Bill Text: IL SB1298 | 2023-2024 | 103rd General Assembly | Chaptered

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Bill Title: Creates the Substance Use Disorder Residential and Detox Rate Equity Act. Requires the General Assembly to appropriate sufficient funds to the Department of Human Services, for State Fiscal Year 2024 and for each State fiscal year thereafter, to ensure reimbursement rates will be increased and subsequently adjusted upward by an amount equal to the Consumer Price Index-U from the previous year, not to exceed 5% in any State fiscal year, for licensed or certified community-based substance use disorder treatment providers under community service grant programs for persons with substance use disorders, including, but not limited to, certain residential and withdrawal management services provided in accordance with criteria established by the American Society of Addiction Medicine. Amends the Illinois Public Aid Code. In the Medical Assistance Article of the Code, provides that on and after January 1, 2024, the inpatient, per diem rate to be paid to a hospital for inpatient psychiatric services shall be not less than 90% of the per diem rate established under a specified provision of the Code. Makes changes to provisions concerning funding to the human poison control center designated under the Poison Control System Act; hospital reimbursement rates for specified inpatient and outpatient services; medical assistance coverage for cognitive assessment and care planning services provided to a person who experiences signs or symptoms of cognitive impairment; the supportive living program rate for dementia care; and Prospective Payment System rates increases for federally qualified health centers. Amends the Specialized Mental Health Rehabilitation Act of 2013. Provides that beginning July 1, 2023, for improving the quality of life and the quality of care at specialized mental health rehabilitation facilities, a payment of no less than $10.50 per day, per single room occupancy shall be added to the existing $15 additional per day, per single room occupancy rate for a total of at least $25.50 per day, per single room occupancy. Sets forth a rate increase for each Medicaid-occupied bed in dual-occupancy rooms. Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, subject to federal approval, on and after July 1, 2023, the reimbursement rates paid to providers of private duty nursing services for medically fragile and technology dependent children shall be at a specified percentage rate higher than the reimbursement rates in effect for nursing services on June 30, 2023. Amends the Illinois Act on the Aging. Increases rates for homemaker services, subject to federal approval. Requires providers of in-home services to be required to certify to the Department on Aging that they remain in compliance with the mandated wage increase for direct service workers. Provides that fringe benefits shall not be reduced in relation to the rate increases described in the amendatory Act. Amends the Medical Assistance Article of the Illinois Public Aid Code. Increases the reimbursement rate for ventilator services, speech therapy services, physical therapy services, and occupational therapy services. Establishes a $60 personal needs allowance for nursing home residents who are eligible for medical assistance. Amends the Rebuild Illinois Mental Health Workforce Act. Increases the Mobile Crisis Response Medicaid Payment rate, the Crisis Intervention Medicaid Payment rate, and other specified rates. In a provision concerning reimbursement rates for ambulance services, provides that ambulance services includes medical transportation services provided by means of air ambulance. Provides for an increase in the base rate for both base charges and mileage charges for medical transportation services provided by means of an air ambulance. In a provision concerning the tiered exceptional care per diem rates for medically complex for the developmentally disabled facilities, provides that, subject to federal approval, each tier rate shall be increased 6% over the amount in effect on the effective date of the amendatory Act. Provides that, subject to federal approval, the Department of Healthcare and Family Services shall increase the base rate of reimbursement for both base charges and mileage charges for ground ambulance service providers not participating in the Ground Emergency Medical Transportation (GEMT) Program for medical transportation services provided by means of a ground ambulance to a level not lower than 140% (rather than 112%) of the base rate in effect as of January 1, 2023 (rather than July 30, 2018). Makes other changes. Some provisions take effect immediately. Some provisions take effect July 1, 2023.

Spectrum: Partisan Bill (Democrat 5-0)

Status: (Passed) 2023-06-16 - Public Act . . . . . . . . . 103-0102 [SB1298 Detail]

Download: Illinois-2023-SB1298-Chaptered.html

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Public Act 103-0102
SB1298 Enrolled LRB103 28018 CPF 54397 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
ARTICLE 1.
Section 1-1. Short title. This Article may be cited as the
Substance Use Disorder Residential and Detox Rate Equity Act.
References in this Article to "this Act" mean this Article.
Section 1-5. Funding for licensed or certified
community-based substance use disorder treatment providers.
Subject to federal approval, beginning on January 1, 2024 for
State Fiscal Year 2024, and for each State fiscal year
thereafter, the General Assembly shall appropriate sufficient
funds to the Department of Human Services to ensure
reimbursement rates will be increased and subsequently
adjusted upward by an amount equal to the Consumer Price
Index-U from the previous year, not to exceed 5% in any State
fiscal year, for licensed or certified substance use disorder
treatment providers of ASAM Level 3 residential/inpatient
services under community service grant programs for persons
with substance use disorders.
If there is a decrease in the Consumer Price Index-U,
rates shall remain unchanged for that State fiscal year. The

Department of Human Services shall increase the grant contract
amount awarded to each eligible community-based substance use
disorder treatment provider to ensure that the level and
number of services provided under community service grant
programs shall not be reduced by increasing the amount
available to each provider under the community service grant
programs to address the increased rate for each such service.
The Department shall adopt rules, including emergency
rules in accordance with Section 5-45 of the Illinois
Administrative Procedure Act, to implement the provisions of
this Act.
As used in this Act, "Consumer Price Index-U" means the
index published by the Bureau of Labor Statistics of the
United States Department of Labor that measures the average
change in prices of goods and services purchased by all urban
consumers, United States city average, all items, 1982-84 =
100.
ARTICLE 5.
Section 5-10. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.35 as follows:
(5 ILCS 100/5-45.35 new)
Sec. 5-45.35. Emergency rulemaking; Substance Use Disorder
Residential and Detox Rate Equity. To provide for the

expeditious and timely implementation of the Substance Use
Disorder Residential and Detox Rate Equity Act, emergency
rules implementing the Substance Use Disorder Residential and
Detox Rate Equity Act may be adopted in accordance with
Section 5-45 by the Department of Human Services and the
Department of Healthcare and Family Services. The adoption of
emergency rules authorized by Section 5-45 and this Section is
deemed to be necessary for the public interest, safety, and
welfare.
This Section is repealed one year after the effective date
of this amendatory Act of the 103rd General Assembly.
Section 5-15. The Substance Use Disorder Act is amended by
changing Section 55-30 as follows:
(20 ILCS 301/55-30)
Sec. 55-30. Rate increase.
(a) The Department shall by rule develop the increased
rate methodology and annualize the increased rate beginning
with State fiscal year 2018 contracts to licensed providers of
community-based substance use disorder intervention or
treatment, based on the additional amounts appropriated for
the purpose of providing a rate increase to licensed
providers. The Department shall adopt rules, including
emergency rules under subsection (y) of Section 5-45 of the
Illinois Administrative Procedure Act, to implement the

provisions of this Section.
(b) (Blank).
(c) Beginning on July 1, 2022, the Division of Substance
Use Prevention and Recovery shall increase reimbursement rates
for all community-based substance use disorder treatment and
intervention services by 47%, including, but not limited to,
all of the following:
(1) Admission and Discharge Assessment.
(2) Level 1 (Individual).
(3) Level 1 (Group).
(4) Level 2 (Individual).
(5) Level 2 (Group).
(6) Case Management.
(7) Psychiatric Evaluation.
(8) Medication Assisted Recovery.
(9) Community Intervention.
(10) Early Intervention (Individual).
(11) Early Intervention (Group).
Beginning in State Fiscal Year 2023, and every State
fiscal year thereafter, reimbursement rates for those
community-based substance use disorder treatment and
intervention services shall be adjusted upward by an amount
equal to the Consumer Price Index-U from the previous year,
not to exceed 2% in any State fiscal year. If there is a
decrease in the Consumer Price Index-U, rates shall remain
unchanged for that State fiscal year. The Department shall

adopt rules, including emergency rules in accordance with the
Illinois Administrative Procedure Act, to implement the
provisions of this Section.
As used in this subsection, "consumer price index-u" means
the index published by the Bureau of Labor Statistics of the
United States Department of Labor that measures the average
change in prices of goods and services purchased by all urban
consumers, United States city average, all items, 1982-84 =
100.
(d) Beginning on January 1, 2024, subject to federal
approval, the Division of Substance Use Prevention and
Recovery shall increase reimbursement rates for all ASAM level
3 residential/inpatient substance use disorder treatment and
intervention services by 30%, including, but not limited to,
the following services:
(1) ASAM level 3.5 Clinically Managed High-Intensity
Residential Services for adults;
(2) ASAM level 3.5 Clinically Managed Medium-Intensity
Residential Services for adolescents;
(3) ASAM level 3.2 Clinically Managed Residential
Withdrawal Management;
(4) ASAM level 3.7 Medically Monitored Intensive
Inpatient Services for adults and Medically Monitored
High-Intensity Inpatient Services for adolescents; and
(5) ASAM level 3.1 Clinically Managed Low-Intensity
Residential Services for adults and adolescents.

(Source: P.A. 101-81, eff. 7-12-19; 102-699, eff. 4-19-22.)
Section 5-20. The Illinois Public Aid Code is amended by
adding Section 5-47 as follows:
(305 ILCS 5/5-47 new)
Sec. 5-47. Medicaid reimbursement rates; substance use
disorder treatment providers and facilities.
(a) Beginning on January 1, 2024, subject to federal
approval, the Department of Healthcare and Family Services, in
conjunction with the Department of Human Services' Division of
Substance Use Prevention and Recovery, shall provide a 30%
increase in reimbursement rates for all Medicaid-covered ASAM
Level 3 residential/inpatient substance use disorder treatment
services.
No existing or future reimbursement rates or add-ons shall
be reduced or changed to address this proposed rate increase.
No later than 3 months after the effective date of this
amendatory Act of the 103rd General Assembly, the Department
of Healthcare and Family Services shall submit any necessary
application to the federal Centers for Medicare and Medicaid
Services to implement the requirements of this Section.
(b) Parity in community-based behavioral health rates;
implementation plan for cost reporting. For the purpose of
understanding behavioral health services cost structures and
their impact on the Medical Assistance Program, the Department

of Healthcare and Family Services shall engage stakeholders to
develop a plan for the regular collection of cost reporting
for all entity-based substance use disorder providers. Data
shall be used to inform on the effectiveness and efficiency of
Illinois Medicaid rates. The Department and stakeholders shall
develop a plan by April 1, 2024. The Department shall engage
stakeholders on implementation of the plan. The plan, at
minimum, shall consider all of the following:
(1) Alignment with certified community behavioral
health clinic requirements, standards, policies, and
procedures.
(2) Inclusion of prospective costs to measure what is
needed to increase services and capacity.
(3) Consideration of differences in collection and
policies based on the size of providers.
(4) Consideration of additional administrative time
and costs.
(5) Goals, purposes, and usage of data collected from
cost reports.
(6) Inclusion of qualitative data in addition to
quantitative data.
(7) Technical assistance for providers for completing
cost reports including initial training by the Department
for providers.
(8) Implementation of a timeline which allows an
initial grace period for providers to adjust internal

procedures and data collection.
Details from collected cost reports shall be made publicly
available on the Department's website and costs shall be used
to ensure the effectiveness and efficiency of Illinois
Medicaid rates.
(c) Reporting; access to substance use disorder treatment
services and recovery supports. By no later than April 1,
2024, the Department of Healthcare and Family Services, with
input from the Department of Human Services' Division of
Substance Use Prevention and Recovery, shall submit a report
to the General Assembly regarding access to treatment services
and recovery supports for persons diagnosed with a substance
use disorder. The report shall include, but is not limited to,
the following information:
(1) The number of providers enrolled in the Illinois
Medical Assistance Program certified to provide substance
use disorder treatment services, aggregated by ASAM level
of care, and recovery supports.
(2) The number of Medicaid customers in Illinois with
a diagnosed substance use disorder receiving substance use
disorder treatment, aggregated by provider type and ASAM
level of care.
(3) A comparison of Illinois' substance use disorder
licensure and certification requirements with those of
comparable state Medicaid programs.
(4) Recommendations for and an analysis of the impact

of aligning reimbursement rates for outpatient substance
use disorder treatment services with reimbursement rates
for community-based mental health treatment services.
(5) Recommendations for expanding substance use
disorder treatment to other qualified provider entities
and licensed professionals of the healing arts. The
recommendations shall include an analysis of the
opportunities to maximize the flexibilities permitted by
the federal Centers for Medicare and Medicaid Services for
expanding access to the number and types of qualified
substance use disorder providers.
ARTICLE 10.
Section 10-1. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.36 as follows:
(5 ILCS 100/5-45.36 new)
Sec. 5-45.36. Emergency rulemaking; Medicaid reimbursement
rates for hospital inpatient and outpatient services. To
provide for the expeditious and timely implementation of the
changes made by this amendatory Act of the 103rd General
Assembly to Sections 5-5.05, 14-12, 14-12.5, and 14-12.7 of
the Illinois Public Aid Code, emergency rules implementing the
changes made by this amendatory Act of the 103rd General
Assembly to Sections 5-5.05, 14-12, 14-12.5, and 14-12.7 of

the Illinois Public Aid Code may be adopted in accordance with
Section 5-45 by the Department of Healthcare and Family
Services. The adoption of emergency rules authorized by
Section 5-45 and this Section is deemed to be necessary for the
public interest, safety, and welfare.
This Section is repealed one year after the effective date
of this amendatory Act of the 103rd General Assembly.
Section 10-5. The Illinois Public Aid Code is amended by
changing Sections 5-5.05, 5A-12.7, 12-4.105, and 14-12 and by
adding Sections 14-12.5 and 14-12.7 as follows:
(305 ILCS 5/5-5.05)
Sec. 5-5.05. Hospitals; psychiatric services.
(a) On and after January 1, 2024 July 1, 2008, the
inpatient, per diem rate to be paid to a hospital for inpatient
psychiatric services shall be not less than 90% of the per diem
rate established in accordance with paragraph (b-5) of this
section, subject to the provisions of Section 14-12.5 $363.77.
(b) For purposes of this Section, "hospital" means a the
following:
(1) Advocate Christ Hospital, Oak Lawn, Illinois.
(2) Barnes-Jewish Hospital, St. Louis, Missouri.
(3) BroMenn Healthcare, Bloomington, Illinois.
(4) Jackson Park Hospital, Chicago, Illinois.
(5) Katherine Shaw Bethea Hospital, Dixon, Illinois.

(6) Lawrence County Memorial Hospital, Lawrenceville,
Illinois.
(7) Advocate Lutheran General Hospital, Park Ridge,
Illinois.
(8) Mercy Hospital and Medical Center, Chicago,
Illinois.
(9) Methodist Medical Center of Illinois, Peoria,
Illinois.
(10) Provena United Samaritans Medical Center,
Danville, Illinois.
(11) Rockford Memorial Hospital, Rockford, Illinois.
(12) Sarah Bush Lincoln Health Center, Mattoon,
Illinois.
(13) Provena Covenant Medical Center, Urbana,
Illinois.
(14) Rush-Presbyterian-St. Luke's Medical Center,
Chicago, Illinois.
(15) Mt. Sinai Hospital, Chicago, Illinois.
(16) Gateway Regional Medical Center, Granite City,
Illinois.
(17) St. Mary of Nazareth Hospital, Chicago, Illinois.
(18) Provena St. Mary's Hospital, Kankakee, Illinois.
(19) St. Mary's Hospital, Decatur, Illinois.
(20) Memorial Hospital, Belleville, Illinois.
(21) Swedish Covenant Hospital, Chicago, Illinois.
(22) Trinity Medical Center, Rock Island, Illinois.

(23) St. Elizabeth Hospital, Chicago, Illinois.
(24) Richland Memorial Hospital, Olney, Illinois.
(25) St. Elizabeth's Hospital, Belleville, Illinois.
(26) Samaritan Health System, Clinton, Iowa.
(27) St. John's Hospital, Springfield, Illinois.
(28) St. Mary's Hospital, Centralia, Illinois.
(29) Loretto Hospital, Chicago, Illinois.
(30) Kenneth Hall Regional Hospital, East St. Louis,
Illinois.
(31) Hinsdale Hospital, Hinsdale, Illinois.
(32) Pekin Hospital, Pekin, Illinois.
(33) University of Chicago Medical Center, Chicago,
Illinois.
(34) St. Anthony's Health Center, Alton, Illinois.
(35) OSF St. Francis Medical Center, Peoria, Illinois.
(36) Memorial Medical Center, Springfield, Illinois.
(37) A hospital with a distinct part unit for
psychiatric services that begins operating on or after
July 1, 2008.
For purposes of this Section, "inpatient psychiatric
services" means those services provided to patients who are in
need of short-term acute inpatient hospitalization for active
treatment of an emotional or mental disorder.
(b-5) Notwithstanding any other provision of this Section,
and subject to appropriation, the inpatient, per diem rate to
be paid to all safety-net hospitals for inpatient psychiatric

services on and after January 1, 2021 shall be at least $630,
subject to the provisions of Section 14-12.5.
(b-10) Notwithstanding any other provision of this
Section, effective with dates of service on and after January
1, 2022, any general acute care hospital with more than 9,500
inpatient psychiatric Medicaid days in any calendar year shall
be paid the inpatient per diem rate of no less than $630,
subject to the provisions of Section 14-12.5.
(c) No rules shall be promulgated to implement this
Section. For purposes of this Section, "rules" is given the
meaning contained in Section 1-70 of the Illinois
Administrative Procedure Act.
(d) (Blank). This Section shall not be in effect during
any period of time that the State has in place a fully
operational hospital assessment plan that has been approved by
the Centers for Medicare and Medicaid Services of the U.S.
Department of Health and Human Services.
(e) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 102-4, eff. 4-27-21; 102-674, eff. 11-30-21.)
(305 ILCS 5/5A-12.7)
(Section scheduled to be repealed on December 31, 2026)

