any action or proceeding had or commenced in an administrative, civil, or criminal cause regarding the Department of Human Services before the effective date of this amendatory Act of the 99th General Assembly; and those actions or proceedings may be defended, prosecuted, and continued by the Department of Human Services.

(f) The Individual Care Grant program shall be inoperative during the calendar year in which implementation begins of any remedies in response to litigation against the Department of Healthcare and Family Services related to children's behavioral health and the general status of children's behavioral health in this State. Individual Care Grant recipients in the program the year it becomes inoperative shall continue to remain in the program until it is clinically appropriate for them to step down in level of care. (Source: P.A. 99-479, eff. 9-10-15.) (Text of Section after amendment by P.A. 101-461) Sec. 5-5.23. Children's mental health services. (a) The Department of Healthcare and Family Services, by rule, shall require the screening and assessment of a child prior to any Medicaid-funded admission to an inpatient hospital for psychiatric services to be funded by Medicaid. The screening and assessment shall include a determination of the appropriateness and availability of out-patient support services for necessary treatment. The Department, by rule, shall establish methods and standards of payment for the screening, assessment, and necessary alternative support services. (b) The Department of Healthcare and Family Services, to the extent allowable under federal law, shall secure federal financial participation for Individual Care Grant expenditures made by the Department of Healthcare and Family Services for the Medicaid optional service authorized under Section 1905(h) of the federal Social Security Act, pursuant to the provisions of Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act. The Department of Healthcare and Family Services may exercise the authority under this Section as is necessary to administer Individual Care Grants as authorized under Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act. (c) The Department of Healthcare and Family Services shall work collaboratively with the Department of Children and Family Services and the Division of Mental Health of the Department of Human Services to implement subsections (a) and (b). (d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (e) All rights, powers, duties, and responsibilities currently exercised by the Department of Human Services related to the Individual Care Grant program are transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services to be completed and implemented within 6 months after the effective date of this amendatory Act of the 99th General Assembly. For the purposes of the Successor Agency Act, the Department of Healthcare and Family Services is declared to be the successor agency of the Department of Human Services, but only with respect to the functions of the Department of Human Services that are transferred to the Department of Healthcare and Family Services under this amendatory Act of the 99th General Assembly.(1) Each act done by the Department of Healthcare and

Family Services in exercise of the transferred powers, duties, rights, and responsibilities shall have the same legal effect as if done by the Department of Human Services or its offices.

(2) Any rules of the Department of Human Services

(3) All unexpended appropriations and balances and

(4) Existing personnel and positions of the

(5) All books, records, papers, documents, property

(6) Whenever reports or notices are now required to

(7) 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.(1) As used in this subsection and in subsections (h)

through (s):

(A) "Youth" means a person under the age of 18. (B) "Emerging adult" means a person who is 18

through 20 years of age.

21 through 25 years of age.

(2) The Department shall amend 89 Ill. Adm. Code 139

in accordance with this Section and consistent with the timelines outlined in this Section.

(3) Implementation of any amended requirements shall

be completed within 8 months of the adoption of any amendment to 89 Ill. Adm. Code 139 that is consistent with the provisions of this Section.

(4) To align the Family Support Program with the

Medicaid system of care, the services available to a youth, emerging adult, or transition-age adult through the Family Support Program shall include all Medicaid community-based mental health treatment services and all Family Support Program services included under 89 Ill. Adm. Code 139. No person receiving services through the Family Support Program or the Specialized Family Support Program shall become a Medicaid enrollee unless Medicaid eligibility criteria are met and the person is enrolled in Medicaid. No part of this Section creates an entitlement to services through the Family Support Program, the Specialized Family Support Program, or the Medicaid program.

(5) The Family Support Program shall align with the

following system of care principles:

(A) Treatment and support services shall be based

on the results of an integrated behavioral health assessment and treatment plan using an instrument approved by the Department of Healthcare and Family Services.

(B) Strong interagency collaboration between all

State agencies the parent or legal guardian is involved with for services, including the Department of Healthcare and Family Services, the Department of Human Services, the Department of Children and Family Services, the Department of Juvenile Justice, and the Illinois State Board of Education.

trauma-informed treatment approaches.

(D) For a youth, full participation of the parent

or legal guardian at all levels of treatment through a process that is family-centered and youth-focused. The process shall include consideration of the services and supports the parent, legal guardian, or caregiver requires for family stabilization, and shall connect such person or persons to services based on available insurance coverage.

(h) Eligibility for the Family Support Program. Eligibility criteria established under 89 Ill. Adm. Code 139 for the Family Support Program shall include the following: (1) Individuals applying to the program must be under

the age of 26.

(2) Requirements for parental or legal guardian

involvement are applicable to youth and to emerging adults or transition-age adults who have a guardian appointed under Article XIa of the Probate Act.

(3) Youth, emerging adults, and transition-age adults

are eligible for services under the Family Support Program upon their third inpatient admission to a hospital or similar treatment facility for the primary purpose of psychiatric treatment within the most recent 12 months and are hospitalized for the purpose of psychiatric treatment.

(4) School participation for emerging adults applying

for services under the Family Support Program may be waived by request of the individual at the sole discretion of the Department of Healthcare and Family Services.

(5) School participation is not applicable to

transition-age adults.

(i) Notification of Family Support Program and Specialized Family Support Program services. (1) Within 12 months after the effective date of this

amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services, with meaningful stakeholder input through a working group of psychiatric hospitals, Family Support Program providers, family support organizations, the Community and Residential Services Authority, a statewide association representing a majority of hospitals, and foster care alumni advocates, shall establish a clear process by which a youth's or emerging adult's parents, guardian, or caregiver, or the emerging adult or transition-age adult, is identified, notified, and educated about the Family Support Program and the Specialized Family Support Program upon a first psychiatric inpatient hospital admission, and any following psychiatric inpatient admissions. Notification and education may take place through a Family Support Program coordinator, a mobile crisis response provider, a Comprehensive Community Based Youth Services provider, the Community and Residential Services Authority, or any other designated provider or coordinator identified by the Department of Healthcare and Family Services. In developing this process, the Department of Healthcare and Family Services and the working group shall take into account the unique needs of emerging adults and transition-age adults without parental involvement who are eligible for services under the Family Support Program. The Department of Healthcare and Family Services and the working group shall ensure the appropriate provider or coordinator is required to assist individuals and their parents, guardians, or caregivers, as applicable, in the completion of the application or referral process for the Family Support Program or the Specialized Family Support Program.

(2) Upon a youth's, emerging adult's or

transition-age adult's second psychiatric inpatient hospital admission, the hospital must ensure that the youth's parents, guardian, or caregiver, or the emerging adult or transition-age adult, have been notified of the Family Support Program and the Specialized Family Support Program prior to hospital discharge.

(3) Psychiatric lockout as last resort. (A) Prior to referring any youth to the

Department of Children and Family Services for the filing of a petition in accordance with subparagraph (c) of paragraph (1) of Section 2-4 of the Juvenile Court Act of 1987 alleging that the youth is dependent because the youth was left in a psychiatric hospital beyond medical necessity, the hospital shall educate the youth and the youth's parents, guardian, or caregiver about the Family Support Program and the Specialized Family Support Program and shall assist with connections to the designated Family Support Program coordinator in the service area. Once this process has begun, any such youth shall be considered a youth for whom an application for the Family Support Program is pending with the Department of Healthcare and Family Services or an active application for the Family Support Program was being reviewed by the Department for the purposes of subparagraph (b) of paragraph (1) of Section 2-4 of the Juvenile Court Act of 1987.

(B) No state agency or hospital shall coach a

parent or guardian of a youth in a psychiatric hospital inpatient unit to lock out or otherwise relinquish custody of a youth to the Department of Children and Family Services for the sole purpose of obtaining necessary mental health treatment for the youth. In the absence of abuse or neglect, a psychiatric lockout or custody relinquishment to the Department of Children and Family Services shall only be considered as the option of last resort.

(4) Development of new Family Support Program

services.

(A) Development of specialized therapeutic

residential treatment for youth and emerging adults with high-acuity mental health conditions. Through a working group led by the Department of Healthcare and Family Services that includes the Department of Children and Family Services and residential treatment providers for youth and emerging adults, the Department of Healthcare and Family Services, within 12 months after the effective date of this amendatory Act of the 101st General Assembly, shall develop a plan for the development of specialized therapeutic residential treatment beds similar to a qualified residential treatment program, as defined in the federal Family First Prevention Services Act, for youth in the Family Support Program with high-acuity mental health needs. The Department of Healthcare and Family Services and the Department of Children and Family Services shall work together to maximize federal funding through Medicaid and Title IV-E of the Social Security Act in the development and implementation of this plan.

(B) Using the Department of Children and Family

Services' beyond medical necessity data over the last 5 years and any other relevant, available data, the Department of Healthcare and Family Services shall assess the estimated number of these specialized high-acuity residential treatment beds that are needed in each region of the State based on the number of youth remaining in psychiatric hospitals beyond medical necessity and the number of youth placed out-of-state who need this level of care. The Department of Healthcare and Family Services shall report the results of this assessment to the General Assembly by no later than December 31, 2020.

residential treatment model for emerging adults and transition-age adults. Within 30 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services, in partnership with the Department of Human Services' Division of Mental Health and with significant and meaningful stakeholder input through a working group of providers and other stakeholders, shall develop a supportive housing model for emerging adults and transition-age adults receiving services through the Family Support Program who need residential treatment and support to enable recovery. Such a model shall be age-appropriate and shall allow the residential component of the model to be in a community-based setting combined with intensive community-based mental health 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:(1) Targeted use of specialized therapeutic

residential treatment for youth and emerging adults with high-acuity mental health conditions through appropriation limitation. No more than 12% of all annual Family Support Program funds shall be spent on this level of care in any given state fiscal year.

(2) Targeted use of residential treatment model

established for emerging adults and transition-age adults through appropriation limitation. No more than one-quarter of all annual Family Support Program funds shall be spent on this level of care in any given state fiscal year.

(l) Exhausting third party insurance coverage first. (A) A parent, legal guardian, emerging adult, or

transition-age adult with private insurance coverage shall work with the Department of Healthcare and Family Services, or its designee, to identify insurance coverage for any and all benefits covered by their plan. If insurance cost-sharing by any method for treatment is cost-prohibitive for the parent, legal guardian, emerging adult, or transition-age adult, Family Support Program funds may be applied as a payer of last resort toward insurance cost-sharing for purposes of using private insurance coverage to the fullest extent for the recommended treatment. If the Department, or its agent, has a concern relating to the parent's, legal guardian's, emerging adult's, or transition-age adult's insurer's compliance with Illinois or federal insurance requirements relating to the coverage of mental health or substance use disorders, it shall refer all relevant information to the applicable regulatory authority.

(B) The Department of Healthcare and Family Services

shall use Medicaid funds first for an individual who has Medicaid coverage if the treatment or service recommended using an integrated behavioral health assessment and treatment plan (using the instrument approved by the Department of Healthcare and Family Services) is covered by Medicaid.

cover the needed treatment or service, Family Support Program funds shall be used to cover the services offered through the Family Support Program.

