Bill Amendment: IL SB1321 | 2019-2020 | 101st General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: DHS-CHILD CARE PROGRAM

Status: 2019-08-05 - Public Act . . . . . . . . . 101-0209 [SB1321 Detail]

Download: Illinois-2019-SB1321-House_Amendment_001.html

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Rep. Gregory Harris

Filed: 5/28/2019

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AMENDMENT TO SENATE BILL 1321
AMENDMENT NO. ______. Amend Senate Bill 1321 by replacing
everything after the enacting clause with the following:
"Section 5. The Department of Healthcare and Family
Services Law of the Civil Administrative Code of Illinois is
amended by changing Section 2205-30 as follows:
(20 ILCS 2205/2205-30)
(Section scheduled to be repealed on December 1, 2020)
Sec. 2205-30. Long-term care services and supports
comprehensive study and actuarial modeling.
(a) The Department of Healthcare and Family Services shall
commission a comprehensive study of long-term care trends,
future projections, and actuarial analysis of a new long-term
services and supports benefit. Upon completion of the study,
the Department shall prepare a report on the study that
includes the following:

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(1) an extensive analysis of long-term care trends in
Illinois, including the number of Illinoisans needing
long-term care, the number of paid and unpaid caregivers,
the existing long-term care programs' utilization and
impact on the State budget; out-of-pocket spending and
spend-down to qualify for medical assistance coverage, the
financial and health impacts of caregiving on the family,
wages of paid caregivers and the effects of compensation on
the availability of this workforce, the current market for
private long-term care insurance, and a brief assessment of
the existing system of long-term services and supports in
terms of health, well-being, and the ability of
participants to continue living in their communities;
(2) an analysis of long-term care costs and utilization
projections through at least 2050 and the estimated impact
of such costs and utilization projections on the State
budget, increases in the senior population; projections of
the number of paid and unpaid caregivers in relation to
demand for services, and projections of the impact of
housing cost burdens and a lack of affordable housing on
seniors and people with disabilities;
(3) an actuarial analysis of options for a new
long-term services and supports benefit program, including
an analysis of potential tax sources and necessary levels,
a vesting period, the maximum daily benefit dollar amount,
the total maximum dollar amount of the benefit, and the

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duration of the benefit; and
(4) a qualitative analysis of a new benefit's impact on
seniors and people with disabilities, including their
families and caregivers, public and private long-term care
services, and the State budget.
The report must project under multiple possible
configurations the numbers of persons covered year over year,
utilization rates, total spending, and the benefit fund's ratio
balance and solvency. The benefit fund must initially be
structured to be solvent for 75 years. The report must detail
the sensitivity of these projections to the level of care
criteria that define long-term care need and examine the
feasibility of setting a lower threshold, based on a lower need
for ongoing assistance in routine life activities.
The report must also detail the amount of out-of-pocket
costs avoided, the number of persons who delayed or avoided
utilization of medical assistance benefits, an analysis on the
projected increased utilization of home-based and
community-based services over skilled nursing facilities and
savings therewith, and savings to the State's existing
long-term care programs due to the new long-term services and
supports benefit.
(b) The entity chosen to conduct the actuarial analysis
shall be a nationally-recognized organization with experience
modeling public and private long-term care financing programs.
(c) The study shall begin after January 1, 2019, and be

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completed before December 1, 2020 2019. Upon completion, the
report on the study shall be filed with the Clerk of the House
of Representatives and the Secretary of the Senate in
electronic form only, in the manner that the Clerk and the
Secretary shall direct.
(d) This Section is repealed December 1, 2020.
(Source: P.A. 100-587, eff. 6-4-18.)
Section 10. The Illinois Procurement Code is amended by
adding Section 20-25.1 as follows:
(30 ILCS 500/20-25.1 new)
Sec. 20-25.1. Special expedited procurement.
(a) The Chief Procurement Officer shall work with the
Department of Healthcare and Family Services to identify an
appropriate method of source selection that will result in an
executed contract for the technology required by Section
5-30.12 of the Illinois Public Aid Code no later than August 1,
2019 in order to target implementation of the technology to be
procured by January 1, 2020. The method of source selection may
be sole source, emergency, or other expedited process.
(b) Due to the negative impact on access to critical State
health care services and the ability to draw federal match for
services being reimbursed caused by issues with implementation
of the Integrated Eligibility System by the Department of Human
Services, the Department of Healthcare and Family Services, and

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the Department of Innovation and Technology, the General
Assembly finds that a threat to public health exists and to
prevent or minimize serious disruption in critical State
services that affect health, an emergency purchase of a vendor
shall be made by the Department of Healthcare and Family
Services to assess the Integrated Eligibility System for
critical gaps and processing errors and to monitor the
performance of the Integrated Eligibility System vendor under
the terms of its contract. The emergency purchase shall not
exceed 2 years. Notwithstanding any other provision of this
Code, such emergency purchase shall extend without a hearing
required by Section 20-30 until the integrated eligibility
system is stabilized and performing according to the needs of
the State to ensure continued access to health care for
eligible individuals.
Section 15. The Illinois Banking Act is amended by changing
Section 48.1 as follows:
(205 ILCS 5/48.1) (from Ch. 17, par. 360)
Sec. 48.1. Customer financial records; confidentiality.
(a) For the purpose of this Section, the term "financial
records" means any original, any copy, or any summary of:
(1) a document granting signature authority over a
deposit or account;
(2) a statement, ledger card or other record on any

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deposit or account, which shows each transaction in or with
respect to that account;
(3) a check, draft or money order drawn on a bank or
issued and payable by a bank; or
(4) any other item containing information pertaining
to any relationship established in the ordinary course of a
bank's business between a bank and its customer, including
financial statements or other financial information
provided by the customer.
(b) This Section does not prohibit:
(1) The preparation, examination, handling or
maintenance of any financial records by any officer,
employee or agent of a bank having custody of the records,
or the examination of the records by a certified public
accountant engaged by the bank to perform an independent
audit.
(2) The examination of any financial records by, or the
furnishing of financial records by a bank to, any officer,
employee or agent of (i) the Commissioner of Banks and Real
Estate, (ii) after May 31, 1997, a state regulatory
authority authorized to examine a branch of a State bank
located in another state, (iii) the Comptroller of the
Currency, (iv) the Federal Reserve Board, or (v) the
Federal Deposit Insurance Corporation for use solely in the
exercise of his duties as an officer, employee, or agent.
(3) The publication of data furnished from financial

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records relating to customers where the data cannot be
identified to any particular customer or account.
(4) The making of reports or returns required under
Chapter 61 of the Internal Revenue Code of 1986.
(5) Furnishing information concerning the dishonor of
any negotiable instrument permitted to be disclosed under
the Uniform Commercial Code.
(6) The exchange in the regular course of business of
(i) credit information between a bank and other banks or
financial institutions or commercial enterprises, directly
or through a consumer reporting agency or (ii) financial
records or information derived from financial records
between a bank and other banks or financial institutions or
commercial enterprises for the purpose of conducting due
diligence pursuant to a purchase or sale involving the bank
or assets or liabilities of the bank.
(7) The furnishing of information to the appropriate
law enforcement authorities where the bank reasonably
believes it has been the victim of a crime.
(8) The furnishing of information under the Revised
Uniform Unclaimed Property Act.
(9) The furnishing of information under the Illinois
Income Tax Act and the Illinois Estate and
Generation-Skipping Transfer Tax Act.
(10) The furnishing of information under the federal
Currency and Foreign Transactions Reporting Act Title 31,

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United States Code, Section 1051 et seq.
(11) The furnishing of information under any other
statute that by its terms or by regulations promulgated
thereunder requires the disclosure of financial records
other than by subpoena, summons, warrant, or court order.
(12) The furnishing of information about the existence
of an account of a person to a judgment creditor of that
person who has made a written request for that information.
(13) The exchange in the regular course of business of
information between commonly owned banks in connection
with a transaction authorized under paragraph (23) of
Section 5 and conducted at an affiliate facility.
(14) The furnishing of information in accordance with
the federal Personal Responsibility and Work Opportunity
Reconciliation Act of 1996. Any bank governed by this Act
shall enter into an agreement for data exchanges with a
State agency provided the State agency pays to the bank a
reasonable fee not to exceed its actual cost incurred. A
bank providing information in accordance with this item
shall not be liable to any account holder or other person
for any disclosure of information to a State agency, for
encumbering or surrendering any assets held by the bank in
response to a lien or order to withhold and deliver issued
by a State agency, or for any other action taken pursuant
to this item, including individual or mechanical errors,
provided the action does not constitute gross negligence or

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willful misconduct. A bank shall have no obligation to
hold, encumber, or surrender assets until it has been
served with a subpoena, summons, warrant, court or
administrative order, lien, or levy.
(15) The exchange in the regular course of business of
information between a bank and any commonly owned affiliate
of the bank, subject to the provisions of the Financial
Institutions Insurance Sales Law.
(16) The furnishing of information to law enforcement
authorities, the Illinois Department on Aging and its
regional administrative and provider agencies, the
Department of Human Services Office of Inspector General,
or public guardians: (i) upon subpoena by the investigatory
entity or the guardian, or (ii) if there is suspicion by
the bank that a customer who is an elderly person or person
with a disability has been or may become the victim of
financial exploitation. For the purposes of this item (16),
the term: (i) "elderly person" means a person who is 60 or
more years of age, (ii) "disabled person" means a person
who has or reasonably appears to the bank to have a
physical or mental disability that impairs his or her
ability to seek or obtain protection from or prevent
financial exploitation, and (iii) "financial exploitation"
means tortious or illegal use of the assets or resources of
an elderly or disabled person, and includes, without
limitation, misappropriation of the elderly or disabled

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person's assets or resources by undue influence, breach of
fiduciary relationship, intimidation, fraud, deception,
extortion, or the use of assets or resources in any manner
contrary to law. A bank or person furnishing information
pursuant to this item (16) shall be entitled to the same
rights and protections as a person furnishing information
under the Adult Protective Services Act and the Illinois
Domestic Violence Act of 1986.
(17) The disclosure of financial records or
information as necessary to effect, administer, or enforce
a transaction requested or authorized by the customer, or
in connection with:
(A) servicing or processing a financial product or
service requested or authorized by the customer;
(B) maintaining or servicing a customer's account
with the bank; or
(C) a proposed or actual securitization or
secondary market sale (including sales of servicing
rights) related to a transaction of a customer.
Nothing in this item (17), however, authorizes the sale
of the financial records or information of a customer
without the consent of the customer.
(18) The disclosure of financial records or
information as necessary to protect against actual or
potential fraud, unauthorized transactions, claims, or
other liability.

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(19)(A) (a) The disclosure of financial records or
information related to a private label credit program
between a financial institution and a private label party
in connection with that private label credit program. Such
information is limited to outstanding balance, available
credit, payment and performance and account history,
product references, purchase information, and information
related to the identity of the customer.
(B)(1) For purposes of this paragraph (19) of
subsection (b) of Section 48.1, a "private label credit
program" means a credit program involving a financial
institution and a private label party that is used by a
customer of the financial institution and the private label
party primarily for payment for goods or services sold,
manufactured, or distributed by a private label party.
(2) For purposes of this paragraph (19) of subsection
(b) of Section 48.1, a "private label party" means, with
respect to a private label credit program, any of the
following: a retailer, a merchant, a manufacturer, a trade
group, or any such person's affiliate, subsidiary, member,
agent, or service provider.
(20)(A) (a) The furnishing of financial records of a
customer to the Department to aid the Department's initial
determination or subsequent re-determination of the
customer's eligibility for Medicaid and Medicaid long-term
care benefits for long-term care when requested by the

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Department, provided that the Department receives an
authorization of the customer and maintains the
authorization in accordance with the requirements of 42
U.S.C. 1396w.
(B) The furnishing of financial records of a customer
to the Department to aid the Department's initial
determination or subsequent re-determination of the
customer's eligibility for Medicaid and Medicaid long-term
care benefits for long-term care services when requested by
someone other than the customer or the Department services,
provided that the bank receives the written consent and
authorization of the customer, which shall:
(1) have the customer's signature notarized;
(2) be signed by at least one witness who certifies
that he or she believes the customer to be of sound
mind and memory;
(1) (3) be tendered to the bank at the earliest
practicable time following its execution,
certification, and notarization;
(2) (4) specifically limit the disclosure of the
customer's financial records to the Department; and
(3) (5) be in substantially the following form:
CUSTOMER CONSENT AND AUTHORIZATION
FOR RELEASE OF FINANCIAL RECORDS

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I, ......................................., hereby authorize
(Name of Customer)
.............................................................
(Name of Financial Institution)
.............................................................
(Address of Financial Institution)
to disclose the following financial records:
any and all information concerning my deposit, savings, money
market, certificate of deposit, individual retirement,
retirement plan, 401(k) plan, incentive plan, employee benefit
plan, mutual fund and loan accounts (including, but not limited
to, any indebtedness or obligation for which I am a
co-borrower, co-obligor, guarantor, or surety), and any and all
other accounts in which I have an interest and any other
information regarding me in the possession of the Financial
Institution,
to the Illinois Department of Human Services or the Illinois
Department of Healthcare and Family Services, or both ("the
Department"), for the following purpose(s):
to aid in the initial determination or re-determination by the

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State of Illinois of my eligibility for Medicaid long-term care
benefits, pursuant to applicable law.
I understand that this Consent and Authorization may be revoked
by me in writing at any time before my financial records, as
described above, are disclosed, and that this Consent and
Authorization is valid until the Financial Institution
receives my written revocation. This Consent and Authorization
shall constitute valid authorization for the Department
identified above to inspect all such financial records set
forth above, and to request and receive copies of such
financial records from the Financial Institution (subject to
such records search and reproduction reimbursement policies as
the Financial Institution may have in place). An executed copy
of this Consent and Authorization shall be sufficient and as
good as the original and permission is hereby granted to honor
a photostatic or electronic copy of this Consent and
Authorization. Disclosure is strictly limited to the
Department identified above and no other person or entity shall
receive my financial records pursuant to this Consent and
Authorization. By signing this form, I agree to indemnify and
hold the Financial Institution harmless from any and all
claims, demands, and losses, including reasonable attorneys
fees and expenses, arising from or incurred in its reliance on
this Consent and Authorization. As used herein, "Customer"
shall mean "Member" if the Financial Institution is a credit

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union.
....................... ......................
(Date) (Signature of Customer)
......................
......................
(Address of Customer)
......................
(Customer's birth date)
(month/day/year)
The undersigned witness certifies that .................,
known to me to be the same person whose name is subscribed as
the customer to the foregoing Consent and Authorization,
appeared before me and the notary public and acknowledged
signing and delivering the instrument as his or her free and
voluntary act for the uses and purposes therein set forth. I
believe him or her to be of sound mind and memory. The
undersigned witness also certifies that the witness is not an
owner, operator, or relative of an owner or operator of a
long-term care facility in which the customer is a patient or
resident.
Dated: ................. ......................