Sec. 5A-12.7. Continuation of hospital access payments on
and after July 1, 2020.
(a) To preserve and improve access to hospital services,
for hospital services rendered on and after July 1, 2020, the
Department shall, except for hospitals described in subsection
(b) of Section 5A-3, make payments to hospitals or require
capitated managed care organizations to make payments as set
forth in this Section. Payments under this Section are not due
and payable, however, until: (i) the methodologies described
in this Section are approved by the federal government in an
appropriate State Plan amendment or directed payment preprint;
and (ii) the assessment imposed under this Article is
determined to be a permissible tax under Title XIX of the
Social Security Act. In determining the hospital access
payments authorized under subsection (g) of this Section, if a
hospital ceases to qualify for payments from the pool, the
payments for all hospitals continuing to qualify for payments
from such pool shall be uniformly adjusted to fully expend the
aggregate net amount of the pool, with such adjustment being
effective on the first day of the second month following the
date the hospital ceases to receive payments from such pool.
(b) Amounts moved into claims-based rates and distributed
in accordance with Section 14-12 shall remain in those
claims-based rates.
(c) Graduate medical education.
(1) The calculation of graduate medical education

payments shall be based on the hospital's Medicare cost
report ending in Calendar Year 2018, as reported in the
Healthcare Cost Report Information System file, release
date September 30, 2019. An Illinois hospital reporting
intern and resident cost on its Medicare cost report shall
be eligible for graduate medical education payments.
(2) Each hospital's annualized Medicaid Intern
Resident Cost is calculated using annualized intern and
resident total costs obtained from Worksheet B Part I,
Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
96-98, and 105-112 multiplied by the percentage that the
hospital's Medicaid days (Worksheet S3 Part I, Column 7,
Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
hospital's total days (Worksheet S3 Part I, Column 8,
Lines 14, 16-18, and 32).
(3) An annualized Medicaid indirect medical education
(IME) payment is calculated for each hospital using its
IME payments (Worksheet E Part A, Line 29, Column 1)
multiplied by the percentage that its Medicaid days
(Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
and 32) comprise of its Medicare days (Worksheet S3 Part
I, Column 6, Lines 2, 3, 4, 14, and 16-18).
(4) For each hospital, its annualized Medicaid Intern
Resident Cost and its annualized Medicaid IME payment are
summed, and, except as capped at 120% of the average cost
per intern and resident for all qualifying hospitals as

calculated under this paragraph, is multiplied by the
applicable reimbursement factor as described in this
paragraph, to determine the hospital's final graduate
medical education payment. Each hospital's average cost
per intern and resident shall be calculated by summing its
total annualized Medicaid Intern Resident Cost plus its
annualized Medicaid IME payment and dividing that amount
by the hospital's total Full Time Equivalent Residents and
Interns. If the hospital's average per intern and resident
cost is greater than 120% of the same calculation for all
qualifying hospitals, the hospital's per intern and
resident cost shall be capped at 120% of the average cost
for all qualifying hospitals.
(A) For the period of July 1, 2020 through
December 31, 2022, the applicable reimbursement factor
shall be 22.6%.
(B) For the period of January 1, 2023 through
December 31, 2026, the applicable reimbursement factor
shall be 35% for all qualified safety-net hospitals,
as defined in Section 5-5e.1 of this Code, and all
hospitals with 100 or more Full Time Equivalent
Residents and Interns, as reported on the hospital's
Medicare cost report ending in Calendar Year 2018, and
for all other qualified hospitals the applicable
reimbursement factor shall be 30%.
(d) Fee-for-service supplemental payments. For the period

of July 1, 2020 through December 31, 2022, each Illinois
hospital shall receive an annual payment equal to the amounts
below, to be paid in 12 equal installments on or before the
seventh State business day of each month, except that no
payment shall be due within 30 days after the later of the date
of notification of federal approval of the payment
methodologies required under this Section or any waiver
required under 42 CFR 433.68, at which time the sum of amounts
required under this Section prior to the date of notification
is due and payable.
(1) For critical access hospitals, $385 per covered
inpatient day contained in paid fee-for-service claims and
$530 per paid fee-for-service outpatient claim for dates
of service in Calendar Year 2019 in the Department's
Enterprise Data Warehouse as of May 11, 2020.
(2) For safety-net hospitals, $960 per covered
inpatient day contained in paid fee-for-service claims and
$625 per paid fee-for-service outpatient claim for dates
of service in Calendar Year 2019 in the Department's
Enterprise Data Warehouse as of May 11, 2020.
(3) For long term acute care hospitals, $295 per
covered inpatient day contained in paid fee-for-service
claims for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of May 11, 2020.
(4) For freestanding psychiatric hospitals, $125 per
covered inpatient day contained in paid fee-for-service

claims and $130 per paid fee-for-service outpatient claim
for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of May 11, 2020.
(5) For freestanding rehabilitation hospitals, $355
per covered inpatient day contained in paid
fee-for-service claims for dates of service in Calendar
Year 2019 in the Department's Enterprise Data Warehouse as
of May 11, 2020.
(6) For all general acute care hospitals and high
Medicaid hospitals as defined in subsection (f), $350 per
covered inpatient day for dates of service in Calendar
Year 2019 contained in paid fee-for-service claims and
$620 per paid fee-for-service outpatient claim in the
Department's Enterprise Data Warehouse as of May 11, 2020.
(7) Alzheimer's treatment access payment. Each
Illinois academic medical center or teaching hospital, as
defined in Section 5-5e.2 of this Code, that is identified
as the primary hospital affiliate of one of the Regional
Alzheimer's Disease Assistance Centers, as designated by
the Alzheimer's Disease Assistance Act and identified in
the Department of Public Health's Alzheimer's Disease
State Plan dated December 2016, shall be paid an
Alzheimer's treatment access payment equal to the product
of the qualifying hospital's State Fiscal Year 2018 total
inpatient fee-for-service days multiplied by the
applicable Alzheimer's treatment rate of $226.30 for

hospitals located in Cook County and $116.21 for hospitals
located outside Cook County.
(d-2) Fee-for-service supplemental payments. Beginning
January 1, 2023, each Illinois hospital shall receive an
annual payment equal to the amounts listed below, to be paid in
12 equal installments on or before the seventh State business
day of each month, except that no payment shall be due within
30 days after the later of the date of notification of federal
approval of the payment methodologies required under this
Section or any waiver required under 42 CFR 433.68, at which
time the sum of amounts required under this Section prior to
the date of notification is due and payable. The Department
may adjust the rates in paragraphs (1) through (7) to comply
with the federal upper payment limits, with such adjustments
being determined so that the total estimated spending by
hospital class, under such adjusted rates, remains
substantially similar to the total estimated spending under
the original rates set forth in this subsection.
(1) For critical access hospitals, as defined in
subsection (f), $750 per covered inpatient day contained
in paid fee-for-service claims and $750 per paid
fee-for-service outpatient claim for dates of service in
Calendar Year 2019 in the Department's Enterprise Data
Warehouse as of August 6, 2021.
(2) For safety-net hospitals, as described in
subsection (f), $1,350 per inpatient day contained in paid

fee-for-service claims and $1,350 per paid fee-for-service
outpatient claim for dates of service in Calendar Year
2019 in the Department's Enterprise Data Warehouse as of
August 6, 2021.
(3) For long term acute care hospitals, $550 per
covered inpatient day contained in paid fee-for-service
claims for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of August 6,
2021.
(4) For freestanding psychiatric hospitals, $200 per
covered inpatient day contained in paid fee-for-service
claims and $200 per paid fee-for-service outpatient claim
for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of August 6,
2021.
(5) For freestanding rehabilitation hospitals, $550
per covered inpatient day contained in paid
fee-for-service claims and $125 per paid fee-for-service
outpatient claim for dates of service in Calendar Year
2019 in the Department's Enterprise Data Warehouse as of
August 6, 2021.
(6) For all general acute care hospitals and high
Medicaid hospitals as defined in subsection (f), $500 per
covered inpatient day for dates of service in Calendar
Year 2019 contained in paid fee-for-service claims and
$500 per paid fee-for-service outpatient claim in the

Department's Enterprise Data Warehouse as of August 6,
2021.
(7) For public hospitals, as defined in subsection
(f), $275 per covered inpatient day contained in paid
fee-for-service claims and $275 per paid fee-for-service
outpatient claim for dates of service in Calendar Year
2019 in the Department's Enterprise Data Warehouse as of
August 6, 2021.
(8) Alzheimer's treatment access payment. Each
Illinois academic medical center or teaching hospital, as
defined in Section 5-5e.2 of this Code, that is identified
as the primary hospital affiliate of one of the Regional
Alzheimer's Disease Assistance Centers, as designated by
the Alzheimer's Disease Assistance Act and identified in
the Department of Public Health's Alzheimer's Disease
State Plan dated December 2016, shall be paid an
Alzheimer's treatment access payment equal to the product
of the qualifying hospital's Calendar Year 2019 total
inpatient fee-for-service days, in the Department's
Enterprise Data Warehouse as of August 6, 2021, multiplied
by the applicable Alzheimer's treatment rate of $244.37
for hospitals located in Cook County and $312.03 for
hospitals located outside Cook County.
(e) The Department shall require managed care
organizations (MCOs) to make directed payments and
pass-through payments according to this Section. Each calendar

year, the Department shall require MCOs to pay the maximum
amount out of these funds as allowed as pass-through payments
under federal regulations. The Department shall require MCOs
to make such pass-through payments as specified in this
Section. The Department shall require the MCOs to pay the
remaining amounts as directed Payments as specified in this
Section. The Department shall issue payments to the
Comptroller by the seventh business day of each month for all
MCOs that are sufficient for MCOs to make the directed
payments and pass-through payments according to this Section.
The Department shall require the MCOs to make pass-through
payments and directed payments using electronic funds
transfers (EFT), if the hospital provides the information
necessary to process such EFTs, in accordance with directions
provided monthly by the Department, within 7 business days of
the date the funds are paid to the MCOs, as indicated by the
"Paid Date" on the website of the Office of the Comptroller if
the funds are paid by EFT and the MCOs have received directed
payment instructions. If funds are not paid through the
Comptroller by EFT, payment must be made within 7 business
days of the date actually received by the MCO. The MCO will be
considered to have paid the pass-through payments when the
payment remittance number is generated or the date the MCO
sends the check to the hospital, if EFT information is not
supplied. If an MCO is late in paying a pass-through payment or
directed payment as required under this Section (including any

extensions granted by the Department), it shall pay a penalty,
unless waived by the Department for reasonable cause, to the
Department equal to 5% of the amount of the pass-through
payment or directed payment not paid on or before the due date
plus 5% of the portion thereof remaining unpaid on the last day
of each 30-day period thereafter. Payments to MCOs that would
be paid consistent with actuarial certification and enrollment
in the absence of the increased capitation payments under this
Section shall not be reduced as a consequence of payments made
under this subsection. The Department shall publish and
maintain on its website for a period of no less than 8 calendar
quarters, the quarterly calculation of directed payments and
pass-through payments owed to each hospital from each MCO. All
calculations and reports shall be posted no later than the
first day of the quarter for which the payments are to be
issued.
(f)(1) For purposes of allocating the funds included in
capitation payments to MCOs, Illinois hospitals shall be
divided into the following classes as defined in
administrative rules:
(A) Beginning July 1, 2020 through December 31, 2022,
critical access hospitals. Beginning January 1, 2023,
"critical access hospital" means a hospital designated by
the Department of Public Health as a critical access
hospital, excluding any hospital meeting the definition of
a public hospital in subparagraph (F).

(B) Safety-net hospitals, except that stand-alone
children's hospitals that are not specialty children's
hospitals will not be included. For the calendar year
beginning January 1, 2023, and each calendar year
thereafter, assignment to the safety-net class shall be
based on the annual safety-net rate year beginning 15
months before the beginning of the first Payout Quarter of
the calendar year.
(C) Long term acute care hospitals.
(D) Freestanding psychiatric hospitals.
(E) Freestanding rehabilitation hospitals.
(F) Beginning January 1, 2023, "public hospital" means
a hospital that is owned or operated by an Illinois
Government body or municipality, excluding a hospital
provider that is a State agency, a State university, or a
county with a population of 3,000,000 or more.
(G) High Medicaid hospitals.
(i) As used in this Section, "high Medicaid
hospital" means a general acute care hospital that:
(I) For the payout periods July 1, 2020
through December 31, 2022, is not a safety-net
hospital or critical access hospital and that has
a Medicaid Inpatient Utilization Rate above 30% or
a hospital that had over 35,000 inpatient Medicaid
days during the applicable period. For the period
July 1, 2020 through December 31, 2020, the

applicable period for the Medicaid Inpatient
Utilization Rate (MIUR) is the rate year 2020 MIUR
and for the number of inpatient days it is State
fiscal year 2018. Beginning in calendar year 2021,
the Department shall use the most recently
determined MIUR, as defined in subsection (h) of
Section 5-5.02, and for the inpatient day
threshold, the State fiscal year ending 18 months
prior to the beginning of the calendar year. For
purposes of calculating MIUR under this Section,
children's hospitals and affiliated general acute
care hospitals shall be considered a single
hospital.
(II) For the calendar year beginning January
1, 2023, and each calendar year thereafter, is not
a public hospital, safety-net hospital, or
critical access hospital and that qualifies as a
regional high volume hospital or is a hospital
that has a Medicaid Inpatient Utilization Rate
(MIUR) above 30%. As used in this item, "regional
high volume hospital" means a hospital which ranks
in the top 2 quartiles based on total hospital
services volume, of all eligible general acute
care hospitals, when ranked in descending order
based on total hospital services volume, within
the same Medicaid managed care region, as

designated by the Department, as of January 1,
2022. As used in this item, "total hospital
services volume" means the total of all Medical
Assistance hospital inpatient admissions plus all
Medical Assistance hospital outpatient visits. For
purposes of determining regional high volume
hospital inpatient admissions and outpatient
visits, the Department shall use dates of service
provided during State Fiscal Year 2020 for the
Payout Quarter beginning January 1, 2023. The
Department shall use dates of service from the
State fiscal year ending 18 month before the
beginning of the first Payout Quarter of the
subsequent annual determination period.
(ii) For the calendar year beginning January 1,
2023, the Department shall use the Rate Year 2022
Medicaid inpatient utilization rate (MIUR), as defined
in subsection (h) of Section 5-5.02. For each
subsequent annual determination, the Department shall
use the MIUR applicable to the rate year ending
September 30 of the year preceding the beginning of
the calendar year.
(H) General acute care hospitals. As used under this
Section, "general acute care hospitals" means all other
Illinois hospitals not identified in subparagraphs (A)
through (G).

(2) Hospitals' qualification for each class shall be
assessed prior to the beginning of each calendar year and the
new class designation shall be effective January 1 of the next
year. The Department shall publish by rule the process for
establishing class determination.
(3) Beginning January 1, 2024, the Department may reassign
hospitals or entire hospital classes as defined above, if
federal limits on the payments to the class to which the
hospitals are assigned based on the criteria in this
subsection prevent the Department from making payments to the
class that would otherwise be due under this Section. The
Department shall publish the criteria and composition of each
new class based on the reassignments, and the projected impact
on payments to each hospital under the new classes on its
website by November 15 of the year before the year in which the
class changes become effective.
(g) Fixed pool directed payments. Beginning July 1, 2020,
the Department shall issue payments to MCOs which shall be
used to issue directed payments to qualified Illinois
safety-net hospitals and critical access hospitals on a
monthly basis in accordance with this subsection. Prior to the
beginning of each Payout Quarter beginning July 1, 2020, the
Department shall use encounter claims data from the
Determination Quarter, accepted by the Department's Medicaid
Management Information System for inpatient and outpatient
services rendered by safety-net hospitals and critical access

hospitals to determine a quarterly uniform per unit add-on for
each hospital class.
(1) Inpatient per unit add-on. A quarterly uniform per
diem add-on shall be derived by dividing the quarterly
Inpatient Directed Payments Pool amount allocated to the
applicable hospital class by the total inpatient days
contained on all encounter claims received during the
Determination Quarter, for all hospitals in the class.
(A) Each hospital in the class shall have a
quarterly inpatient directed payment calculated that
is equal to the product of the number of inpatient days
attributable to the hospital used in the calculation
of the quarterly uniform class per diem add-on,
multiplied by the calculated applicable quarterly
uniform class per diem add-on of the hospital class.
(B) Each hospital shall be paid 1/3 of its
quarterly inpatient directed payment in each of the 3
months of the Payout Quarter, in accordance with
directions provided to each MCO by the Department.
(2) Outpatient per unit add-on. A quarterly uniform
per claim add-on shall be derived by dividing the
quarterly Outpatient Directed Payments Pool amount
allocated to the applicable hospital class by the total
outpatient encounter claims received during the
Determination Quarter, for all hospitals in the class.
(A) Each hospital in the class shall have a

quarterly outpatient directed payment calculated that
is equal to the product of the number of outpatient
encounter claims attributable to the hospital used in
the calculation of the quarterly uniform class per
claim add-on, multiplied by the calculated applicable
quarterly uniform class per claim add-on of the
hospital class.
(B) Each hospital shall be paid 1/3 of its
quarterly outpatient directed payment in each of the 3
months of the Payout Quarter, in accordance with
directions provided to each MCO by the Department.
(3) Each MCO shall pay each hospital the Monthly
Directed Payment as identified by the Department on its
quarterly determination report.
(4) Definitions. As used in this subsection:
(A) "Payout Quarter" means each 3 month calendar
quarter, beginning July 1, 2020.
(B) "Determination Quarter" means each 3 month
calendar quarter, which ends 3 months prior to the
first day of each Payout Quarter.
(5) For the period July 1, 2020 through December 2020,
the following amounts shall be allocated to the following
hospital class directed payment pools for the quarterly
development of a uniform per unit add-on:
(A) $2,894,500 for hospital inpatient services for
critical access hospitals.

(B) $4,294,374 for hospital outpatient services
for critical access hospitals.
(C) $29,109,330 for hospital inpatient services
for safety-net hospitals.
(D) $35,041,218 for hospital outpatient services
for safety-net hospitals.
(6) For the period January 1, 2023 through December
31, 2023, the Department shall establish the amounts that
shall be allocated to the hospital class directed payment
fixed pools identified in this paragraph for the quarterly
development of a uniform per unit add-on. The Department
shall establish such amounts so that the total amount of
payments to each hospital under this Section in calendar
year 2023 is projected to be substantially similar to the
total amount of such payments received by the hospital
under this Section in calendar year 2021, adjusted for
increased funding provided for fixed pool directed
payments under subsection (g) in calendar year 2022,
assuming that the volume and acuity of claims are held
constant. The Department shall publish the directed
payment fixed pool amounts to be established under this
paragraph on its website by November 15, 2022.
(A) Hospital inpatient services for critical
access hospitals.
(B) Hospital outpatient services for critical
access hospitals.

(C) Hospital inpatient services for public
hospitals.
(D) Hospital outpatient services for public
hospitals.
(E) Hospital inpatient services for safety-net
hospitals.
(F) Hospital outpatient services for safety-net
hospitals.
(7) Semi-annual rate maintenance review. The
Department shall ensure that hospitals assigned to the
fixed pools in paragraph (6) are paid no less than 95% of
the annual initial rate for each 6-month period of each
annual payout period. For each calendar year, the
Department shall calculate the annual initial rate per day
and per visit for each fixed pool hospital class listed in
paragraph (6), by dividing the total of all applicable
inpatient or outpatient directed payments issued in the
preceding calendar year to the hospitals in each fixed
pool class for the calendar year, plus any increase
resulting from the annual adjustments described in
subsection (i), by the actual applicable total service
units for the preceding calendar year which were the basis
of the total applicable inpatient or outpatient directed
payments issued to the hospitals in each fixed pool class
in the calendar year, except that for calendar year 2023,
the service units from calendar year 2021 shall be used.