(m) Service authorization. A youth, emerging adult, or transition-age adult enrolled in the Family Support Program or the Specialized Family Support Program shall be eligible to receive a mental health treatment service covered by the applicable program if the medical necessity criteria established by the Department of Healthcare and Family Services are met. (n) Streamlined application. The Department of Healthcare and Family Services shall revise the Family Support Program applications and the application process to reflect the changes made to this Section by this amendatory Act of the 101st General Assembly within 8 months after the adoption of any amendments to 89 Ill. Adm. Code 139. (o) Study of reimbursement policies during planned and unplanned absences of youth and emerging adults in Family Support Program residential treatment settings. The Department of Healthcare and Family Services shall undertake a study of those standards of the Department of Children and Family Services and other states for reimbursement of residential treatment during planned and unplanned absences to determine if reimbursing residential providers for such unplanned absences positively impacts the availability of residential treatment for youth and emerging adults. The Department of Healthcare and Family Services shall begin the study on July 1, 2019 and shall report its findings and the results of the study to the General Assembly, along with any recommendations for or against adopting a similar policy, by December 31, 2020. (p) Public awareness and educational campaign for all relevant providers. The Department of Healthcare and Family Services shall engage in a public awareness campaign to educate hospitals with psychiatric units, crisis response providers such as Screening, Assessment and Support Services providers and Comprehensive Community Based Youth Services agencies, schools, and other community institutions and providers across Illinois on the changes made by this amendatory Act of the 101st General Assembly to the Family Support Program. The Department of Healthcare and Family Services shall produce written materials geared for the appropriate target audience, develop webinars, and conduct outreach visits over a 12-month period beginning after implementation of the changes made to this Section by this amendatory Act of the 101st General Assembly. (q) Maximizing federal matching funds for the Family Support Program and the Specialized Family Support Program. The Department of Healthcare and Family Services, as the sole Medicaid State agency, shall seek approval from the federal Centers for Medicare and Medicaid Services within 12 months after the effective date of this amendatory Act of the 101st General Assembly to draw additional federal Medicaid matching funds for individuals served under the Family Support Program or the Specialized Family Support Program who are not covered by the Department's medical assistance programs. The Department of Children and Family Services, as the State agency responsible for administering federal funds pursuant to Title IV-E of the Social Security Act, shall submit a State Plan to the federal government within 12 months after the effective date of this amendatory Act of the 101st General Assembly to maximize the use of federal Title IV-E prevention funds through the federal Family First Prevention Services Act, to provide mental health and substance use disorder treatment services and supports, including, but not limited to, the provision of short-term crisis and transition beds post-hospitalization for youth who are at imminent risk of entering Illinois' youth welfare system solely due to the inability to access mental health or substance use treatment services. (r) Outcomes and data reported annually to the General Assembly. Beginning in 2021, the Department of Healthcare and Family Services shall submit an annual report to the General Assembly that includes the following information with respect to the time period covered by the report:(1) The number and ages of youth, emerging adults,

and transition-age adults who requested services under the Family Support Program and the Specialized Family Support Program and the services received.

(2) The number and ages of youth, emerging adults,

and transition-age adults who requested services under the Specialized Family Support Program who were eligible for services based on the number of hospitalizations.

(3) The number and ages of youth, emerging adults,

and transition-age adults who applied for Family Support Program or Specialized Family Support Program services but did not receive any services.

(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.)

(305 ILCS 5/5-5.24) Sec. 5-5.24. Prenatal and perinatal care. The Department of Healthcare and Family Services may provide reimbursement under this Article for all prenatal and perinatal health care services that are provided for the purpose of preventing low-birthweight infants, reducing the need for neonatal intensive care hospital services, and promoting perinatal health. These services may include comprehensive risk assessments for pregnant women, women with infants, and infants, lactation counseling, nutrition counseling, childbirth support, psychosocial counseling, treatment and prevention of periodontal disease, and other support services that have been proven to improve birth outcomes. The Department shall maximize the use of preventive prenatal and perinatal health care services consistent with federal statutes, rules, and regulations. The Department of Public Aid (now Department of Healthcare and Family Services) shall develop a plan for prenatal and perinatal preventive health care and shall present the plan to the General Assembly by January 1, 2004. On or before January 1, 2006 and every 2 years thereafter, the Department shall report to the General Assembly concerning the effectiveness of prenatal and perinatal health care services reimbursed under this Section in preventing low-birthweight infants and reducing the need for neonatal intensive care hospital services. Each such report shall include an evaluation of how the ratio of expenditures for treating low-birthweight infants compared with the investment in promoting healthy births and infants in local community areas throughout Illinois relates to healthy infant development in those areas. On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12.)

(305 ILCS 5/5-5.25) Sec. 5-5.25. Access to behavioral health and medical services. (a) The General Assembly finds that providing access to behavioral health and medical 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, 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; and (ii) a method to reimburse providers for mental health 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. 100-385, eff. 1-1-18; 100-790, eff. 8-10-18; 100-1019, eff. 1-1-19; 101-81, eff. 7-12-19.)

(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 5/5-5a) (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:(1) Nursing facility services delivered by a nursing

facility licensed under the Nursing Home Care Act.

(2) Home health services. (3) Services delivered by a facility designated as a

Children's Habilitation Center.

(4) Services delivered by a supportive living

facility as defined in Section 5-5.01a.

(5) Services delivered by a specialized mental health

rehabilitation facility licensed under the Specialized Mental Health Rehabilitation Act of 2013.

(6) Ambulance services. (7) Pharmacy services. (8) Services delivered by a federally qualified

health center as defined in Section 1905 (l)(2)(B) of the federal Social Security Act.

(9) Services delivered by a Managed Care Entity, with

the exception of the rate paid to Managed Care Entities for services attributed to hospitals.

(10) Services for the treatment of hemophilia. (11) Primary care physician services. (12) Dental services. (13) Optometric services. (14) Podiatry services. (15) Hospice care, including routine home care,

continuous home care, inpatient respite care, and general inpatient care.

(16) Laboratory services or services provided by

independent laboratories.

(17) Durable medical equipment and supplies. (18) Renal dialysis services. (19) Birth Center Services. (20) Emergency services other than those offered by

or in a hospital.

(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: (1) Delink the per diem rate paid for supportive

living facility services from the per diem rate paid for nursing facility services, effective for services provided on or after May 1, 2011 and before July 1, 2019.

(2) Cease payment for bed reserves in nursing

facilities and specialized mental health rehabilitation facilities; for purposes of therapeutic home visits for individuals scoring as TBI on the MDS 3.0, beginning June 1, 2015, the Department shall approve payments for bed reserves in nursing facilities and specialized mental health rehabilitation facilities that have at least a 90% occupancy level and at least 80% of their residents are Medicaid eligible. Payment shall be at a daily rate of 75% of an individual's current Medicaid per diem and shall not exceed 10 days in a calendar month.

(2.5) Cease payment for bed reserves for purposes of

inpatient hospitalizations to intermediate care facilities for persons with development disabilities, except in the instance of residents who are under 21 years of age.

(3) Cease payment of the $10 per day add-on payment

to nursing facilities for certain residents with developmental disabilities.

(b) After the application of subsection (a), notwithstanding any other provision of this Code to the contrary and to the extent permitted by federal law, on and after July 1, 2012, the rates of reimbursement for services and other payments provided under this Code shall further be reduced as follows: (1) Rates or payments for physician services, dental

services, or community health center services reimbursed through an encounter rate, and services provided under the Medicaid Rehabilitation Option of the Illinois Title XIX State Plan shall not be further reduced, except as provided in Section 5-5b.1.

(2) Rates or payments, or the portion thereof, paid

to a provider that is operated by a unit of local government or State University that provides the non-federal share of such services shall not be further reduced, except as provided in Section 5-5b.1.

(3) Rates or payments for hospital services delivered

by a hospital defined as a Safety-Net Hospital under Section 5-5e.1 of this Code shall not be further reduced, except as provided in Section 5-5b.1.

(4) Rates or payments for hospital services delivered

by a Critical Access Hospital, which is an Illinois hospital designated as a critical care hospital by the Department of Public Health in accordance with 42 CFR 485, Subpart F, shall not be further reduced, except as provided in Section 5-5b.1.

(5) Rates or payments for Nursing Facility Services

shall only be further adjusted pursuant to Section 5-5.2 of this Code.

(6) Rates or payments for services delivered by long

term care facilities licensed under the ID/DD Community Care Act or the MC/DD Act and developmental training services shall not be further reduced.

(7) Rates or payments for services provided under

capitation rates shall be adjusted taking into consideration the rates reduction and covered services required by Public Act 97-689.

(8) For hospitals not previously described in this

subsection, the rates or payments for hospital services shall be further reduced by 3.5%, except for payments authorized under Section 5A-12.4 of this Code.

(9) For all other rates or payments for services

delivered by providers not specifically referenced in paragraphs (1) through (8), rates or payments shall be further reduced by 2.7%.

(c) Any assessment imposed by this Code shall continue and nothing in this Section shall be construed to cause it to cease. (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) 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 home health visits shall be $72. (f) 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 the certified nursing assistant component of the home health agency rate shall be $20. (Source: P.A. 101-10, eff. 6-5-19.)

(305 ILCS 5/5-5e.1) Sec. 5-5e.1. Safety-Net Hospitals.(a) A Safety-Net Hospital is an Illinois hospital that:(1) is licensed by the Department of Public Health as

a general acute care or pediatric hospital; and

(2) is a disproportionate share hospital, as

described in Section 1923 of the federal Social Security Act, as determined by the Department; and

(3) meets one of the following:(A) has a MIUR of at least 40% and a charity

percent of at least 4%; or

(B) has a MIUR of at least 50%.(b) Definitions. As used in this Section:(1) "Charity percent" means the ratio of (i) the

hospital's charity charges for services provided to individuals without health insurance or another source of third party coverage to (ii) the Illinois total hospital charges, each as reported on the hospital's OBRA form.

(2) "MIUR" means Medicaid Inpatient Utilization Rate

and is defined as a fraction, the numerator of which is the number of a hospital's inpatient days provided in the hospital's fiscal year ending 3 years prior to the rate year, to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act, 42 USC 1396a et seq., excluding those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of Section 5-2 of this Article, and the denominator of which is the total number of the hospital's inpatient days in that same period, excluding those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of Section 5-2 of this Article.

(3) "OBRA form" means form HFS-3834, OBRA '93 data

collection form, for the rate year.

(4) "Rate year" means the 12-month period beginning

on October 1.

(c) Beginning July 1, 2012 and ending on June 30, 2020, a hospital that would have qualified for the rate year beginning October 1, 2011, shall be a Safety-Net Hospital.(d) No later than August 15 preceding the rate year, each hospital shall submit the OBRA form to the Department. Prior to October 1, the Department shall notify each hospital whether it has qualified as a Safety-Net Hospital.(e) The Department may promulgate rules in order to implement this Section. (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. 100-581, eff. 3-12-18.)

(305 ILCS 5/5-5e.2) Sec. 5-5e.2. Academic medical centers and major teaching hospital status.(a) Hospitals dedicated to medical research and medical education shall be classified each State fiscal year in 3 tiers based on specific criteria: (1) Tier I. A private academic medical center must: (A) be a hospital located in Illinois which is

either:

(i) under common ownership with the college

of medicine of a non-public college or university;

(ii) a freestanding hospital in which the

majority of the clinical chiefs of service or clinical department chairs are department chairmen in an affiliated non-public Illinois medical school; or

(iii) a children's hospital which is

separately incorporated and non-integrated into the academic medical center hospital but which is the pediatric partner for an academic medical center hospital and which serves as the primary teaching hospital for pediatrics for its affiliated Illinois medical school. A hospital identified herein is deemed to meet the additional Tier I criteria if its partner academic medical center hospital meets the Tier I criteria;

(B) serve as the training site for at least 30

graduate medical education programs accredited by Accreditation Council for Graduate Medical Education;

affiliated off-campus sites no less than 500 medical students, interns, residents, and fellows during the calendar year preceding the beginning of the State fiscal year;

(D) perform, either itself or through its

affiliated university, at least $12,000,000 in medical research funded through grants or contracts from the National Institutes of Health either directly or, with respect to hospitals described in item (ii) of subparagraph (A) of this paragraph, have as its affiliated non-public Illinois medical school a medical school that performs either itself or through its affiliated University medical research funded using at least $12,000,000 in grants or contracts from the National Institutes of Health; and

(E) expend directly or indirectly through an

affiliated non-public medical school or as part of a hospital system as defined in paragraph (4) of subsection (h) of Section 3-8 of the Service Use Tax Act no less than $5,000,000 toward medical research and education during the calendar year preceding the beginning of the State fiscal year.

(2) Tier II. A public academic medical center must: (A) be a hospital located in Illinois which is a

primary teaching hospital affiliated with;

(i) University of Illinois School of Medicine

at Chicago; or

(ii) University of Illinois School of

Medicine at Peoria; or

(iii) University of Illinois School of

Medicine at Rockford; or

(iv) University of Illinois School of

Medicine at Urbana; or

(v) Southern Illinois University School of

Medicine in Springfield; and

(B) contribute no less than $2,500,000 toward

medical research and education during the calendar year preceding the beginning of the State fiscal year.

(3) Tier III. A major teaching hospital must: (A) be an Illinois hospital with 100 or more

interns and residents or with a ratio of interns and residents to beds greater than or equal to 0.25; and

(B) support at least one graduate medical

education program accredited by Accreditation Council for Graduate Medical Education.