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(Signature of Witness)
......................
(Print Name of Witness)
......................
......................
(Address of Witness)
State of Illinois)
) ss.
County of .......)
The undersigned, a notary public in and for the above county
and state, certifies that .........., known to me to be the
same person whose name is subscribed as the customer to the
foregoing Consent and Authorization, appeared before me
together with the witness, .........., in person and
acknowledged signing and delivering the instrument as the free
and voluntary act of the customer for the uses and purposes
therein set forth.
Dated:.......................................................
Notary Public:...............................................
My commission expires:.......................................

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(C) (b) In no event shall the bank distribute the
customer's financial records to the long-term care
facility from which the customer seeks initial or
continuing residency or long-term care services.
(D) (c) A bank providing financial records of a
customer in good faith relying on a consent and
authorization executed and tendered in accordance with
this paragraph (20) shall not be liable to the customer or
any other person in relation to the bank's disclosure of
the customer's financial records to the Department. The
customer signing the consent and authorization shall
indemnify and hold the bank harmless that relies in good
faith upon the consent and authorization and incurs a loss
because of such reliance. The bank recovering under this
indemnification provision shall also be entitled to
reasonable attorney's fees and the expenses of recovery.
(E) (d) A bank shall be reimbursed by the customer for
all costs reasonably necessary and directly incurred in
searching for, reproducing, and disclosing a customer's
financial records required or requested to be produced
pursuant to any consent and authorization executed under
this paragraph (20). The requested financial records shall
be delivered to the Department within 10 days after
receiving a properly executed consent and authorization or
at the earliest practicable time thereafter if the
requested records cannot be delivered within 10 days. , but

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delivery may be delayed until the final reimbursement of
all costs is received by the bank. The bank may honor a
photostatic or electronic copy of a properly executed
consent and authorization. Notwithstanding any other
provision of law, the delays of a customer, bank, or
long-term care facility in providing required information
or supporting documentation for the long-term care service
authorization process shall not be attributable to the
Department when evaluating the Department's compliance
with Medicaid timeliness standards.
(F) (e) Nothing in this paragraph (20) shall impair,
abridge, or abrogate the right of a customer to:
(1) directly disclose his or her financial records
to the Department or any other person; or
(2) authorize his or her attorney or duly appointed
agent to request and obtain the customer's financial
records and disclose those financial records to the
Department.
(G) (f) For purposes of this paragraph (20),
"Department" means the Department of Human Services and the
Department of Healthcare and Family Services or any
successor administrative agency of either agency. Nothing
in this paragraph (20) is intended to impair the
Department's ability to operate an asset verification
system in accordance with 42 U.S.C. 1396w, provided the
customer's authorization is obtained by the Department.

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(b)(1) For purposes of this paragraph (19) of
subsection (b) of Section 48.1, a "private label credit
program" means a credit program involving a financial
institution and a private label party that is used by a
customer of the financial institution and the private label
party primarily for payment for goods or services sold,
manufactured, or distributed by a private label party.
(2) For purposes of this paragraph (19) of subsection
(b) of Section 48.1, a "private label party" means, with
respect to a private label credit program, any of the
following: a retailer, a merchant, a manufacturer, a trade
group, or any such person's affiliate, subsidiary, member,
agent, or service provider.
(c) Except as otherwise provided by this Act, a bank may
not disclose to any person, except to the customer or his duly
authorized agent, any financial records or financial
information obtained from financial records relating to that
customer of that bank unless:
(1) the customer has authorized disclosure to the
person;
(2) the financial records are disclosed in response to
a lawful subpoena, summons, warrant, citation to discover
assets, or court order which meets the requirements of
subsection (d) of this Section; or
(3) the bank is attempting to collect an obligation
owed to the bank and the bank complies with the provisions

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of Section 2I of the Consumer Fraud and Deceptive Business
Practices Act.
(d) A bank shall disclose financial records under paragraph
(2) of subsection (c) of this Section under a lawful subpoena,
summons, warrant, citation to discover assets, or court order
only after the bank mails a copy of the subpoena, summons,
warrant, citation to discover assets, or court order to the
person establishing the relationship with the bank, if living,
and, otherwise his personal representative, if known, at his
last known address by first class mail, postage prepaid, unless
the bank is specifically prohibited from notifying the person
by order of court or by applicable State or federal law. A bank
shall not mail a copy of a subpoena to any person pursuant to
this subsection if the subpoena was issued by a grand jury
under the Statewide Grand Jury Act.
(e) Any officer or employee of a bank who knowingly and
willfully furnishes financial records in violation of this
Section is guilty of a business offense and, upon conviction,
shall be fined not more than $1,000.
(f) Any person who knowingly and willfully induces or
attempts to induce any officer or employee of a bank to
disclose financial records in violation of this Section is
guilty of a business offense and, upon conviction, shall be
fined not more than $1,000.
(g) A bank shall be reimbursed for costs that are
reasonably necessary and that have been directly incurred in

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searching for, reproducing, or transporting books, papers,
records, or other data required or requested to be produced
pursuant to a lawful subpoena, summons, warrant, citation to
discover assets, or court order. The Commissioner shall
determine the rates and conditions under which payment may be
made.
(Source: P.A. 99-143, eff. 7-27-15; 100-22, eff. 1-1-18;
100-664, eff. 1-1-19; 100-888, eff. 8-14-18; revised
10-22-18.)
Section 20. The Savings Bank Act is amended by changing
Section 4013 as follows:
(205 ILCS 205/4013) (from Ch. 17, par. 7304-13)
Sec. 4013. Access to books and records; communication with
members and shareholders.
(a) Every member or shareholder shall have the right to
inspect books and records of the savings bank that pertain to
his accounts. Otherwise, the right of inspection and
examination of the books and records shall be limited as
provided in this Act, and no other person shall have access to
the books and records nor shall be entitled to a list of the
members or shareholders.
(b) For the purpose of this Section, the term "financial
records" means any original, any copy, or any summary of (1) a
document granting signature authority over a deposit or

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account; (2) a statement, ledger card, or other record on any
deposit or account that shows each transaction in or with
respect to that account; (3) a check, draft, or money order
drawn on a savings bank or issued and payable by a savings
bank; or (4) any other item containing information pertaining
to any relationship established in the ordinary course of a
savings bank's business between a savings bank and its
customer, including financial statements or other financial
information provided by the member or shareholder.
(c) This Section does not prohibit:
(1) The preparation, examination, handling, or
maintenance of any financial records by any officer,
employee, or agent of a savings bank having custody of
records or examination of records by a certified public
accountant engaged by the savings bank to perform an
independent audit.
(2) The examination of any financial records by, or the
furnishing of financial records by a savings bank to, any
officer, employee, or agent of the Commissioner of Banks
and Real Estate or the federal depository institution
regulator for use solely in the exercise of his duties as
an officer, employee, or agent.
(3) The publication of data furnished from financial
records relating to members or holders of capital where the
data cannot be identified to any particular member,
shareholder, or account.

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(4) The making of reports or returns required under
Chapter 61 of the Internal Revenue Code of 1986.
(5) Furnishing information concerning the dishonor of
any negotiable instrument permitted to be disclosed under
the Uniform Commercial Code.
(6) The exchange in the regular course of business of
(i) credit information between a savings bank and other
savings banks or financial institutions or commercial
enterprises, directly or through a consumer reporting
agency or (ii) financial records or information derived
from financial records between a savings bank and other
savings banks or financial institutions or commercial
enterprises for the purpose of conducting due diligence
pursuant to a purchase or sale involving the savings bank
or assets or liabilities of the savings bank.
(7) The furnishing of information to the appropriate
law enforcement authorities where the savings bank
reasonably believes it has been the victim of a crime.
(8) The furnishing of information pursuant to the
Revised Uniform Unclaimed Property Act.
(9) The furnishing of information pursuant to the
Illinois Income Tax Act and the Illinois Estate and
Generation-Skipping Transfer Tax Act.
(10) The furnishing of information pursuant to the
federal Currency and Foreign Transactions Reporting Act,
(Title 31, United States Code, Section 1051 et seq.).

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(11) The furnishing of information pursuant to any
other statute which by its terms or by regulations
promulgated thereunder requires the disclosure of
financial records other than by subpoena, summons,
warrant, or court order.
(12) The furnishing of information in accordance with
the federal Personal Responsibility and Work Opportunity
Reconciliation Act of 1996. Any savings bank governed by
this Act shall enter into an agreement for data exchanges
with a State agency provided the State agency pays to the
savings bank a reasonable fee not to exceed its actual cost
incurred. A savings bank providing information in
accordance with this item shall not be liable to any
account holder or other person for any disclosure of
information to a State agency, for encumbering or
surrendering any assets held by the savings bank in
response to a lien or order to withhold and deliver issued
by a State agency, or for any other action taken pursuant
to this item, including individual or mechanical errors,
provided the action does not constitute gross negligence or
willful misconduct. A savings bank shall have no obligation
to hold, encumber, or surrender assets until it has been
served with a subpoena, summons, warrant, court or
administrative order, lien, or levy.
(13) The furnishing of information to law enforcement
authorities, the Illinois Department on Aging and its

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regional administrative and provider agencies, the
Department of Human Services Office of Inspector General,
or public guardians: (i) upon subpoena by the investigatory
entity or the guardian, or (ii) if there is suspicion by
the savings bank that a customer who is an elderly person
or person with a disability has been or may become the
victim of financial exploitation. For the purposes of this
item (13), the term: (i) "elderly person" means a person
who is 60 or more years of age, (ii) "person with a
disability" means a person who has or reasonably appears to
the savings bank to have a physical or mental disability
that impairs his or her ability to seek or obtain
protection from or prevent financial exploitation, and
(iii) "financial exploitation" means tortious or illegal
use of the assets or resources of an elderly person or
person with a disability, and includes, without
limitation, misappropriation of the assets or resources of
the elderly person or person with a disability by undue
influence, breach of fiduciary relationship, intimidation,
fraud, deception, extortion, or the use of assets or
resources in any manner contrary to law. A savings bank or
person furnishing information pursuant to this item (13)
shall be entitled to the same rights and protections as a
person furnishing information under the Adult Protective
Services Act and the Illinois Domestic Violence Act of
1986.