(A) The Department shall calculate the effective
rate, per day and per visit, for the payout periods of
January to June and July to December of each year, for
each fixed pool listed in paragraph (6), by dividing
50% of the annual pool by the total applicable
reported service units for the 2 applicable
determination quarters.
(B) If the effective rate calculated in
subparagraph (A) is less than 95% of the annual
initial rate assigned to the class for each pool under
paragraph (6), the Department shall adjust the payment
for each hospital to a level equal to no less than 95%
of the annual initial rate, by issuing a retroactive
adjustment payment for the 6-month period under review
as identified in subparagraph (A).
(h) Fixed rate directed payments. Effective July 1, 2020,
the Department shall issue payments to MCOs which shall be
used to issue directed payments to Illinois hospitals not
identified in paragraph (g) on a monthly basis. Prior to the
beginning of each Payout Quarter beginning July 1, 2020, the
Department shall use encounter claims data from the
Determination Quarter, accepted by the Department's Medicaid
Management Information System for inpatient and outpatient
services rendered by hospitals in each hospital class
identified in paragraph (f) and not identified in paragraph
(g). For the period July 1, 2020 through December 2020, the

Department shall direct MCOs to make payments as follows:
(1) For general acute care hospitals an amount equal
to $1,750 multiplied by the hospital's category of service
20 case mix index for the determination quarter multiplied
by the hospital's total number of inpatient admissions for
category of service 20 for the determination quarter.
(2) For general acute care hospitals an amount equal
to $160 multiplied by the hospital's category of service
21 case mix index for the determination quarter multiplied
by the hospital's total number of inpatient admissions for
category of service 21 for the determination quarter.
(3) For general acute care hospitals an amount equal
to $80 multiplied by the hospital's category of service 22
case mix index for the determination quarter multiplied by
the hospital's total number of inpatient admissions for
category of service 22 for the determination quarter.
(4) For general acute care hospitals an amount equal
to $375 multiplied by the hospital's category of service
24 case mix index for the determination quarter multiplied
by the hospital's total number of category of service 24
paid EAPG (EAPGs) for the determination quarter.
(5) For general acute care hospitals an amount equal
to $240 multiplied by the hospital's category of service
27 and 28 case mix index for the determination quarter
multiplied by the hospital's total number of category of
service 27 and 28 paid EAPGs for the determination

quarter.
(6) For general acute care hospitals an amount equal
to $290 multiplied by the hospital's category of service
29 case mix index for the determination quarter multiplied
by the hospital's total number of category of service 29
paid EAPGs for the determination quarter.
(7) For high Medicaid hospitals an amount equal to
$1,800 multiplied by the hospital's category of service 20
case mix index for the determination quarter multiplied by
the hospital's total number of inpatient admissions for
category of service 20 for the determination quarter.
(8) For high Medicaid hospitals an amount equal to
$160 multiplied by the hospital's category of service 21
case mix index for the determination quarter multiplied by
the hospital's total number of inpatient admissions for
category of service 21 for the determination quarter.
(9) For high Medicaid hospitals an amount equal to $80
multiplied by the hospital's category of service 22 case
mix index for the determination quarter multiplied by the
hospital's total number of inpatient admissions for
category of service 22 for the determination quarter.
(10) For high Medicaid hospitals an amount equal to
$400 multiplied by the hospital's category of service 24
case mix index for the determination quarter multiplied by
the hospital's total number of category of service 24 paid
EAPG outpatient claims for the determination quarter.

(11) For high Medicaid hospitals an amount equal to
$240 multiplied by the hospital's category of service 27
and 28 case mix index for the determination quarter
multiplied by the hospital's total number of category of
service 27 and 28 paid EAPGs for the determination
quarter.
(12) For high Medicaid hospitals an amount equal to
$290 multiplied by the hospital's category of service 29
case mix index for the determination quarter multiplied by
the hospital's total number of category of service 29 paid
EAPGs for the determination quarter.
(13) For long term acute care hospitals the amount of
$495 multiplied by the hospital's total number of
inpatient days for the determination quarter.
(14) For psychiatric hospitals the amount of $210
multiplied by the hospital's total number of inpatient
days for category of service 21 for the determination
quarter.
(15) For psychiatric hospitals the amount of $250
multiplied by the hospital's total number of outpatient
claims for category of service 27 and 28 for the
determination quarter.
(16) For rehabilitation hospitals the amount of $410
multiplied by the hospital's total number of inpatient
days for category of service 22 for the determination
quarter.

(17) For rehabilitation hospitals the amount of $100
multiplied by the hospital's total number of outpatient
claims for category of service 29 for the determination
quarter.
(18) Effective for the Payout Quarter beginning
January 1, 2023, for the directed payments to hospitals
required under this subsection, the Department shall
establish the amounts that shall be used to calculate such
directed payments using the methodologies specified in
this paragraph. The Department shall use a single, uniform
rate, adjusted for acuity as specified in paragraphs (1)
through (12), for all categories of inpatient services
provided by each class of hospitals and a single uniform
rate, adjusted for acuity as specified in paragraphs (1)
through (12), for all categories of outpatient services
provided by each class of hospitals. The Department shall
establish such amounts so that the total amount of
payments to each hospital under this Section in calendar
year 2023 is projected to be substantially similar to the
total amount of such payments received by the hospital
under this Section in calendar year 2021, adjusted for
increased funding provided for fixed pool directed
payments under subsection (g) in calendar year 2022,
assuming that the volume and acuity of claims are held
constant. The Department shall publish the directed
payment amounts to be established under this subsection on

its website by November 15, 2022.
(19) Each hospital shall be paid 1/3 of their
quarterly inpatient and outpatient directed payment in
each of the 3 months of the Payout Quarter, in accordance
with directions provided to each MCO by the Department.
20 Each MCO shall pay each hospital the Monthly
Directed Payment amount as identified by the Department on
its quarterly determination report.
Notwithstanding any other provision of this subsection, if
the Department determines that the actual total hospital
utilization data that is used to calculate the fixed rate
directed payments is substantially different than anticipated
when the rates in this subsection were initially determined
for unforeseeable circumstances (such as the COVID-19 pandemic
or some other public health emergency), the Department may
adjust the rates specified in this subsection so that the
total directed payments approximate the total spending amount
anticipated when the rates were initially established.
Definitions. As used in this subsection:
(A) "Payout Quarter" means each calendar quarter,
beginning July 1, 2020.
(B) "Determination Quarter" means each calendar
quarter which ends 3 months prior to the first day of
each Payout Quarter.
(C) "Case mix index" means a hospital specific
calculation. For inpatient claims the case mix index

is calculated each quarter by summing the relative
weight of all inpatient Diagnosis-Related Group (DRG)
claims for a category of service in the applicable
Determination Quarter and dividing the sum by the
number of sum total of all inpatient DRG admissions
for the category of service for the associated claims.
The case mix index for outpatient claims is calculated
each quarter by summing the relative weight of all
paid EAPGs in the applicable Determination Quarter and
dividing the sum by the sum total of paid EAPGs for the
associated claims.
(i) Beginning January 1, 2021, the rates for directed
payments shall be recalculated in order to spend the
additional funds for directed payments that result from
reduction in the amount of pass-through payments allowed under
federal regulations. The additional funds for directed
payments shall be allocated proportionally to each class of
hospitals based on that class' proportion of services.
(1) Beginning January 1, 2024, the fixed pool directed
payment amounts and the associated annual initial rates
referenced in paragraph (6) of subsection (f) for each
hospital class shall be uniformly increased by a ratio of
not less than, the ratio of the total pass-through
reduction amount pursuant to paragraph (4) of subsection
(j), for the hospitals comprising the hospital fixed pool
directed payment class for the next calendar year, to the

total inpatient and outpatient directed payments for the
hospitals comprising the hospital fixed pool directed
payment class paid during the preceding calendar year.
(2) Beginning January 1, 2024, the fixed rates for the
directed payments referenced in paragraph (18) of
subsection (h) for each hospital class shall be uniformly
increased by a ratio of not less than, the ratio of the
total pass-through reduction amount pursuant to paragraph
(4) of subsection (j), for the hospitals comprising the
hospital directed payment class for the next calendar
year, to the total inpatient and outpatient directed
payments for the hospitals comprising the hospital fixed
rate directed payment class paid during the preceding
calendar year.
(j) Pass-through payments.
(1) For the period July 1, 2020 through December 31,
2020, the Department shall assign quarterly pass-through
payments to each class of hospitals equal to one-fourth of
the following annual allocations:
(A) $390,487,095 to safety-net hospitals.
(B) $62,553,886 to critical access hospitals.
(C) $345,021,438 to high Medicaid hospitals.
(D) $551,429,071 to general acute care hospitals.
(E) $27,283,870 to long term acute care hospitals.
(F) $40,825,444 to freestanding psychiatric
hospitals.

(G) $9,652,108 to freestanding rehabilitation
hospitals.
(2) For the period of July 1, 2020 through December
31, 2020, the pass-through payments shall at a minimum
ensure hospitals receive a total amount of monthly
payments under this Section as received in calendar year
2019 in accordance with this Article and paragraph (1) of
subsection (d-5) of Section 14-12, exclusive of amounts
received through payments referenced in subsection (b).
(3) For the calendar year beginning January 1, 2023,
the Department shall establish the annual pass-through
allocation to each class of hospitals and the pass-through
payments to each hospital so that the total amount of
payments to each hospital under this Section in calendar
year 2023 is projected to be substantially similar to the
total amount of such payments received by the hospital
under this Section in calendar year 2021, adjusted for
increased funding provided for fixed pool directed
payments under subsection (g) in calendar year 2022,
assuming that the volume and acuity of claims are held
constant. The Department shall publish the pass-through
allocation to each class and the pass-through payments to
each hospital to be established under this subsection on
its website by November 15, 2022.
(4) For the calendar years beginning January 1, 2021
and , January 1, 2022, and January 1, 2024, and each

calendar year thereafter, each hospital's pass-through
payment amount shall be reduced proportionally to the
reduction of all pass-through payments required by federal
regulations. Beginning January 1, 2024, the Department
shall reduce total pass-through payments by the minimum
amount necessary to comply with federal regulations.
Pass-through payments to safety-net hospitals as defined
in Section 5-5e.1 of this Code, shall not be reduced until
all pass-through payments to other hospitals have been
eliminated. All other hospitals shall have their
pass-through payments reduced proportionally.
(k) At least 30 days prior to each calendar year, the
Department shall notify each hospital of changes to the
payment methodologies in this Section, including, but not
limited to, changes in the fixed rate directed payment rates,
the aggregate pass-through payment amount for all hospitals,
and the hospital's pass-through payment amount for the
upcoming calendar year.
(l) Notwithstanding any other provisions of this Section,
the Department may adopt rules to change the methodology for
directed and pass-through payments as set forth in this
Section, but only to the extent necessary to obtain federal
approval of a necessary State Plan amendment or Directed
Payment Preprint or to otherwise conform to federal law or
federal regulation.
(m) As used in this subsection, "managed care

organization" or "MCO" means an entity which contracts with
the Department to provide services where payment for medical
services is made on a capitated basis, excluding contracted
entities for dual eligible or Department of Children and
Family Services youth populations.
(n) In order to address the escalating infant mortality
rates among minority communities in Illinois, the State shall,
subject to appropriation, create a pool of funding of at least
$50,000,000 annually to be disbursed among safety-net
hospitals that maintain perinatal designation from the
Department of Public Health. The funding shall be used to
preserve or enhance OB/GYN services or other specialty
services at the receiving hospital, with the distribution of
funding to be established by rule and with consideration to
perinatal hospitals with safe birthing levels and quality
metrics for healthy mothers and babies.
(o) In order to address the growing challenges of
providing stable access to healthcare in rural Illinois,
including perinatal services, behavioral healthcare including
substance use disorder services (SUDs) and other specialty
services, and to expand access to telehealth services among
rural communities in Illinois, the Department of Healthcare
and Family Services, subject to appropriation, shall
administer a program to provide at least $10,000,000 in
financial support annually to critical access hospitals for
delivery of perinatal and OB/GYN services, behavioral

healthcare including SUDS, other specialty services and
telehealth services. The funding shall be used to preserve or
enhance perinatal and OB/GYN services, behavioral healthcare
including SUDS, other specialty services, as well as the
explanation of telehealth services by the receiving hospital,
with the distribution of funding to be established by rule.
(p) For calendar year 2023, the final amounts, rates, and
payments under subsections (c), (d-2), (g), (h), and (j) shall
be established by the Department, so that the sum of the total
estimated annual payments under subsections (c), (d-2), (g),
(h), and (j) for each hospital class for calendar year 2023, is
no less than:
(1) $858,260,000 to safety-net hospitals.
(2) $86,200,000 to critical access hospitals.
(3) $1,765,000,000 to high Medicaid hospitals.
(4) $673,860,000 to general acute care hospitals.
(5) $48,330,000 to long term acute care hospitals.
(6) $89,110,000 to freestanding psychiatric hospitals.
(7) $24,300,000 to freestanding rehabilitation
hospitals.
(8) $32,570,000 to public hospitals.
(q) Hospital Pandemic Recovery Stabilization Payments. The
Department shall disburse a pool of $460,000,000 in stability
payments to hospitals prior to April 1, 2023. The allocation
of the pool shall be based on the hospital directed payment
classes and directed payments issued, during Calendar Year

2022 with added consideration to safety net hospitals, as
defined in subdivision (f)(1)(B) of this Section, and critical
access hospitals.
(Source: P.A. 101-650, eff. 7-7-20; 102-4, eff. 4-27-21;
102-16, eff. 6-17-21; 102-886, eff. 5-17-22; 102-1115, eff.
1-9-23.)
(305 ILCS 5/12-4.105)
Sec. 12-4.105. Human poison control center; payment
program. Subject to funding availability resulting from
transfers made from the Hospital Provider Fund to the
Healthcare Provider Relief Fund as authorized under this Code,
for State fiscal year 2017 and State fiscal year 2018, and for
each State fiscal year thereafter in which the assessment
under Section 5A-2 is imposed, the Department of Healthcare
and Family Services shall pay to the human poison control
center designated under the Poison Control System Act an
amount of not less than $3,000,000 for each of State fiscal
years 2017 through 2020, and for State fiscal years 2021
through 2023 2026 an amount of not less than $3,750,000 and for
State fiscal years 2024 through 2026 an amount of not less than
$4,000,000 and for the period July 1, 2026 through December
31, 2026 an amount of not less than $2,000,000 $1,875,000, if
the human poison control center is in operation.
(Source: P.A. 101-650, eff. 7-7-20; 102-886, eff. 5-17-22.)

(305 ILCS 5/14-12)
Sec. 14-12. Hospital rate reform payment system. The
hospital payment system pursuant to Section 14-11 of this
Article shall be as follows:
(a) Inpatient hospital services. Effective for discharges
on and after July 1, 2014, reimbursement for inpatient general
acute care services shall utilize the All Patient Refined
Diagnosis Related Grouping (APR-DRG) software, version 30,
distributed by 3MTM Health Information System.
(1) The Department shall establish Medicaid weighting
factors to be used in the reimbursement system established
under this subsection. Initial weighting factors shall be
the weighting factors as published by 3M Health
Information System, associated with Version 30.0 adjusted
for the Illinois experience.
(2) The Department shall establish a
statewide-standardized amount to be used in the inpatient
reimbursement system. The Department shall publish these
amounts on its website no later than 10 calendar days
prior to their effective date.
(3) In addition to the statewide-standardized amount,
the Department shall develop adjusters to adjust the rate
of reimbursement for critical Medicaid providers or
services for trauma, transplantation services, perinatal
care, and Graduate Medical Education (GME).
(4) The Department shall develop add-on payments to

account for exceptionally costly inpatient stays,
consistent with Medicare outlier principles. Outlier fixed
loss thresholds may be updated to control for excessive
growth in outlier payments no more frequently than on an
annual basis, but at least once every 4 years. Upon
updating the fixed loss thresholds, the Department shall
be required to update base rates within 12 months.
(5) The Department shall define those hospitals or
distinct parts of hospitals that shall be exempt from the
APR-DRG reimbursement system established under this
Section. The Department shall publish these hospitals'
inpatient rates on its website no later than 10 calendar
days prior to their effective date.
(6) Beginning July 1, 2014 and ending on December 31,
2023 June 30, 2024, in addition to the
statewide-standardized amount, the Department shall
develop an adjustor to adjust the rate of reimbursement
for safety-net hospitals defined in Section 5-5e.1 of this
Code excluding pediatric hospitals.
(7) Beginning July 1, 2014, in addition to the
statewide-standardized amount, the Department shall
develop an adjustor to adjust the rate of reimbursement
for Illinois freestanding inpatient psychiatric hospitals
that are not designated as children's hospitals by the
Department but are primarily treating patients under the
age of 21.

(7.5) (Blank).
(8) Beginning July 1, 2018, in addition to the
statewide-standardized amount, the Department shall adjust
the rate of reimbursement for hospitals designated by the
Department of Public Health as a Perinatal Level II or II+
center by applying the same adjustor that is applied to
Perinatal and Obstetrical care cases for Perinatal Level
III centers, as of December 31, 2017.
(9) Beginning July 1, 2018, in addition to the
statewide-standardized amount, the Department shall apply
the same adjustor that is applied to trauma cases as of
December 31, 2017 to inpatient claims to treat patients
with burns, including, but not limited to, APR-DRGs 841,
842, 843, and 844.
(10) Beginning July 1, 2018, the
statewide-standardized amount for inpatient general acute
care services shall be uniformly increased so that base
claims projected reimbursement is increased by an amount
equal to the funds allocated in paragraph (1) of
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of this subsection
and paragraphs (3) and (4) of subsection (b) multiplied by
40%.
(11) Beginning July 1, 2018, the reimbursement for
inpatient rehabilitation services shall be increased by
the addition of a $96 per day add-on.