(b) All hospitals seeking to qualify for Tier I, Tier II, or Tier III recognition must annually submit a report to the Department with supporting documentation and attesting to meeting the requirements in this Section. Such reporting must also describe each hospital's education and research activities for the preceding year. (Source: P.A. 98-104, eff. 7-22-13.)

(305 ILCS 5/5-5f) Sec. 5-5f. Elimination and limitations of medical assistance services. Notwithstanding any other provision of this Code to the contrary, on and after July 1, 2012:(a) The following services shall no longer be a

covered service available under this Code: group psychotherapy for residents of any facility licensed under the Nursing Home Care Act or the Specialized Mental Health Rehabilitation Act of 2013; and adult chiropractic services.

(b) The Department shall place the following

limitations on services: (i) the Department shall limit adult eyeglasses to one pair every 2 years; however, the limitation does not apply to an individual who needs different eyeglasses following a surgical procedure such as cataract surgery; (ii) the Department shall set an annual limit of a maximum of 20 visits for each of the following services: adult speech, hearing, and language therapy services, adult occupational therapy services, and physical therapy services; on or after October 1, 2014, the annual maximum limit of 20 visits shall expire but the Department may require prior approval for all individuals for speech, hearing, and language therapy services, occupational therapy services, and physical therapy services; (iii) the Department shall limit adult podiatry services to individuals with diabetes; on or after October 1, 2014, podiatry services shall not be limited to individuals with diabetes; (iv) the Department shall pay for caesarean sections at the normal vaginal delivery rate unless a caesarean section was medically necessary; (v) the Department shall limit adult dental services to emergencies; beginning July 1, 2013, the Department shall ensure that the following conditions are recognized as emergencies: (A) dental services necessary for an individual in order for the individual to be cleared for a medical procedure, such as a transplant; (B) extractions and dentures necessary for a diabetic to receive proper nutrition; (C) extractions and dentures necessary as a result of cancer treatment; and (D) dental services necessary for the health of a pregnant woman prior to delivery of her baby; on or after July 1, 2014, adult dental services shall no longer be limited to emergencies, and dental services necessary for the health of a pregnant woman prior to delivery of her baby shall continue to be covered; and (vi) effective July 1, 2012, the Department shall place limitations and require concurrent review on every inpatient detoxification stay to prevent repeat admissions to any hospital for detoxification within 60 days of a previous inpatient detoxification stay. The Department shall convene a workgroup of hospitals, substance abuse providers, care coordination entities, managed care plans, and other stakeholders to develop recommendations for quality standards, diversion to other settings, and admission criteria for patients who need inpatient detoxification, which shall be published on the Department's website no later than September 1, 2013.

the following services: wheelchair repairs costing more than $400, coronary artery bypass graft, and bariatric surgery consistent with Medicare standards concerning patient responsibility. Wheelchair repair prior approval requests shall be adjudicated within one business day of receipt of complete supporting documentation. Providers may not break wheelchair repairs into separate claims for purposes of staying under the $400 threshold for requiring prior approval. The wholesale price of manual and power wheelchairs, durable medical equipment and supplies, and complex rehabilitation technology products and services shall be defined as actual acquisition cost including all discounts.

(d) The Department shall establish benchmarks for

hospitals to measure and align payments to reduce potentially preventable hospital readmissions, inpatient complications, and unnecessary emergency room visits. In doing so, the Department shall consider items, including, but not limited to, historic and current acuity of care and historic and current trends in readmission. The Department shall publish provider-specific historical readmission data and anticipated potentially preventable targets 60 days prior to the start of the program. In the instance of readmissions, the Department shall adopt policies and rates of reimbursement for services and other payments provided under this Code to ensure that, by June 30, 2013, expenditures to hospitals are reduced by, at a minimum, $40,000,000.

(e) The Department shall establish utilization

controls for the hospice program such that it shall not pay for other care services when an individual is in hospice.

(f) For home health services, the Department shall

require Medicare certification of providers participating in the program and implement the Medicare face-to-face encounter rule. The Department shall require providers to implement auditable electronic service verification based on global positioning systems or other cost-effective technology.

(g) For the Home Services Program operated by the

Department of Human Services and the Community Care Program operated by the Department on Aging, the Department of Human Services, in cooperation with the Department on Aging, shall implement an electronic service verification based on global positioning systems or other cost-effective technology.

(h) Effective with inpatient hospital admissions on

or after July 1, 2012, the Department shall reduce the payment for a claim that indicates the occurrence of a provider-preventable condition during the admission as specified by the Department in rules. The Department shall not pay for services related to an other provider-preventable condition.

As used in this subsection (h):"Provider-preventable condition" means a health care

acquired condition as defined under the federal Medicaid regulation found at 42 CFR 447.26 or an other provider-preventable condition.

"Other provider-preventable condition" means a wrong

surgical or other invasive procedure performed on a patient, a surgical or other invasive procedure performed on the wrong body part, or a surgical procedure or other invasive procedure performed on the wrong patient.

(i) The Department shall implement cost savings

initiatives for advanced imaging services, cardiac imaging services, pain management services, and back surgery. Such initiatives shall be designed to achieve annual costs savings.

(j) The Department shall ensure that beneficiaries

with a diagnosis of epilepsy or seizure disorder in Department records will not require prior approval for anticonvulsants.

(Source: P.A. 100-135, eff. 8-18-17; 101-209, eff. 8-5-19.)

(305 ILCS 5/5-5g) Sec. 5-5g. Long-term care patient; resident status. Long-term care providers shall submit all changes in resident status, including, but not limited to, death, discharge, changes in patient credit, third party liability, and Medicare coverage, to the Department through the Medical Electronic Data Interchange System, the Recipient Eligibility Verification System, or the Electronic Data Interchange System established under 89 Ill. Adm. Code 140.55(b) in compliance with the schedule below:(1) 15 calendar days after a resident's death;(2) 15 calendar days after a resident's discharge;(3) 45 calendar days after being informed of a change

in the resident's income;

(4) 45 calendar days after being informed of a change

in a resident's third party liability;

(5) 45 calendar days after a resident's move to

exceptional care services; and

(6) 45 calendar days after a resident's need for

services requiring reimbursement under the ventilator or traumatic brain injury enhanced rate.

(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 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. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17; 100-453, eff. 8-25-17; 100-513, eff. 1-1-18; 100-538, eff. 1-1-18; 100-863, eff. 8-14-18.)

(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: (1) Provide that any provider affiliated with the

managed care community network may also provide services on a fee-for-service basis to Illinois Department clients not enrolled in such managed care entities.

(2) Provide client education services as determined

and approved by the Illinois Department, including but not limited to (i) education regarding appropriate utilization of health care services in a managed care system, (ii) written disclosure of treatment policies and restrictions or limitations on health services, including, but not limited to, physical services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, and radiological examinations, and (iii) written notice that the enrollee may receive from another provider those covered services that are not provided by the managed care community network.

(3) Provide that enrollees within the system may

choose the site for provision of services and the panel of health care providers.

(4) Not discriminate in enrollment or disenrollment

practices among recipients of medical services or enrollees based on health status.

(5) Provide a quality assurance and utilization

review program that meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.

(6) Issue a managed care community network

identification card to each enrollee upon enrollment. The card must contain all of the following:

(A) The enrollee's health plan. (B) The name and telephone number of the

enrollee's primary care physician or the site for receiving primary care services.

eligibility for benefits and authorization for services that is available 24 hours per day, 7 days per week.

(7) Ensure that every primary care physician and

pharmacy in the managed care community network meets the standards established by the Illinois Department for accessibility and quality of care. The Illinois Department shall arrange for and oversee an evaluation of the standards established under this paragraph (7) and may recommend any necessary changes to these standards.

(8) Provide a procedure for handling complaints that

meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.

(9) Maintain, retain, and make available to the

Illinois Department records, data, and information, in a uniform manner determined by the Illinois Department, sufficient for the Illinois Department to monitor utilization, accessibility, and quality of care.

(10) (Blank). The Illinois Department shall contract with an entity or entities to provide external peer-based quality assurance review for the managed health care programs administered by the Illinois Department. The entity shall meet all federal requirements for an external quality review organization. Each managed care community network must demonstrate its ability to bear the financial risk of serving individuals under this program. The Illinois Department shall by rule adopt standards for assessing the solvency and financial soundness of each managed care community network. Any solvency and financial standards adopted for managed care community networks shall be no more restrictive than the solvency and financial standards adopted under Section 1856(a) of the Social Security Act for provider-sponsored organizations under Part C of Title XVIII of the Social Security Act. The Illinois Department may implement the amendatory changes to this Code made by this amendatory Act of 1998 through the use of emergency rules in accordance with Section 5-45 of the Illinois Administrative Procedure Act. For purposes of that Act, the adoption of rules to implement these changes is deemed an emergency and necessary for the public interest, safety, and welfare. (c) Not later than June 30, 1996, the Illinois Department shall enter into one or more cooperative arrangements with the Department of Public Health for the purpose of developing a single survey for nursing facilities, including but not limited to facilities funded under Title XVIII or Title XIX of the federal Social Security Act or both, which shall be administered and conducted solely by the Department of Public Health. The Departments shall test the single survey process on a pilot basis, with both the Departments of Public Aid and Public Health represented on the consolidated survey team. The pilot will sunset June 30, 1997. After June 30, 1997, unless otherwise determined by the Governor, a single survey shall be implemented by the Department of Public Health which would not preclude staff from the Department of Healthcare and Family Services (formerly Department of Public Aid) from going on-site to nursing facilities to perform necessary audits and reviews which shall not replicate the single State agency survey required by this Act. This Section shall not apply to community or intermediate care facilities for persons with developmental disabilities. (d) Nothing in this Code in any way limits or otherwise impairs the authority or power of the Illinois Department to enter into a negotiated contract pursuant to this Section with a managed care community network or a health maintenance organization, as defined in the Health Maintenance Organization Act, that provides for termination or nonrenewal of the contract without cause, upon notice as provided in the contract, and without a hearing. (Source: P.A. 95-331, eff. 8-21-07; 96-1501, eff. 1-25-11.)

(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:(1) Subject to federal and State privacy and

confidentiality laws and regulations, meet standards for timely eligibility verification and enrollment, and annual redetermination of eligibility, of applicants for and recipients of means-tested health benefits sponsored by the State, including medical assistance under this Code.

(2) Receive and update data electronically from the

Social Security Administration, the U.S. Postal Service, the Illinois Secretary of State, the Department of Revenue, the Department of Employment Security, and other governmental entities, as appropriate and to the extent allowed by law, for verification of any factor of eligibility for medical assistance and for updating addresses of applicants and recipients of medical assistance and other health benefit programs administered by the Department. Data relevant to eligibility shall be provided for no other purpose than to verify the eligibility of new applicants or current recipients of health benefits provided by the State. Data shall be requested or provided for any individual only insofar as that new applicant or current recipient's circumstances are relevant to that individual's or another individual's eligibility for State-sponsored health benefits.

(3) Meet federal requirements for timely installation

by January 1, 2014 to provide integration with a Health Benefits Exchange pursuant to the requirements of the federal Affordable Care Act and the Reconciliation Act and any subsequent amendments thereto and to ensure capture of the maximum available federal financial participation (FFP).

(4) Meet federal requirements for compliance with

architectural standards, including, but not limited to, (i) the use of a module development as outlined by the Medicaid Information Technology Architecture standards, (ii) the use of federally approved open-interfaces where they exist, (iii) the use or the creation of open-interfaces where necessary, and (iv) the use of rules technology that can dynamically accept and modify rules in standard formats.

(5) Include plans to ensure coordination with the

State of Illinois Framework Project that will (i) expedite and simplify access to services provided by Illinois human services programs; (ii) streamline administration and data sharing; (iii) enhance planning capacity, program evaluation, and fraud detection or prevention with access to cross-agency data; and (iv) simplify service reporting for contracted providers.

(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 5/5-13.2) 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. Lien on real property interests. The State shall have a lien on all legal and equitable interests of recipients in real property, whether vested or contingent, including legal and equitable rights and interests of the recipient to coal, gas, oil, iron, and other underground mineral resources, for medical assistance paid under this Article and for payments made to preserve the lien, to the extent those liens are allowed under the federal Social Security Act. The lien shall attach to those interests owned or subsequently acquired by persons who were recipients on or after the effective date of this amendatory Act of 1993. The liens shall be recorded and filed and are otherwise subject to all the conditions of Sections 3-10.1 through 3-10.10 of this Code. (Source: P.A. 88-85; 88-670, eff. 12-2-94.)