10100SB1321ham001 - 26 - LRB101 10606 KTG 61299 a
(14) The disclosure of financial records or
information as necessary to effect, administer, or enforce
a transaction requested or authorized by the member or
holder of capital, or in connection with:
(A) servicing or processing a financial product or
service requested or authorized by the member or holder
of capital;
(B) maintaining or servicing an account of a member
or holder of capital with the savings bank; or
(C) a proposed or actual securitization or
secondary market sale (including sales of servicing
rights) related to a transaction of a member or holder
of capital.
Nothing in this item (14), however, authorizes the sale
of the financial records or information of a member or
holder of capital without the consent of the member or
holder of capital.
(15) The exchange in the regular course of business of
information between a savings bank and any commonly owned
affiliate of the savings bank, subject to the provisions of
the Financial Institutions Insurance Sales Law.
(16) The disclosure of financial records or
information as necessary to protect against or prevent
actual or potential fraud, unauthorized transactions,
claims, or other liability.
(17)(a) The disclosure of financial records or

10100SB1321ham001 - 27 - LRB101 10606 KTG 61299 a
information related to a private label credit program
between a financial institution and a private label party
in connection with that private label credit program. Such
information is limited to outstanding balance, available
credit, payment and performance and account history,
product references, purchase information, and information
related to the identity of the customer.
(b)(1) For purposes of this paragraph (17) of
subsection (c) of Section 4013, a "private label credit
program" means a credit program involving a financial
institution and a private label party that is used by a
customer of the financial institution and the private label
party primarily for payment for goods or services sold,
manufactured, or distributed by a private label party.
(2) For purposes of this paragraph (17) of subsection
(c) of Section 4013, a "private label party" means, with
respect to a private label credit program, any of the
following: a retailer, a merchant, a manufacturer, a trade
group, or any such person's affiliate, subsidiary, member,
agent, or service provider.
(18)(a) The furnishing of financial records of a
customer to the Department to aid the Department's initial
determination or subsequent re-determination of the
customer's eligibility for Medicaid and Medicaid long-term
care benefits for long-term care services when requested by
the Department, provided that the Department receives an

10100SB1321ham001 - 28 - LRB101 10606 KTG 61299 a
authorization of the customer and maintains the
authorization in accordance with the requirements of 42
U.S.C. 1396w.
(b) The furnishing of financial records of a customer
to the Department to aid the Department's initial
determination or subsequent re-determination of the
customer's eligibility for Medicaid and Medicaid long-term
care benefits for long-term care services when requested by
someone other than the customer or the Department, provided
that the savings bank receives the written consent and
authorization of the customer, which shall:
(1) have the customer's signature notarized;
(2) be signed by at least one witness who certifies
that he or she believes the customer to be of sound
mind and memory;
(1) (3) be tendered to the savings bank at the
earliest practicable time following its execution,
certification, and notarization;
(2) (4) specifically limit the disclosure of the
customer's financial records to the Department; and
(3) (5) be in substantially the following form:
CUSTOMER CONSENT AND AUTHORIZATION
FOR RELEASE OF FINANCIAL RECORDS
I, ......................................., hereby authorize

10100SB1321ham001 - 29 - LRB101 10606 KTG 61299 a
(Name of Customer)
.............................................................
(Name of Financial Institution)
.............................................................
(Address of Financial Institution)
to disclose the following financial records:
any and all information concerning my deposit, savings, money
market, certificate of deposit, individual retirement,
retirement plan, 401(k) plan, incentive plan, employee benefit
plan, mutual fund and loan accounts (including, but not limited
to, any indebtedness or obligation for which I am a
co-borrower, co-obligor, guarantor, or surety), and any and all
other accounts in which I have an interest and any other
information regarding me in the possession of the Financial
Institution,
to the Illinois Department of Human Services or the Illinois
Department of Healthcare and Family Services, or both ("the
Department"), for the following purpose(s):
to aid in the initial determination or re-determination by the
State of Illinois of my eligibility for Medicaid long-term care

10100SB1321ham001 - 30 - LRB101 10606 KTG 61299 a
benefits, pursuant to applicable law.
I understand that this Consent and Authorization may be revoked
by me in writing at any time before my financial records, as
described above, are disclosed, and that this Consent and
Authorization is valid until the Financial Institution
receives my written revocation. This Consent and Authorization
shall constitute valid authorization for the Department
identified above to inspect all such financial records set
forth above, and to request and receive copies of such
financial records from the Financial Institution (subject to
such records search and reproduction reimbursement policies as
the Financial Institution may have in place). An executed copy
of this Consent and Authorization shall be sufficient and as
good as the original and permission is hereby granted to honor
a photostatic or electronic copy of this Consent and
Authorization. Disclosure is strictly limited to the
Department identified above and no other person or entity shall
receive my financial records pursuant to this Consent and
Authorization. By signing this form, I agree to indemnify and
hold the Financial Institution harmless from any and all
claims, demands, and losses, including reasonable attorneys
fees and expenses, arising from or incurred in its reliance on
this Consent and Authorization. As used herein, "Customer"
shall mean "Member" if the Financial Institution is a credit
union.

10100SB1321ham001 - 31 - LRB101 10606 KTG 61299 a
....................... ......................
(Date) (Signature of Customer)
......................
......................
(Address of Customer)
......................
(Customer's birth date)
(month/day/year)
The undersigned witness certifies that .................,
known to me to be the same person whose name is subscribed as
the customer to the foregoing Consent and Authorization,
appeared before me and the notary public and acknowledged
signing and delivering the instrument as his or her free and
voluntary act for the uses and purposes therein set forth. I
believe him or her to be of sound mind and memory. The
undersigned witness also certifies that the witness is not an
owner, operator, or relative of an owner or operator of a
long-term care facility in which the customer is a patient or
resident.
Dated: ................. ......................
(Signature of Witness)

10100SB1321ham001 - 32 - LRB101 10606 KTG 61299 a
......................
(Print Name of Witness)
......................
......................
(Address of Witness)
State of Illinois)
) ss.
County of .......)
The undersigned, a notary public in and for the above county
and state, certifies that .........., known to me to be the
same person whose name is subscribed as the customer to the
foregoing Consent and Authorization, appeared before me
together with the witness, .........., in person and
acknowledged signing and delivering the instrument as the free
and voluntary act of the customer for the uses and purposes
therein set forth.
Dated:.......................................................
Notary Public:...............................................
My commission expires:.......................................
(c) (b) In no event shall the savings bank distribute

10100SB1321ham001 - 33 - LRB101 10606 KTG 61299 a
the customer's financial records to the long-term care
facility from which the customer seeks initial or
continuing residency or long-term care services.
(d) (c) A savings bank providing financial records of a
customer in good faith relying on a consent and
authorization executed and tendered in accordance with
this paragraph (18) shall not be liable to the customer or
any other person in relation to the savings bank's
disclosure of the customer's financial records to the
Department. The customer signing the consent and
authorization shall indemnify and hold the savings bank
harmless that relies in good faith upon the consent and
authorization and incurs a loss because of such reliance.
The savings bank recovering under this indemnification
provision shall also be entitled to reasonable attorney's
fees and the expenses of recovery.
(e) (d) A savings bank shall be reimbursed by the
customer for all costs reasonably necessary and directly
incurred in searching for, reproducing, and disclosing a
customer's financial records required or requested to be
produced pursuant to any consent and authorization
executed under this paragraph (18). The requested
financial records shall be delivered to the Department
within 10 days after receiving a properly executed consent
and authorization or at the earliest practicable time
thereafter if the requested records cannot be delivered

10100SB1321ham001 - 34 - LRB101 10606 KTG 61299 a
within 10 days. , but delivery may be delayed until the
final reimbursement of all costs is received by the savings
bank. The savings bank may honor a photostatic or
electronic copy of a properly executed consent and
authorization. Notwithstanding any other provision of law,
the delays of a customer, bank, or long-term care facility
in providing required information or supporting
documentation for the long-term care service authorization
process shall not be attributable to the Department when
evaluating the Department's compliance with Medicaid
timeliness standards.
(f) (e) Nothing in this paragraph (18) shall impair,
abridge, or abrogate the right of a customer to:
(1) directly disclose his or her financial records
to the Department or any other person; or
(2) authorize his or her attorney or duly appointed
agent to request and obtain the customer's financial
records and disclose those financial records to the
Department.
(g) (f) For purposes of this paragraph (18),
"Department" means the Department of Human Services and the
Department of Healthcare and Family Services or any
successor administrative agency of either agency. Nothing
in this paragraph (18) is intended to impair the
Department's ability to operate an asset verification
system in accordance with 42 U.S.C. 1396w, provided the

10100SB1321ham001 - 35 - LRB101 10606 KTG 61299 a
customer's authorization is obtained by the Department.
(d) A savings bank may not disclose to any person, except
to the member or holder of capital or his duly authorized
agent, any financial records relating to that member or
shareholder of the savings bank unless:
(1) the member or shareholder has authorized
disclosure to the person; or
(2) the financial records are disclosed in response to
a lawful subpoena, summons, warrant, citation to discover
assets, or court order that meets the requirements of
subsection (e) of this Section.
(e) A savings bank shall disclose financial records under
subsection (d) of this Section pursuant to a lawful subpoena,
summons, warrant, citation to discover assets, or court order
only after the savings bank mails a copy of the subpoena,
summons, warrant, citation to discover assets, or court order
to the person establishing the relationship with the savings
bank, if living, and otherwise, his personal representative, if
known, at his last known address by first class mail, postage
prepaid, unless the savings bank is specifically prohibited
from notifying the person by order of court.
(f) Any officer or employee of a savings bank who knowingly
and willfully furnishes financial records in violation of this
Section is guilty of a business offense and, upon conviction,
shall be fined not more than $1,000.
(g) Any person who knowingly and willfully induces or

10100SB1321ham001 - 36 - LRB101 10606 KTG 61299 a
attempts to induce any officer or employee of a savings bank to
disclose financial records in violation of this Section is
guilty of a business offense and, upon conviction, shall be
fined not more than $1,000.
(h) If any member or shareholder desires to communicate
with the other members or shareholders of the savings bank with
reference to any question pending or to be presented at an
annual or special meeting, the savings bank shall give that
person, upon request, a statement of the approximate number of
members or shareholders entitled to vote at the meeting and an
estimate of the cost of preparing and mailing the
communication. The requesting member shall submit the
communication to the Commissioner who, upon finding it to be
appropriate and truthful, shall direct that it be prepared and
mailed to the members upon the requesting member's or
shareholder's payment or adequate provision for payment of the
expenses of preparation and mailing.
(i) A savings bank shall be reimbursed for costs that are
necessary and that have been directly incurred in searching
for, reproducing, or transporting books, papers, records, or
other data of a customer required to be reproduced pursuant to
a lawful subpoena, warrant, citation to discover assets, or
court order.
(j) Notwithstanding the provisions of this Section, a
savings bank may sell or otherwise make use of lists of
customers' names and addresses. All other information

10100SB1321ham001 - 37 - LRB101 10606 KTG 61299 a
regarding a customer's account is subject to the disclosure
provisions of this Section. At the request of any customer,
that customer's name and address shall be deleted from any list
that is to be sold or used in any other manner beyond
identification of the customer's accounts.
(Source: P.A. 99-143, eff. 7-27-15; 100-22, eff. 1-1-18;
100-201, eff. 8-18-17; 100-664, eff. 1-1-19.)
Section 25. The Illinois Credit Union Act is amended by
changing Section 10 as follows:
(205 ILCS 305/10) (from Ch. 17, par. 4411)
Sec. 10. Credit union records; member financial records.
(1) A credit union shall establish and maintain books,
records, accounting systems and procedures which accurately
reflect its operations and which enable the Department to
readily ascertain the true financial condition of the credit
union and whether it is complying with this Act.
(2) A photostatic or photographic reproduction of any
credit union records shall be admissible as evidence of
transactions with the credit union.
(3)(a) For the purpose of this Section, the term "financial
records" means any original, any copy, or any summary of (1) a
document granting signature authority over an account, (2) a
statement, ledger card or other record on any account which
shows each transaction in or with respect to that account, (3)

10100SB1321ham001 - 38 - LRB101 10606 KTG 61299 a
a check, draft or money order drawn on a financial institution
or other entity or issued and payable by or through a financial
institution or other entity, or (4) any other item containing
information pertaining to any relationship established in the
ordinary course of business between a credit union and its
member, including financial statements or other financial
information provided by the member.
(b) This Section does not prohibit:
(1) The preparation, examination, handling or
maintenance of any financial records by any officer,
employee or agent of a credit union having custody of such
records, or the examination of such records by a certified
public accountant engaged by the credit union to perform an
independent audit.
(2) The examination of any financial records by or the
furnishing of financial records by a credit union to any
officer, employee or agent of the Department, the National
Credit Union Administration, Federal Reserve board or any
insurer of share accounts for use solely in the exercise of
his duties as an officer, employee or agent.
(3) The publication of data furnished from financial
records relating to members where the data cannot be
identified to any particular customer of account.
(4) The making of reports or returns required under
Chapter 61 of the Internal Revenue Code of 1954.
(5) Furnishing information concerning the dishonor of

10100SB1321ham001 - 39 - LRB101 10606 KTG 61299 a
any negotiable instrument permitted to be disclosed under
the Uniform Commercial Code.
(6) The exchange in the regular course of business of
(i) credit information between a credit union and other
credit unions or financial institutions or commercial
enterprises, directly or through a consumer reporting
agency or (ii) financial records or information derived
from financial records between a credit union and other
credit unions or financial institutions or commercial
enterprises for the purpose of conducting due diligence
pursuant to a merger or a purchase or sale of assets or
liabilities of the credit union.
(7) The furnishing of information to the appropriate
law enforcement authorities where the credit union
reasonably believes it has been the victim of a crime.
(8) The furnishing of information pursuant to the
Revised Uniform Unclaimed Property Act.
(9) The furnishing of information pursuant to the
Illinois Income Tax Act and the Illinois Estate and
Generation-Skipping Transfer Tax Act.
(10) The furnishing of information pursuant to the
federal "Currency and Foreign Transactions Reporting Act",
Title 31, United States Code, Section 1051 et sequentia.
(11) The furnishing of information pursuant to any
other statute which by its terms or by regulations
promulgated thereunder requires the disclosure of

10100SB1321ham001 - 40 - LRB101 10606 KTG 61299 a
financial records other than by subpoena, summons, warrant
or court order.
(12) The furnishing of information in accordance with
the federal Personal Responsibility and Work Opportunity
Reconciliation Act of 1996. Any credit union governed by
this Act shall enter into an agreement for data exchanges
with a State agency provided the State agency pays to the
credit union a reasonable fee not to exceed its actual cost
incurred. A credit union providing information in
accordance with this item shall not be liable to any
account holder or other person for any disclosure of
information to a State agency, for encumbering or
surrendering any assets held by the credit union in
response to a lien or order to withhold and deliver issued
by a State agency, or for any other action taken pursuant
to this item, including individual or mechanical errors,
provided the action does not constitute gross negligence or
willful misconduct. A credit union shall have no obligation
to hold, encumber, or surrender assets until it has been
served with a subpoena, summons, warrant, court or
administrative order, lien, or levy.
(13) The furnishing of information to law enforcement
authorities, the Illinois Department on Aging and its
regional administrative and provider agencies, the
Department of Human Services Office of Inspector General,
or public guardians: (i) upon subpoena by the investigatory