(b) Outpatient hospital services. Effective for dates of
service on and after July 1, 2014, reimbursement for
outpatient services shall utilize the Enhanced Ambulatory
Procedure Grouping (EAPG) software, version 3.7 distributed by
3MTM Health Information System.
(1) The Department shall establish Medicaid weighting
factors to be used in the reimbursement system established
under this subsection. The initial weighting factors shall
be the weighting factors as published by 3M Health
Information System, associated with Version 3.7.
(2) The Department shall establish service specific
statewide-standardized amounts to be used in the
reimbursement system.
(A) The initial statewide standardized amounts,
with the labor portion adjusted by the Calendar Year
2013 Medicare Outpatient Prospective Payment System
wage index with reclassifications, shall be published
by the Department on its website no later than 10
calendar days prior to their effective date.
(B) The Department shall establish adjustments to
the statewide-standardized amounts for each Critical
Access Hospital, as designated by the Department of
Public Health in accordance with 42 CFR 485, Subpart
F. For outpatient services provided on or before June
30, 2018, the EAPG standardized amounts are determined
separately for each critical access hospital such that

simulated EAPG payments using outpatient base period
paid claim data plus payments under Section 5A-12.4 of
this Code net of the associated tax costs are equal to
the estimated costs of outpatient base period claims
data with a rate year cost inflation factor applied.
(3) In addition to the statewide-standardized amounts,
the Department shall develop adjusters to adjust the rate
of reimbursement for critical Medicaid hospital outpatient
providers or services, including outpatient high volume or
safety-net hospitals. Beginning July 1, 2018, the
outpatient high volume adjustor shall be increased to
increase annual expenditures associated with this adjustor
by $79,200,000, based on the State Fiscal Year 2015 base
year data and this adjustor shall apply to public
hospitals, except for large public hospitals, as defined
under 89 Ill. Adm. Code 148.25(a).
(4) Beginning July 1, 2018, in addition to the
statewide standardized amounts, the Department shall make
an add-on payment for outpatient expensive devices and
drugs. This add-on payment shall at least apply to claim
lines that: (i) are assigned with one of the following
EAPGs: 490, 1001 to 1020, and coded with one of the
following revenue codes: 0274 to 0276, 0278; or (ii) are
assigned with one of the following EAPGs: 430 to 441, 443,
444, 460 to 465, 495, 496, 1090. The add-on payment shall
be calculated as follows: the claim line's covered charges

multiplied by the hospital's total acute cost to charge
ratio, less the claim line's EAPG payment plus $1,000,
multiplied by 0.8.
(5) Beginning July 1, 2018, the statewide-standardized
amounts for outpatient services shall be increased by a
uniform percentage so that base claims projected
reimbursement is increased by an amount equal to no less
than the funds allocated in paragraph (1) of subsection
(b) of Section 5A-12.6, less the amount allocated under
paragraphs (8) and (9) of subsection (a) and paragraphs
(3) and (4) of this subsection multiplied by 46%.
(6) Effective for dates of service on or after July 1,
2018, the Department shall establish adjustments to the
statewide-standardized amounts for each Critical Access
Hospital, as designated by the Department of Public Health
in accordance with 42 CFR 485, Subpart F, such that each
Critical Access Hospital's standardized amount for
outpatient services shall be increased by the applicable
uniform percentage determined pursuant to paragraph (5) of
this subsection. It is the intent of the General Assembly
that the adjustments required under this paragraph (6) by
Public Act 100-1181 shall be applied retroactively to
claims for dates of service provided on or after July 1,
2018.
(7) Effective for dates of service on or after March
8, 2019 (the effective date of Public Act 100-1181), the

Department shall recalculate and implement an updated
statewide-standardized amount for outpatient services
provided by hospitals that are not Critical Access
Hospitals to reflect the applicable uniform percentage
determined pursuant to paragraph (5).
(1) Any recalculation to the
statewide-standardized amounts for outpatient services
provided by hospitals that are not Critical Access
Hospitals shall be the amount necessary to achieve the
increase in the statewide-standardized amounts for
outpatient services increased by a uniform percentage,
so that base claims projected reimbursement is
increased by an amount equal to no less than the funds
allocated in paragraph (1) of subsection (b) of
Section 5A-12.6, less the amount allocated under
paragraphs (8) and (9) of subsection (a) and
paragraphs (3) and (4) of this subsection, for all
hospitals that are not Critical Access Hospitals,
multiplied by 46%.
(2) It is the intent of the General Assembly that
the recalculations required under this paragraph (7)
by Public Act 100-1181 shall be applied prospectively
to claims for dates of service provided on or after
March 8, 2019 (the effective date of Public Act
100-1181) and that no recoupment or repayment by the
Department or an MCO of payments attributable to

recalculation under this paragraph (7), issued to the
hospital for dates of service on or after July 1, 2018
and before March 8, 2019 (the effective date of Public
Act 100-1181), shall be permitted.
(8) The Department shall ensure that all necessary
adjustments to the managed care organization capitation
base rates necessitated by the adjustments under
subparagraph (6) or (7) of this subsection are completed
and applied retroactively in accordance with Section
5-30.8 of this Code within 90 days of March 8, 2019 (the
effective date of Public Act 100-1181).
(9) Within 60 days after federal approval of the
change made to the assessment in Section 5A-2 by Public
Act 101-650 this amendatory Act of the 101st General
Assembly, the Department shall incorporate into the EAPG
system for outpatient services those services performed by
hospitals currently billed through the Non-Institutional
Provider billing system.
(b-5) Notwithstanding any other provision of this Section,
beginning with dates of service on and after January 1, 2023,
any general acute care hospital with more than 500 outpatient
psychiatric Medicaid services to persons under 19 years of age
in any calendar year shall be paid the outpatient add-on
payment of no less than $113.
(c) In consultation with the hospital community, the
Department is authorized to replace 89 Ill. Adm. Admin. Code

152.150 as published in 38 Ill. Reg. 4980 through 4986 within
12 months of June 16, 2014 (the effective date of Public Act
98-651). If the Department does not replace these rules within
12 months of June 16, 2014 (the effective date of Public Act
98-651), the rules in effect for 152.150 as published in 38
Ill. Reg. 4980 through 4986 shall remain in effect until
modified by rule by the Department. Nothing in this subsection
shall be construed to mandate that the Department file a
replacement rule.
(d) Transition period. There shall be a transition period
to the reimbursement systems authorized under this Section
that shall begin on the effective date of these systems and
continue until June 30, 2018, unless extended by rule by the
Department. To help provide an orderly and predictable
transition to the new reimbursement systems and to preserve
and enhance access to the hospital services during this
transition, the Department shall allocate a transitional
hospital access pool of at least $290,000,000 annually so that
transitional hospital access payments are made to hospitals.
(1) After the transition period, the Department may
begin incorporating the transitional hospital access pool
into the base rate structure; however, the transitional
hospital access payments in effect on June 30, 2018 shall
continue to be paid, if continued under Section 5A-16.
(2) After the transition period, if the Department
reduces payments from the transitional hospital access

pool, it shall increase base rates, develop new adjustors,
adjust current adjustors, develop new hospital access
payments based on updated information, or any combination
thereof by an amount equal to the decreases proposed in
the transitional hospital access pool payments, ensuring
that the entire transitional hospital access pool amount
shall continue to be used for hospital payments.
(d-5) Hospital and health care transformation program. The
Department shall develop a hospital and health care
transformation program to provide financial assistance to
hospitals in transforming their services and care models to
better align with the needs of the communities they serve. The
payments authorized in this Section shall be subject to
approval by the federal government.
(1) Phase 1. In State fiscal years 2019 through 2020,
the Department shall allocate funds from the transitional
access hospital pool to create a hospital transformation
pool of at least $262,906,870 annually and make hospital
transformation payments to hospitals. Subject to Section
5A-16, in State fiscal years 2019 and 2020, an Illinois
hospital that received either a transitional hospital
access payment under subsection (d) or a supplemental
payment under subsection (f) of this Section in State
fiscal year 2018, shall receive a hospital transformation
payment as follows:
(A) If the hospital's Rate Year 2017 Medicaid

inpatient utilization rate is equal to or greater than
45%, the hospital transformation payment shall be
equal to 100% of the sum of its transitional hospital
access payment authorized under subsection (d) and any
supplemental payment authorized under subsection (f).
(B) If the hospital's Rate Year 2017 Medicaid
inpatient utilization rate is equal to or greater than
25% but less than 45%, the hospital transformation
payment shall be equal to 75% of the sum of its
transitional hospital access payment authorized under
subsection (d) and any supplemental payment authorized
under subsection (f).
(C) If the hospital's Rate Year 2017 Medicaid
inpatient utilization rate is less than 25%, the
hospital transformation payment shall be equal to 50%
of the sum of its transitional hospital access payment
authorized under subsection (d) and any supplemental
payment authorized under subsection (f).
(2) Phase 2.
(A) The funding amount from phase one shall be
incorporated into directed payment and pass-through
payment methodologies described in Section 5A-12.7.
(B) Because there are communities in Illinois that
experience significant health care disparities due to
systemic racism, as recently emphasized by the
COVID-19 pandemic, aggravated by social determinants

of health and a lack of sufficiently allocated
healthcare resources, particularly community-based
services, preventive care, obstetric care, chronic
disease management, and specialty care, the Department
shall establish a health care transformation program
that shall be supported by the transformation funding
pool. It is the intention of the General Assembly that
innovative partnerships funded by the pool must be
designed to establish or improve integrated health
care delivery systems that will provide significant
access to the Medicaid and uninsured populations in
their communities, as well as improve health care
equity. It is also the intention of the General
Assembly that partnerships recognize and address the
disparities revealed by the COVID-19 pandemic, as well
as the need for post-COVID care. During State fiscal
years 2021 through 2027, the hospital and health care
transformation program shall be supported by an annual
transformation funding pool of up to $150,000,000,
pending federal matching funds, to be allocated during
the specified fiscal years for the purpose of
facilitating hospital and health care transformation.
No disbursement of moneys for transformation projects
from the transformation funding pool described under
this Section shall be considered an award, a grant, or
an expenditure of grant funds. Funding agreements made

in accordance with the transformation program shall be
considered purchases of care under the Illinois
Procurement Code, and funds shall be expended by the
Department in a manner that maximizes federal funding
to expend the entire allocated amount.
The Department shall convene, within 30 days after
March 12, 2021 (the effective date of Public Act
101-655) this amendatory Act of the 101st General
Assembly, a workgroup that includes subject matter
experts on healthcare disparities and stakeholders
from distressed communities, which could be a
subcommittee of the Medicaid Advisory Committee, to
review and provide recommendations on how Department
policy, including health care transformation, can
improve health disparities and the impact on
communities disproportionately affected by COVID-19.
The workgroup shall consider and make recommendations
on the following issues: a community safety-net
designation of certain hospitals, racial equity, and a
regional partnership to bring additional specialty
services to communities.
(C) As provided in paragraph (9) of Section 3 of
the Illinois Health Facilities Planning Act, any
hospital participating in the transformation program
may be excluded from the requirements of the Illinois
Health Facilities Planning Act for those projects

related to the hospital's transformation. To be
eligible, the hospital must submit to the Health
Facilities and Services Review Board approval from the
Department that the project is a part of the
hospital's transformation.
(D) As provided in subsection (a-20) of Section
32.5 of the Emergency Medical Services (EMS) Systems
Act, a hospital that received hospital transformation
payments under this Section may convert to a
freestanding emergency center. To be eligible for such
a conversion, the hospital must submit to the
Department of Public Health approval from the
Department that the project is a part of the
hospital's transformation.
(E) Criteria for proposals. To be eligible for
funding under this Section, a transformation proposal
shall meet all of the following criteria:
(i) the proposal shall be designed based on
community needs assessment completed by either a
University partner or other qualified entity with
significant community input;
(ii) the proposal shall be a collaboration
among providers across the care and community
spectrum, including preventative care, primary
care specialty care, hospital services, mental
health and substance abuse services, as well as

community-based entities that address the social
determinants of health;
(iii) the proposal shall be specifically
designed to improve healthcare outcomes and reduce
healthcare disparities, and improve the
coordination, effectiveness, and efficiency of
care delivery;
(iv) the proposal shall have specific
measurable metrics related to disparities that
will be tracked by the Department and made public
by the Department;
(v) the proposal shall include a commitment to
include Business Enterprise Program certified
vendors or other entities controlled and managed
by minorities or women; and
(vi) the proposal shall specifically increase
access to primary, preventive, or specialty care.
(F) Entities eligible to be funded.
(i) Proposals for funding should come from
collaborations operating in one of the most
distressed communities in Illinois as determined
by the U.S. Centers for Disease Control and
Prevention's Social Vulnerability Index for
Illinois and areas disproportionately impacted by
COVID-19 or from rural areas of Illinois.
(ii) The Department shall prioritize

partnerships from distressed communities, which
include Business Enterprise Program certified
vendors or other entities controlled and managed
by minorities or women and also include one or
more of the following: safety-net hospitals,
critical access hospitals, the campuses of
hospitals that have closed since January 1, 2018,
or other healthcare providers designed to address
specific healthcare disparities, including the
impact of COVID-19 on individuals and the
community and the need for post-COVID care. All
funded proposals must include specific measurable
goals and metrics related to improved outcomes and
reduced disparities which shall be tracked by the
Department.
(iii) The Department should target the funding
in the following ways: $30,000,000 of
transformation funds to projects that are a
collaboration between a safety-net hospital,
particularly community safety-net hospitals, and
other providers and designed to address specific
healthcare disparities, $20,000,000 of
transformation funds to collaborations between
safety-net hospitals and a larger hospital partner
that increases specialty care in distressed
communities, $30,000,000 of transformation funds

to projects that are a collaboration between
hospitals and other providers in distressed areas
of the State designed to address specific
healthcare disparities, $15,000,000 to
collaborations between critical access hospitals
and other providers designed to address specific
healthcare disparities, and $15,000,000 to
cross-provider collaborations designed to address
specific healthcare disparities, and $5,000,000 to
collaborations that focus on workforce
development.
(iv) The Department may allocate up to
$5,000,000 for planning, racial equity analysis,
or consulting resources for the Department or
entities without the resources to develop a plan
to meet the criteria of this Section. Any contract
for consulting services issued by the Department
under this subparagraph shall comply with the
provisions of Section 5-45 of the State Officials
and Employees Ethics Act. Based on availability of
federal funding, the Department may directly
procure consulting services or provide funding to
the collaboration. The provision of resources
under this subparagraph is not a guarantee that a
project will be approved.
(v) The Department shall take steps to ensure

that safety-net hospitals operating in
under-resourced communities receive priority
access to hospital and healthcare transformation
funds, including consulting funds, as provided
under this Section.
(G) Process for submitting and approving projects
for distressed communities. The Department shall issue
a template for application. The Department shall post
any proposal received on the Department's website for
at least 2 weeks for public comment, and any such
public comment shall also be considered in the review
process. Applicants may request that proprietary
financial information be redacted from publicly posted
proposals and the Department in its discretion may
agree. Proposals for each distressed community must
include all of the following:
(i) A detailed description of how the project
intends to affect the goals outlined in this
subsection, describing new interventions, new
technology, new structures, and other changes to
the healthcare delivery system planned.
(ii) A detailed description of the racial and
ethnic makeup of the entities' board and
leadership positions and the salaries of the
executive staff of entities in the partnership
that is seeking to obtain funding under this

Section.
(iii) A complete budget, including an overall
timeline and a detailed pathway to sustainability
within a 5-year period, specifying other sources
of funding, such as in-kind, cost-sharing, or
private donations, particularly for capital needs.
There is an expectation that parties to the
transformation project dedicate resources to the
extent they are able and that these expectations
are delineated separately for each entity in the
proposal.
(iv) A description of any new entities formed
or other legal relationships between collaborating
entities and how funds will be allocated among
participants.
(v) A timeline showing the evolution of sites
and specific services of the project over a 5-year
period, including services available to the
community by site.
(vi) Clear milestones indicating progress
toward the proposed goals of the proposal as
checkpoints along the way to continue receiving
funding. The Department is authorized to refine
these milestones in agreements, and is authorized
to impose reasonable penalties, including
repayment of funds, for substantial lack of

progress.
(vii) A clear statement of the level of
commitment the project will include for minorities
and women in contracting opportunities, including
as equity partners where applicable, or as
subcontractors and suppliers in all phases of the
project.
(viii) If the community study utilized is not
the study commissioned and published by the
Department, the applicant must define the
methodology used, including documentation of clear
community participation.
(ix) A description of the process used in
collaborating with all levels of government in the
community served in the development of the
project, including, but not limited to,
legislators and officials of other units of local
government.
(x) Documentation of a community input process
in the community served, including links to
proposal materials on public websites.
(xi) Verifiable project milestones and quality
metrics that will be impacted by transformation.
These project milestones and quality metrics must
be identified with improvement targets that must
be met.

(xii) Data on the number of existing employees
by various job categories and wage levels by the
zip code of the employees' residence and
benchmarks for the continued maintenance and
improvement of these levels. The proposal must
also describe any retraining or other workforce
development planned for the new project.
(xiii) If a new entity is created by the
project, a description of how the board will be
reflective of the community served by the
proposal.
(xiv) An explanation of how the proposal will
address the existing disparities that exacerbated
the impact of COVID-19 and the need for post-COVID
care in the community, if applicable.
(xv) An explanation of how the proposal is
designed to increase access to care, including
specialty care based upon the community's needs.
(H) The Department shall evaluate proposals for
compliance with the criteria listed under subparagraph
(G). Proposals meeting all of the criteria may be
eligible for funding with the areas of focus
prioritized as described in item (ii) of subparagraph
(F). Based on the funds available, the Department may
negotiate funding agreements with approved applicants
to maximize federal funding. Nothing in this

subsection requires that an approved project be funded
to the level requested. Agreements shall specify the
amount of funding anticipated annually, the
methodology of payments, the limit on the number of
years such funding may be provided, and the milestones
and quality metrics that must be met by the projects in
order to continue to receive funding during each year
of the program. Agreements shall specify the terms and
conditions under which a health care facility that
receives funds under a purchase of care agreement and
closes in violation of the terms of the agreement must
pay an early closure fee no greater than 50% of the
funds it received under the agreement, prior to the
Health Facilities and Services Review Board
considering an application for closure of the
facility. Any project that is funded shall be required
to provide quarterly written progress reports, in a
form prescribed by the Department, and at a minimum
shall include the progress made in achieving any
milestones or metrics or Business Enterprise Program
commitments in its plan. The Department may reduce or
end payments, as set forth in transformation plans, if
milestones or metrics or Business Enterprise Program
commitments are not achieved. The Department shall
seek to make payments from the transformation fund in
a manner that is eligible for federal matching funds.

In reviewing the proposals, the Department shall
take into account the needs of the community, data
from the study commissioned by the Department from the
University of Illinois-Chicago if applicable, feedback
from public comment on the Department's website, as
well as how the proposal meets the criteria listed
under subparagraph (G). Alignment with the
Department's overall strategic initiatives shall be an
important factor. To the extent that fiscal year
funding is not adequate to fund all eligible projects
that apply, the Department shall prioritize
applications that most comprehensively and effectively
address the criteria listed under subparagraph (G).
(3) (Blank).
(4) Hospital Transformation Review Committee. There is
created the Hospital Transformation Review Committee. The
Committee shall consist of 14 members. No later than 30
days after March 12, 2018 (the effective date of Public
Act 100-581), the 4 legislative leaders shall each appoint
3 members; the Governor shall appoint the Director of
Healthcare and Family Services, or his or her designee, as
a member; and the Director of Healthcare and Family
Services shall appoint one member. Any vacancy shall be
filled by the applicable appointing authority within 15
calendar days. The members of the Committee shall select a
Chair and a Vice-Chair from among its members, provided

that the Chair and Vice-Chair cannot be appointed by the
same appointing authority and must be from different
political parties. The Chair shall have the authority to
establish a meeting schedule and convene meetings of the
Committee, and the Vice-Chair shall have the authority to
convene meetings in the absence of the Chair. The
Committee may establish its own rules with respect to
meeting schedule, notice of meetings, and the disclosure
of documents; however, the Committee shall not have the
power to subpoena individuals or documents and any rules
must be approved by 9 of the 14 members. The Committee
shall perform the functions described in this Section and
advise and consult with the Director in the administration
of this Section. In addition to reviewing and approving
the policies, procedures, and rules for the hospital and
health care transformation program, the Committee shall
consider and make recommendations related to qualifying
criteria and payment methodologies related to safety-net
hospitals and children's hospitals. Members of the
Committee appointed by the legislative leaders shall be
subject to the jurisdiction of the Legislative Ethics
Commission, not the Executive Ethics Commission, and all
requests under the Freedom of Information Act shall be
directed to the applicable Freedom of Information officer
for the General Assembly. The Department shall provide
operational support to the Committee as necessary. The