(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: (a) The Department, by rule, shall establish criteria

to determine which clients must participate in this program;

(b) Providers participating in the program may be

paid an amount per patient per month, to be set by the Illinois Department, for managing each recipient's medical care;

shall be physicians licensed to practice medicine in all its branches, and the Illinois Department may terminate a provider's participation if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department;

(d) Each recipient required to participate in the

program must select from a panel of primary care providers or networks established by the Department in their communities;

(e) A recipient may change his designated primary

care provider:

(1) when the designated source becomes

unavailable, as the Illinois Department shall determine by rule; or

(2) when the designated primary care provider

notifies the Illinois Department that it wishes to withdraw from any obligation as primary care provider; or

(3) in other situations, as the Illinois

Department shall provide by rule;

(f) The Illinois Department shall, by rule, establish

procedures for providing medical services when the designated source becomes unavailable or wishes to withdraw from any obligation as primary care provider taking into consideration the need for emergency or temporary medical assistance and ensuring that the recipient has continuous and unrestricted access to medical care from the date on which such unavailability or withdrawal becomes effective until such time as the recipient designates a primary care source;

(g) Only medical care services authorized by a

recipient's designated provider, except for emergency services, services performed by a provider that is owned or operated by a county and that provides non-emergency services without regard to ability to pay and such other services as provided by the Illinois Department, shall be subject to payment by the Illinois Department. The Illinois Department shall enter into an intergovernmental agreement with each county that owns or operates such a provider to develop and implement policies to minimize the provision of medical care services provided by county owned or operated providers pursuant to the foregoing exception.

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: (a) It shall be conducted for a period of no less

than 5 consecutive fiscal years in one urban area containing a high proportion, as determined by Department of Healthcare and Family Services and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment and in one rural area containing a high proportion, as determined by Department of Healthcare and Family Services and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment.

(b) Providers participating in the program shall be

paid an amount per patient per month, to be set by the Illinois Department, for the case management services provided.

shall be nurses or social workers, licensed to practice in Illinois, who comply with the rules and regulations established by the Illinois Department and the Inter-Agency Agreement between the Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Public Health. The Illinois Department may terminate a provider's participation in the program if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department.

(d) Each eligible participant in an area where the

Case Management Services Program is being conducted may voluntarily designate a case manager, of her own choosing to assume responsibility for her care.

(e) A participant may change her designated case

manager provided that she informs the Illinois Department by the 20th day of the month in order for the change to be effective in the following month.

(f) The Illinois Department shall, by rule, establish

procedures for providing case management services when the designated source becomes unavailable or wishes to withdraw from any obligation as case management services provider.

(g) In accordance with rules adopted by the Illinois

Department, a participant may discontinue participation in the program upon timely notice to the Illinois Department, in which case the participant shall remain eligible for assistance under all applicable provisions of Article V of this Code.

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: (1) At least 75% of its membership is composed of

hospitals that are qualified on or after July 1, 1994 as disproportionate share hospitals.

(2) At least 75% of its managed care enrollees

receive services at the disproportionate share hospitals or those hospitals' affiliated sites.

(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) (Text of Section from P.A. 101-81) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, and 356z.32 of the Illinois Insurance Code and (ii) be subject to the provisions of Sections 356z.19, 364.01, 370c, and 370c.1 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. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19.) (Text of Section from P.A. 101-218) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code and (ii) be subject to the provisions of Sections 356z.19, 364.01, 370c, and 370c.1 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. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-218, eff. 1-1-20.) (Text of Section from P.A. 101-281) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code and (ii) be subject to the provisions of Sections 356z.19, 364.01, 370c, and 370c.1 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. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-281, eff. 1-1-20.) (Text of Section from P.A. 101-371) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code and (ii) be subject to the provisions of Sections 356z.19, 364.01, 370c, and 370c.1 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. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-371, eff. 1-1-20.) (Text of Section from P.A. 101-574) Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, and 356z.33 of the Illinois Insurance Code and (ii) be subject to the provisions of Sections 356z.19, 364.01, 370c, and 370c.1 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. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-574, eff. 1-1-20.)

(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: (1) A managed health care entity may not offer or

provide any gift, favor, or other inducement in marketing its health care delivery system to integrated health care program enrollees. A managed health care entity may provide health care related items that are of nominal value and pre-approved by the Department to prospective enrollees. A managed health care entity may also provide to enrollees health care related items that have been pre-approved by the Department as an incentive to manage their health care appropriately.

(2) All persons employed or otherwise engaged by a

managed health care entity to market the entity's health care delivery system to recipients or to supervise that marketing shall register with the Illinois Department.

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: (A) That while hospitals have traditionally

provided charitable care to indigent patients, this burden is not equally borne by all hospitals operating in this State. Some hospitals continue to provide significant amounts of care to low-income persons while others provide very little such care; and

(B) That access to hospital care in this State by

the indigent citizens of Illinois would be seriously impaired by the closing of hospitals that provide significant amounts of care to low-income persons.

(2) To help expand the availability of hospital care

for all citizens of this State, it is the policy of the State to implement programs that more equitably distribute the burden of providing hospital care to Illinois' low-income population and that improve access to health care in Illinois.

(3) The Illinois Department may develop and implement

a program that lessens the burden of providing hospital care to Illinois' low-income population, taking into account the costs that must be incurred by hospitals providing significant amounts of care to low-income persons, and may develop adjustments to increase rates to improve access to health care in Illinois. The Illinois Department shall prescribe by rule the criteria, standards and procedures for effecting such adjustments in the rates of hospital payments for services provided to eligible low-income persons (under Articles V, VI and VII of this Code) under this Article.

(b) The Illinois Department shall require hospitals certified to participate in the federal Medicaid program to: (1) provide equal access to available services to

low-income persons who are eligible for assistance under Articles V, VI and VII of this Code;

(2) provide data and reports on the provision of

uncompensated care.

(c) From the effective date of this amendatory Act of 1992 until July 1, 1992, nothing in this Section 5-17 shall be construed as creating a private right of action on behalf of any individual. (d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 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 5/5-19) (from Ch. 23, par. 5-19) Sec. 5-19. Healthy Kids Program. (a) Any child under the age of 21 eligible to receive Medical Assistance from the Illinois Department under Article V of this Code shall be eligible for Early and Periodic Screening, Diagnosis and Treatment services provided by the Healthy Kids Program of the Illinois Department under the Social Security Act, 42 U.S.C. 1396d(r). (b) Enrollment of Children in Medicaid. The Illinois Department shall provide for receipt and initial processing of applications for Medical Assistance for all pregnant women and children under the age of 21 at locations in addition to those used for processing applications for cash assistance, including disproportionate share hospitals, federally qualified health centers and other sites as selected by the Illinois Department. (c) Healthy Kids Examinations. The Illinois Department shall consider any examination of a child eligible for the Healthy Kids services provided by a medical provider meeting the requirements and complying with the rules and regulations of the Illinois Department to be reimbursed as a Healthy Kids examination. (d) Medical Screening Examinations. (1) The Illinois Department shall insure Medicaid

coverage for periodic health, vision, hearing, and dental screenings for children eligible for Healthy Kids services scheduled from a child's birth up until the child turns 21 years. The Illinois Department shall pay for vision, hearing, dental and health screening examinations for any child eligible for Healthy Kids services by qualified providers at intervals established by Department rules.

(2) The Illinois Department shall pay for an

interperiodic health, vision, hearing, or dental screening examination for any child eligible for Healthy Kids services whenever an examination is:

(A) requested by a child's parent, guardian, or

custodian, or is determined to be necessary or appropriate by social services, developmental, health, or educational personnel; or

(B) necessary for enrollment in school; or (C) necessary for enrollment in a licensed day

care program, including Head Start; or

(D) necessary for placement in a licensed child

welfare facility, including a foster home, group home or child care institution; or

(E) necessary for attendance at a camping

program; or

(F) necessary for participation in an organized

athletic program; or

(G) necessary for enrollment in an early

childhood education program recognized by the Illinois State Board of Education; or

(H) necessary for participation in a Women,

Infant, and Children (WIC) program; or

(I) deemed appropriate by the Illinois Department. (e) Minimum Screening Protocols For Periodic Health Screening Examinations. Health Screening Examinations must include the following services: (1) Comprehensive Health and Development Assessment

including:

(A) Development/Mental Health/Psychosocial

Assessment; and

(B) Assessment of nutritional status including

tests for iron deficiency and anemia for children at the following ages: 9 months, 2 years, 8 years, and 18 years;

(2) Comprehensive unclothed physical exam; (3) Appropriate immunizations at a minimum, as

required by the Secretary of the U.S. Department of Health and Human Services under 42 U.S.C. 1396d(r).

(4) Appropriate laboratory tests including blood lead

levels appropriate for age and risk factors.

(A) Anemia test. (B) Sickle cell test. (C) Tuberculin test at 12 months of age and every

1-2 years thereafter unless the treating health care professional determines that testing is medically contraindicated.

(D) Other -- The Illinois Department shall insure

that testing for HIV, drug exposure, and sexually transmitted diseases is provided for as clinically indicated.

(5) Health Education. The Illinois Department shall

require providers to provide anticipatory guidance as recommended by the American Academy of Pediatrics.

(6) Vision Screening. The Illinois Department shall

require providers to provide vision screenings consistent with those set forth in the Department of Public Health's Administrative Rules.

(7) Hearing Screening. The Illinois Department shall

require providers to provide hearing screenings consistent with those set forth in the Department of Public Health's Administrative Rules.

(8) Dental Screening. The Illinois Department shall

require providers to provide dental screenings consistent with those set forth in the Department of Public Health's Administrative Rules.

(f) Covered Medical Services. The Illinois Department shall provide coverage for all necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects, physical and mental illnesses, and conditions whether discovered by the screening services or not for all children eligible for Medical Assistance under Article V of this Code. (g) Notice of Healthy Kids Services. (1) The Illinois Department shall inform any child

eligible for Healthy Kids services and the child's family about the benefits provided under the Healthy Kids Program, including, but not limited to, the following: what services are available under Healthy Kids, including discussion of the periodicity schedules and immunization schedules, that services are provided at no cost to eligible children, the benefits of preventive health care, where the services are available, how to obtain them, and that necessary transportation and scheduling assistance is available.

(2) The Illinois Department shall widely disseminate

information regarding the availability of the Healthy Kids Program throughout the State by outreach activities which shall include, but not be limited to, (i) the development of cooperation agreements with local school districts, public health agencies, clinics, hospitals and other health care providers, including developmental disability and mental health providers, and with charities, to notify the constituents of each of the Program and assist individuals, as feasible, with applying for the Program, (ii) using the media for public service announcements and advertisements of the Program, and (iii) developing posters advertising the Program for display in hospital and clinic waiting rooms.

(3) The Illinois Department shall utilize accepted

methods for informing persons who are illiterate, blind, deaf, or cannot understand the English language, including but not limited to public services announcements and advertisements in the foreign language media of radio, television and newspapers.

(4) The Illinois Department shall provide notice of

the Healthy Kids Program to every child eligible for Healthy Kids services and his or her family at the following times:

(A) orally by the intake worker and in writing at

the time of application for Medical Assistance;

(B) at the time the applicant is informed that he

or she is eligible for Medical Assistance benefits; and

periodic health, vision, hearing, and dental examination for any child eligible for Healthy Kids services. Notice given under this subparagraph (C) must state that a screening examination is due under the periodicity schedules and must advise the eligible child and his or her family that the Illinois Department will provide assistance in scheduling an appointment and arranging medical transportation.

(h) Data Collection. The Illinois Department shall collect data in a usable form to track utilization of Healthy Kids screening examinations by children eligible for Healthy Kids services, including but not limited to data showing screening examinations and immunizations received, a summary of follow-up treatment received by children eligible for Healthy Kids services and the number of children receiving dental, hearing and vision services. (i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e. (Source: P.A. 97-689, eff. 6-14-12.)

(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. (1) The Integrated Care Program shall encompass

services administered to recipients of medical assistance under this Article to prevent exacerbations and complications using cost-effective, evidence-based practice guidelines and mental health management strategies.

(2) The Department may utilize and expand upon

existing contractual arrangements with integrated care plans under the Integrated Care Program for providing the coordinated care provisions of this Section.