10100SB1321ham001 - 41 - LRB101 10606 KTG 61299 a
entity or the guardian, or (ii) if there is suspicion by
the credit union that a member who is an elderly person or
person with a disability has been or may become the victim
of financial exploitation. For the purposes of this item
(13), the term: (i) "elderly person" means a person who is
60 or more years of age, (ii) "person with a disability"
means a person who has or reasonably appears to the credit
union to have a physical or mental disability that impairs
his or her ability to seek or obtain protection from or
prevent financial exploitation, and (iii) "financial
exploitation" means tortious or illegal use of the assets
or resources of an elderly person or person with a
disability, and includes, without limitation,
misappropriation of the elderly or disabled person's
assets or resources by undue influence, breach of fiduciary
relationship, intimidation, fraud, deception, extortion,
or the use of assets or resources in any manner contrary to
law. A credit union or person furnishing information
pursuant to this item (13) shall be entitled to the same
rights and protections as a person furnishing information
under the Adult Protective Services Act and the Illinois
Domestic Violence Act of 1986.
(14) The disclosure of financial records or
information as necessary to effect, administer, or enforce
a transaction requested or authorized by the member, or in
connection with:

10100SB1321ham001 - 42 - LRB101 10606 KTG 61299 a
(A) servicing or processing a financial product or
service requested or authorized by the member;
(B) maintaining or servicing a member's account
with the credit union; or
(C) a proposed or actual securitization or
secondary market sale (including sales of servicing
rights) related to a transaction of a member.
Nothing in this item (14), however, authorizes the sale
of the financial records or information of a member without
the consent of the member.
(15) The disclosure of financial records or
information as necessary to protect against or prevent
actual or potential fraud, unauthorized transactions,
claims, or other liability.
(16)(a) The disclosure of financial records or
information related to a private label credit program
between a financial institution and a private label party
in connection with that private label credit program. Such
information is limited to outstanding balance, available
credit, payment and performance and account history,
product references, purchase information, and information
related to the identity of the customer.
(b)(1) For purposes of this item paragraph (16) of
subsection (b) of Section 10, a "private label credit
program" means a credit program involving a financial
institution and a private label party that is used by a

10100SB1321ham001 - 43 - LRB101 10606 KTG 61299 a
customer of the financial institution and the private label
party primarily for payment for goods or services sold,
manufactured, or distributed by a private label party.
(2) For purposes of this item paragraph (16) of
subsection (b) of Section 10, a "private label party"
means, with respect to a private label credit program, any
of the following: a retailer, a merchant, a manufacturer, a
trade group, or any such person's affiliate, subsidiary,
member, agent, or service provider.
(17)(a) The furnishing of financial records of a member
to the Department to aid the Department's initial
determination or subsequent re-determination of the
member's eligibility for Medicaid and Medicaid long-term
care benefits for long-term care services when requested by
the Department, provided that the Department receives an
authorization of the customer and maintains the
authorization in accordance with the requirements of 42
U.S.C. 1396w.
(b) The furnishing of financial records of a customer
to the Department to aid the Department's initial
determination or subsequent re-determination of the
customer's eligibility for Medicaid and Medicaid long-term
care benefits for long-term care services when requested by
someone other than the customer or the Department, provided
that the credit union receives the written consent and
authorization of the member, which shall:

10100SB1321ham001 - 44 - LRB101 10606 KTG 61299 a
(1) have the member's signature notarized;
(2) be signed by at least one witness who certifies
that he or she believes the member to be of sound mind
and memory;
(1) (3) be tendered to the credit union at the
earliest practicable time following its execution,
certification, and notarization;
(2) (4) specifically limit the disclosure of the
member's financial records to the Department; and
(3) (5) be in substantially the following form:
CUSTOMER CONSENT AND AUTHORIZATION
FOR RELEASE OF FINANCIAL RECORDS
I, ......................................., hereby authorize
(Name of Customer)
.............................................................
(Name of Financial Institution)
.............................................................
(Address of Financial Institution)
to disclose the following financial records:
any and all information concerning my deposit, savings, money

10100SB1321ham001 - 45 - LRB101 10606 KTG 61299 a
market, certificate of deposit, individual retirement,
retirement plan, 401(k) plan, incentive plan, employee benefit
plan, mutual fund and loan accounts (including, but not limited
to, any indebtedness or obligation for which I am a
co-borrower, co-obligor, guarantor, or surety), and any and all
other accounts in which I have an interest and any other
information regarding me in the possession of the Financial
Institution,
to the Illinois Department of Human Services or the Illinois
Department of Healthcare and Family Services, or both ("the
Department"), for the following purpose(s):
to aid in the initial determination or re-determination by the
State of Illinois of my eligibility for Medicaid long-term care
benefits, pursuant to applicable law.
I understand that this Consent and Authorization may be revoked
by me in writing at any time before my financial records, as
described above, are disclosed, and that this Consent and
Authorization is valid until the Financial Institution
receives my written revocation. This Consent and Authorization
shall constitute valid authorization for the Department
identified above to inspect all such financial records set
forth above, and to request and receive copies of such
financial records from the Financial Institution (subject to

10100SB1321ham001 - 46 - LRB101 10606 KTG 61299 a
such records search and reproduction reimbursement policies as
the Financial Institution may have in place). An executed copy
of this Consent and Authorization shall be sufficient and as
good as the original and permission is hereby granted to honor
a photostatic or electronic copy of this Consent and
Authorization. Disclosure is strictly limited to the
Department identified above and no other person or entity shall
receive my financial records pursuant to this Consent and
Authorization. By signing this form, I agree to indemnify and
hold the Financial Institution harmless from any and all
claims, demands, and losses, including reasonable attorneys
fees and expenses, arising from or incurred in its reliance on
this Consent and Authorization. As used herein, "Customer"
shall mean "Member" if the Financial Institution is a credit
union.
....................... ......................
(Date) (Signature of Customer)
......................
......................
(Address of Customer)
......................
(Customer's birth date)
(month/day/year)

10100SB1321ham001 - 47 - LRB101 10606 KTG 61299 a
The undersigned witness certifies that .................,
known to me to be the same person whose name is subscribed as
the customer to the foregoing Consent and Authorization,
appeared before me and the notary public and acknowledged
signing and delivering the instrument as his or her free and
voluntary act for the uses and purposes therein set forth. I
believe him or her to be of sound mind and memory. The
undersigned witness also certifies that the witness is not an
owner, operator, or relative of an owner or operator of a
long-term care facility in which the customer is a patient or
resident.
Dated: ................. ......................
(Signature of Witness)
......................
(Print Name of Witness)
......................
......................
(Address of Witness)
State of Illinois)
) ss.
County of .......)

10100SB1321ham001 - 48 - LRB101 10606 KTG 61299 a
The undersigned, a notary public in and for the above county
and state, certifies that .........., known to me to be the
same person whose name is subscribed as the customer to the
foregoing Consent and Authorization, appeared before me
together with the witness, .........., in person and
acknowledged signing and delivering the instrument as the free
and voluntary act of the customer for the uses and purposes
therein set forth.
Dated:.......................................................
Notary Public:...............................................
My commission expires:.......................................
(c) (b) In no event shall the credit union distribute
the member's financial records to the long-term care
facility from which the member seeks initial or continuing
residency or long-term care services.
(d) (c) A credit union providing financial records of a
member in good faith relying on a consent and authorization
executed and tendered in accordance with this item
subparagraph (17) shall not be liable to the member or any
other person in relation to the credit union's disclosure
of the member's financial records to the Department. The
member signing the consent and authorization shall
indemnify and hold the credit union harmless that relies in

10100SB1321ham001 - 49 - LRB101 10606 KTG 61299 a
good faith upon the consent and authorization and incurs a
loss because of such reliance. The credit union recovering
under this indemnification provision shall also be
entitled to reasonable attorney's fees and the expenses of
recovery.
(e) (d) A credit union shall be reimbursed by the
member for all costs reasonably necessary and directly
incurred in searching for, reproducing, and disclosing a
member's financial records required or requested to be
produced pursuant to any consent and authorization
executed under this subparagraph (17). The requested
financial records shall be delivered to the Department
within 10 days after receiving a properly executed consent
and authorization or at the earliest practicable time
thereafter if the requested records cannot be delivered
within 10 days. , but delivery may be delayed until the
final reimbursement of all costs is received by the credit
union. The credit union may honor a photostatic or
electronic copy of a properly executed consent and
authorization. Notwithstanding any other provision of law,
the delays of a customer, bank or long-term care facility
in providing required information or supporting
documentation for the long-term care service authorization
process shall not be attributable to the Department when
evaluating the Department's compliance with Medicaid
timeliness standards.

10100SB1321ham001 - 50 - LRB101 10606 KTG 61299 a
(f) (e) Nothing in this item subparagraph (17) shall
impair, abridge, or abrogate the right of a member to:
(1) directly disclose his or her financial records
to the Department or any other person; or
(2) authorize his or her attorney or duly appointed
agent to request and obtain the member's financial
records and disclose those financial records to the
Department.
(g) (f) For purposes of this item subparagraph (17),
"Department" means the Department of Human Services and the
Department of Healthcare and Family Services or any
successor administrative agency of either agency. Nothing
in this item (17) is intended to impair the Department's
ability to operate an asset verification system in
accordance with 42 U.S.C. 1396w, provided the customer's
authorization is obtained by the Department.
(18) (17) The furnishing of the financial records of a
member to an appropriate law enforcement authority,
without prior notice to or consent of the member, upon
written request of the law enforcement authority, when
reasonable suspicion of an imminent threat to the personal
security and safety of the member exists that necessitates
an expedited release of the member's financial records, as
determined by the law enforcement authority. The law
enforcement authority shall include a brief explanation of
the imminent threat to the member in its written request to

10100SB1321ham001 - 51 - LRB101 10606 KTG 61299 a
the credit union. The written request shall reflect that it
has been authorized by a supervisory or managerial official
of the law enforcement authority. The decision to furnish
the financial records of a member to a law enforcement
authority shall be made by a supervisory or managerial
official of the credit union. A credit union providing
information in accordance with this item (18) (17) shall
not be liable to the member or any other person for the
disclosure of the information to the law enforcement
authority.
(c) Except as otherwise provided by this Act, a credit
union may not disclose to any person, except to the member or
his duly authorized agent, any financial records relating to
that member of the credit union unless:
(1) the member has authorized disclosure to the person;
(2) the financial records are disclosed in response to
a lawful subpoena, summons, warrant, citation to discover
assets, or court order that meets the requirements of
subparagraph (3)(d) (d) of this Section; or
(3) the credit union is attempting to collect an
obligation owed to the credit union and the credit union
complies with the provisions of Section 2I of the Consumer
Fraud and Deceptive Business Practices Act.
(d) A credit union shall disclose financial records under
item (3)(c)(2) subparagraph (c)(2) of this Section pursuant to
a lawful subpoena, summons, warrant, citation to discover

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assets, or court order only after the credit union mails a copy
of the subpoena, summons, warrant, citation to discover assets,
or court order to the person establishing the relationship with
the credit union, if living, and otherwise his personal
representative, if known, at his last known address by first
class mail, postage prepaid unless the credit union is
specifically prohibited from notifying the person by order of
court or by applicable State or federal law. In the case of a
grand jury subpoena, a credit union shall not mail a copy of a
subpoena to any person pursuant to this subsection if the
subpoena was issued by a grand jury under the Statewide Grand
Jury Act or notifying the person would constitute a violation
of the federal Right to Financial Privacy Act of 1978.
(e)(1) Any officer or employee of a credit union who
knowingly and willfully wilfully furnishes financial records
in violation of this Section is guilty of a business offense
and upon conviction thereof shall be fined not more than
$1,000.
(2) Any person who knowingly and willfully wilfully induces
or attempts to induce any officer or employee of a credit union
to disclose financial records in violation of this Section is
guilty of a business offense and upon conviction thereof shall
be fined not more than $1,000.
(f) A credit union shall be reimbursed for costs which are
reasonably necessary and which have been directly incurred in
searching for, reproducing or transporting books, papers,

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records or other data of a member required or requested to be
produced pursuant to a lawful subpoena, summons, warrant,
citation to discover assets, or court order. The Secretary and
the Director may determine, by rule, the rates and conditions
under which payment shall be made. Delivery of requested
documents may be delayed until final reimbursement of all costs
is received.
(Source: P.A. 99-143, eff. 7-27-15; 100-22, eff. 1-1-18;
100-664, eff. 1-1-19; 100-778, eff. 8-10-18; revised
10-18-18.)
Section 30. The Children's Health Insurance Program Act is
amended by changing Section 7 as follows:
(215 ILCS 106/7)
Sec. 7. Eligibility verification. Notwithstanding any
other provision of this Act, with respect to applications for
benefits provided under the Program, eligibility shall be
determined in a manner that ensures program integrity and that
complies with federal law and regulations while minimizing
unnecessary barriers to enrollment. To this end, as soon as
practicable, and unless the Department receives written denial
from the federal government, this Section shall be implemented:
(a) The Department of Healthcare and Family Services or its
designees shall:
(1) By no later than July 1, 2011, require verification