Committee is dissolved on April 1, 2019.
(e) Beginning 36 months after initial implementation, the
Department shall update the reimbursement components in
subsections (a) and (b), including standardized amounts and
weighting factors, and at least once every 4 years and no more
frequently than annually thereafter. The Department shall
publish these updates on its website no later than 30 calendar
days prior to their effective date.
(f) Continuation of supplemental payments. Any
supplemental payments authorized under Illinois Administrative
Code 148 effective January 1, 2014 and that continue during
the period of July 1, 2014 through December 31, 2014 shall
remain in effect as long as the assessment imposed by Section
5A-2 that is in effect on December 31, 2017 remains in effect.
(g) Notwithstanding subsections (a) through (f) of this
Section and notwithstanding the changes authorized under
Section 5-5b.1, any updates to the system shall not result in
any diminishment of the overall effective rates of
reimbursement as of the implementation date of the new system
(July 1, 2014). These updates shall not preclude variations in
any individual component of the system or hospital rate
variations. Nothing in this Section shall prohibit the
Department from increasing the rates of reimbursement or
developing payments to ensure access to hospital services.
Nothing in this Section shall be construed to guarantee a
minimum amount of spending in the aggregate or per hospital as

spending may be impacted by factors, including, but not
limited to, the number of individuals in the medical
assistance program and the severity of illness of the
individuals.
(h) The Department shall have the authority to modify by
rulemaking any changes to the rates or methodologies in this
Section as required by the federal government to obtain
federal financial participation for expenditures made under
this Section.
(i) Except for subsections (g) and (h) of this Section,
the Department shall, pursuant to subsection (c) of Section
5-40 of the Illinois Administrative Procedure Act, provide for
presentation at the June 2014 hearing of the Joint Committee
on Administrative Rules (JCAR) additional written notice to
JCAR of the following rules in order to commence the second
notice period for the following rules: rules published in the
Illinois Register, rule dated February 21, 2014 at 38 Ill.
Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic
Related Grouping (DRG) Prospective Payment System (PPS)), and
4977 (Hospital Reimbursement Changes), and published in the
Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
(Specialized Health Care Delivery Systems) and 6505 (Hospital
Services).
(j) Out-of-state hospitals. Beginning July 1, 2018, for
purposes of determining for State fiscal years 2019 and 2020

and subsequent fiscal years the hospitals eligible for the
payments authorized under subsections (a) and (b) of this
Section, the Department shall include out-of-state hospitals
that are designated a Level I pediatric trauma center or a
Level I trauma center by the Department of Public Health as of
December 1, 2017.
(k) The Department shall notify each hospital and managed
care organization, in writing, of the impact of the updates
under this Section at least 30 calendar days prior to their
effective date.
(l) This Section is subject to Section 14-12.5.
(Source: P.A. 101-81, eff. 7-12-19; 101-650, eff. 7-7-20;
101-655, eff. 3-12-21; 102-682, eff. 12-10-21; 102-1037, eff.
6-2-22; revised 8-22-22.)
(305 ILCS 5/14-12.5 new)
Sec. 14-12.5. Hospital rate updates.
(a) Notwithstanding any other provision of this Code, the
hospital rates of reimbursement authorized under Sections
5-5.05, 14-12, and 14-13 of this Code shall be adjusted in
accordance with the provisions of this Section.
(b) Notwithstanding any other provision of this Code,
effective for dates of service on and after January 1, 2024,
subject to federal approval, hospital reimbursement rates
shall be revised as follows:
(1) For inpatient general acute care services, the

statewide-standardized amount and the per diem rates for
hospitals exempt from the APR-DRG reimbursement system, in
effect January 1, 2023, shall be increased by 10%.
(2) For inpatient psychiatric services:
(A) For safety-net hospitals, the hospital
specific per diem rate in effect January 1, 2023 and
the minimum per diem rate of $630, authorized in
subsection (b-5) of Section 5-5.05 of this Code, shall
be increased by 10%.
(B) For all general acute care hospitals that are
not safety-net hospitals, the inpatient psychiatric
care per diem rates in effect January 1, 2023 shall be
increased by 10%, except that all rates shall be at
least 90% of the minimum inpatient psychiatric care
per diem rate for safety-net hospitals as authorized
in subsection (b-5) of Section 5-5.05 of this Code
including the adjustments authorized in this Section.
The statewide default per diem rate for a hospital
opening a new psychiatric distinct part unit, shall be
set at 90% of the minimum inpatient psychiatric care
per diem rate for safety-net hospitals as authorized
in subsection (b-5) of Section 5-5.05 of this Code,
including the adjustment authorized in this Section.
(C) For all psychiatric specialty hospitals, the
per diem rates in effect January 1, 2023, shall be
increased by 10%, except that all rates shall be at

least 90% of the minimum inpatient per diem rate for
safety-net hospitals as authorized in subsection (b-5)
of Section 5-5.05 of this Code, including the
adjustments authorized in this Section. The statewide
default per diem rate for a new psychiatric specialty
hospital shall be set at 90% of the minimum inpatient
psychiatric care per diem rate for safety-net
hospitals as authorized in subsection (b-5) of Section
5-5.05 of this Code, including the adjustment
authorized in this Section.
(3) For inpatient rehabilitative services, all
hospital specific per diem rates in effect January 1,
2023, shall be increased by 10%. The statewide default
inpatient rehabilitative services per diem rates, for
general acute care hospitals and for rehabilitation
specialty hospitals respectively, shall be increased by
10%.
(4) The statewide-standardized amount for outpatient
general acute care services in effect January 1, 2023,
shall be increased by 10%.
(5) The statewide-standardized amount for outpatient
psychiatric care services in effect January 1, 2023, shall
be increased by 10%.
(6) The statewide-standardized amount for outpatient
rehabilitative care services in effect January 1, 2023,
shall be increased by 10%.

(7) The per diem rate in effect January 1, 2023, as
authorized in subsection (a) of Section 14-13 of this
Article shall be increased by 10%.
(8) Beginning on and after January 1, 2024, subject to
federal approval, in addition to the statewide
standardized amount, an add-on payment of $210 shall be
paid for each inpatient General Acute and Psychiatric day
of care, excluding Medicare-Medicaid dual eligible
crossover days, for all safety-net hospitals defined in
Section 5-5e.1 of this Code.
(A) For Psychiatric days of care, the Department
may implement payment of this add-on by increasing the
hospital specific psychiatric per diem rate, adjusted
in accordance with subparagraph (A) of paragraph (2)
of subsection (b) by $210, or by a separate add-on
payment.
(B) If the add-on adjustment is added to the
hospital specific psychiatric per diem rate to
operationalize payment, the Department shall provide a
rate sheet to each safety-net hospital, which
identifies the hospital psychiatric per diem rate
before and after the adjustment.
(C) The add-on adjustment shall not be considered
when setting the 90% minimum rate identified in
paragraph (2) of subsection (b).
(c) The Department shall take all actions necessary to

ensure the changes authorized in this amendatory Act of the
103rd General Assembly are in effect for dates of service on
and after January 1, 2024, including publishing all
appropriate public notices, applying for federal approval of
amendments to the Illinois Title XIX State Plan, and adopting
administrative rules if necessary.
(d) The Department of Healthcare and Family Services may
adopt rules necessary to implement the changes made by this
amendatory Act of the 103rd General Assembly through the use
of emergency rulemaking in accordance with Section 5-45 of the
Illinois Administrative Procedure Act. The 24-month limitation
on the adoption of emergency rules does not apply to rules
adopted under this Section. The General Assembly finds that
the adoption of rules to implement the changes made by this
amendatory Act of the 103rd General Assembly is deemed an
emergency and necessary for the public interest, safety, and
welfare.
(e) The Department shall ensure that all necessary
adjustments to the managed care organization capitation base
rates necessitated by the adjustments in this Section are
completed, published, and applied in accordance with Section
5-30.8 of this Code 90 days prior to the implementation date of
the changes required under this amendatory Act of the 103rd
General Assembly.
(f) The Department shall publish updated rate sheets for
all hospitals 30 days prior to the effective date of the rate

increase, or within 30 days after federal approval by the
Centers for Medicare and Medicaid Services, whichever is
later.
(305 ILCS 5/14-12.7 new)
Sec. 14-12.7. Public critical access hospital
stabilization program.
(a) In order to address the growing challenges of
providing stable access to healthcare in rural Illinois, by
October 1, 2023, the Department shall adopt rules to implement
for dates of service on and after January 1, 2024, subject to
federal approval, a program to provide at least $3,500,000 in
annual financial support to public, critical access hospitals
in Illinois, for the delivery of perinatal and obstetrical or
gynecological services, behavioral healthcare services,
including substance use disorder services, telehealth
services, and other specialty services.
(b) The funding allocation methodology shall provide added
consideration to the services provided by qualifying hospitals
designated by the Department of Public Health as a perinatal
center.
(c) Public critical access hospitals qualifying under this
Section shall not be eligible for payment under subsection (o)
of Section 5A-12.7 of this Code.
(d) As used in this Section, "public critical access
hospital" means a hospital designated by the Department of

Public Health as a critical access hospital and that is owned
or operated by an Illinois Government body or municipality.
ARTICLE 15.
Section 15-5. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant individuals, provided by an individual licensed
to practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or

corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; (16.5) services performed by
a chiropractic physician licensed under the Medical Practice

Act of 1987 and acting within the scope of his or her license,
including, but not limited to, chiropractic manipulative
treatment; and (17) any other medical care, and any other type
of remedial care recognized under the laws of this State. The
term "any other type of remedial care" shall include nursing
care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided
through the Illinois Tobacco Quitline shall be covered under
the medical assistance program for persons who are otherwise

eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable
Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of
understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a

vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever
the person may select.

On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally

enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare
and Family Services shall administer and regulate a
school-based dental program that allows for the out-of-office
delivery of preventative dental services in a school setting
to children under 19 years of age. The Department shall
establish, by rule, guidelines for participation by providers
and set requirements for follow-up referral care based on the
requirements established in the Dental Office Reference Manual
published by the Department that establishes the requirements
for dentists participating in the All Kids Dental School
Program. Every effort shall be made by the Department when
developing the program requirements to consider the different
geographic differences of both urban and rural areas of the
State for initial treatment and necessary follow-up care. No
provider shall be charged a fee by any unit of local government
to participate in the school-based dental program administered
by the Department. Nothing in this paragraph shall be
construed to limit or preempt a home rule unit's or school

district's authority to establish, change, or administer a
school-based dental program in addition to, or independent of,
the school-based dental program administered by the
Department.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for
individuals 35 years of age or older who are eligible for
medical assistance under this Article, as follows:
(A) A baseline mammogram for individuals 35 to 39
years of age.
(B) An annual mammogram for individuals 40 years of
age or older.
(C) A mammogram at the age and intervals considered
medically necessary by the individual's health care

provider for individuals 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 or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the

frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that

would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography and, after
January 1, 2023 (the effective date of Public Act 102-1018)
this amendatory Act of the 102nd General Assembly, breast
tomosynthesis.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography

facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast

cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts

in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
The Department shall provide coverage and reimbursement
for a human papillomavirus (HPV) vaccine that is approved for
marketing by the federal Food and Drug Administration for all
persons between the ages of 9 and 45 and persons of the age of
46 and above who have been diagnosed with cervical dysplasia
with a high risk of recurrence or progression. The Department
shall disallow any preauthorization requirements for the
administration of the human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise
eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be
conditioned on the use of a screening instrument approved by
the Department.
Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program

licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information
from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.

The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse

medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical

services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and

accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the

Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other

interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon the category of risk
of the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be

subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following

exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 120
calendar days of receipt by the facility of required

prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;

employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing

and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
or post-adjudicated predictive modeling with an integrated
case management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,

the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:

(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of the same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an

increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care

services and facilities, as it affects persons eligible for
medical assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(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 shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure

Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of

medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service and managed care medical
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established
under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, or (3)
lifetime restriction limit mandate.
On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees or hospital fees related to the dispensing, distribution,
and administration of the opioid antagonist, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
As used in this Section, "opioid antagonist" means a drug that
binds to opioid receptors and blocks or inhibits the effect of
opioids acting on those receptors, including, but not limited
to, naloxone hydrochloride or any other similarly acting drug
approved by the U.S. Food and Drug Administration. The
Department shall not impose a copayment on the coverage
provided for naloxone hydrochloride under the medical
assistance program.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for

marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date
of Public Act 102-665), the Department shall seek federal
approval of a State Plan amendment to expand coverage for
family planning services that includes presumptive eligibility
to individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare

and Medicaid Services of a Title XIX State Plan amendment
electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of
the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,
subject to criteria established in accordance with all
applicable laws.
Notwithstanding any other provision of this Code,
community-based pediatric palliative care from a trained
interdisciplinary team shall be covered under the medical
assistance program as provided in Section 15 of the Pediatric
Palliative Care Act.
Notwithstanding any other provision of this Code, within
12 months after June 2, 2022 (the effective date of Public Act
102-1037) this amendatory Act of the 102nd General Assembly
and subject to federal approval, acupuncture services
performed by an acupuncturist licensed under the Acupuncture
Practice Act who is acting within the scope of his or her
license shall be covered under the medical assistance program.
The Department shall apply for any federal waiver or State
Plan amendment, if required, to implement this paragraph. The
Department may adopt any rules, including standards and
criteria, necessary to implement this paragraph.

Notwithstanding any other provision of this Code,
beginning on January 1, 2024, subject to federal approval,
cognitive assessment and care planning services provided to a
person who experiences signs or symptoms of cognitive
impairment, as defined by the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;
102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
1-1-23; revised 2-5-23.)
ARTICLE 20.
Section 20-5. The Illinois Public Aid Code is amended by
changing Section 5-5.01a as follows:
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program.
(a) The Department shall establish and provide oversight
for a program of supportive living facilities that seek to

promote resident independence, dignity, respect, and
well-being in the most cost-effective manner.
A supportive living facility is (i) a free-standing
facility or (ii) a distinct physical and operational entity
within a mixed-use building that meets the criteria
established in subsection (d). A supportive living facility
integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents
their own separate, private, and distinct living units.
Sites for the operation of the program shall be selected
by the Department based upon criteria that may include the
need for services in a geographic area, the availability of
funding, and the site's ability to meet the standards.
(b) Beginning July 1, 2014, subject to federal approval,
the Medicaid rates for supportive living facilities shall be
equal to the supportive living facility Medicaid rate
effective on June 30, 2014 increased by 8.85%. Once the
assessment imposed at Article V-G of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act, the Department shall increase the Medicaid rates for
supportive living facilities effective on July 1, 2014 by
9.09%. The Department shall apply this increase retroactively
to coincide with the imposition of the assessment in Article
V-G of this Code in accordance with the approval for federal
financial participation by the Centers for Medicare and
Medicaid Services.

The Medicaid rates for supportive living facilities
effective on July 1, 2017 must be equal to the rates in effect
for supportive living facilities on June 30, 2017 increased by
2.8%.
The Medicaid rates for supportive living facilities
effective on July 1, 2018 must be equal to the rates in effect
for supportive living facilities on June 30, 2018.
Subject to federal approval, the Medicaid rates for
supportive living services on and after July 1, 2019 must be at
least 54.3% of the average total nursing facility services per
diem for the geographic areas defined by the Department while
maintaining the rate differential for dementia care and must
be updated whenever the total nursing facility service per
diems are updated. Beginning July 1, 2022, upon the
implementation of the Patient Driven Payment Model, Medicaid
rates for supportive living services must be at least 54.3% of
the average total nursing services per diem rate for the
geographic areas. For purposes of this provision, the average
total nursing services per diem rate shall include all add-ons
for nursing facilities for the geographic area provided for in
Section 5-5.2. The rate differential for dementia care must be
maintained in these rates and the rates shall be updated
whenever nursing facility per diem rates are updated.
Subject to federal approval, beginning January 1, 2024,
the dementia care rate for supportive living services must be
no less than the non-dementia care supportive living services

rate multiplied by 1.5.
(c) The Department may adopt rules to implement this
Section. Rules that establish or modify the services,
standards, and conditions for participation in the program
shall be adopted by the Department in consultation with the
Department on Aging, the Department of Rehabilitation
Services, and the Department of Mental Health and
Developmental Disabilities (or their successor agencies).
(d) Subject to federal approval by the Centers for
Medicare and Medicaid Services, the Department shall accept
for consideration of certification under the program any
application for a site or building where distinct parts of the
site or building are designated for purposes other than the
provision of supportive living services, but only if:
(1) those distinct parts of the site or building are
not designated for the purpose of providing assisted
living services as required under the Assisted Living and
Shared Housing Act;
(2) those distinct parts of the site or building are
completely separate from the part of the building used for
the provision of supportive living program services,
including separate entrances;
(3) those distinct parts of the site or building do
not share any common spaces with the part of the building
used for the provision of supportive living program
services; and

(4) those distinct parts of the site or building do
not share staffing with the part of the building used for
the provision of supportive living program services.
(e) Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good
standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois
Health Facilities Planning Act.
(f) Section 9817 of the American Rescue Plan Act of 2021
(Public Law 117-2) authorizes a 10% enhanced federal medical
assistance percentage for supportive living services for a
12-month period from April 1, 2021 through March 31, 2022.
Subject to federal approval, including the approval of any
necessary waiver amendments or other federally required
documents or assurances, for a 12-month period the Department
must pay a supplemental $26 per diem rate to all supportive
living facilities with the additional federal financial
participation funds that result from the enhanced federal
medical assistance percentage from April 1, 2021 through March
31, 2022. The Department may issue parameters around how the
supplemental payment should be spent, including quality
improvement activities. The Department may alter the form,
methods, or timeframes concerning the supplemental per diem
rate to comply with any subsequent changes to federal law,
changes made by guidance issued by the federal Centers for
Medicare and Medicaid Services, or other changes necessary to

receive the enhanced federal medical assistance percentage.
(Source: P.A. 101-10, eff. 6-5-19; 102-43, eff. 7-6-21;
102-699, eff. 4-19-22.)
ARTICLE 25.
Section 25-5. The Illinois Public Aid Code is amended by
adding Section 12-4.57 as follows:
(305 ILCS 5/12-4.57 new)
Sec. 12-4.57. Prospective Payment System rates; increase
for federally qualified health centers. Beginning January 1,
2024, subject to federal approval, the Department of
Healthcare and Family Services shall increase the Prospective
Payment System rates for federally qualified health centers to
a level calculated to spend an additional $50,000,000 in the
first year of application using an alternative payment method
acceptable to the Centers for Medicare and Medicaid Services
and a trade association representing a majority of federally
qualified health centers operating in Illinois, including a
rate increase that is an equal percentage increase to the
rates paid to each federally qualified health center.
ARTICLE 30.
Section 30-5. The Specialized Mental Health Rehabilitation

Act of 2013 is amended by changing Section 5-107 as follows:
(210 ILCS 49/5-107)
Sec. 5-107. Quality of life enhancement. Beginning on July
1, 2019, for improving the quality of life and the quality of
care, an additional payment shall be awarded to a facility for
their single occupancy rooms. This payment shall be in
addition to the rate for recovery and rehabilitation. The
additional rate for single room occupancy shall be no less
than $10 per day, per single room occupancy. The Department of
Healthcare and Family Services shall adjust payment to
Medicaid managed care entities to cover these costs. Beginning
July 1, 2022, for improving the quality of life and the quality
of care, a payment of no less than $5 per day, per single room
occupancy shall be added to the existing $10 additional per
day, per single room occupancy rate for a total of at least $15
per day, per single room occupancy. For improving the quality
of life and the quality of care, on January 1, 2024, a payment
of no less than $10.50 per day, per single room occupancy shall
be added to the existing $15 additional per day, per single
room occupancy rate for a total of at least $25.50 per day, per
single room occupancy. Beginning July 1, 2022, for improving
the quality of life and the quality of care, an additional
payment shall be awarded to a facility for its dual-occupancy
rooms. This payment shall be in addition to the rate for
recovery and rehabilitation. The additional rate for

dual-occupancy rooms shall be no less than $10 per day, per
Medicaid-occupied bed, in each dual-occupancy room. Beginning
January 1, 2024, for improving the quality of life and the
quality of care, a payment of no less than $4.50 per day, per
dual-occupancy room shall be added to the existing $10
additional per day, per dual-occupancy room rate for a total
of at least $14.50, per Medicaid-occupied bed, in each
dual-occupancy room. The Department of Healthcare and Family
Services shall adjust payment to Medicaid managed care
entities to cover these costs. As used in this Section,
"dual-occupancy room" means a room that contains 2 resident
beds.
(Source: P.A. 101-10, eff. 6-5-19; 102-699, eff. 4-19-22.)
ARTICLE 35.
Section 35-5. The Illinois Public Aid Code is amended by
changing Section 5-2b as follows:
(305 ILCS 5/5-2b)
Sec. 5-2b. Medically fragile and technology dependent
children eligibility and program; provider reimbursement
rates.
(a) Notwithstanding any other provision of law except as
provided in Section 5-30a, on and after September 1, 2012,
subject to federal approval, medical assistance under this