(3) Payment for such coordinated care shall be based

on arrangements where the State pays for performance related to mental health outcomes on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements such as provider-based care coordination.

(4) The Department shall examine whether chronic

mental health management programs and services for recipients with specific chronic mental health conditions do any or all of the following:

(A) Improve the patient's overall mental health

in a more expeditious and cost-effective manner.

(B) Lower costs in other aspects of the medical

assistance program, such as hospital admissions, emergency room visits, or more frequent and inappropriate psychotropic drug use.

(5) The Department shall work with the facilities and

any integrated care plan participating in the program to identify and correct barriers to the successful implementation of this subsection (e) prior to and during the implementation to best facilitate the goals and objectives of this subsection (e).

(f) A hospital that is located in a county of the State in which the Department mandates some or all of the beneficiaries of the Medical Assistance Program residing in the county to enroll in a Care Coordination Program, as set forth in Section 5-30 of this Code, shall not be eligible for any non-claims based payments not mandated by Article V-A of this Code for which it would otherwise be qualified to receive, unless the hospital is a Coordinated Care Participating Hospital no later than 60 days after June 14, 2012 (the effective date of Public Act 97-689) or 60 days after the first mandatory enrollment of a beneficiary in a Coordinated Care program. For purposes of this subsection, "Coordinated Care Participating Hospital" means a hospital that meets one of the following criteria: (1) The hospital has entered into a contract to

provide hospital services with one or more MCOs to enrollees of the care coordination program.

(2) The hospital has not been offered a contract by a

care coordination plan that the Department has determined to be a good faith offer and that pays at least as much as the Department would pay, on a fee-for-service basis, not including disproportionate share hospital adjustment payments or any other supplemental adjustment or add-on payment to the base fee-for-service rate, except to the extent such adjustments or add-on payments are incorporated into the development of the applicable MCO capitated rates.

As used in this subsection (f), "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis. (g) No later than August 1, 2013, the Department shall issue a purchase of care solicitation for Accountable Care Entities (ACE) to serve any children and parents or caretaker relatives of children eligible for medical assistance under this Article. An ACE may be a single corporate structure or a network of providers organized through contractual relationships with a single corporate entity. The solicitation shall require that: (1) An ACE operating in Cook County be capable of

serving at least 40,000 eligible individuals in that county; an ACE operating in Lake, Kane, DuPage, or Will Counties be capable of serving at least 20,000 eligible individuals in those counties and an ACE operating in other regions of the State be capable of serving at least 10,000 eligible individuals in the region in which it operates. During initial periods of mandatory enrollment, the Department shall require its enrollment services contractor to use a default assignment algorithm that ensures if possible an ACE reaches the minimum enrollment levels set forth in this paragraph.

(2) An ACE must include at a minimum the following

types of providers: primary care, specialty care, hospitals, and behavioral healthcare.

(3) An ACE shall have a governance structure that

includes the major components of the health care delivery system, including one representative from each of the groups listed in paragraph (2).

(4) An ACE must be an integrated delivery system,

including a network able to provide the full range of services needed by Medicaid beneficiaries and system capacity to securely pass clinical information across participating entities and to aggregate and analyze that data in order to coordinate care.

(5) An ACE must be capable of providing both care

coordination and complex case management, as necessary, to beneficiaries. To be responsive to the solicitation, a potential ACE must outline its care coordination and complex case management model and plan to reduce the cost of care.

(6) In the first 18 months of operation, unless the

ACE selects a shorter period, an ACE shall be paid care coordination fees on a per member per month basis that are projected to be cost neutral to the State during the term of their payment and, subject to federal approval, be eligible to share in additional savings generated by their care coordination.

(7) In months 19 through 36 of operation, unless the

ACE selects a shorter period, an ACE shall be paid on a pre-paid capitation basis for all medical assistance covered services, under contract terms similar to Managed Care Organizations (MCO), with the Department sharing the risk through either stop-loss insurance for extremely high cost individuals or corridors of shared risk based on the overall cost of the total enrollment in the ACE. The ACE shall be responsible for claims processing, encounter data submission, utilization control, and quality assurance.

(8) In the fourth and subsequent years of operation,

an ACE shall convert to a Managed Care Community Network (MCCN), as defined in this Article, or Health Maintenance Organization pursuant to the Illinois Insurance Code, accepting full-risk capitation payments.

The Department shall allow potential ACE entities 5 months from the date of the posting of the solicitation to submit proposals. After the solicitation is released, in addition to the MCO rate development data available on the Department's website, subject to federal and State confidentiality and privacy laws and regulations, the Department shall provide 2 years of de-identified summary service data on the targeted population, split between children and adults, showing the historical type and volume of services received and the cost of those services to those potential bidders that sign a data use agreement. The Department may add up to 2 non-state government employees with expertise in creating integrated delivery systems to its review team for the purchase of care solicitation described in this subsection. Any such individuals must sign a no-conflict disclosure and confidentiality agreement and agree to act in accordance with all applicable State laws. During the first 2 years of an ACE's operation, the Department shall provide claims data to the ACE on its enrollees on a periodic basis no less frequently than monthly. Nothing in this subsection shall be construed to limit the Department's mandate to enroll 50% of its beneficiaries into care coordination systems by January 1, 2015, using all available care coordination delivery systems, including Care Coordination Entities (CCE), MCCNs, or MCOs, nor be construed to affect the current CCEs, MCCNs, and MCOs selected to serve seniors and persons with disabilities prior to that date. Nothing in this subsection precludes the Department from considering future proposals for new ACEs or expansion of existing ACEs at the discretion of the Department. (h) Department contracts with MCOs and other entities reimbursed by risk based capitation shall have a minimum medical loss ratio of 85%, shall require the entity to establish an appeals and grievances process for consumers and providers, and shall require the entity to provide a quality assurance and utilization review program. Entities contracted with the Department to coordinate healthcare regardless of risk shall be measured utilizing the same quality metrics. The quality metrics may be population specific. Any contracted entity serving at least 5,000 seniors or people with disabilities or 15,000 individuals in other populations covered by the Medical Assistance Program that has been receiving full-risk capitation for a year shall be accredited by a national accreditation organization authorized by the Department within 2 years after the date it is eligible to become accredited. The requirements of this subsection shall apply to contracts with MCOs entered into or renewed or extended after June 1, 2013. (h-5) The Department shall monitor and enforce compliance by MCOs with agreements they have entered into with providers on issues that include, but are not limited to, timeliness of payment, payment rates, and processes for obtaining prior approval. The Department may impose sanctions on MCOs for violating provisions of those agreements that include, but are not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. As used in this subsection (h-5), "MCO" has the meaning ascribed to that term in Section 5-30.1 of this Code. (i) Unless otherwise required by federal law, Medicaid Managed Care Entities and their respective business associates shall not disclose, directly or indirectly, including by sending a bill or explanation of benefits, information concerning the sensitive health services received by enrollees of the Medicaid Managed Care Entity to any person other than covered entities and business associates, which may receive, use, and further disclose such information solely for the purposes permitted under applicable federal and State laws and regulations if such use and further disclosure satisfies all applicable requirements of such laws and regulations. The Medicaid Managed Care Entity or its respective business associates may disclose information concerning the sensitive health services if the enrollee who received the sensitive health services requests the information from the Medicaid Managed Care Entity or its respective business associates and authorized the sending of a bill or explanation of benefits. Communications including, but not limited to, statements of care received or appointment reminders either directly or indirectly to the enrollee from the health care provider, health care professional, and care coordinators, remain permissible. Medicaid Managed Care Entities or their respective business associates may communicate directly with their enrollees regarding care coordination activities for those enrollees. For the purposes of this subsection, the term "Medicaid Managed Care Entity" includes Care Coordination Entities, Accountable Care Entities, Managed Care Organizations, and Managed Care Community Networks. For purposes of this subsection, the term "sensitive health services" means mental health services, substance abuse treatment services, reproductive health services, family planning services, services for sexually transmitted infections and sexually transmitted diseases, and services for sexual assault or domestic abuse. Services include prevention, screening, consultation, examination, treatment, or follow-up. For purposes of this subsection, "business associate", "covered entity", "disclosure", and "use" have the meanings ascribed to those terms in 45 CFR 160.103. Nothing in this subsection shall be construed to relieve a Medicaid Managed Care Entity or the Department of any duty to report incidents of sexually transmitted infections to the Department of Public Health or to the local board of health in accordance with regulations adopted under a statute or ordinance or to report incidents of sexually transmitted infections as necessary to comply with the requirements under Section 5 of the Abused and Neglected Child Reporting Act or as otherwise required by State or federal law.The Department shall create policy in order to implement the requirements in this subsection. (j) Managed Care Entities (MCEs), including MCOs and all other care coordination organizations, shall develop and maintain a written language access policy that sets forth the standards, guidelines, and operational plan to ensure language appropriate services and that is consistent with the standard of meaningful access for populations with limited English proficiency. The language access policy shall describe how the MCEs will provide all of the following required services:(1) Translation (the written replacement of text from

one language into another) of all vital documents and forms as identified by the Department.

(2) Qualified interpreter services (the oral

communication of a message from one language into another by a qualified interpreter).

(3) Staff training on the language access policy,

including how to identify language needs, access and provide language assistance services, work with interpreters, request translations, and track the use of language assistance services.

(4) Data tracking that identifies the language need.(5) Notification to participants on the availability

of language access services and on how to access such 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:(1) emergency services, as defined by Section 10 of

the Managed Care Reform and Patient Rights Act;

(2) emergency medical screening examinations, as

defined by Section 10 of the Managed Care Reform and Patient Rights Act;

(3) post-stabilization medical services, as defined

by Section 10 of the Managed Care Reform and Patient Rights Act; and

(4) emergency medical conditions, as defined by

Section 10 of the Managed Care Reform and Patient Rights Act.

(b) As provided by Section 5-16.12, managed care organizations are subject to the provisions of the Managed Care Reform and Patient Rights Act.(c) An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid fee-for-service program methodology, including all policy adjusters, including but not limited to Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates.(d) An MCO shall pay for all post-stabilization services as a covered service in any of the following situations:(1) the MCO authorized such services;(2) such services were administered to maintain the

enrollee's stabilized condition within one hour after a request to the MCO for authorization of further post-stabilization services;

(3) the MCO did not respond to a request to authorize

such services within one hour;

(4) the MCO could not be contacted; or(5) the MCO and the treating provider, if the

treating provider is a non-affiliated provider, could not reach an agreement concerning the enrollee's care and an affiliated provider was unavailable for a consultation, in which case the MCO must pay for such services rendered by the treating non-affiliated provider until an affiliated provider was reached and either concurred with the treating non-affiliated provider's plan of care or assumed responsibility for the enrollee's care. Such payment shall be made at the default rate of reimbursement 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 that such adjustments are incorporated in the development of the applicable MCO capitated rates.

(e) The following requirements apply to MCOs in determining payment for all emergency services:(1) MCOs shall not impose any requirements for prior

approval of emergency services.

(2) The MCO shall cover emergency services provided

to enrollees who are temporarily away from their residence and outside the contracting area to the extent that the enrollees would be entitled to the emergency services if they still were within the contracting area.

(3) The MCO shall have no obligation to cover medical

services provided on an emergency basis that are not covered services under the contract.

(4) The MCO shall not condition coverage for

emergency services on the treating provider notifying the MCO of the enrollee's screening and treatment within 10 days after presentation for emergency services.

(5) The determination of the attending emergency

physician, or the provider actually treating the enrollee, of whether an enrollee is sufficiently stabilized for discharge or transfer to another facility, shall be binding on the MCO. The MCO shall cover emergency services for all enrollees whether the emergency services are provided by an affiliated or non-affiliated provider.

(6) The MCO's financial responsibility for

post-stabilization care services it has not pre-approved ends when:

(A) a plan physician with privileges at the

treating hospital assumes responsibility for the enrollee's care;

(B) a plan physician assumes responsibility for

the enrollee's care through transfer;

treating physician reach an agreement concerning the enrollee's care; or

(D) the enrollee is discharged. (f) Network adequacy and transparency.(1) The Department shall:(A) ensure that an adequate provider network is

in place, taking into consideration health professional shortage areas and medically underserved areas;

(B) publicly release an explanation of its

process for analyzing network adequacy;

have an adequate network in place; and

(D) require MCOs, including Medicaid Managed Care

Entities as defined in Section 5-30.2, to meet provider directory requirements under Section 5-30.3.