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of, at a minimum, one month's income from all sources
required for determining the eligibility of applicants to
the Program. Such verification shall take the form of pay
stubs, business or income and expense records for
self-employed persons, letters from employers, and any
other valid documentation of income including data
obtained electronically by the Department or its designees
from other sources as described in subsection (b) of this
Section.
(2) By no later than October 1, 2011, require
verification of, at a minimum, one month's income from all
sources required for determining the continued eligibility
of recipients at their annual review of eligibility under
the Program. Such verification shall take the form of pay
stubs, business or income and expense records for
self-employed persons, letters from employers, and any
other valid documentation of income including data
obtained electronically by the Department or its designees
from other sources as described in subsection (b) of this
Section. A month's income may be verified by a single pay
stub with the monthly income extrapolated from the time
period covered by the pay stub. The Department shall send a
notice to the recipient at least 60 days prior to the end
of the period of eligibility that informs them of the
requirements for continued eligibility. Information the
Department receives prior to the annual review, including

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information available to the Department as a result of the
recipient's application for other non-health care
benefits, that is sufficient to make a determination of
continued eligibility for medical assistance or for
benefits provided under the Program may be reviewed and
verified, and subsequent action taken including client
notification of continued eligibility for medical
assistance or for benefits provided under the Program. The
date of client notification establishes the date for
subsequent annual eligibility reviews. If a recipient does
not fulfill the requirements for continued eligibility by
the deadline established in the notice, a notice of
cancellation shall be issued to the recipient and coverage
shall end no later than the last day of the month following
on the last day of the eligibility period. A recipient's
eligibility may be reinstated without requiring a new
application if the recipient fulfills the requirements for
continued eligibility prior to the end of the third month
following the last date of coverage (or longer period if
required by federal regulations). Nothing in this Section
shall prevent an individual whose coverage has been
cancelled from reapplying for health benefits at any time.
(3) By no later than July 1, 2011, require verification
of Illinois residency.
(b) The Department shall establish or continue cooperative
arrangements with the Social Security Administration, the

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Illinois Secretary of State, the Department of Human Services,
the Department of Revenue, the Department of Employment
Security, and any other appropriate entity to gain electronic
access, to the extent allowed by law, to information available
to those entities that may be appropriate for electronically
verifying any factor of eligibility for benefits under the
Program. Data relevant to eligibility shall be provided for no
other purpose than to verify the eligibility of new applicants
or current recipients of health benefits under the Program.
Data will be requested or provided for any new applicant or
current recipient only insofar as that individual's
circumstances are relevant to that individual's or another
individual's eligibility.
(c) Within 90 days of the effective date of this amendatory
Act of the 96th General Assembly, the Department of Healthcare
and Family Services shall send notice to current recipients
informing them of the changes regarding their eligibility
verification.
(Source: P.A. 98-651, eff. 6-16-14.)
Section 35. The Covering ALL KIDS Health Insurance Act is
amended by changing Section 7 as follows:
(215 ILCS 170/7)
(Section scheduled to be repealed on October 1, 2019)
Sec. 7. Eligibility verification. Notwithstanding any

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other provision of this Act, with respect to applications for
benefits provided under the Program, eligibility shall be
determined in a manner that ensures program integrity and that
complies with federal law and regulations while minimizing
unnecessary barriers to enrollment. To this end, as soon as
practicable, and unless the Department receives written denial
from the federal government, this Section shall be implemented:
(a) The Department of Healthcare and Family Services or its
designees shall:
(1) By July 1, 2011, require verification of, at a
minimum, one month's income from all sources required for
determining the eligibility of applicants to the Program.
Such verification shall take the form of pay stubs,
business or income and expense records for self-employed
persons, letters from employers, and any other valid
documentation of income including data obtained
electronically by the Department or its designees from
other sources as described in subsection (b) of this
Section.
(2) By October 1, 2011, require verification of, at a
minimum, one month's income from all sources required for
determining the continued eligibility of recipients at
their annual review of eligibility under the Program. Such
verification shall take the form of pay stubs, business or
income and expense records for self-employed persons,
letters from employers, and any other valid documentation

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of income including data obtained electronically by the
Department or its designees from other sources as described
in subsection (b) of this Section. A month's income may be
verified by a single pay stub with the monthly income
extrapolated from the time period covered by the pay stub.
The Department shall send a notice to recipients at least
60 days prior to the end of their period of eligibility
that informs them of the requirements for continued
eligibility. Information the Department receives prior to
the annual review, including information available to the
Department as a result of the recipient's application for
other non-health care benefits, that is sufficient to make
a determination of continued eligibility for benefits
provided under this Act, the Children's Health Insurance
Program Act, or Article V of the Illinois Public Aid Code
may be reviewed and verified, and subsequent action taken
including client notification of continued eligibility for
benefits provided under this Act, the Children's Health
Insurance Program Act, or Article V of the Illinois Public
Aid Code. The date of client notification establishes the
date for subsequent annual eligibility reviews. If a
recipient does not fulfill the requirements for continued
eligibility by the deadline established in the notice, a
notice of cancellation shall be issued to the recipient and
coverage shall end no later than the last day of the month
following on the last day of the eligibility period. A

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recipient's eligibility may be reinstated without
requiring a new application if the recipient fulfills the
requirements for continued eligibility prior to the end of
the third month following the last date of coverage (or
longer period if required by federal regulations). Nothing
in this Section shall prevent an individual whose coverage
has been cancelled from reapplying for health benefits at
any time.
(3) By July 1, 2011, require verification of Illinois
residency.
(b) The Department shall establish or continue cooperative
arrangements with the Social Security Administration, the
Illinois Secretary of State, the Department of Human Services,
the Department of Revenue, the Department of Employment
Security, and any other appropriate entity to gain electronic
access, to the extent allowed by law, to information available
to those entities that may be appropriate for electronically
verifying any factor of eligibility for benefits under the
Program. Data relevant to eligibility shall be provided for no
other purpose than to verify the eligibility of new applicants
or current recipients of health benefits under the Program.
Data will be requested or provided for any new applicant or
current recipient only insofar as that individual's
circumstances are relevant to that individual's or another
individual's eligibility.
(c) Within 90 days of the effective date of this amendatory

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Act of the 96th General Assembly, the Department of Healthcare
and Family Services shall send notice to current recipients
informing them of the changes regarding their eligibility
verification.
(Source: P.A. 98-651, eff. 6-16-14.)
Section 40. The Illinois Public Aid Code is amended by
changing Sections 5-4.1, 5-5, 5-5f, 5-30.1, 5A-4, 11-5.1,
11-5.3, 11-5.4, and 12-4.42 and by adding Sections 5-5.10,
5-30.12, and 14-13 as follows:
(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 provide
that recipients under any Article of this Code shall pay a fee
as a co-payment for services. Co-payments shall be maximized to
the extent permitted by federal law, except that the Department
shall impose a co-pay of $2 on generic drugs. Provided,
however, that any such rule must provide that no co-payment
requirement can exist for renal dialysis, radiation therapy,
cancer chemotherapy, or insulin, and other products necessary
on a recurring basis, the absence of which would be life
threatening, or where co-payment expenditures for required
services and/or medications for chronic diseases that the
Illinois Department shall by rule designate shall cause an

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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. 96-1501, eff. 1-25-11; 97-74, eff. 6-30-11;
97-689, eff. 6-14-12.)
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing home,
or elsewhere; (6) medical care, or any other type of remedial
care furnished by licensed practitioners; (7) home health care
services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and
treatment of periodontal disease and dental caries disease for

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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

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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.

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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

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(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

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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:

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(A) A baseline mammogram for women 35 to 39 years of
age.
(B) An annual mammogram for women 40 years of age or
older.
(C) A mammogram at the age and intervals considered
medically necessary by the woman's health care provider for
women under 40 years of age and having a family history of
breast cancer, prior personal history of breast cancer,
positive genetic testing, or other risk factors.
(D) A comprehensive ultrasound screening 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

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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

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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.

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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

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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,

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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.

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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

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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

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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,

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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

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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

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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,

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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

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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

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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

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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,

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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

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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.

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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

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community-based long term care interests. This Section shall
not restrict the Department from implementing lower level of
care eligibility criteria for community-based services in
circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation and
programs for monitoring of utilization of health care services
and facilities, as it affects persons eligible for medical
assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General Assembly

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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

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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,

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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.
Notwithstanding any other provision of this Code, the
Illinois Department shall authorize licensed dietitian
nutritionists and certified diabetes educators to counsel

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senior diabetes patients in the senior diabetes patients' homes
to remove the hurdle of transportation for senior diabetes
patients to receive treatment.
(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 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.)
(305 ILCS 5/5-5.10 new)
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.

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(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.
(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

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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 shall 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,

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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.
(c) The Department shall require prior approval of 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

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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

10100SB1321ham001 - 95 - LRB101 10606 KTG 61299 a
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

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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.)
(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

10100SB1321ham001 - 97 - LRB101 10606 KTG 61299 a
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

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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

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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;
(C) a contracting entity representative and the
treating physician reach an agreement concerning the
enrollee's care; or
(D) the enrollee is discharged.
(f) Network adequacy and transparency.

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(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;
(C) periodically ensure that an MCO continues to
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

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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

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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.
(C) The Department shall share at least monthly its
expedited provider list and the frequency with which it
pays providers on the expedited list. The Department may
establish a process for MCOs to expedite payments to
providers based on criteria established by the Department.
(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

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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
(C) such rules shall be published for a review and
comment period of no less than 30 days on the
Department's website with final rules remaining
available on the Department's website.
(3) 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

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relationship is out of network.
(4) 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

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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

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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.

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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.

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

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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.

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(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. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff.
6-4-18.)
(305 ILCS 5/5-30.12 new)
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

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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

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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.
(305 ILCS 5/5A-4) (from Ch. 23, par. 5A-4)
Sec. 5A-4. Payment of assessment; penalty.
(a) The assessment imposed by Section 5A-2 for State fiscal
year 2009 through State fiscal year 2018 or as provided in
Section 5A-16, shall be due and payable in monthly
installments, each equaling one-twelfth of the assessment for
the year, on the fourteenth State business day of each month.

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No installment payment of an assessment imposed by Section 5A-2
shall be due and payable, however, until after the Comptroller
has issued the payments required under this Article.
Except as provided in subsection (a-5) of this Section, the
assessment imposed by subsection (b-5) of Section 5A-2 for the
portion of State fiscal year 2012 beginning June 10, 2012
through June 30, 2012, and for State fiscal year 2013 through
State fiscal year 2018 or as provided in Section 5A-16, shall
be due and payable in monthly installments, each equaling
one-twelfth of the assessment for the year, on the 17th State
business day of each month. No installment payment of an
assessment imposed by subsection (b-5) of Section 5A-2 shall be
due and payable, however, until after: (i) the Department
notifies the hospital provider, in writing, that the payment
methodologies to hospitals required under Section 5A-12.4,
have been approved by the Centers for Medicare and Medicaid
Services of the U.S. Department of Health and Human Services,
and the waiver under 42 CFR 433.68 for the assessment imposed
by subsection (b-5) of Section 5A-2, if necessary, has been
granted by the Centers for Medicare and Medicaid Services of
the U.S. Department of Health and Human Services; and (ii) the
Comptroller has issued the payments required under Section
5A-12.4. Upon notification to the Department of approval of the
payment methodologies required under Section 5A-12.4 and the
waiver granted under 42 CFR 433.68, if necessary, all
installments otherwise due under subsection (b-5) of Section

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5A-2 prior to the date of notification shall be due and payable
to the Department upon written direction from the Department
and issuance by the Comptroller of the payments required under
Section 5A-12.4.
Except as provided in subsection (a-5) of this Section, the
assessment imposed under Section 5A-2 for State fiscal year
2019 and each subsequent State fiscal year shall be due and
payable in monthly installments, each equaling one-twelfth of
the assessment for the year, on the 17th 14th State business
day of each month. No installment payment of an assessment
imposed by Section 5A-2 shall be due and payable, however,
until after: (i) the Department notifies the hospital provider,
in writing, that the payment methodologies to hospitals
required under Section 5A-12.6 have been approved by the
Centers for Medicare and Medicaid Services of the U.S.
Department of Health and Human Services, and the waiver under
42 CFR 433.68 for the assessment imposed by Section 5A-2, if
necessary, has been granted by the Centers for Medicare and
Medicaid Services of the U.S. Department of Health and Human
Services; and (ii) the Comptroller has issued the payments
required under Section 5A-12.6. Upon notification to the
Department of approval of the payment methodologies required
under Section 5A-12.6 and the waiver granted under 42 CFR
433.68, if necessary, all installments otherwise due under
Section 5A-2 prior to the date of notification shall be due and
payable to the Department upon written direction from the