Article shall be available to children who qualify as persons
with a disability, as defined under the federal Supplemental
Security Income program and who are medically fragile and
technology dependent. The program shall allow eligible
children to receive the medical assistance provided under this
Article in the community and must maximize, to the fullest
extent permissible under federal law, federal reimbursement
and family cost-sharing, including co-pays, premiums, or any
other family contributions, except that the Department shall
be permitted to incentivize the utilization of selected
services through the use of cost-sharing adjustments. The
Department shall establish the policies, procedures,
standards, services, and criteria for this program by rule.
(b) Notwithstanding any other provision of this Code,
subject to federal approval, on and after January 1, 2024, the
reimbursement rates for nursing paid through Nursing and
Personal Care Services for non-waiver customers and to
providers of private duty nursing services for children
eligible for medical assistance under this Section shall be
20% higher than the reimbursement rates in effect for nursing
services on December 31, 2023.
(Source: P.A. 100-990, eff. 1-1-19.)
ARTICLE 40.
Section 40-5. The Illinois Public Aid Code is amended by

changing Section 5-5.2 as follows:
(305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)
Sec. 5-5.2. Payment.
(a) All nursing facilities that are grouped pursuant to
Section 5-5.1 of this Act shall receive the same rate of
payment for similar services.
(b) It shall be a matter of State policy that the Illinois
Department shall utilize a uniform billing cycle throughout
the State for the long-term care providers.
(c) (Blank).
(c-1) Notwithstanding any other provisions of this Code,
the methodologies for reimbursement of nursing services as
provided under this Article shall no longer be applicable for
bills payable for nursing services rendered on or after a new
reimbursement system based on the Patient Driven Payment Model
(PDPM) has been fully operationalized, which shall take effect
for services provided on or after the implementation of the
PDPM reimbursement system begins. For the purposes of this
amendatory Act of the 102nd General Assembly, the
implementation date of the PDPM reimbursement system and all
related provisions shall be July 1, 2022 if the following
conditions are met: (i) the Centers for Medicare and Medicaid
Services has approved corresponding changes in the
reimbursement system and bed assessment; and (ii) the
Department has filed rules to implement these changes no later

than June 1, 2022. Failure of the Department to file rules to
implement the changes provided in this amendatory Act of the
102nd General Assembly no later than June 1, 2022 shall result
in the implementation date being delayed to October 1, 2022.
(d) The new nursing services reimbursement methodology
utilizing the Patient Driven Payment Model, which shall be
referred to as the PDPM reimbursement system, taking effect
July 1, 2022, upon federal approval by the Centers for
Medicare and Medicaid Services, shall be based on the
following:
(1) The methodology shall be resident-centered,
facility-specific, cost-based, and based on guidance from
the Centers for Medicare and Medicaid Services.
(2) Costs shall be annually rebased and case mix index
quarterly updated. The nursing services methodology will
be assigned to the Medicaid enrolled residents on record
as of 30 days prior to the beginning of the rate period in
the Department's Medicaid Management Information System
(MMIS) as present on the last day of the second quarter
preceding the rate period based upon the Assessment
Reference Date of the Minimum Data Set (MDS).
(3) Regional wage adjustors based on the Health
Service Areas (HSA) groupings and adjusters in effect on
April 30, 2012 shall be included, except no adjuster shall
be lower than 1.06.
(4) PDPM nursing case mix indices in effect on March

1, 2022 shall be assigned to each resident class at no less
than 0.7858 of the Centers for Medicare and Medicaid
Services PDPM unadjusted case mix values, in effect on
March 1, 2022.
(5) The pool of funds available for distribution by
case mix and the base facility rate shall be determined
using the formula contained in subsection (d-1).
(6) The Department shall establish a variable per diem
staffing add-on in accordance with the most recent
available federal staffing report, currently the Payroll
Based Journal, for the same period of time, and if
applicable adjusted for acuity using the same quarter's
MDS. The Department shall rely on Payroll Based Journals
provided to the Department of Public Health to make a
determination of non-submission. If the Department is
notified by a facility of missing or inaccurate Payroll
Based Journal data or an incorrect calculation of
staffing, the Department must make a correction as soon as
the error is verified for the applicable quarter.
Facilities with at least 70% of the staffing indicated
by the STRIVE study shall be paid a per diem add-on of $9,
increasing by equivalent steps for each whole percentage
point until the facilities reach a per diem of $14.88.
Facilities with at least 80% of the staffing indicated by
the STRIVE study shall be paid a per diem add-on of $14.88,
increasing by equivalent steps for each whole percentage

point until the facilities reach a per diem add-on of
$23.80. Facilities with at least 92% of the staffing
indicated by the STRIVE study shall be paid a per diem
add-on of $23.80, increasing by equivalent steps for each
whole percentage point until the facilities reach a per
diem add-on of $29.75. Facilities with at least 100% of
the staffing indicated by the STRIVE study shall be paid a
per diem add-on of $29.75, increasing by equivalent steps
for each whole percentage point until the facilities reach
a per diem add-on of $35.70. Facilities with at least 110%
of the staffing indicated by the STRIVE study shall be
paid a per diem add-on of $35.70, increasing by equivalent
steps for each whole percentage point until the facilities
reach a per diem add-on of $38.68. Facilities with at
least 125% or higher of the staffing indicated by the
STRIVE study shall be paid a per diem add-on of $38.68.
Beginning April 1, 2023, no nursing facility's variable
staffing per diem add-on shall be reduced by more than 5%
in 2 consecutive quarters. For the quarters beginning July
1, 2022 and October 1, 2022, no facility's variable per
diem staffing add-on shall be calculated at a rate lower
than 85% of the staffing indicated by the STRIVE study. No
facility below 70% of the staffing indicated by the STRIVE
study shall receive a variable per diem staffing add-on
after December 31, 2022.
(7) For dates of services beginning July 1, 2022, the

PDPM nursing component per diem for each nursing facility
shall be the product of the facility's (i) statewide PDPM
nursing base per diem rate, $92.25, adjusted for the
facility average PDPM case mix index calculated quarterly
and (ii) the regional wage adjuster, and then add the
Medicaid access adjustment as defined in (e-3) of this
Section. Transition rates for services provided between
July 1, 2022 and October 1, 2023 shall be the greater of
the PDPM nursing component per diem or:
(A) for the quarter beginning July 1, 2022, the
RUG-IV nursing component per diem;
(B) for the quarter beginning October 1, 2022, the
sum of the RUG-IV nursing component per diem
multiplied by 0.80 and the PDPM nursing component per
diem multiplied by 0.20;
(C) for the quarter beginning January 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.60 and the PDPM nursing component per
diem multiplied by 0.40;
(D) for the quarter beginning April 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.40 and the PDPM nursing component per
diem multiplied by 0.60;
(E) for the quarter beginning July 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.20 and the PDPM nursing component per

diem multiplied by 0.80; or
(F) for the quarter beginning October 1, 2023 and
each subsequent quarter, the transition rate shall end
and a nursing facility shall be paid 100% of the PDPM
nursing component per diem.
(d-1) Calculation of base year Statewide RUG-IV nursing
base per diem rate.
(1) Base rate spending pool shall be:
(A) The base year resident days which are
calculated by multiplying the number of Medicaid
residents in each nursing home as indicated in the MDS
data defined in paragraph (4) by 365.
(B) Each facility's nursing component per diem in
effect on July 1, 2012 shall be multiplied by
subsection (A).
(C) Thirteen million is added to the product of
subparagraph (A) and subparagraph (B) to adjust for
the exclusion of nursing homes defined in paragraph
(5).
(2) For each nursing home with Medicaid residents as
indicated by the MDS data defined in paragraph (4),
weighted days adjusted for case mix and regional wage
adjustment shall be calculated. For each home this
calculation is the product of:
(A) Base year resident days as calculated in
subparagraph (A) of paragraph (1).

(B) The nursing home's regional wage adjustor
based on the Health Service Areas (HSA) groupings and
adjustors in effect on April 30, 2012.
(C) Facility weighted case mix which is the number
of Medicaid residents as indicated by the MDS data
defined in paragraph (4) multiplied by the associated
case weight for the RUG-IV 48 grouper model using
standard RUG-IV procedures for index maximization.
(D) The sum of the products calculated for each
nursing home in subparagraphs (A) through (C) above
shall be the base year case mix, rate adjusted
weighted days.
(3) The Statewide RUG-IV nursing base per diem rate:
(A) on January 1, 2014 shall be the quotient of the
paragraph (1) divided by the sum calculated under
subparagraph (D) of paragraph (2);
(B) on and after July 1, 2014 and until July 1,
2022, shall be the amount calculated under
subparagraph (A) of this paragraph (3) plus $1.76; and
(C) beginning July 1, 2022 and thereafter, $7
shall be added to the amount calculated under
subparagraph (B) of this paragraph (3) of this
Section.
(4) Minimum Data Set (MDS) comprehensive assessments
for Medicaid residents on the last day of the quarter used
to establish the base rate.

(5) Nursing facilities designated as of July 1, 2012
by the Department as "Institutions for Mental Disease"
shall be excluded from all calculations under this
subsection. The data from these facilities shall not be
used in the computations described in paragraphs (1)
through (4) above to establish the base rate.
(e) Beginning July 1, 2014, the Department shall allocate
funding in the amount up to $10,000,000 for per diem add-ons to
the RUGS methodology for dates of service on and after July 1,
2014:
(1) $0.63 for each resident who scores in I4200
Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
(2) $2.67 for each resident who scores either a "1" or
"2" in any items S1200A through S1200I and also scores in
RUG groups PA1, PA2, BA1, or BA2.
(e-1) (Blank).
(e-2) For dates of services beginning January 1, 2014 and
ending September 30, 2023, the RUG-IV nursing component per
diem for a nursing home shall be the product of the statewide
RUG-IV nursing base per diem rate, the facility average case
mix index, and the regional wage adjustor. For dates of
service beginning July 1, 2022 and ending September 30, 2023,
the Medicaid access adjustment described in subsection (e-3)
shall be added to the product.
(e-3) A Medicaid Access Adjustment of $4 adjusted for the
facility average PDPM case mix index calculated quarterly

shall be added to the statewide PDPM nursing per diem for all
facilities with annual Medicaid bed days of at least 70% of all
occupied bed days adjusted quarterly. For each new calendar
year and for the 6-month period beginning July 1, 2022, the
percentage of a facility's occupied bed days comprised of
Medicaid bed days shall be determined by the Department
quarterly. For dates of service beginning January 1, 2023, the
Medicaid Access Adjustment shall be increased to $4.75. This
subsection shall be inoperative on and after January 1, 2028.
(f) (Blank).
(g) Notwithstanding any other provision of this Code, on
and after July 1, 2012, for facilities not designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease", rates effective May 1, 2011 shall be
adjusted as follows:
(1) (Blank);
(2) (Blank);
(3) Facility rates for the capital and support
components shall be reduced by 1.7%.
(h) Notwithstanding any other provision of this Code, on
and after July 1, 2012, nursing facilities designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease" and "Institutions for Mental Disease" that
are facilities licensed under the Specialized Mental Health
Rehabilitation Act of 2013 shall have the nursing,
socio-developmental, capital, and support components of their

reimbursement rate effective May 1, 2011 reduced in total by
2.7%.
(i) On and after July 1, 2014, the reimbursement rates for
the support component of the nursing facility rate for
facilities licensed under the Nursing Home Care Act as skilled
or intermediate care facilities shall be the rate in effect on
June 30, 2014 increased by 8.17%.
(i-1) Subject to federal approval, on and after January 1,
2024, the reimbursement rates for the support component of the
nursing facility rate for facilities licensed under the
Nursing Home Care Act as skilled or intermediate care
facilities shall be the rate in effect on June 30, 2023
increased by 12%.
(j) Notwithstanding any other provision of law, subject to
federal approval, effective July 1, 2019, sufficient funds
shall be allocated for changes to rates for facilities
licensed under the Nursing Home Care Act as skilled nursing
facilities or intermediate care facilities for dates of
services on and after July 1, 2019: (i) to establish, through
June 30, 2022 a per diem add-on to the direct care per diem
rate not to exceed $70,000,000 annually in the aggregate
taking into account federal matching funds for the purpose of
addressing the facility's unique staffing needs, adjusted
quarterly and distributed by a weighted formula based on
Medicaid bed days on the last day of the second quarter
preceding the quarter for which the rate is being adjusted.

Beginning July 1, 2022, the annual $70,000,000 described in
the preceding sentence shall be dedicated to the variable per
diem add-on for staffing under paragraph (6) of subsection
(d); and (ii) in an amount not to exceed $170,000,000 annually
in the aggregate taking into account federal matching funds to
permit the support component of the nursing facility rate to
be updated as follows:
(1) 80%, or $136,000,000, of the funds shall be used
to update each facility's rate in effect on June 30, 2019
using the most recent cost reports on file, which have had
a limited review conducted by the Department of Healthcare
and Family Services and will not hold up enacting the rate
increase, with the Department of Healthcare and Family
Services.
(2) After completing the calculation in paragraph (1),
any facility whose rate is less than the rate in effect on
June 30, 2019 shall have its rate restored to the rate in
effect on June 30, 2019 from the 20% of the funds set
aside.
(3) The remainder of the 20%, or $34,000,000, shall be
used to increase each facility's rate by an equal
percentage.
(k) During the first quarter of State Fiscal Year 2020,
the Department of Healthcare of Family Services must convene a
technical advisory group consisting of members of all trade
associations representing Illinois skilled nursing providers

to discuss changes necessary with federal implementation of
Medicare's Patient-Driven Payment Model. Implementation of
Medicare's Patient-Driven Payment Model shall, by September 1,
2020, end the collection of the MDS data that is necessary to
maintain the current RUG-IV Medicaid payment methodology. The
technical advisory group must consider a revised reimbursement
methodology that takes into account transparency,
accountability, actual staffing as reported under the
federally required Payroll Based Journal system, changes to
the minimum wage, adequacy in coverage of the cost of care, and
a quality component that rewards quality improvements.
(l) The Department shall establish per diem add-on
payments to improve the quality of care delivered by
facilities, including:
(1) Incentive payments determined by facility
performance on specified quality measures in an initial
amount of $70,000,000. Nothing in this subsection shall be
construed to limit the quality of care payments in the
aggregate statewide to $70,000,000, and, if quality of
care has improved across nursing facilities, the
Department shall adjust those add-on payments accordingly.
The quality payment methodology described in this
subsection must be used for at least State Fiscal Year
2023. Beginning with the quarter starting July 1, 2023,
the Department may add, remove, or change quality metrics
and make associated changes to the quality payment

methodology as outlined in subparagraph (E). Facilities
designated by the Centers for Medicare and Medicaid
Services as a special focus facility or a hospital-based
nursing home do not qualify for quality payments.
(A) Each quality pool must be distributed by
assigning a quality weighted score for each nursing
home which is calculated by multiplying the nursing
home's quality base period Medicaid days by the
nursing home's star rating weight in that period.
(B) Star rating weights are assigned based on the
nursing home's star rating for the LTS quality star
rating. As used in this subparagraph, "LTS quality
star rating" means the long-term stay quality rating
for each nursing facility, as assigned by the Centers
for Medicare and Medicaid Services under the Five-Star
Quality Rating System. The rating is a number ranging
from 0 (lowest) to 5 (highest).
(i) Zero-star or one-star rating has a weight
of 0.
(ii) Two-star rating has a weight of 0.75.
(iii) Three-star rating has a weight of 1.5.
(iv) Four-star rating has a weight of 2.5.
(v) Five-star rating has a weight of 3.5.
(C) Each nursing home's quality weight score is
divided by the sum of all quality weight scores for
qualifying nursing homes to determine the proportion

of the quality pool to be paid to the nursing home.
(D) The quality pool is no less than $70,000,000
annually or $17,500,000 per quarter. The Department
shall publish on its website the estimated payments
and the associated weights for each facility 45 days
prior to when the initial payments for the quarter are
to be paid. The Department shall assign each facility
the most recent and applicable quarter's STAR value
unless the facility notifies the Department within 15
days of an issue and the facility provides reasonable
evidence demonstrating its timely compliance with
federal data submission requirements for the quarter
of record. If such evidence cannot be provided to the
Department, the STAR rating assigned to the facility
shall be reduced by one from the prior quarter.
(E) The Department shall review quality metrics
used for payment of the quality pool and make
recommendations for any associated changes to the
methodology for distributing quality pool payments in
consultation with associations representing long-term
care providers, consumer advocates, organizations
representing workers of long-term care facilities, and
payors. The Department may establish, by rule, changes
to the methodology for distributing quality pool
payments.
(F) The Department shall disburse quality pool

payments from the Long-Term Care Provider Fund on a
monthly basis in amounts proportional to the total
quality pool payment determined for the quarter.
(G) The Department shall publish any changes in
the methodology for distributing quality pool payments
prior to the beginning of the measurement period or
quality base period for any metric added to the
distribution's methodology.
(2) Payments based on CNA tenure, promotion, and CNA
training for the purpose of increasing CNA compensation.
It is the intent of this subsection that payments made in
accordance with this paragraph be directly incorporated
into increased compensation for CNAs. As used in this
paragraph, "CNA" means a certified nursing assistant as
that term is described in Section 3-206 of the Nursing
Home Care Act, Section 3-206 of the ID/DD Community Care
Act, and Section 3-206 of the MC/DD Act. The Department
shall establish, by rule, payments to nursing facilities
equal to Medicaid's share of the tenure wage increments
specified in this paragraph for all reported CNA employee
hours compensated according to a posted schedule
consisting of increments at least as large as those
specified in this paragraph. The increments are as
follows: an additional $1.50 per hour for CNAs with at
least one and less than 2 years' experience plus another
$1 per hour for each additional year of experience up to a

maximum of $6.50 for CNAs with at least 6 years of
experience. For purposes of this paragraph, Medicaid's
share shall be the ratio determined by paid Medicaid bed
days divided by total bed days for the applicable time
period used in the calculation. In addition, and additive
to any tenure increments paid as specified in this
paragraph, the Department shall establish, by rule,
payments supporting Medicaid's share of the
promotion-based wage increments for CNA employee hours
compensated for that promotion with at least a $1.50
hourly increase. Medicaid's share shall be established as
it is for the tenure increments described in this
paragraph. Qualifying promotions shall be defined by the
Department in rules for an expected 10-15% subset of CNAs
assigned intermediate, specialized, or added roles such as
CNA trainers, CNA scheduling "captains", and CNA
specialists for resident conditions like dementia or
memory care or behavioral health.
(m) The Department shall work with nursing facility
industry representatives to design policies and procedures to
permit facilities to address the integrity of data from
federal reporting sites used by the Department in setting
facility rates.
(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff.
5-31-22; 102-1118, eff. 1-18-23.)