(2) Each MCO shall confirm its receipt of information

submitted specific to physician or dentist additions or physician or dentist deletions from the MCO's provider network within 3 days after receiving all required information from contracted physicians or dentists, and electronic physician and dental directories must be updated consistent with current rules as published by the Centers for Medicare and Medicaid Services or its successor agency.

(g) Timely payment of claims.(1) The MCO shall pay a claim within 30 days of

receiving a claim that contains all the essential information needed to adjudicate the claim.

(2) The MCO shall notify the billing party of its

inability to adjudicate a claim within 30 days of receiving that claim.

(3) The MCO shall pay a penalty that is at least

equal to the timely payment interest penalty imposed under Section 368a of the Illinois Insurance Code for any claims not timely paid.

(A) When an MCO is required to pay a timely

payment interest penalty to a provider, the MCO must calculate and pay the timely payment interest penalty that is due to the provider within 30 days after the payment of the claim. In no event shall a provider be required to request or apply for payment of any owed timely payment interest penalties.

(B) Such payments shall be reported separately

from the claim payment for services rendered to the MCO's enrollee and clearly identified as interest payments.

(4)(A) The Department shall require MCOs to expedite

payments to providers identified on the Department's expedited provider list, determined in accordance with 89 Ill. Adm. Code 140.71(b), on a schedule at least as frequently as the providers are paid under the Department's fee-for-service expedited provider schedule.

(B) Compliance with the expedited provider

requirement may be satisfied by an MCO through the use of a Periodic Interim Payment (PIP) program that has been mutually agreed to and documented between the MCO and the provider, and the PIP program ensures that any expedited provider receives regular and periodic payments based on prior period payment experience from that MCO. Total payments under the PIP program may be reconciled against future PIP payments on a schedule mutually agreed to between the MCO and the provider.

expedited provider list and the frequency with which it pays providers on the expedited list.

(g-5) Recognizing that the rapid transformation of the Illinois Medicaid program may have unintended operational challenges for both payers and providers:(1) in no instance shall a medically necessary

covered service rendered in good faith, based upon eligibility information documented by the provider, be denied coverage or diminished in payment amount if the eligibility or coverage information available at the time the service was rendered is later found to be inaccurate in the assignment of coverage responsibility between MCOs or the fee-for-service system, except for instances when an individual is deemed to have not been eligible for coverage under the Illinois Medicaid program; and

(2) the Department shall, by December 31, 2016, adopt

rules establishing policies that shall be included in the Medicaid managed care policy and procedures manual addressing payment resolutions in situations in which a provider renders services based upon information obtained after verifying a patient's eligibility and coverage plan through either the Department's current enrollment system or a system operated by the coverage plan identified by the patient presenting for services:

(A) such medically necessary covered services

shall be considered rendered in good faith;

(B) such policies and procedures shall be

developed in consultation with industry representatives of the Medicaid managed care health plans and representatives of provider associations representing the majority of providers within the identified provider industry; and

and comment period of no less than 30 days on the Department's website with final rules remaining available on the Department's website.

The rules on payment resolutions shall include, but not be limited to:(A) the extension of the timely filing period;(B) retroactive prior authorizations; and(C) guaranteed minimum payment rate of no less than

the current, as of the date of service, fee-for-service rate, plus all applicable add-ons, when the resulting service relationship is out of network.

The rules shall be applicable for both MCO coverage and fee-for-service coverage. If the fee-for-service system is ultimately determined to have been responsible for coverage on the date of service, the Department shall provide for an extended period for claims submission outside the standard timely filing requirements. (g-6) MCO Performance Metrics Report.(1) The Department shall publish, on at least a

quarterly basis, each MCO's operational performance, including, but not limited to, the following categories of metrics:

(A) claims payment, including timeliness and

accuracy;

(B) prior authorizations;(C) grievance and appeals;(D) utilization statistics;(E) provider disputes;(F) provider credentialing; and(G) member and provider customer service. (2) The Department shall ensure that the metrics

report is accessible to providers online by January 1, 2017.

(3) The metrics shall be developed in consultation

with industry representatives of the Medicaid managed care health plans and representatives of associations representing the majority of providers within the identified industry.

(4) Metrics shall be defined and incorporated into

the applicable Managed Care Policy Manual issued by the Department.

(g-7) MCO claims processing and performance analysis. In order to monitor MCO payments to hospital providers, pursuant to this amendatory Act of the 100th General Assembly, 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. The Department shall post the contracted claims report required by HealthChoice Illinois on its website every 3 months. (g-8) Dispute resolution process. The Department shall maintain a provider complaint portal through which a provider can submit to the Department unresolved disputes with an MCO. An unresolved dispute means an MCO's decision that denies in whole or in part a claim for reimbursement to a provider for health care services rendered by the provider to an enrollee of the MCO with which the provider disagrees. Disputes shall not be submitted to the portal until the provider has availed itself of the MCO's internal dispute resolution process. Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the Department of Healthcare and Family Services' complaint portal no sooner than 30 days after submitting to the MCO's internal process and not later than 30 days after the unsatisfactory resolution of the internal MCO process or 60 days after submitting the dispute to the MCO internal process. Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy. Within 10 business days of receipt of a complaint, the Department shall present such disputes to the appropriate MCO, which shall then have 30 days to issue its written proposal to resolve the dispute. The Department may grant one 30-day extension of this time frame to one of the parties to resolve the dispute. If the dispute remains unresolved at the end of this time frame or the provider is not satisfied with the MCO's written proposal to resolve the dispute, the provider may, within 30 days, request the Department to review the dispute and make a final determination. Within 30 days of the request for Department review of the dispute, both the provider and the MCO shall present all relevant information to the Department for resolution and make individuals with knowledge of the issues available to the Department for further inquiry if needed. Within 30 days of receiving the relevant information on the dispute, or the lapse of the period for submitting such information, the Department shall issue a written decision on the dispute based on contractual terms between the provider and the MCO, contractual terms between the MCO and the Department of Healthcare and Family Services and applicable Medicaid policy. The decision of the Department shall be final. By January 1, 2020, the Department shall establish by rule further details of this dispute resolution process. Disputes between MCOs and providers presented to the Department for resolution are not contested cases, as defined in Section 1-30 of the Illinois Administrative Procedure Act, conferring any right to an administrative hearing. (g-9)(1) The Department shall publish annually on its website a report on the calculation of each managed care organization's medical loss ratio showing the following: (A) Premium revenue, with appropriate adjustments. (B) Benefit expense, setting forth the aggregate

amount spent for the following:

(i) Direct paid claims.(ii) Subcapitation payments.(iii) Other claim payments.(iv) Direct reserves.(v) Gross recoveries.(vi) Expenses for activities that improve health

care quality as allowed by the Department.

(2) The medical loss ratio shall be calculated consistent with federal law and regulation following a claims runout period determined by the Department. (g-10)(1) "Liability effective date" means the date on which an MCO becomes responsible for payment for medically necessary and covered services rendered by a provider to one of its enrollees in accordance with the contract terms between the MCO and the provider. The liability effective date shall be the later of: (A) The execution date of a network participation

contract agreement.

(B) The date the provider or its representative

submits to the MCO the complete and accurate standardized roster form for the provider in the format approved by the Department.

Department's provider enrollment subsystem within the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) System.

(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. (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. (Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)

(305 ILCS 5/5-30.2) Sec. 5-30.2. Monthly reports; managed care enrollment.(a) As used in this Section, "Medicaid Managed Care Entity" means a Managed Care Organization (MCO), a Managed Care Community Network (MCCN), an Accountable Care Entity (ACE), or a Care Coordination Entity (CCE) contracted by the Department. (b) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of persons in the State's medical assistance program. In addition, as soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of recipients of medical assistance into a Medicaid Managed Care Entity contracted by the Department. As soon as practical if the data is reasonably available, but no later than January 1, 2017, the monthly reports shall include all of the following information for the medical assistance program generally and, separately, for each Medicaid Managed Care Entity contracted by the Department: (1) Total enrollment. (2) The number of persons enrolled in the medical

assistance program under items 18 and 19 of Section 5-2.

(3) The number of children enrolled. (4) The number of parents and caretakers of minor

children enrolled.

(5) The number of women enrolled on the basis of

pregnancy.

(6) The number of seniors enrolled.(7) The number of persons enrolled on the basis of

disability.

(c) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website detailing the percentage of persons enrolled in each Medicaid Managed Care Entity that was assigned using an auto-assignment algorithm. This percentage should also report the type of enrollee who was assigned using an auto-assignment algorithm, including, but not limited to, persons enrolled in the medical assistance program in each of the groups listed in subsection (b) of this Section.(d) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include data on the 2 most recently available months and data comparing the most recently available month to that month in the prior year. (e) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include a breakdown of language preference for enrollees by English, Spanish, and the next 4 most commonly used languages. (f) The Department must annually publish on its website each Medicaid Managed Care Entity's quality metrics outcomes and must make public an independent annual quality review report on the State's Medicaid managed care delivery system. (Source: P.A. 99-86, eff. 7-21-15.)

(305 ILCS 5/5-30.3) Sec. 5-30.3. Empowering meaningful patient choice in Medicaid Managed Care.(a) Definitions. As used in this Section: "Client enrollment services broker" means a vendor the Department contracts with to carry out activities related to Medicaid recipients' enrollment, disenrollment, and renewal with Medicaid Managed Care Entities. "Composite domains" means the synthesized categories reflecting the standardized quality performance measures included in the consumer quality comparison tool. At a minimum, these composite domains shall display Medicaid Managed Care Entities' individual Plan performance on standardized quality, timeliness, and access measures. "Consumer quality comparison tool" means an online and paper tool developed by the Department with input from interested stakeholders reflecting the performance of Medicaid Managed Care Entity Plans on standardized quality performance measures. This tool shall be designed in a consumer-friendly and easily understandable format. "Covered services" means those health care services to which a covered person is entitled to under the terms of the Medicaid Managed Care Entity Plan. "Facilities" includes, but is not limited to, federally qualified health centers, skilled nursing facilities, and rehabilitation centers. "Hospitals" includes, but is not limited to, acute care, rehabilitation, children's, and cancer hospitals."Integrated provider directory" means a searchable database bringing together network data from multiple Medicaid Managed Care Entities that is available through client enrollment services."Medicaid eligibility redetermination" means the process by which the eligibility of a Medicaid recipient is reviewed by the Department to determine if the recipient's medical benefits will continue, be modified, or terminated."Medicaid Managed Care Entity" has the same meaning as defined in Section 5-30.2 of this Code.(b) Provider directory transparency.(1) Each Medicaid Managed Care Entity shall: (A) Make available on the entity's website a

provider directory in a machine readable file and format.

(B) Make provider directories publicly accessible

without the necessity of providing a password, a username, or personally identifiable information.

and regulations, including 42 CFR 438.10, pertaining to provider directories within Medicaid Managed Care.

(D) Request, at least annually, provider office

hours for each of the following provider types:

(i) Health care professionals, including

dental and vision providers.

(ii) Hospitals.(iii) Facilities, other than hospitals.(iv) Pharmacies, other than hospitals.(v) Durable medical equipment suppliers,

other than hospitals.

Medicaid Managed Care Entities shall publish the

provider office hours in the provider directory upon receipt.

(E) Confirm with the Medicaid Managed Care

Entity's contracted providers who have not submitted claims within the past 6 months that the contracted providers intend to remain in the network and correct any incorrect provider directory information as necessary.

(F) Ensure that in situations in which a Medicaid

Managed Care Entity Plan enrollee receives covered services from a non-participating provider due to a material misrepresentation in a Medicaid Managed Care Entity's online electronic provider directory, the Medicaid Managed Care Entity Plan enrollee shall not be held responsible for any costs resulting from that material misrepresentation.

(G) Conspicuously display an e-mail address and a

toll-free telephone number to which any individual may report any inaccuracy in the provider directory. If the Medicaid Managed Care Entity receives a report from any person who specifically identifies provider directory information as inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic directory.

(2) The Department shall: (A) Regularly monitor Medicaid Managed Care

Entities to ensure that they are compliant with the requirements under paragraph (1) of subsection (b).