10100SB1321ham001 - 115 - LRB101 10606 KTG 61299 a
Department and issuance by the Comptroller of the payments
required under Section 5A-12.6.
(a-5) The Illinois Department may accelerate the schedule
upon which assessment installments are due and payable by
hospitals with a payment ratio greater than or equal to one.
Such acceleration of due dates for payment of the assessment
may be made only in conjunction with a corresponding
acceleration in access payments identified in Section 5A-12.2,
Section 5A-12.4, or Section 5A-12.6 to the same hospitals. For
the purposes of this subsection (a-5), a hospital's payment
ratio is defined as the quotient obtained by dividing the total
payments for the State fiscal year, as authorized under Section
5A-12.2, Section 5A-12.4, or Section 5A-12.6, by the total
assessment for the State fiscal year imposed under Section 5A-2
or subsection (b-5) of Section 5A-2.
(b) The Illinois Department is authorized to establish
delayed payment schedules for hospital providers that are
unable to make installment payments when due under this Section
due to financial difficulties, as determined by the Illinois
Department.
(c) If a hospital provider fails to pay the full amount of
an installment when due (including any extensions granted under
subsection (b)), there shall, unless waived by the Illinois
Department for reasonable cause, be added to the assessment
imposed by Section 5A-2 a penalty assessment equal to the
lesser of (i) 5% of the amount of the installment not paid on

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or before the due date plus 5% of the portion thereof remaining
unpaid on the last day of each 30-day period thereafter or (ii)
100% of the installment amount not paid on or before the due
date. For purposes of this subsection, payments will be
credited first to unpaid installment amounts (rather than to
penalty or interest), beginning with the most delinquent
installments.
(d) Any assessment amount that is due and payable to the
Illinois Department more frequently than once per calendar
quarter shall be remitted to the Illinois Department by the
hospital provider by means of electronic funds transfer. The
Illinois Department may provide for remittance by other means
if (i) the amount due is less than $10,000 or (ii) electronic
funds transfer is unavailable for this purpose.
(Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19.)
(305 ILCS 5/11-5.1)
Sec. 11-5.1. Eligibility verification. Notwithstanding any
other provision of this Code, with respect to applications for
medical assistance provided under Article V of this Code,
eligibility shall be determined in a manner that ensures
program integrity and complies with federal laws and
regulations while minimizing unnecessary barriers to
enrollment. To this end, as soon as practicable, and unless the
Department receives written denial from the federal
government, this Section shall be implemented:

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(a) The Department of Healthcare and Family Services or its
designees shall:
(1) By no later than July 1, 2011, require verification
of, at a minimum, one month's income from all sources
required for determining the eligibility of applicants for
medical assistance under this Code. Such verification
shall take the form of pay stubs, business or income and
expense records for self-employed persons, letters from
employers, and any other valid documentation of income
including data obtained electronically by the Department
or its designees from other sources as described in
subsection (b) of this Section.
(2) By no later than October 1, 2011, require
verification of, at a minimum, one month's income from all
sources required for determining the continued eligibility
of recipients at their annual review of eligibility for
medical assistance under this Code. Information the
Department receives prior to the annual review, including
information available to the Department as a result of the
recipient's application for other non-Medicaid benefits,
that is sufficient to make a determination of continued
Medicaid eligibility may be reviewed and verified, and
subsequent action taken including client notification of
continued Medicaid eligibility. The date of client
notification establishes the date for subsequent annual
Medicaid eligibility reviews. Such verification shall take

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the form of pay stubs, business or income and expense
records for self-employed persons, letters from employers,
and any other valid documentation of income including data
obtained electronically by the Department or its designees
from other sources as described in subsection (b) of this
Section. A month's income may be verified by a single pay
stub with the monthly income extrapolated from the time
period covered by the pay stub. The Department shall send a
notice to recipients at least 60 days prior to the end of
their period of eligibility that informs them of the
requirements for continued eligibility. If a recipient
does not fulfill the requirements for continued
eligibility by the deadline established in the notice a
notice of cancellation shall be issued to the recipient and
coverage shall end no later than the last day of the month
following on the last day of the eligibility period. A
recipient's eligibility may be reinstated without
requiring a new application if the recipient fulfills the
requirements for continued eligibility prior to the end of
the third month following the last date of coverage (or
longer period if required by federal regulations). Nothing
in this Section shall prevent an individual whose coverage
has been cancelled from reapplying for health benefits at
any time.
(3) By no later than July 1, 2011, require verification
of Illinois residency.

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The Department, with federal approval, may choose to adopt
continuous financial eligibility for a full 12 months for
adults on Medicaid.
(b) The Department shall establish or continue cooperative
arrangements with the Social Security Administration, the
Illinois Secretary of State, the Department of Human Services,
the Department of Revenue, the Department of Employment
Security, and any other appropriate entity to gain electronic
access, to the extent allowed by law, to information available
to those entities that may be appropriate for electronically
verifying any factor of eligibility for benefits under the
Program. Data relevant to eligibility shall be provided for no
other purpose than to verify the eligibility of new applicants
or current recipients of health benefits under the Program.
Data shall be requested or provided for any new applicant or
current recipient only insofar as that individual's
circumstances are relevant to that individual's or another
individual's eligibility.
(c) Within 90 days of the effective date of this amendatory
Act of the 96th General Assembly, the Department of Healthcare
and Family Services shall send notice to current recipients
informing them of the changes regarding their eligibility
verification.
(d) As soon as practical if the data is reasonably
available, but no later than January 1, 2017, the Department
shall compile on a monthly basis data on eligibility

10100SB1321ham001 - 120 - LRB101 10606 KTG 61299 a
redeterminations of beneficiaries of medical assistance
provided under Article V of this Code. This data shall be
posted on the Department's website, and data from prior months
shall be retained and available on the Department's website.
The data compiled and reported shall include the following:
(1) The total number of redetermination decisions made
in a month and, of that total number, the number of
decisions to continue or change benefits and the number of
decisions to cancel benefits.
(2) A breakdown of enrollee language preference for the
total number of redetermination decisions made in a month
and, of that total number, a breakdown of enrollee language
preference for the number of decisions to continue or
change benefits, and a breakdown of enrollee language
preference for the number of decisions to cancel benefits.
The language breakdown shall include, at a minimum,
English, Spanish, and the next 4 most commonly used
languages.
(3) The percentage of cancellation decisions made in a
month due to each of the following:
(A) The beneficiary's ineligibility due to excess
income.
(B) The beneficiary's ineligibility due to not
being an Illinois resident.
(C) The beneficiary's ineligibility due to being
deceased.

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(D) The beneficiary's request to cancel benefits.
(E) The beneficiary's lack of response after
notices mailed to the beneficiary are returned to the
Department as undeliverable by the United States
Postal Service.
(F) The beneficiary's lack of response to a request
for additional information when reliable information
in the beneficiary's account, or other more current
information, is unavailable to the Department to make a
decision on whether to continue benefits.
(G) Other reasons tracked by the Department for the
purpose of ensuring program integrity.
(4) If a vendor is utilized to provide services in
support of the Department's redetermination decision
process, the total number of redetermination decisions
made in a month and, of that total number, the number of
decisions to continue or change benefits, and the number of
decisions to cancel benefits (i) with the involvement of
the vendor and (ii) without the involvement of the vendor.
(5) Of the total number of benefit cancellations in a
month, the number of beneficiaries who return from
cancellation within one month, the number of beneficiaries
who return from cancellation within 2 months, and the
number of beneficiaries who return from cancellation
within 3 months. Of the number of beneficiaries who return
from cancellation within 3 months, the percentage of those

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cancellations due to each of the reasons listed under
paragraph (3) of this subsection.
(e) The Department shall conduct a complete review of the
Medicaid redetermination process in order to identify changes
that can increase the use of ex parte redetermination
processing. This review shall be completed within 90 days after
the effective date of this amendatory Act of the 101st General
Assembly. Within 90 days of completion of the review, the
Department shall seek written federal approval of policy
changes the review recommended and implement once approved. The
review shall specifically include, but not be limited to, use
of ex parte redeterminations of the following populations:
(1) Recipients of developmental disabilities services.
(2) Recipients of benefits under the State's Aid to the
Aged, Blind, or Disabled program.
(3) Recipients of Medicaid long-term care services and
supports, including waiver services.
(4) All Modified Adjusted Gross Income (MAGI)
populations.
(5) Populations with no verifiable income.
(6) Self-employed people.
The report shall also outline populations and
circumstances in which an ex parte redetermination is not a
recommended option.
(f) The Department shall explore and implement, as
practical and technologically possible, roles that

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stakeholders outside State agencies can play to assist in
expediting eligibility determinations and redeterminations
within 24 months after the effective date of this amendatory
Act of the 101st General Assembly. Such practical roles to be
explored to expedite the eligibility determination processes
shall include the implementation of hospital presumptive
eligibility, as authorized by the Patient Protection and
Affordable Care Act.
(g) The Department or its designee shall seek federal
approval to enhance the reasonable compatibility standard from
5% to 10%.
(h) Reporting. The Department of Healthcare and Family
Services and the Department of Human Services shall publish
quarterly reports on their progress in implementing policies
and practices pursuant to this Section as modified by this
amendatory Act of the 101st General Assembly.
(1) The reports shall include, but not be limited to,
the following:
(A) Medical application processing, including a
breakdown of the number of MAGI, non-MAGI, long-term
care, and other medical cases pending for various
incremental time frames between 0 to 181 or more days.
(B) Medical redeterminations completed, including:
(i) a breakdown of the number of households that were
redetermined ex parte and those that were not; (ii) the
reasons households were not redetermined ex parte; and

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(iii) the relative percentages of these reasons.
(C) A narrative discussion on issues identified in
the functioning of the State's Integrated Eligibility
System and progress on addressing those issues, as well
as progress on implementing strategies to address
eligibility backlogs, including expanding ex parte
determinations to ensure timely eligibility
determinations and renewals.
(2) Initial reports shall be issued within 90 days
after the effective date of this amendatory Act of the
101st General Assembly.
(3) All reports shall be published on the Department's
website.
(Source: P.A. 98-651, eff. 6-16-14; 99-86, eff. 7-21-15.)
(305 ILCS 5/11-5.3)
Sec. 11-5.3. Procurement of vendor to verify eligibility
for assistance under Article V.
(a) No later than 60 days after the effective date of this
amendatory Act of the 97th General Assembly, the Chief
Procurement Officer for General Services, in consultation with
the Department of Healthcare and Family Services, shall conduct
and complete any procurement necessary to procure a vendor to
verify eligibility for assistance under Article V of this Code.
Such authority shall include procuring a vendor to assist the
Chief Procurement Officer in conducting the procurement. The

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Chief Procurement Officer and the Department shall jointly
negotiate final contract terms with a vendor selected by the
Chief Procurement Officer. Within 30 days of selection of an
eligibility verification vendor, the Department of Healthcare
and Family Services shall enter into a contract with the
selected vendor. The Department of Healthcare and Family
Services and the Department of Human Services shall cooperate
with and provide any information requested by the Chief
Procurement Officer to conduct the procurement.
(b) Notwithstanding any other provision of law, any
procurement or contract necessary to comply with this Section
shall be exempt from: (i) the Illinois Procurement Code
pursuant to Section 1-10(h) of the Illinois Procurement Code,
except that bidders shall comply with the disclosure
requirement in Sections 50-10.5(a) through (d), 50-13, 50-35,
and 50-37 of the Illinois Procurement Code and a vendor awarded
a contract under this Section shall comply with Section 50-37
of the Illinois Procurement Code; (ii) any administrative rules
of this State pertaining to procurement or contract formation;
and (iii) any State or Department policies or procedures
pertaining to procurement, contract formation, contract award,
and Business Enterprise Program approval.
(c) Upon becoming operational, the contractor shall
conduct data matches using the name, date of birth, address,
and Social Security Number of each applicant and recipient
against public records to verify eligibility. The contractor,

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upon preliminary determination that an enrollee is eligible or
ineligible, shall notify the Department, except that the
contractor shall not make preliminary determinations regarding
the eligibility of persons residing in long term care
facilities whose income and resources were at or below the
applicable financial eligibility standards at the time of their
last review. Within 20 business days of such notification, the
Department shall accept the recommendation or reject it with a
stated reason. The Department shall retain final authority over
eligibility determinations. The contractor shall keep a record
of all preliminary determinations of ineligibility
communicated to the Department. Within 30 days of the end of
each calendar quarter, the Department and contractor shall file
a joint report on a quarterly basis to the Governor, the
Speaker of the House of Representatives, the Minority Leader of
the House of Representatives, the Senate President, and the
Senate Minority Leader. The report shall include, but shall not
be limited to, monthly recommendations of preliminary
determinations of eligibility or ineligibility communicated by
the contractor, the actions taken on those preliminary
determinations by the Department, and the stated reasons for
those recommendations that the Department rejected.
(d) An eligibility verification vendor contract shall be
awarded for an initial 2-year period with up to a maximum of 2
one-year renewal options. Nothing in this Section shall compel
the award of a contract to a vendor that fails to meet the

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needs of the Department. A contract with a vendor to assist in
the procurement shall be awarded for a period of time not to
exceed 6 months.
(e) The provisions of this Section shall be administered in
compliance with federal law.
(f) The State's Integrated Eligibility System shall be on a
3-year audit cycle by the Office of the Auditor General.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
(305 ILCS 5/11-5.4)
(Text of Section from P.A. 100-665)
Sec. 11-5.4. Expedited long-term care eligibility
determination and enrollment.
(a) Establishment of the expedited long-term care
eligibility determination and enrollment system shall be a
joint venture of the Departments of Human Services and
Healthcare and Family Services and the Department on Aging.
(b) Streamlined application enrollment process; expedited
eligibility process. The streamlined application and
enrollment process must include, but need not be limited to,
the following:
(1) On or before July 1, 2019, a streamlined
application and enrollment process shall be put in place
which must include, but need not be limited to, the
following:
(A) Minimize the burden on applicants by