ARTICLE 45.
Section 45-5. The Illinois Act on the Aging is amended by
changing Section 4.02 as follows:
(20 ILCS 105/4.02) (from Ch. 23, par. 6104.02)
Sec. 4.02. Community Care Program. The Department shall
establish a program of services to prevent unnecessary
institutionalization of persons age 60 and older in need of
long term care or who are established as persons who suffer
from Alzheimer's disease or a related disorder under the
Alzheimer's Disease Assistance Act, thereby enabling them to
remain in their own homes or in other living arrangements.
Such preventive services, which may be coordinated with other
programs for the aged and monitored by area agencies on aging
in cooperation with the Department, may include, but are not
limited to, any or all of the following:
(a) (blank);
(b) (blank);
(c) home care aide services;
(d) personal assistant services;
(e) adult day services;
(f) home-delivered meals;
(g) education in self-care;
(h) personal care services;

(i) adult day health services;
(j) habilitation services;
(k) respite care;
(k-5) community reintegration services;
(k-6) flexible senior services;
(k-7) medication management;
(k-8) emergency home response;
(l) other nonmedical social services that may enable
the person to become self-supporting; or
(m) clearinghouse for information provided by senior
citizen home owners who want to rent rooms to or share
living space with other senior citizens.
The Department shall establish eligibility standards for
such services. In determining the amount and nature of
services for which a person may qualify, consideration shall
not be given to the value of cash, property or other assets
held in the name of the person's spouse pursuant to a written
agreement dividing marital property into equal but separate
shares or pursuant to a transfer of the person's interest in a
home to his spouse, provided that the spouse's share of the
marital property is not made available to the person seeking
such services.
Beginning January 1, 2008, the Department shall require as
a condition of eligibility that all new financially eligible
applicants apply for and enroll in medical assistance under
Article V of the Illinois Public Aid Code in accordance with

rules promulgated by the Department.
The Department shall, in conjunction with the Department
of Public Aid (now Department of Healthcare and Family
Services), seek appropriate amendments under Sections 1915 and
1924 of the Social Security Act. The purpose of the amendments
shall be to extend eligibility for home and community based
services under Sections 1915 and 1924 of the Social Security
Act to persons who transfer to or for the benefit of a spouse
those amounts of income and resources allowed under Section
1924 of the Social Security Act. Subject to the approval of
such amendments, the Department shall extend the provisions of
Section 5-4 of the Illinois Public Aid Code to persons who, but
for the provision of home or community-based services, would
require the level of care provided in an institution, as is
provided for in federal law. Those persons no longer found to
be eligible for receiving noninstitutional services due to
changes in the eligibility criteria shall be given 45 days
notice prior to actual termination. Those persons receiving
notice of termination may contact the Department and request
the determination be appealed at any time during the 45 day
notice period. The target population identified for the
purposes of this Section are persons age 60 and older with an
identified service need. Priority shall be given to those who
are at imminent risk of institutionalization. The services
shall be provided to eligible persons age 60 and older to the
extent that the cost of the services together with the other

personal maintenance expenses of the persons are reasonably
related to the standards established for care in a group
facility appropriate to the person's condition. These
non-institutional services, pilot projects or experimental
facilities may be provided as part of or in addition to those
authorized by federal law or those funded and administered by
the Department of Human Services. The Departments of Human
Services, Healthcare and Family Services, Public Health,
Veterans' Affairs, and Commerce and Economic Opportunity and
other appropriate agencies of State, federal and local
governments shall cooperate with the Department on Aging in
the establishment and development of the non-institutional
services. The Department shall require an annual audit from
all personal assistant and home care aide vendors contracting
with the Department under this Section. The annual audit shall
assure that each audited vendor's procedures are in compliance
with Department's financial reporting guidelines requiring an
administrative and employee wage and benefits cost split as
defined in administrative rules. The audit is a public record
under the Freedom of Information Act. The Department shall
execute, relative to the nursing home prescreening project,
written inter-agency agreements with the Department of Human
Services and the Department of Healthcare and Family Services,
to effect the following: (1) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (2) the establishment and

development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped. On and after July 1, 1996, all nursing home
prescreenings for individuals 60 years of age or older shall
be conducted by the Department.
As part of the Department on Aging's routine training of
case managers and case manager supervisors, the Department may
include information on family futures planning for persons who
are age 60 or older and who are caregivers of their adult
children with developmental disabilities. The content of the
training shall be at the Department's discretion.
The Department is authorized to establish a system of
recipient copayment for services provided under this Section,
such copayment to be based upon the recipient's ability to pay
but in no case to exceed the actual cost of the services
provided. Additionally, any portion of a person's income which
is equal to or less than the federal poverty standard shall not
be considered by the Department in determining the copayment.
The level of such copayment shall be adjusted whenever
necessary to reflect any change in the officially designated
federal poverty standard.
The Department, or the Department's authorized
representative, may recover the amount of moneys expended for
services provided to or in behalf of a person under this
Section by a claim against the person's estate or against the
estate of the person's surviving spouse, but no recovery may

be had until after the death of the surviving spouse, if any,
and then only at such time when there is no surviving child who
is under age 21 or blind or who has a permanent and total
disability. This paragraph, however, shall not bar recovery,
at the death of the person, of moneys for services provided to
the person or in behalf of the person under this Section to
which the person was not entitled; provided that such recovery
shall not be enforced against any real estate while it is
occupied as a homestead by the surviving spouse or other
dependent, if no claims by other creditors have been filed
against the estate, or, if such claims have been filed, they
remain dormant for failure of prosecution or failure of the
claimant to compel administration of the estate for the
purpose of payment. This paragraph shall not bar recovery from
the estate of a spouse, under Sections 1915 and 1924 of the
Social Security Act and Section 5-4 of the Illinois Public Aid
Code, who precedes a person receiving services under this
Section in death. All moneys for services paid to or in behalf
of the person under this Section shall be claimed for recovery
from the deceased spouse's estate. "Homestead", as used in
this paragraph, means the dwelling house and contiguous real
estate occupied by a surviving spouse or relative, as defined
by the rules and regulations of the Department of Healthcare
and Family Services, regardless of the value of the property.
The Department shall increase the effectiveness of the
existing Community Care Program by:

(1) ensuring that in-home services included in the
care plan are available on evenings and weekends;
(2) ensuring that care plans contain the services that
eligible participants need based on the number of days in
a month, not limited to specific blocks of time, as
identified by the comprehensive assessment tool selected
by the Department for use statewide, not to exceed the
total monthly service cost maximum allowed for each
service; the Department shall develop administrative rules
to implement this item (2);
(3) ensuring that the participants have the right to
choose the services contained in their care plan and to
direct how those services are provided, based on
administrative rules established by the Department;
(4) ensuring that the determination of need tool is
accurate in determining the participants' level of need;
to achieve this, the Department, in conjunction with the
Older Adult Services Advisory Committee, shall institute a
study of the relationship between the Determination of
Need scores, level of need, service cost maximums, and the
development and utilization of service plans no later than
May 1, 2008; findings and recommendations shall be
presented to the Governor and the General Assembly no
later than January 1, 2009; recommendations shall include
all needed changes to the service cost maximums schedule
and additional covered services;

(5) ensuring that homemakers can provide personal care
services that may or may not involve contact with clients,
including but not limited to:
(A) bathing;
(B) grooming;
(C) toileting;
(D) nail care;
(E) transferring;
(F) respiratory services;
(G) exercise; or
(H) positioning;
(6) ensuring that homemaker program vendors are not
restricted from hiring homemakers who are family members
of clients or recommended by clients; the Department may
not, by rule or policy, require homemakers who are family
members of clients or recommended by clients to accept
assignments in homes other than the client;
(7) ensuring that the State may access maximum federal
matching funds by seeking approval for the Centers for
Medicare and Medicaid Services for modifications to the
State's home and community based services waiver and
additional waiver opportunities, including applying for
enrollment in the Balance Incentive Payment Program by May
1, 2013, in order to maximize federal matching funds; this
shall include, but not be limited to, modification that
reflects all changes in the Community Care Program

services and all increases in the services cost maximum;
(8) ensuring that the determination of need tool
accurately reflects the service needs of individuals with
Alzheimer's disease and related dementia disorders;
(9) ensuring that services are authorized accurately
and consistently for the Community Care Program (CCP); the
Department shall implement a Service Authorization policy
directive; the purpose shall be to ensure that eligibility
and services are authorized accurately and consistently in
the CCP program; the policy directive shall clarify
service authorization guidelines to Care Coordination
Units and Community Care Program providers no later than
May 1, 2013;
(10) working in conjunction with Care Coordination
Units, the Department of Healthcare and Family Services,
the Department of Human Services, Community Care Program
providers, and other stakeholders to make improvements to
the Medicaid claiming processes and the Medicaid
enrollment procedures or requirements as needed,
including, but not limited to, specific policy changes or
rules to improve the up-front enrollment of participants
in the Medicaid program and specific policy changes or
rules to insure more prompt submission of bills to the
federal government to secure maximum federal matching
dollars as promptly as possible; the Department on Aging
shall have at least 3 meetings with stakeholders by

January 1, 2014 in order to address these improvements;
(11) requiring home care service providers to comply
with the rounding of hours worked provisions under the
federal Fair Labor Standards Act (FLSA) and as set forth
in 29 CFR 785.48(b) by May 1, 2013;
(12) implementing any necessary policy changes or
promulgating any rules, no later than January 1, 2014, to
assist the Department of Healthcare and Family Services in
moving as many participants as possible, consistent with
federal regulations, into coordinated care plans if a care
coordination plan that covers long term care is available
in the recipient's area; and
(13) maintaining fiscal year 2014 rates at the same
level established on January 1, 2013.
By January 1, 2009 or as soon after the end of the Cash and
Counseling Demonstration Project as is practicable, the
Department may, based on its evaluation of the demonstration
project, promulgate rules concerning personal assistant
services, to include, but need not be limited to,
qualifications, employment screening, rights under fair labor
standards, training, fiduciary agent, and supervision
requirements. All applicants shall be subject to the
provisions of the Health Care Worker Background Check Act.
The Department shall develop procedures to enhance
availability of services on evenings, weekends, and on an
emergency basis to meet the respite needs of caregivers.

Procedures shall be developed to permit the utilization of
services in successive blocks of 24 hours up to the monthly
maximum established by the Department. Workers providing these
services shall be appropriately trained.
Beginning on the effective date of this amendatory Act of
1991, no person may perform chore/housekeeping and home care
aide services under a program authorized by this Section
unless that person has been issued a certificate of
pre-service to do so by his or her employing agency.
Information gathered to effect such certification shall
include (i) the person's name, (ii) the date the person was
hired by his or her current employer, and (iii) the training,
including dates and levels. Persons engaged in the program
authorized by this Section before the effective date of this
amendatory Act of 1991 shall be issued a certificate of all
pre- and in-service training from his or her employer upon
submitting the necessary information. The employing agency
shall be required to retain records of all staff pre- and
in-service training, and shall provide such records to the
Department upon request and upon termination of the employer's
contract with the Department. In addition, the employing
agency is responsible for the issuance of certifications of
in-service training completed to their employees.
The Department is required to develop a system to ensure
that persons working as home care aides and personal
assistants receive increases in their wages when the federal

minimum wage is increased by requiring vendors to certify that
they are meeting the federal minimum wage statute for home
care aides and personal assistants. An employer that cannot
ensure that the minimum wage increase is being given to home
care aides and personal assistants shall be denied any
increase in reimbursement costs.
The Community Care Program Advisory Committee is created
in the Department on Aging. The Director shall appoint
individuals to serve in the Committee, who shall serve at
their own expense. Members of the Committee must abide by all
applicable ethics laws. The Committee shall advise the
Department on issues related to the Department's program of
services to prevent unnecessary institutionalization. The
Committee shall meet on a bi-monthly basis and shall serve to
identify and advise the Department on present and potential
issues affecting the service delivery network, the program's
clients, and the Department and to recommend solution
strategies. Persons appointed to the Committee shall be
appointed on, but not limited to, their own and their agency's
experience with the program, geographic representation, and
willingness to serve. The Director shall appoint members to
the Committee to represent provider, advocacy, policy
research, and other constituencies committed to the delivery
of high quality home and community-based services to older
adults. Representatives shall be appointed to ensure
representation from community care providers including, but

not limited to, adult day service providers, homemaker
providers, case coordination and case management units,
emergency home response providers, statewide trade or labor
unions that represent home care aides and direct care staff,
area agencies on aging, adults over age 60, membership
organizations representing older adults, and other
organizational entities, providers of care, or individuals
with demonstrated interest and expertise in the field of home
and community care as determined by the Director.
Nominations may be presented from any agency or State
association with interest in the program. The Director, or his
or her designee, shall serve as the permanent co-chair of the
advisory committee. One other co-chair shall be nominated and
approved by the members of the committee on an annual basis.
Committee members' terms of appointment shall be for 4 years
with one-quarter of the appointees' terms expiring each year.
A member shall continue to serve until his or her replacement
is named. The Department shall fill vacancies that have a
remaining term of over one year, and this replacement shall
occur through the annual replacement of expiring terms. The
Director shall designate Department staff to provide technical
assistance and staff support to the committee. Department
representation shall not constitute membership of the
committee. All Committee papers, issues, recommendations,
reports, and meeting memoranda are advisory only. The
Director, or his or her designee, shall make a written report,

as requested by the Committee, regarding issues before the
Committee.
The Department on Aging and the Department of Human
Services shall cooperate in the development and submission of
an annual report on programs and services provided under this
Section. Such joint report shall be filed with the Governor
and the General Assembly on or before March 31 September 30
each year.
The requirement for reporting to the General Assembly
shall be satisfied by filing copies of the report as required
by Section 3.1 of the General Assembly Organization Act and
filing such additional copies with the State Government Report
Distribution Center for the General Assembly as is required
under paragraph (t) of Section 7 of the State Library Act.
Those persons previously found eligible for receiving
non-institutional services whose services were discontinued
under the Emergency Budget Act of Fiscal Year 1992, and who do
not meet the eligibility standards in effect on or after July
1, 1992, shall remain ineligible on and after July 1, 1992.
Those persons previously not required to cost-share and who
were required to cost-share effective March 1, 1992, shall
continue to meet cost-share requirements on and after July 1,
1992. Beginning July 1, 1992, all clients will be required to
meet eligibility, cost-share, and other requirements and will
have services discontinued or altered when they fail to meet
these requirements.

For the purposes of this Section, "flexible senior
services" refers to services that require one-time or periodic
expenditures including, but not limited to, respite care, home
modification, assistive technology, housing assistance, and
transportation.
The Department shall implement an electronic service
verification based on global positioning systems or other
cost-effective technology for the Community Care Program no
later than January 1, 2014.
The Department shall require, as a condition of
eligibility, enrollment in the medical assistance program
under Article V of the Illinois Public Aid Code (i) beginning
August 1, 2013, if the Auditor General has reported that the
Department has failed to comply with the reporting
requirements of Section 2-27 of the Illinois State Auditing
Act; or (ii) beginning June 1, 2014, if the Auditor General has
reported that the Department has not undertaken the required
actions listed in the report required by subsection (a) of
Section 2-27 of the Illinois State Auditing Act.
The Department shall delay Community Care Program services
until an applicant is determined eligible for medical
assistance under Article V of the Illinois Public Aid Code (i)
beginning August 1, 2013, if the Auditor General has reported
that the Department has failed to comply with the reporting
requirements of Section 2-27 of the Illinois State Auditing
Act; or (ii) beginning June 1, 2014, if the Auditor General has

reported that the Department has not undertaken the required
actions listed in the report required by subsection (a) of
Section 2-27 of the Illinois State Auditing Act.
The Department shall implement co-payments for the
Community Care Program at the federally allowable maximum
level (i) beginning August 1, 2013, if the Auditor General has
reported that the Department has failed to comply with the
reporting requirements of Section 2-27 of the Illinois State
Auditing Act; or (ii) beginning June 1, 2014, if the Auditor
General has reported that the Department has not undertaken
the required actions listed in the report required by
subsection (a) of Section 2-27 of the Illinois State Auditing
Act.
The Department shall continue to provide other Community
Care Program reports as required by statute.
The Department shall conduct a quarterly review of Care
Coordination Unit performance and adherence to service
guidelines. The quarterly review shall be reported to the
Speaker of the House of Representatives, the Minority Leader
of the House of Representatives, the President of the Senate,
and the Minority Leader of the Senate. The Department shall
collect and report longitudinal data on the performance of
each care coordination unit. Nothing in this paragraph shall
be construed to require the Department to identify specific
care coordination units.
In regard to community care providers, failure to comply

with Department on Aging policies shall be cause for
disciplinary action, including, but not limited to,
disqualification from serving Community Care Program clients.
Each provider, upon submission of any bill or invoice to the
Department for payment for services rendered, shall include a
notarized statement, under penalty of perjury pursuant to
Section 1-109 of the Code of Civil Procedure, that the
provider has complied with all Department policies.
The Director of the Department on Aging shall make
information available to the State Board of Elections as may
be required by an agreement the State Board of Elections has
entered into with a multi-state voter registration list
maintenance system.
Within 30 days after July 6, 2017 (the effective date of
Public Act 100-23), rates shall be increased to $18.29 per
hour, for the purpose of increasing, by at least $.72 per hour,
the wages paid by those vendors to their employees who provide
homemaker services. The Department shall pay an enhanced rate
under the Community Care Program to those in-home service
provider agencies that offer health insurance coverage as a
benefit to their direct service worker employees consistent
with the mandates of Public Act 95-713. For State fiscal years
2018 and 2019, the enhanced rate shall be $1.77 per hour. The
rate shall be adjusted using actuarial analysis based on the
cost of care, but shall not be set below $1.77 per hour. The
Department shall adopt rules, including emergency rules under

subsections (y) and (bb) of Section 5-45 of the Illinois
Administrative Procedure Act, to implement the provisions of
this paragraph.
Subject to federal approval, on and after January 1, 2024,
rates for homemaker services shall be increased to $28.07 to
sustain a minimum wage of $17 per hour for direct service
workers. Rates in subsequent State fiscal years shall be no
lower than the rates put into effect upon federal approval.
Providers of in-home services shall be required to certify to
the Department that they remain in compliance with the
mandated wage increase for direct service workers. Fringe
benefits, including, but not limited to, paid time off and
payment for training, health insurance, travel, or
transportation, shall not be reduced in relation to the rate
increases described in this paragraph.
The General Assembly finds it necessary to authorize an
aggressive Medicaid enrollment initiative designed to maximize
federal Medicaid funding for the Community Care Program which
produces significant savings for the State of Illinois. The
Department on Aging shall establish and implement a Community
Care Program Medicaid Initiative. Under the Initiative, the
Department on Aging shall, at a minimum: (i) provide an
enhanced rate to adequately compensate care coordination units
to enroll eligible Community Care Program clients into
Medicaid; (ii) use recommendations from a stakeholder
committee on how best to implement the Initiative; and (iii)

establish requirements for State agencies to make enrollment
in the State's Medical Assistance program easier for seniors.
The Community Care Program Medicaid Enrollment Oversight
Subcommittee is created as a subcommittee of the Older Adult
Services Advisory Committee established in Section 35 of the
Older Adult Services Act to make recommendations on how best
to increase the number of medical assistance recipients who
are enrolled in the Community Care Program. The Subcommittee
shall consist of all of the following persons who must be
appointed within 30 days after the effective date of this
amendatory Act of the 100th General Assembly:
(1) The Director of Aging, or his or her designee, who
shall serve as the chairperson of the Subcommittee.
(2) One representative of the Department of Healthcare
and Family Services, appointed by the Director of
Healthcare and Family Services.
(3) One representative of the Department of Human
Services, appointed by the Secretary of Human Services.
(4) One individual representing a care coordination
unit, appointed by the Director of Aging.
(5) One individual from a non-governmental statewide
organization that advocates for seniors, appointed by the
Director of Aging.
(6) One individual representing Area Agencies on
Aging, appointed by the Director of Aging.
(7) One individual from a statewide association

dedicated to Alzheimer's care, support, and research,
appointed by the Director of Aging.
(8) One individual from an organization that employs
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(9) One member of a trade or labor union representing
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(10) One member of the Senate, who shall serve as
co-chairperson, appointed by the President of the Senate.
(11) One member of the Senate, who shall serve as
co-chairperson, appointed by the Minority Leader of the
Senate.
(12) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Speaker of
the House of Representatives.
(13) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Minority
Leader of the House of Representatives.
(14) One individual appointed by a labor organization
representing frontline employees at the Department of
Human Services.
The Subcommittee shall provide oversight to the Community
Care Program Medicaid Initiative and shall meet quarterly. At
each Subcommittee meeting the Department on Aging shall
provide the following data sets to the Subcommittee: (A) the

number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are enrolled in the State's Medical
Assistance Program; (B) the number of Illinois residents,
categorized by planning and service area, who are receiving
services under the Community Care Program, but are not
enrolled in the State's Medical Assistance Program; and (C)
the number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are eligible for benefits under the State's
Medical Assistance Program, but are not enrolled in the
State's Medical Assistance Program. In addition to this data,
the Department on Aging shall provide the Subcommittee with
plans on how the Department on Aging will reduce the number of
Illinois residents who are not enrolled in the State's Medical
Assistance Program but who are eligible for medical assistance
benefits. The Department on Aging shall enroll in the State's
Medical Assistance Program those Illinois residents who
receive services under the Community Care Program and are
eligible for medical assistance benefits but are not enrolled
in the State's Medicaid Assistance Program. The data provided
to the Subcommittee shall be made available to the public via
the Department on Aging's website.
The Department on Aging, with the involvement of the
Subcommittee, shall collaborate with the Department of Human
Services and the Department of Healthcare and Family Services

on how best to achieve the responsibilities of the Community
Care Program Medicaid Initiative.
The Department on Aging, the Department of Human Services,
and the Department of Healthcare and Family Services shall
coordinate and implement a streamlined process for seniors to
access benefits under the State's Medical Assistance Program.
The Subcommittee shall collaborate with the Department of
Human Services on the adoption of a uniform application
submission process. The Department of Human Services and any
other State agency involved with processing the medical
assistance application of any person enrolled in the Community
Care Program shall include the appropriate care coordination
unit in all communications related to the determination or
status of the application.
The Community Care Program Medicaid Initiative shall
provide targeted funding to care coordination units to help
seniors complete their applications for medical assistance
benefits. On and after July 1, 2019, care coordination units
shall receive no less than $200 per completed application,
which rate may be included in a bundled rate for initial intake
services when Medicaid application assistance is provided in
conjunction with the initial intake process for new program
participants.
The Community Care Program Medicaid Initiative shall cease
operation 5 years after the effective date of this amendatory
Act of the 100th General Assembly, after which the