(B) Require that the client enrollment services

broker use the Medicaid provider number for all providers with a Medicaid Provider number to populate the provider information in the integrated provider directory.

shall, at minimum, make the information in subparagraph (D) of paragraph (1) of subsection (b) available to the client enrollment services broker.

(D) Ensure that the client enrollment services

broker shall, at minimum, have the information in subparagraph (D) of paragraph (1) of subsection (b) available and searchable through the integrated provider directory on its website as soon as possible but no later than January 1, 2017.

(E) Require the client enrollment services broker

to conspicuously display near the integrated provider directory an email address and a toll-free telephone number provided by the Department to which any individual may report inaccuracies in the integrated provider directory. If the Department receives a report that identifies an inaccuracy in the integrated provider directory, the Department shall provide the information about the reported inaccuracy to the appropriate Medicaid Managed Care Entity within 3 business days after the reported inaccuracy is received.

their respective websites a formulary for each Medicaid Managed Care Entity Plan offered and make the formularies easily understandable and publicly accessible without the necessity of providing a password, a username, or personally identifiable information.

(2) Medicaid Managed Care Entities shall provide

printed formularies upon request.

(3) Electronic and print formularies shall display: (A) the medications covered (both generic and

name brand);

(B) if the medication is preferred or not

preferred, and what each term means;

meaning of each tier;

(D) any utilization controls including, but not

limited to, step therapy, prior approval, dosage limits, gender or age restrictions, quantity limits, or other policies that affect access to medications;

(E) any required cost-sharing;(F) a glossary of key terms and explanation of

utilization controls and cost-sharing requirements;

(G) a key or legend for all utilization controls

visible on every page in which specific medication coverage information is displayed; and

(H) directions explaining the process or

processes a consumer may follow to obtain more information if a medication the consumer requires is not covered or listed in the formulary.

(4) Each Medicaid Managed Care Entity shall display

conspicuously with each electronic and printed medication formulary an e-mail address and a toll-free telephone number to which any individual may report any inaccuracy in the formulary. If the Medicaid Managed Care Entity receives a report that the formulary information is inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic formulary.

(5) Each Medicaid Managed Care Entity shall include a

disclosure in the electronic and requested print formularies that provides the date of publication, a statement that the formulary is up to date as of publication, and contact information for questions and requests to receive updated information.

(6) The client enrollment services broker's website

shall display prominently a website URL link to each Medicaid Managed Care Entity's Plan formulary. If a Medicaid enrollee calls the client enrollment services broker with questions regarding formularies, the client enrollment services broker shall offer a brief description of what a formulary is and shall refer the Medicaid enrollee to the appropriate Medicaid Managed Care Entity regarding his or her questions about a specific entity's formulary.

(d) Grievances and appeals. The Department shall display prominently on its website consumer-oriented information describing how a Medicaid enrollee can file a complaint or grievance, request a fair hearing for any adverse action taken by the Department or a Medicaid Managed Care Entity, and access free legal assistance or other assistance made available by the State for Medicaid enrollees to pursue an action.(e) Medicaid redetermination information. The Department shall require the client enrollment services broker to display prominently on the client enrollment services broker's website a description of where a Medicaid enrollee can access information regarding the Medicaid redetermination process. (f) Medicaid care coordination information. The client enrollment services broker shall display prominently on its website, in an easily understandable format, consumer-oriented information regarding the role of care coordination services within Medicaid Managed Care. Such information shall include, but shall not be limited to:(1) a basic description of the role of care

coordination services and examples of specific care coordination activities; and

(2) how a Medicaid enrollee may request care

coordination services from a Medicaid Managed Care Entity.

(g) Consumer quality comparison tool. (1) The Department shall create a consumer quality

comparison tool to assist Medicaid enrollees with Medicaid Managed Care Entity Plan selection. This tool shall provide Medicaid Managed Care Entities' individual Plan performance on a set of standardized quality performance measures. The Department shall ensure that this tool shall be accessible in both a print and online format, with the online format allowing for individuals to access additional detailed Plan performance information.

(2) At a minimum, a printed version of the consumer

quality comparison tool shall be provided by the Department on an annual basis to Medicaid enrollees who are required by the Department to enroll in a Medicaid Managed Care Entity Plan during an enrollee's open enrollment period. The consumer quality comparison tool shall also meet all of the following criteria:

(A) Display Medicaid Managed Care Entities'

individual Plan performance on at least 4 composite domains that reflect Plan quality, timeliness, and access. The composite domains shall draw from the most current available performance data sets including, but not limited to:

(i) Healthcare Effectiveness Data and

Information Set (HEDIS) measures.

(ii) Core Set of Children's Health Care

Quality measures as required under the Children's Health Insurance Program Reauthorization Act (CHIPRA).

(iii) Adult Core Set measures.(iv) Consumer Assessment of Healthcare

Providers and Systems (CAHPS) survey results.

(v) Additional performance measures the

Department deems appropriate to populate the composite domains.

(B) Use a quality rating system developed by the

Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.

Medicaid Managed Care Entities' Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.

(D) Include contact information for the client

enrollment services broker and contact information for Medicaid Managed Care Entities available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.

(E) Include guiding questions designed to assist

individuals selecting a Medicaid Managed Care Entity Plan.

(3) At a minimum, the online version of the consumer

quality comparison tool shall meet all of the following criteria:

(A) Display Medicaid Managed Care Entities'

individual Plan performance for the same composite domains selected by the Department in the printed version of the consumer quality comparison tool. The Department may display additional composite domains in the online version of the consumer quality comparison tool as appropriate.

(B) Display Medicaid Managed Care Entities'

individual Plan performance on each of the standardized performance measures that contribute to each composite domain displayed on the online version of the consumer quality comparison tool.

(D) Include the specific Medicaid Managed Care

Entity Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.

(E) Include a sort function to view Medicaid

Managed Care Entities' individual Plan performance by quality rating and by standardized quality performance measures.

(F) Include contact information for the client

enrollment services broker and for each Medicaid Managed Care Entity.

(G) Include guiding questions designed to assist

individuals in selecting a Medicaid Managed Care Entity Plan.

(H) Prominently display current notice of quality

performance sanctions against Medicaid Managed Care Entities. Notice of the sanctions shall remain present on the online version of the consumer quality comparison tool until the sanctions are lifted.

(4) The online version of the consumer quality

comparison tool shall be displayed prominently on the client enrollment services broker's website.

(5) In the development of the consumer quality

comparison tool, the Department shall establish and publicize a formal process to collect and consider written and oral feedback from consumers, advocates, and stakeholders on aspects of the consumer quality comparison tool, including, but not limited to, the following:

(A) The standardized data sets and surveys,

specific performance measures, and composite domains represented in the consumer quality comparison tool.

(B) The format and presentation of the consumer

quality comparison tool.

notify Medicaid enrollees of the availability of the consumer quality comparison tool.

(6) The Department shall review and update as

appropriate the composite domains and performance measures represented in the print and online versions of the consumer quality comparison tool at least once every 3 years. During the Department's review process, the Department shall solicit engagement in the public feedback process described in paragraph (5).

(7) The Department shall ensure that the consumer

quality comparison tool is available for consumer use as soon as possible but no later than January 1, 2018.

(h) The Department may adopt rules and take any other appropriate action necessary to implement its responsibilities under this Section. (Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.)

(305 ILCS 5/5-30.4) Sec. 5-30.4. Provider inquiry portal. The Department shall establish, no later than January 1, 2018, a web-based portal to accept inquiries and requests for assistance from managed care organizations under contract with the State and providers under contract with managed care organizations to provide direct care. (Source: P.A. 99-719, eff. 1-1-17; 100-201, eff. 8-18-17.)

(305 ILCS 5/5-30.5) Sec. 5-30.5. Managed care; automatic assignment. The Department shall, within a reasonable period of time after relevant data from managed care entities has been collected and analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes into account quality scores and other operational proficiency criteria developed, defined, and adopted by the Department, to automatically assign Medicaid enrollees served under the Family Health Plan and the Integrated Care Program and those Medicaid enrollees eligible for medical assistance pursuant to the Patient Protection and Affordable Care Act (Public Law 111-148) into managed care entities, including Accountable Care Entities, Managed Care Community Networks, and Managed Care Organizations. The quality metrics used shall be measurable for all entities. The algorithm shall not use the quality and proficiency metrics to reassign enrollees out of any plan in which they are enrolled at the time and shall only be used if the client has not voluntarily selected a primary care physician and a managed care entity or care coordination entity. Clients shall have one opportunity within 90 calendar days after auto-assignment by algorithm to select a different managed care entity. The algorithm developed and implemented shall favor assignment into managed care entities with the highest quality scores and levels of compliance with the operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists. (Source: P.A. 99-898, eff. 1-1-17; 100-201, eff. 8-18-17.)

(305 ILCS 5/5-30.6) Sec. 5-30.6. Managed care organization contracts procurement requirement. Beginning on March 12, 2018 (the effective date of Public Act 100-580), any new contract between the Department and a managed care organization as defined in Section 5-30.1 shall be procured in accordance with the Illinois Procurement Code. (a) Application.(1) This Section does not apply to the State of

Illinois Medicaid Managed Care Organization Request for Proposals (2018-24-001) or any agreement, regardless of what it may be called, related to or arising from this procurement, including, but not limited to, contracts, renewals, renegotiated contracts, amendments, and change orders.

(2) This Section does not apply to Medicare-Medicaid

Alignment Initiative contracts executed under Article V-F of this Code.

(b) In the event any provision of this Section or of the Illinois Procurement Code is inconsistent with applicable federal law or would have the effect of foreclosing the use, potential use, or receipt of federal financial participation, the applicable federal law or funding condition shall prevail, but only to the extent of such inconsistency. (Source: P.A. 100-580, eff. 3-12-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-30.7) Sec. 5-30.7. Encounter data guidelines; provider fee schedule. (a) No later than 60 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall publish on its website comprehensive written guidance on the submission of encounter data by managed care organizations. This information shall be updated and published as needed, but at least quarterly. The Department shall inform providers and managed care organizations of any updates via provider notices.(b) The Department shall publish on its website provider fee schedules on both a portable document format (PDF) and EXCEL format. The portable document format shall serve as the ultimate source if there is a discrepancy. (Source: P.A. 100-580, eff. 3-12-18.)

(305 ILCS 5/5-30.8) Sec. 5-30.8. Managed care organization rate transparency.(a) For the establishment of managed care organization (MCO) capitation base rate payments from the State, including, but not limited to: (i) hospital fee schedule reforms and updates, (ii) rates related to a single State-mandated preferred drug list, (iii) rate updates related to the State's preferred drug list, (iv) inclusion of coverage for children with special needs, (v) inclusion of coverage for children within the child welfare system, (vi) annual MCO capitation rates, and (vii) any retroactive provider fee schedule adjustments or other changes required by legislation or other actions, the Department of Healthcare and Family Services shall implement a capitation base rate setting process beginning on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following elements of transparency:(1) The Department shall include participating

MCOs and a statewide trade association representing a majority of participating MCOs in meetings to discuss the impact to base capitation rates as a result of any new or updated hospital fee schedules or other provider fee schedules. Additionally, the Department shall share any data or reports used to develop MCO capitation rates with participating MCOs. This data shall be comprehensive enough for MCO actuaries to recreate and verify the accuracy of the capitation base rate build-up.

(2) The Department shall not limit the number of

experts that each MCO is allowed to bring to the draft capitation base rate meeting or the final capitation base rate review meeting. Draft and final capitation base rate review meetings shall be held in at least 2 locations.

(3) The Department and its contracted actuary shall

meet with all participating MCOs simultaneously and together along with consulting actuaries contracted with statewide trade association representing a majority of Medicaid health plans at the request of the plans. Participating MCOs shall additionally, at their request, be granted individual capitation rate development meetings with the Department.

(4) Any quality incentive or other incentive

withholding of any portion of the actuarially certified capitation rates must be budget-neutral. The entirety of any aggregate withheld amounts must be returned to the MCOs in proportion to their performance on the relevant performance metric. No amounts shall be returned to the Department if all performance measures are not achieved to the extent allowable by federal law and regulations.

(5) Upon request, the Department shall

provide written responses to questions regarding MCO capitation base rates, the capitation base development methodology, and MCO capitation rate data, and all other requests regarding capitation rates from MCOs. Upon request, the Department shall also provide to the MCOs materials used in incorporating provider fee schedules into base capitation rates.