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collecting only the data necessary to determine
eligibility for medical services, long-term care
services, and spousal impoverishment offset.
(B) Integrate online data sources to simplify the
application process by reducing the amount of
information needed to be entered and to expedite
eligibility verification.
(C) Provide online prompts to alert the applicant
that information is missing or not complete.
(D) Provide training and step-by-step written
instructions for caseworkers, applicants, and
providers.
(2) The State must expedite the eligibility process for
applicants meeting specified guidelines, regardless of the
age of the application. The guidelines, subject to federal
approval, must include, but need not be limited to, the
following individually or collectively:
(A) Full Medicaid benefits in the community for a
specified period of time.
(B) No transfer of assets or resources during the
federally prescribed look-back period, as specified in
federal law.
(C) Receives Supplemental Security Income payments
or was receiving such payments at the time of admission
to a nursing facility.
(D) For applicants or recipients with verified

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income at or below 100% of the federal poverty level
when the declared value of their countable resources is
no greater than the allowable amounts pursuant to
Section 5-2 of this Code for classes of eligible
persons for whom a resource limit applies. Such
simplified verification policies shall apply to
community cases as well as long-term care cases.
(3) Subject to federal approval, the Department of
Healthcare and Family Services must implement an ex parte
renewal process for Medicaid-eligible individuals residing
in long-term care facilities. "Renewal" has the same
meaning as "redetermination" in State policies,
administrative rule, and federal Medicaid law. The ex parte
renewal process must be fully operational on or before
January 1, 2019.
(4) The Department of Human Services must use the
standards and distribution requirements described in this
subsection and in Section 11-6 for notification of missing
supporting documents and information during all phases of
the application process: initial, renewal, and appeal.
(c) The Department of Human Services must adopt policies
and procedures to improve communication between long-term care
benefits central office personnel, applicants and their
representatives, and facilities in which the applicants
reside. Such policies and procedures must at a minimum permit
applicants and their representatives and the facility in which

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the applicants reside to speak directly to an individual
trained to take telephone inquiries and provide appropriate
responses.
(d) Effective 30 days after the completion of 3 regionally
based trainings, nursing facilities shall submit all
applications for medical assistance online via the Application
for Benefits Eligibility (ABE) website. This requirement shall
extend to scanning and uploading with the online application
any required additional forms such as the Long Term Care
Facility Notification and the Additional Financial Information
for Long Term Care Applicants as well as scanned copies of any
supporting documentation. Long-term care facility admission
documents must be submitted as required in Section 5-5 of this
Code. No local Department of Human Services office shall refuse
to accept an electronically filed application. No Department of
Human Services office shall request submission of any document
in hard copy.
(e) Notwithstanding any other provision of this Code, the
Department of Human Services and the Department of Healthcare
and Family Services' Office of the Inspector General shall,
upon request, allow an applicant additional time to submit
information and documents needed as part of a review of
available resources or resources transferred during the
look-back period. The initial extension shall not exceed 30
days. A second extension of 30 days may be granted upon
request. Any request for information issued by the State to an

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applicant shall include the following: an explanation of the
information required and the date by which the information must
be submitted; a statement that failure to respond in a timely
manner can result in denial of the application; a statement
that the applicant or the facility in the name of the applicant
may seek an extension; and the name and contact information of
a caseworker in case of questions. Any such request for
information shall also be sent to the facility. In deciding
whether to grant an extension, the Department of Human Services
or the Department of Healthcare and Family Services' Office of
the Inspector General shall take into account what is in the
best interest of the applicant. The time limits for processing
an application shall be tolled during the period of any
extension granted under this subsection.
(f) The Department of Human Services and the Department of
Healthcare and Family Services must jointly compile data on
pending applications, denials, appeals, and redeterminations
into a monthly report, which shall be posted on each
Department's website for the purposes of monitoring long-term
care eligibility processing. The report must specify the number
of applications and redeterminations pending long-term care
eligibility determination and admission and the number of
appeals of denials in the following categories:
(A) Length of time applications, redeterminations, and
appeals are pending - 0 to 45 days, 46 days to 90 days, 91
days to 180 days, 181 days to 12 months, over 12 months to

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18 months, over 18 months to 24 months, and over 24 months.
(B) Percentage of applications and redeterminations
pending in the Department of Human Services' Family
Community Resource Centers, in the Department of Human
Services' long-term care hubs, with the Department of
Healthcare and Family Services' Office of Inspector
General, and those applications which are being tolled due
to requests for extension of time for additional
information.
(C) Status of pending applications, denials, appeals,
and redeterminations.
(g) Beginning on July 1, 2017, the Auditor General shall
report every 3 years to the General Assembly on the performance
and compliance of the Department of Healthcare and Family
Services, the Department of Human Services, and the Department
on Aging in meeting the requirements of this Section and the
federal requirements concerning eligibility determinations for
Medicaid long-term care services and supports, and shall report
any issues or deficiencies and make recommendations. The
Auditor General shall, at a minimum, review, consider, and
evaluate the following:
(1) compliance with federal regulations on furnishing
services as related to Medicaid long-term care services and
supports as provided under 42 CFR 435.930;
(2) compliance with federal regulations on the timely
determination of eligibility as provided under 42 CFR

10100SB1321ham001 - 133 - LRB101 10606 KTG 61299 a
435.912;
(3) the accuracy and completeness of the report
required under paragraph (9) of subsection (e);
(4) the efficacy and efficiency of the task-based
process used for making eligibility determinations in the
centralized offices of the Department of Human Services for
long-term care services, including the role of the State's
integrated eligibility system, as opposed to the
traditional caseworker-specific process from which these
central offices have converted; and
(5) any issues affecting eligibility determinations
related to the Department of Human Services' staff
completing Medicaid eligibility determinations instead of
the designated single-state Medicaid agency in Illinois,
the Department of Healthcare and Family Services.
The Auditor General's report shall include any and all
other areas or issues which are identified through an annual
review. Paragraphs (1) through (5) of this subsection shall not
be construed to limit the scope of the annual review and the
Auditor General's authority to thoroughly and completely
evaluate any and all processes, policies, and procedures
concerning compliance with federal and State law requirements
on eligibility determinations for Medicaid long-term care
services and supports.
(h) The Department of Healthcare and Family Services shall
adopt any rules necessary to administer and enforce any

10100SB1321ham001 - 134 - LRB101 10606 KTG 61299 a
provision of this Section. Rulemaking shall not delay the full
implementation of this Section.
(Source: P.A. 99-153, eff. 7-28-15; 100-380, eff. 8-25-17;
100-665, eff. 8-2-18.)
(Text of Section from P.A. 100-1141)
Sec. 11-5.4. Expedited long-term care eligibility
determination and enrollment.
(a) An expedited long-term care eligibility determination
and enrollment system shall be established to reduce long-term
care determinations to 90 days or fewer by July 1, 2014 and
streamline the long-term care enrollment process.
Establishment of the system shall be a joint venture of the
Department of Human Services and Healthcare and Family Services
and the Department on Aging. The Governor shall name a lead
agency no later than 30 days after the effective date of this
amendatory Act of the 98th General Assembly to assume
responsibility for the full implementation of the
establishment and maintenance of the system. Project outcomes
shall include an enhanced eligibility determination tracking
system accessible to providers and a centralized application
review and eligibility determination with all applicants
reviewed within 90 days of receipt by the State of a complete
application. If the Department of Healthcare and Family
Services' Office of the Inspector General determines that there
is a likelihood that a non-allowable transfer of assets has

10100SB1321ham001 - 135 - LRB101 10606 KTG 61299 a
occurred, and the facility in which the applicant resides is
notified, an extension of up to 90 days shall be permissible.
On or before December 31, 2015, a streamlined application and
enrollment process shall be put in place based on the following
principles:
(1) Minimize the burden on applicants by collecting
only the data necessary to determine eligibility for
medical services, long-term care services, and spousal
impoverishment offset.
(2) Integrate online data sources to simplify the
application process by reducing the amount of information
needed to be entered and to expedite eligibility
verification.
(3) Provide online prompts to alert the applicant that
information is missing or not complete.
(b) The Department shall, on or before July 1, 2014, assess
the feasibility of incorporating all information needed to
determine eligibility for long-term care services, including
asset transfer and spousal impoverishment financials, into the
State's integrated eligibility system identifying all
resources needed and reasonable timeframes for achieving the
specified integration.
(c) The lead agency shall file interim reports with the
Chairs and Minority Spokespersons of the House and Senate Human
Services Committees no later than September 1, 2013 and on
February 1, 2014. The Department of Healthcare and Family

10100SB1321ham001 - 136 - LRB101 10606 KTG 61299 a
Services shall include in the annual Medicaid report for State
Fiscal Year 2014 and every fiscal year thereafter information
concerning implementation of the provisions of this Section.
(d) No later than August 1, 2014, the Auditor General shall
report to the General Assembly concerning the extent to which
the timeframes specified in this Section have been met and the
extent to which State staffing levels are adequate to meet the
requirements of this Section.
(e) The Department of Healthcare and Family Services, the
Department of Human Services, and the Department on Aging shall
take the following steps to achieve federally established
timeframes for eligibility determinations for Medicaid and
long-term care benefits and shall work toward the federal goal
of real time determinations:
(1) The Departments shall review, in collaboration
with representatives of affected providers, all forms and
procedures currently in use, federal guidelines either
suggested or mandated, and staff deployment by September
30, 2014 to identify additional measures that can improve
long-term care eligibility processing and make adjustments
where possible.
(2) No later than June 30, 2014, the Department of
Healthcare and Family Services shall issue vouchers for
advance payments not to exceed $50,000,000 to nursing
facilities with significant outstanding Medicaid liability
associated with services provided to residents with

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Medicaid applications pending and residents facing the
greatest delays. Each facility with an advance payment
shall state in writing whether its own recoupment schedule
will be in 3 or 6 equal monthly installments, as long as
all advances are recouped by June 30, 2015.
(3) The Department of Healthcare and Family Services'
Office of Inspector General and the Department of Human
Services shall immediately forgo resource review and
review of transfers during the relevant look-back period
for applications that were submitted prior to September 1,
2013. An applicant who applied prior to September 1, 2013,
who was denied for failure to cooperate in providing
required information, and whose application was
incorrectly reviewed under the wrong look-back period
rules may request review and correction of the denial based
on this subsection. If found eligible upon review, such
applicants shall be retroactively enrolled.
(4) As soon as practicable, the Department of
Healthcare and Family Services shall implement policies
and promulgate rules to simplify financial eligibility
verification in the following instances: (A) for
applicants or recipients who are receiving Supplemental
Security Income payments or who had been receiving such
payments at the time they were admitted to a nursing
facility and (B) for applicants or recipients with verified
income at or below 100% of the federal poverty level when

10100SB1321ham001 - 138 - LRB101 10606 KTG 61299 a
the declared value of their countable resources is no
greater than the allowable amounts pursuant to Section 5-2
of this Code for classes of eligible persons for whom a
resource limit applies. Such simplified verification
policies shall apply to community cases as well as
long-term care cases.
(5) As soon as practicable, but not later than July 1,
2014, the Department of Healthcare and Family Services and
the Department of Human Services shall jointly begin a
special enrollment project by using simplified eligibility
verification policies and by redeploying caseworkers
trained to handle long-term care cases to prioritize those
cases, until the backlog is eliminated and processing time
is within 90 days. This project shall apply to applications
for long-term care received by the State on or before May
15, 2014.
(6) As soon as practicable, but not later than
September 1, 2014, the Department on Aging shall make
available to long-term care facilities and community
providers upon request, through an electronic method, the
information contained within the Interagency Certification
of Screening Results completed by the pre-screener, in a
form and manner acceptable to the Department of Human
Services.
(7) Effective 30 days after the completion of 3
regionally based trainings, nursing facilities shall

10100SB1321ham001 - 139 - LRB101 10606 KTG 61299 a
submit all applications for medical assistance online via
the Application for Benefits Eligibility (ABE) website.
This requirement shall extend to scanning and uploading
with the online application any required additional forms
such as the Long Term Care Facility Notification and the
Additional Financial Information for Long Term Care
Applicants as well as scanned copies of any supporting
documentation. Long-term care facility admission documents
must be submitted as required in Section 5-5 of this Code.
No local Department of Human Services office shall refuse
to accept an electronically filed application.
(8) Notwithstanding any other provision of this Code,
the Department of Human Services and the Department of
Healthcare and Family Services' Office of the Inspector
General shall, upon request, allow an applicant additional
time to submit information and documents needed as part of
a review of available resources or resources transferred
during the look-back period. The initial extension shall
not exceed 30 days. A second extension of 30 days may be
granted upon request. Any request for information issued by
the State to an applicant shall include the following: an
explanation of the information required and the date by
which the information must be submitted; a statement that
failure to respond in a timely manner can result in denial
of the application; a statement that the applicant or the
facility in the name of the applicant may seek an