(b) For the development of capitation base rates for new capitation rate years: (1) The Department shall take into account emerging

experience in the development of the annual MCO capitation base rates, including, but not limited to, current-year cost and utilization trends observed by MCOs in an actuarially sound manner and in accordance with federal law and regulations.

(2) No later than January 1 of each year, the

Department shall release an agreed upon annual calendar that outlines dates for capitation rate setting meetings for that year. The calendar shall include at least the following meetings and deadlines:

(A) An initial meeting for the Department to

review MCO data and draft rate assumptions to be used in the development of capitation base rates for the following year.

(B) A draft rate meeting after the Department

provides the MCOs with the draft capitation base rates to discuss, review, and seek feedback regarding the draft capitation base rates.

(3) Prior to the submission of final capitation

rates to the federal Centers for Medicare and Medicaid Services, the Department shall provide the MCOs with a final actuarial report including the final capitation base rates for the following year and subsequently conduct a final capitation base review meeting. Final capitation rates shall be marked final.

(c) For the development of capitation base rates reflecting policy changes: (1) Unless contrary to federal law and regulation,

the Department must provide notice to MCOs of any significant operational policy change no later than 60 days prior to the effective date of an operational policy change in order to give MCOs time to prepare for and implement the operational policy change and to ensure that the quality and delivery of enrollee health care is not disrupted. "Operational policy change" means a change to operational requirements such as reporting formats, encounter submission definitional changes, or required provider interfaces made at the sole discretion of the Department and not required by legislation with a retroactive effective date. Nothing in this Section shall be construed as a requirement to delay or prohibit implementation of policy changes that impact enrollee benefits as determined in the sole discretion of the Department.

(2) No later than 60 days after the effective

date of the policy change or program implementation, the Department shall meet with the MCOs regarding the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of that data that shall be utilized to develop capitation base rates.

(3) No later than 60 days after the effective date of

the policy change or program implementation, the Department shall meet with MCOs to review data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change, and shall provide opportunities for questions to be asked and answered.

(4) No later than 60 days after the effective

date of the policy change or program implementation, the Department shall provide the MCOs with draft capitation base rates and shall also conduct a draft capitation base rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.

(d) For the development of capitation base rates for retroactive policy or fee schedule changes: (1) The Department shall meet with the MCOs regarding

the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of the data that shall be utilized to develop capitation base rates.

(2) The Department shall meet with MCOs to review

data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change. The Department shall provide opportunities for questions to be asked and answered.

(3) The Department shall provide the MCOs with draft

capitation rates and shall also conduct a draft rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.

(4) The Department shall inform MCOs no less than

quarterly of upcoming benefit and policy changes to the Medicaid program.

(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) (Text of Section from P.A. 101-10)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 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. 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.) (Text of Section from P.A. 101-62)Sec. 5-30.11. Medicaid managed care organizations; preferred drug lists.(a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy, and community-based organizations, providers, and entities with expertise in drug formulary development. (b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website. Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls. (c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall: (A) convene and meet no less than once per calendar

quarter;

(B) provide regular opportunities for public comment;

and

Act.

All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act.(2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation:(A) one pharmacist licensed to practice pharmacy in

Illinois who is recommended by a statewide organization representing pharmacists;

(B) 4 physicians, recommended by a statewide

organization representing physicians, who are licensed to practice medicine in all its branches in Illinois, have knowledge of and adhere to best practice standards, and have experience treating Illinois Medicaid beneficiaries;

prevention and treatment of HIV, recommended by an HIV healthcare advocacy organization;

(D) at least one clinician recommended by a

healthcare advocacy organization that serves individuals who are affected by chronic diseases that require significant pharmaceutical treatments;

(E) one clinician representing the Illinois

Department; and

(F) one licensed psychiatrist, recommended by a

statewide organization representing psychiatrists, who has experience treating Illinois Medicaid beneficiaries.

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.) (Text of Section from P.A. 101-209)Sec. 5-30.11. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information:(1) The administrative expenses paid to the Medicaid

managed care health plan.

(2) The amount of money the Medicaid managed care

health plan has spent with Business Enterprise Program certified businesses.

(3) The amount of money the Medicaid managed care

health plan has spent with minority-owned and women-owned businesses that are certified by other agencies or private organizations.

(4) The amount of money the Medicaid managed care

health plan has spent with not-for-profit community-based organizations serving predominantly minority communities, as defined by the Department.

(5) The proportion of minorities, people with

disabilities, and women that make up the staff of the Medicaid managed care health plan.

(6) Recommendations for increasing expenditures with

minority-owned and women-owned businesses.

(7) A list of the types of services to which the

Medicaid managed care health plan is contemplating adding new vendors.

(8) The certifications the Medicaid managed care

health plan accepts for minority-owned and women-owned businesses.

(9) The point of contact for potential vendors

seeking to do business with the Medicaid managed care health plan.

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.)

(305 ILCS 5/5-30.12) Sec. 5-30.12. Managed care claim rejection and denial management.(a) In order to provide greater transparency to managed care organizations (MCOs) and providers, the Department shall explore the availability of and, if reasonably available, procure technology that, for all electronic claims, with the exception of direct data entry claims, meets the following needs: (1) The technology shall allow the Department to

fully analyze the root cause of claims denials in the Medicaid managed care programs operated by the Department and expedite solutions that reduce the number of denials to the extent possible.

(2) The technology shall create a single electronic

pipeline through which all claims from all providers submitted for adjudication by the Department or a managed care organization under contract with the Department shall be directed by clearing houses and providers or other claims submitting entities not using clearing houses prior to forwarding to the Department or the appropriate managed care organization.

(3) The technology shall cause all HIPAA-compliant

responses to submitted claims, including rejections, denials, and payments, returned to the submitting provider to pass through the established single pipeline.

(4) The technology shall give the Department the

ability to create edits to be placed at the front end of the pipeline that will reject claims back to the submitting provider with an explanation of why the claim cannot be properly adjudicated by the payer.

(5) The technology shall allow the Department to

customize the language used to explain why a claim is being rejected and how the claim can be corrected for adjudication.

(6) The technology shall send copies of all claims

and claim responses that pass through the pipeline, regardless of the payer to whom they are directed, to the Department's Enterprise Data Warehouse.

(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 5/5-30a) Sec. 5-30a. Exemptions from managed care enrollment; children. Notwithstanding any other provision of law, the Department shall not require any of the following children to enroll in or transition to the State's managed care medical assistance program:(1) Children who are authorized by the Department to

receive in-home shift nursing services as required by the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions under 42 CFR 441.50 et seq.

(2) Children made eligible for medical assistance

through any home and community-based services waiver program for medically fragile and technology dependent children authorized under Section 1915(c) of the Social Security Act.

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 5/5-31) 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: (1) All moneys collected or received by the Illinois

Department from donations and grants from private and public colleges and universities.

(2) All federal matching funds received by the

Illinois Department as a result of expenditures made by the Illinois Department that are attributable to moneys deposited in the Fund.

(3) Any interest or penalty levied in conjunction

with the administration of this Section.

(4) Moneys transferred from another fund in the State

treasury.

(5) All other moneys received for the Fund from any

other source, including interest earned thereon.

(d) 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) (Text of Section from P.A. 101-452)(This Section may contain text from a Public Act with a delayed effective date)Sec. 5-36. Pharmacy benefits. (a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law. (2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies: (A) the Department shall approve any contract between

a third-party administrator and a pharmacy;

(B) the Department's third-party administrator shall

not change the terms of a contract between a third-party administrator and a pharmacy without written approval by the Department; and

not create, modify, implement, or indirectly establish any fee on a pharmacy, pharmacist, or a recipient of medical assistance without written approval by the Department.

(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. 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 the effective date of this amendatory Act of the 101st General Assembly that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section. (d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department. (e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information: (1) whether the pharmacy benefit manager has a

contract, agreement, or other arrangement with a pharmaceutical manufacturer to exclusively dispense or provide a drug to a managed care organization's enrollees, and the aggregate amounts of consideration of economic benefits collected or received pursuant to that arrangement;

(2) the percentage of claims payments made by the

pharmacy benefit manager to pharmacies owned, managed, or controlled by the pharmacy benefit manager or any of the pharmacy benefit manager's management companies, parent companies, subsidiary companies, or jointly held companies;

(3) the aggregate amount of the fees or assessments

imposed on, or collected from, pharmacy providers; and

(4) the average annualized percentage of revenue

collected by the pharmacy benefit manager as a result of each contract it has executed with a managed care organization contracted by the Department to provide medical assistance benefits which is not paid by the pharmacy benefit manager to pharmacy providers and pharmaceutical manufacturers or labelers or in order to perform administrative functions pursuant to its contracts with managed care organizations.

(f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value. The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable. (g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification. As used in this Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies. (h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider: (1) a provision prohibiting the provider from

informing a patient of a less costly alternative to a prescribed medication; or

(2) a provision that prohibits the provider from

dispensing a particular amount of a prescribed medication, if the pharmacy benefit manager allows that amount to be dispensed through a pharmacy owned or controlled by the pharmacy benefit manager, unless the prescription drug is subject to restricted distribution by the United States Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.

(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.) (Text of Section from P.A. 101-461)(This Section may contain text from a Public Act with a delayed effective date)Sec. 5-36. 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 the effective date of this amendatory Act of the 101st General Assembly, 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.)

(305 ILCS 5/5-37) (This Section may contain text from a Public Act with a delayed effective date)Sec. 5-37. Billing mechanism for preventive mental health services delivered to children.(a) The General Assembly finds:(1) It is common for children to have mental health

needs but to not have a full-blown diagnosis of a mental illness. Examples include, but are not limited to, children who have mild or emerging symptoms of a mental health condition (such as meeting some but not all the criteria for a diagnosis, including, but not limited to, symptoms of depression, attentional deficits, anxiety or prodromal symptoms of bipolar disorder or schizophrenia); cutting or engaging in other forms of self-harm; or experiencing violence or trauma).

(2) The federal requirement that Medicaid-covered

children have access to Early and Periodic Screening, Diagnostic and Treatment services includes ensuring that Medicaid-covered children who have a mental health need but do not have a mental health diagnosis have access to treatment.

(3) The Department of Healthcare and Family Services'

existing policy acknowledges this federal requirement by allowing for Medicaid billing for mental health services for children who have a need for services but who do not have a mental health diagnosis in Section 207.3.3 of the Community-Based Behavioral Services Provider Handbook. However, the current policy of the Department of Healthcare and Family Services requires clinicians to specify a diagnosis code and make a notation in the child's medical record that the service is preventive. This effectively requires the clinician to associate a diagnosis with the child and is a major barrier for services because many clinicians rightly are unwilling to document a mental health diagnosis in the medical record when a diagnosis is not medically appropriate.

(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) (This Section may contain text from a Public Act with a delayed effective date)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 5/5-40) (This Section may contain text from a Public Act with a delayed effective date)Sec. 5-40. Human breast milk coverage.(a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:(1) the milk is obtained from a human milk bank that

meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;

(2) the infant's mother is medically or physically

unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the infant's needs or the maternal breast milk is contraindicated;

(3) the milk has been determined to be medically

necessary for the infant; and

(4) one or more of the following applies:(A) the infant's birth weight is below 1,500

grams;

(B) the infant has a congenital or acquired

condition that places the infant at a high risk for development of necrotizing enterocolitis;

(C) the infant has infant hypoglycemia;(D) the infant has congenital heart disease;(E) the infant has had or will have an organ

transplant;

(F) the infant has sepsis; or(G) the infant has any other serious congenital

or acquired condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the infant.

(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:(1) the milk is obtained from a human milk bank that

meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;

(2) the child's mother is medically or physically

unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;

(3) the milk has been determined to be medically

necessary for the child; and

(4) one or more of the following applies:(A) the child has spinal muscular atrophy;(B) the child's birth weight was below 1,500

grams and he or she has long-term feeding or gastrointestinal complications related to prematurity;

transplant; or

(D) the child has a congenital or acquired

condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the child.

(c) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 12 months of age or older, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:(1) the milk is obtained from a human milk bank that

meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;

(2) the child's mother is medically or physically

unable to produce maternal breast milk or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;

(3) the milk has been determined to be medically

necessary for the child; and

(4) the child has spinal muscular atrophy. (Source: P.A. 101-511, eff. 1-1-20.)

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