10100SB1321ham001 - 140 - LRB101 10606 KTG 61299 a
extension; and the name and contact information of a
caseworker in case of questions. Any such request for
information shall also be sent to the facility. In deciding
whether to grant an extension, the Department of Human
Services or the Department of Healthcare and Family
Services' Office of the Inspector General shall take into
account what is in the best interest of the applicant. The
time limits for processing an application shall be tolled
during the period of any extension granted under this
subsection.
(9) The Department of Human Services and the Department
of Healthcare and Family Services must jointly compile data
on pending applications, denials, appeals, and
redeterminations into a monthly report, which shall be
posted on each Department's website for the purposes of
monitoring long-term care eligibility processing. The
report must specify the number of applications and
redeterminations pending long-term care eligibility
determination and admission and the number of appeals of
denials in the following categories:
(A) Length of time applications, redeterminations,
and appeals are pending - 0 to 45 days, 46 days to 90
days, 91 days to 180 days, 181 days to 12 months, over
12 months to 18 months, over 18 months to 24 months,
and over 24 months.
(B) Percentage of applications and

10100SB1321ham001 - 141 - LRB101 10606 KTG 61299 a
redeterminations pending in the Department of Human
Services' Family Community Resource Centers, in the
Department of Human Services' long-term care hubs,
with the Department of Healthcare and Family Services'
Office of Inspector General, and those applications
which are being tolled due to requests for extension of
time for additional information.
(C) Status of pending applications, denials,
appeals, and redeterminations.
(f) Beginning on July 1, 2017, the Auditor General shall
report every 3 years to the General Assembly on the performance
and compliance of the Department of Healthcare and Family
Services, the Department of Human Services, and the Department
on Aging in meeting the requirements of this Section and the
federal requirements concerning eligibility determinations for
Medicaid long-term care services and supports, and shall report
any issues or deficiencies and make recommendations. The
Auditor General shall, at a minimum, review, consider, and
evaluate the following:
(1) compliance with federal regulations on furnishing
services as related to Medicaid long-term care services and
supports as provided under 42 CFR 435.930;
(2) compliance with federal regulations on the timely
determination of eligibility as provided under 42 CFR
435.912;
(3) the accuracy and completeness of the report

10100SB1321ham001 - 142 - LRB101 10606 KTG 61299 a
required under paragraph (9) of subsection (e);
(4) the efficacy and efficiency of the task-based
process used for making eligibility determinations in the
centralized offices of the Department of Human Services for
long-term care services, including the role of the State's
integrated eligibility system, as opposed to the
traditional caseworker-specific process from which these
central offices have converted; and
(5) any issues affecting eligibility determinations
related to the Department of Human Services' staff
completing Medicaid eligibility determinations instead of
the designated single-state Medicaid agency in Illinois,
the Department of Healthcare and Family Services.
The Auditor General's report shall include any and all
other areas or issues which are identified through an annual
review. Paragraphs (1) through (5) of this subsection shall not
be construed to limit the scope of the annual review and the
Auditor General's authority to thoroughly and completely
evaluate any and all processes, policies, and procedures
concerning compliance with federal and State law requirements
on eligibility determinations for Medicaid long-term care
services and supports.
(g) The Department shall adopt rules necessary to
administer and enforce any provision of this Section.
Rulemaking shall not delay the full implementation of this
Section.

10100SB1321ham001 - 143 - LRB101 10606 KTG 61299 a
(h) Beginning on June 29, 2018, provisional eligibility for
medical assistance under Article V of this Code, in the form of
a recipient identification number and any other necessary
credentials to permit an applicant to receive covered services
under Article V benefits, must be issued to any applicant who
has not received a final eligibility determination on his or
her application for Medicaid and Medicaid long-term care
services filed simultaneously or, if already Medicaid
enrolled, application for or Medicaid long-term care services
under Article V of this Code benefits or a notice of an
opportunity for a hearing within the federally prescribed
timeliness requirements for determinations on deadlines for
the processing of such applications. The Department must
maintain the applicant's provisional eligibility Medicaid
enrollment status until a final eligibility determination is
made on the individual's application for long-term care
services approved or the applicant's appeal has been
adjudicated and eligibility is denied. The Department or the
managed care organization, if applicable, must reimburse
providers for services rendered during an applicant's
provisional eligibility period.
(1) Claims for services rendered to an applicant with
provisional eligibility status must be submitted and
processed in the same manner as those submitted on behalf
of beneficiaries determined to qualify for benefits.
(2) An applicant with provisional eligibility

10100SB1321ham001 - 144 - LRB101 10606 KTG 61299 a
enrollment status must have his or her long-term care
benefits paid for under the State's fee-for-service system
during the period of provisional eligibility until the
State makes a final determination on the applicant's
Medicaid or Medicaid long-term care application. If an
individual otherwise eligible for medical assistance under
Article V of this Code is enrolled with a managed care
organization for community benefits at the time the
individual's provisional eligibility for long-term care
services status is issued, the managed care organization is
only responsible for paying benefits covered under the
capitation payment received by the managed care
organization for the individual.
(3) The Department, within 10 business days of issuing
provisional eligibility to an applicant, must submit to the
Office of the Comptroller for payment a voucher for all
retroactive reimbursement due. The Department must clearly
identify such vouchers as provisional eligibility
vouchers.
(Source: P.A. 99-153, eff. 7-28-15; 100-380, eff. 8-25-17;
100-1141, eff. 11-28-18.)
(305 ILCS 5/12-4.42)
Sec. 12-4.42. Medicaid Revenue Maximization.
(a) Purpose. The General Assembly finds that there is a
need to make changes to the administration of services provided

10100SB1321ham001 - 145 - LRB101 10606 KTG 61299 a
by State and local governments in order to maximize federal
financial participation.
(b) Definitions. As used in this Section:
"Community Medicaid mental health services" means all
mental health services outlined in Part 132 of Title 59 of the
Illinois Administrative Code that are funded through DHS,
eligible for federal financial participation, and provided by a
community-based provider.
"Community-based provider" means an entity enrolled as a
provider pursuant to Sections 140.11 and 140.12 of Title 89 of
the Illinois Administrative Code and certified to provide
community Medicaid mental health services in accordance with
Part 132 of Title 59 of the Illinois Administrative Code.
"DCFS" means the Department of Children and Family
Services.
"Department" means the Illinois Department of Healthcare
and Family Services.
"Care facility for persons with a developmental
disability" means an intermediate care facility for persons
with an intellectual disability within the meaning of Title XIX
of the Social Security Act, whether public or private and
whether organized for profit or not-for-profit, but shall not
include any facility operated by the State.
"Care provider for persons with a developmental
disability" means a person conducting, operating, or
maintaining a care facility for persons with a developmental

10100SB1321ham001 - 146 - LRB101 10606 KTG 61299 a
disability. For purposes of this definition, "person" means any
political subdivision of the State, municipal corporation,
individual, firm, partnership, corporation, company, limited
liability company, association, joint stock association, or
trust, or a receiver, executor, trustee, guardian, or other
representative appointed by order of any court.
"DHS" means the Illinois Department of Human Services.
"Hospital" means an institution, place, building, or
agency located in this State that is licensed as a general
acute hospital by the Illinois Department of Public Health
under the Hospital Licensing Act, whether public or private and
whether organized for profit or not-for-profit.
"Long term care facility" means (i) a skilled nursing or
intermediate long term care facility, whether public or private
and whether organized for profit or not-for-profit, that is
subject to licensure by the Illinois Department of Public
Health under the Nursing Home Care Act, including a county
nursing home directed and maintained under Section 5-1005 of
the Counties Code, and (ii) a part of a hospital in which
skilled or intermediate long term care services within the
meaning of Title XVIII or XIX of the Social Security Act are
provided; except that the term "long term care facility" does
not include a facility operated solely as an intermediate care
facility for the intellectually disabled within the meaning of
Title XIX of the Social Security Act.
"Long term care provider" means (i) a person licensed by

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the Department of Public Health to operate and maintain a
skilled nursing or intermediate long term care facility or (ii)
a hospital provider that provides skilled or intermediate long
term care services within the meaning of Title XVIII or XIX of
the Social Security Act. For purposes of this definition,
"person" means any political subdivision of the State,
municipal corporation, individual, firm, partnership,
corporation, company, limited liability company, association,
joint stock association, or trust, or a receiver, executor,
trustee, guardian, or other representative appointed by order
of any court.
"State-operated facility for persons with a developmental
disability" means an intermediate care facility for persons
with an intellectual disability within the meaning of Title XIX
of the Social Security Act operated by the State.
(c) Administration and deposit of Revenues. The Department
shall coordinate the implementation of changes required by
Public Act 96-1405 amongst the various State and local
government bodies that administer programs referred to in this
Section.
Revenues generated by program changes mandated by any
provision in this Section, less reasonable administrative
costs associated with the implementation of these program
changes, which would otherwise be deposited into the General
Revenue Fund shall be deposited into the Healthcare Provider
Relief Fund.

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The Department shall issue a report to the General Assembly
detailing the implementation progress of Public Act 96-1405 as
a part of the Department's Medical Programs annual report for
fiscal years 2010 and 2011.
(d) Acceleration of payment vouchers. To the extent
practicable and permissible under federal law, the Department
shall create all vouchers for long term care facilities and
facilities for persons with a developmental disability for
dates of service in the month in which the enhanced federal
medical assistance percentage (FMAP) originally set forth in
the American Recovery and Reinvestment Act (ARRA) expires and
for dates of service in the month prior to that month and
shall, no later than the 15th of the month in which the
enhanced FMAP expires, submit these vouchers to the Comptroller
for payment.
The Department of Human Services shall create the necessary
documentation for State-operated facilities for persons with a
developmental disability so that the necessary data for all
dates of service before the expiration of the enhanced FMAP
originally set forth in the ARRA can be adjudicated by the
Department no later than the 15th of the month in which the
enhanced FMAP expires.
(e) Billing of DHS community Medicaid mental health
services. No later than July 1, 2011, community Medicaid mental
health services provided by a community-based provider must be
billed directly to the Department.

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(f) DCFS Medicaid services. The Department shall work with
DCFS to identify existing programs, pending qualifying
services, that can be converted in an economically feasible
manner to Medicaid in order to secure federal financial
revenue.
(g) (Blank). Third Party Liability recoveries. The
Department shall contract with a vendor to support the
Department in coordinating benefits for Medicaid enrollees.
The scope of work shall include, at a minimum, the
identification of other insurance for Medicaid enrollees and
the recovery of funds paid by the Department when another payer
was liable. The vendor may be paid a percentage of actual cash
recovered when practical and subject to federal law.
(h) Public health departments. The Department shall
identify unreimbursed costs for persons covered by Medicaid who
are served by the Chicago Department of Public Health.
The Department shall assist the Chicago Department of
Public Health in determining total unreimbursed costs
associated with the provision of healthcare services to
Medicaid enrollees.
The Department shall determine and draw the maximum
allowable federal matching dollars associated with the cost of
Chicago Department of Public Health services provided to
Medicaid enrollees.
(i) Acceleration of hospital-based payments. The
Department shall, by the 10th day of the month in which the

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enhanced FMAP originally set forth in the ARRA expires, create
vouchers for all State fiscal year 2011 hospital payments
exempt from the prompt payment requirements of the ARRA. The
Department shall submit these vouchers to the Comptroller for
payment.
(Source: P.A. 99-143, eff. 7-27-15; 100-201, eff. 8-18-17.)
(305 ILCS 5/14-13 new)
Sec. 14-13. Reimbursement for inpatient stays extended
beyond medical necessity.
(a) By October 1, 2019, the Department shall by rule
implement a methodology effective for dates of service July 1,
2019 and later to reimburse hospitals for inpatient stays
extended beyond medical necessity due to the inability of the
Department or the managed care organization in which a
recipient is enrolled or the hospital discharge planner to find
an appropriate placement after discharge from the hospital.
(b) The methodology shall provide reasonable compensation
for the services provided attributable to the days of the
extended stay for which the prevailing rate methodology
provides no reimbursement. The Department may use a day outlier
program to satisfy this requirement. The reimbursement rate
shall be set at a level so as not to act as an incentive to
avoid transfer to the appropriate level of care needed or
placement, after discharge.
(c) The Department shall require managed care

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organizations to adopt this methodology or an alternative
methodology that pays at least as much as the Department's
adopted methodology unless otherwise mutually agreed upon
contractual language is developed by the provider and the
managed care organization for a risk-based or innovative
payment methodology.
(d) Days beyond medical necessity shall not be eligible for
per diem add-on payments under the Medicaid High Volume
Adjustment (MHVA) or the Medicaid Percentage Adjustment (MPA)
programs.
(e) For services covered by the fee-for-service program,
reimbursement under this Section shall only be made for days
beyond medical necessity that occur after the hospital has
notified the Department of the need for post-discharge
placement. For services covered by a managed care organization,
hospitals shall notify the appropriate managed care
organization of an admission within 24 hours of admission. For
every 24-hour period beyond the initial 24 hours after
admission that the hospital fails to notify the managed care
organization of the admission, reimbursement under this
subsection shall be reduced by one day.
Section 45. The Illinois Public Aid Code is amended by
reenacting and changing Section 5-5.07 as follows:
(305 ILCS 5/5-5.07)

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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. This Section is repealed 6 months after the
effective date of this amendatory Act of the 100th General
Assembly.
(Source: P.A. 100-646, eff. 7-27-18.)
Section 99. Effective date. This Act takes effect upon
becoming law.".