Subcommittee shall dissolve.
(Source: P.A. 101-10, eff. 6-5-19; 102-1071, eff. 6-10-22.)
ARTICLE 50.
Section 50-5. The Illinois Public Aid Code is amended by
changing Section 5-5.2 as follows:
(305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)
Sec. 5-5.2. Payment.
(a) All nursing facilities that are grouped pursuant to
Section 5-5.1 of this Act shall receive the same rate of
payment for similar services.
(b) It shall be a matter of State policy that the Illinois
Department shall utilize a uniform billing cycle throughout
the State for the long-term care providers.
(c) (Blank).
(c-1) Notwithstanding any other provisions of this Code,
the methodologies for reimbursement of nursing services as
provided under this Article shall no longer be applicable for
bills payable for nursing services rendered on or after a new
reimbursement system based on the Patient Driven Payment Model
(PDPM) has been fully operationalized, which shall take effect
for services provided on or after the implementation of the
PDPM reimbursement system begins. For the purposes of this
amendatory Act of the 102nd General Assembly, the

implementation date of the PDPM reimbursement system and all
related provisions shall be July 1, 2022 if the following
conditions are met: (i) the Centers for Medicare and Medicaid
Services has approved corresponding changes in the
reimbursement system and bed assessment; and (ii) the
Department has filed rules to implement these changes no later
than June 1, 2022. Failure of the Department to file rules to
implement the changes provided in this amendatory Act of the
102nd General Assembly no later than June 1, 2022 shall result
in the implementation date being delayed to October 1, 2022.
(d) The new nursing services reimbursement methodology
utilizing the Patient Driven Payment Model, which shall be
referred to as the PDPM reimbursement system, taking effect
July 1, 2022, upon federal approval by the Centers for
Medicare and Medicaid Services, shall be based on the
following:
(1) The methodology shall be resident-centered,
facility-specific, cost-based, and based on guidance from
the Centers for Medicare and Medicaid Services.
(2) Costs shall be annually rebased and case mix index
quarterly updated. The nursing services methodology will
be assigned to the Medicaid enrolled residents on record
as of 30 days prior to the beginning of the rate period in
the Department's Medicaid Management Information System
(MMIS) as present on the last day of the second quarter
preceding the rate period based upon the Assessment

Reference Date of the Minimum Data Set (MDS).
(3) Regional wage adjustors based on the Health
Service Areas (HSA) groupings and adjusters in effect on
April 30, 2012 shall be included, except no adjuster shall
be lower than 1.06.
(4) PDPM nursing case mix indices in effect on March
1, 2022 shall be assigned to each resident class at no less
than 0.7858 of the Centers for Medicare and Medicaid
Services PDPM unadjusted case mix values, in effect on
March 1, 2022.
(5) The pool of funds available for distribution by
case mix and the base facility rate shall be determined
using the formula contained in subsection (d-1).
(6) The Department shall establish a variable per diem
staffing add-on in accordance with the most recent
available federal staffing report, currently the Payroll
Based Journal, for the same period of time, and if
applicable adjusted for acuity using the same quarter's
MDS. The Department shall rely on Payroll Based Journals
provided to the Department of Public Health to make a
determination of non-submission. If the Department is
notified by a facility of missing or inaccurate Payroll
Based Journal data or an incorrect calculation of
staffing, the Department must make a correction as soon as
the error is verified for the applicable quarter.
Facilities with at least 70% of the staffing indicated

by the STRIVE study shall be paid a per diem add-on of $9,
increasing by equivalent steps for each whole percentage
point until the facilities reach a per diem of $14.88.
Facilities with at least 80% of the staffing indicated by
the STRIVE study shall be paid a per diem add-on of $14.88,
increasing by equivalent steps for each whole percentage
point until the facilities reach a per diem add-on of
$23.80. Facilities with at least 92% of the staffing
indicated by the STRIVE study shall be paid a per diem
add-on of $23.80, increasing by equivalent steps for each
whole percentage point until the facilities reach a per
diem add-on of $29.75. Facilities with at least 100% of
the staffing indicated by the STRIVE study shall be paid a
per diem add-on of $29.75, increasing by equivalent steps
for each whole percentage point until the facilities reach
a per diem add-on of $35.70. Facilities with at least 110%
of the staffing indicated by the STRIVE study shall be
paid a per diem add-on of $35.70, increasing by equivalent
steps for each whole percentage point until the facilities
reach a per diem add-on of $38.68. Facilities with at
least 125% or higher of the staffing indicated by the
STRIVE study shall be paid a per diem add-on of $38.68.
Beginning April 1, 2023, no nursing facility's variable
staffing per diem add-on shall be reduced by more than 5%
in 2 consecutive quarters. For the quarters beginning July
1, 2022 and October 1, 2022, no facility's variable per

diem staffing add-on shall be calculated at a rate lower
than 85% of the staffing indicated by the STRIVE study. No
facility below 70% of the staffing indicated by the STRIVE
study shall receive a variable per diem staffing add-on
after December 31, 2022.
(7) For dates of services beginning July 1, 2022, the
PDPM nursing component per diem for each nursing facility
shall be the product of the facility's (i) statewide PDPM
nursing base per diem rate, $92.25, adjusted for the
facility average PDPM case mix index calculated quarterly
and (ii) the regional wage adjuster, and then add the
Medicaid access adjustment as defined in (e-3) of this
Section. Transition rates for services provided between
July 1, 2022 and October 1, 2023 shall be the greater of
the PDPM nursing component per diem or:
(A) for the quarter beginning July 1, 2022, the
RUG-IV nursing component per diem;
(B) for the quarter beginning October 1, 2022, the
sum of the RUG-IV nursing component per diem
multiplied by 0.80 and the PDPM nursing component per
diem multiplied by 0.20;
(C) for the quarter beginning January 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.60 and the PDPM nursing component per
diem multiplied by 0.40;
(D) for the quarter beginning April 1, 2023, the

sum of the RUG-IV nursing component per diem
multiplied by 0.40 and the PDPM nursing component per
diem multiplied by 0.60;
(E) for the quarter beginning July 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.20 and the PDPM nursing component per
diem multiplied by 0.80; or
(F) for the quarter beginning October 1, 2023 and
each subsequent quarter, the transition rate shall end
and a nursing facility shall be paid 100% of the PDPM
nursing component per diem.
(d-1) Calculation of base year Statewide RUG-IV nursing
base per diem rate.
(1) Base rate spending pool shall be:
(A) The base year resident days which are
calculated by multiplying the number of Medicaid
residents in each nursing home as indicated in the MDS
data defined in paragraph (4) by 365.
(B) Each facility's nursing component per diem in
effect on July 1, 2012 shall be multiplied by
subsection (A).
(C) Thirteen million is added to the product of
subparagraph (A) and subparagraph (B) to adjust for
the exclusion of nursing homes defined in paragraph
(5).
(2) For each nursing home with Medicaid residents as

indicated by the MDS data defined in paragraph (4),
weighted days adjusted for case mix and regional wage
adjustment shall be calculated. For each home this
calculation is the product of:
(A) Base year resident days as calculated in
subparagraph (A) of paragraph (1).
(B) The nursing home's regional wage adjustor
based on the Health Service Areas (HSA) groupings and
adjustors in effect on April 30, 2012.
(C) Facility weighted case mix which is the number
of Medicaid residents as indicated by the MDS data
defined in paragraph (4) multiplied by the associated
case weight for the RUG-IV 48 grouper model using
standard RUG-IV procedures for index maximization.
(D) The sum of the products calculated for each
nursing home in subparagraphs (A) through (C) above
shall be the base year case mix, rate adjusted
weighted days.
(3) The Statewide RUG-IV nursing base per diem rate:
(A) on January 1, 2014 shall be the quotient of the
paragraph (1) divided by the sum calculated under
subparagraph (D) of paragraph (2);
(B) on and after July 1, 2014 and until July 1,
2022, shall be the amount calculated under
subparagraph (A) of this paragraph (3) plus $1.76; and
(C) beginning July 1, 2022 and thereafter, $7

shall be added to the amount calculated under
subparagraph (B) of this paragraph (3) of this
Section.
(4) Minimum Data Set (MDS) comprehensive assessments
for Medicaid residents on the last day of the quarter used
to establish the base rate.
(5) Nursing facilities designated as of July 1, 2012
by the Department as "Institutions for Mental Disease"
shall be excluded from all calculations under this
subsection. The data from these facilities shall not be
used in the computations described in paragraphs (1)
through (4) above to establish the base rate.
(e) Beginning July 1, 2014, the Department shall allocate
funding in the amount up to $10,000,000 for per diem add-ons to
the RUGS methodology for dates of service on and after July 1,
2014:
(1) $0.63 for each resident who scores in I4200
Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
(2) $2.67 for each resident who scores either a "1" or
"2" in any items S1200A through S1200I and also scores in
RUG groups PA1, PA2, BA1, or BA2.
(e-1) (Blank).
(e-2) For dates of services beginning January 1, 2014 and
ending September 30, 2023, the RUG-IV nursing component per
diem for a nursing home shall be the product of the statewide
RUG-IV nursing base per diem rate, the facility average case

mix index, and the regional wage adjustor. For dates of
service beginning July 1, 2022 and ending September 30, 2023,
the Medicaid access adjustment described in subsection (e-3)
shall be added to the product.
(e-3) A Medicaid Access Adjustment of $4 adjusted for the
facility average PDPM case mix index calculated quarterly
shall be added to the statewide PDPM nursing per diem for all
facilities with annual Medicaid bed days of at least 70% of all
occupied bed days adjusted quarterly. For each new calendar
year and for the 6-month period beginning July 1, 2022, the
percentage of a facility's occupied bed days comprised of
Medicaid bed days shall be determined by the Department
quarterly. For dates of service beginning January 1, 2023, the
Medicaid Access Adjustment shall be increased to $4.75. This
subsection shall be inoperative on and after January 1, 2028.
(e-4) Subject to federal approval, on and after January 1,
2024, the Department shall increase the rate add-on at
paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
for ventilator services from $208 per day to $481 per day.
Payment is subject to the criteria and requirements under 89
Ill. Adm. Code 147.335.
(f) (Blank).
(g) Notwithstanding any other provision of this Code, on
and after July 1, 2012, for facilities not designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease", rates effective May 1, 2011 shall be

adjusted as follows:
(1) (Blank);
(2) (Blank);
(3) Facility rates for the capital and support
components shall be reduced by 1.7%.
(h) Notwithstanding any other provision of this Code, on
and after July 1, 2012, nursing facilities designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease" and "Institutions for Mental Disease" that
are facilities licensed under the Specialized Mental Health
Rehabilitation Act of 2013 shall have the nursing,
socio-developmental, capital, and support components of their
reimbursement rate effective May 1, 2011 reduced in total by
2.7%.
(i) On and after July 1, 2014, the reimbursement rates for
the support component of the nursing facility rate for
facilities licensed under the Nursing Home Care Act as skilled
or intermediate care facilities shall be the rate in effect on
June 30, 2014 increased by 8.17%.
(j) Notwithstanding any other provision of law, subject to
federal approval, effective July 1, 2019, sufficient funds
shall be allocated for changes to rates for facilities
licensed under the Nursing Home Care Act as skilled nursing
facilities or intermediate care facilities for dates of
services on and after July 1, 2019: (i) to establish, through
June 30, 2022 a per diem add-on to the direct care per diem

rate not to exceed $70,000,000 annually in the aggregate
taking into account federal matching funds for the purpose of
addressing the facility's unique staffing needs, adjusted
quarterly and distributed by a weighted formula based on
Medicaid bed days on the last day of the second quarter
preceding the quarter for which the rate is being adjusted.
Beginning July 1, 2022, the annual $70,000,000 described in
the preceding sentence shall be dedicated to the variable per
diem add-on for staffing under paragraph (6) of subsection
(d); and (ii) in an amount not to exceed $170,000,000 annually
in the aggregate taking into account federal matching funds to
permit the support component of the nursing facility rate to
be updated as follows:
(1) 80%, or $136,000,000, of the funds shall be used
to update each facility's rate in effect on June 30, 2019
using the most recent cost reports on file, which have had
a limited review conducted by the Department of Healthcare
and Family Services and will not hold up enacting the rate
increase, with the Department of Healthcare and Family
Services.
(2) After completing the calculation in paragraph (1),
any facility whose rate is less than the rate in effect on
June 30, 2019 shall have its rate restored to the rate in
effect on June 30, 2019 from the 20% of the funds set
aside.
(3) The remainder of the 20%, or $34,000,000, shall be

used to increase each facility's rate by an equal
percentage.
(k) During the first quarter of State Fiscal Year 2020,
the Department of Healthcare of Family Services must convene a
technical advisory group consisting of members of all trade
associations representing Illinois skilled nursing providers
to discuss changes necessary with federal implementation of
Medicare's Patient-Driven Payment Model. Implementation of
Medicare's Patient-Driven Payment Model shall, by September 1,
2020, end the collection of the MDS data that is necessary to
maintain the current RUG-IV Medicaid payment methodology. The
technical advisory group must consider a revised reimbursement
methodology that takes into account transparency,
accountability, actual staffing as reported under the
federally required Payroll Based Journal system, changes to
the minimum wage, adequacy in coverage of the cost of care, and
a quality component that rewards quality improvements.
(l) The Department shall establish per diem add-on
payments to improve the quality of care delivered by
facilities, including:
(1) Incentive payments determined by facility
performance on specified quality measures in an initial
amount of $70,000,000. Nothing in this subsection shall be
construed to limit the quality of care payments in the
aggregate statewide to $70,000,000, and, if quality of
care has improved across nursing facilities, the

Department shall adjust those add-on payments accordingly.
The quality payment methodology described in this
subsection must be used for at least State Fiscal Year
2023. Beginning with the quarter starting July 1, 2023,
the Department may add, remove, or change quality metrics
and make associated changes to the quality payment
methodology as outlined in subparagraph (E). Facilities
designated by the Centers for Medicare and Medicaid
Services as a special focus facility or a hospital-based
nursing home do not qualify for quality payments.
(A) Each quality pool must be distributed by
assigning a quality weighted score for each nursing
home which is calculated by multiplying the nursing
home's quality base period Medicaid days by the
nursing home's star rating weight in that period.
(B) Star rating weights are assigned based on the
nursing home's star rating for the LTS quality star
rating. As used in this subparagraph, "LTS quality
star rating" means the long-term stay quality rating
for each nursing facility, as assigned by the Centers
for Medicare and Medicaid Services under the Five-Star
Quality Rating System. The rating is a number ranging
from 0 (lowest) to 5 (highest).
(i) Zero-star or one-star rating has a weight
of 0.
(ii) Two-star rating has a weight of 0.75.

(iii) Three-star rating has a weight of 1.5.
(iv) Four-star rating has a weight of 2.5.
(v) Five-star rating has a weight of 3.5.
(C) Each nursing home's quality weight score is
divided by the sum of all quality weight scores for
qualifying nursing homes to determine the proportion
of the quality pool to be paid to the nursing home.
(D) The quality pool is no less than $70,000,000
annually or $17,500,000 per quarter. The Department
shall publish on its website the estimated payments
and the associated weights for each facility 45 days
prior to when the initial payments for the quarter are
to be paid. The Department shall assign each facility
the most recent and applicable quarter's STAR value
unless the facility notifies the Department within 15
days of an issue and the facility provides reasonable
evidence demonstrating its timely compliance with
federal data submission requirements for the quarter
of record. If such evidence cannot be provided to the
Department, the STAR rating assigned to the facility
shall be reduced by one from the prior quarter.
(E) The Department shall review quality metrics
used for payment of the quality pool and make
recommendations for any associated changes to the
methodology for distributing quality pool payments in
consultation with associations representing long-term

care providers, consumer advocates, organizations
representing workers of long-term care facilities, and
payors. The Department may establish, by rule, changes
to the methodology for distributing quality pool
payments.
(F) The Department shall disburse quality pool
payments from the Long-Term Care Provider Fund on a
monthly basis in amounts proportional to the total
quality pool payment determined for the quarter.
(G) The Department shall publish any changes in
the methodology for distributing quality pool payments
prior to the beginning of the measurement period or
quality base period for any metric added to the
distribution's methodology.
(2) Payments based on CNA tenure, promotion, and CNA
training for the purpose of increasing CNA compensation.
It is the intent of this subsection that payments made in
accordance with this paragraph be directly incorporated
into increased compensation for CNAs. As used in this
paragraph, "CNA" means a certified nursing assistant as
that term is described in Section 3-206 of the Nursing
Home Care Act, Section 3-206 of the ID/DD Community Care
Act, and Section 3-206 of the MC/DD Act. The Department
shall establish, by rule, payments to nursing facilities
equal to Medicaid's share of the tenure wage increments
specified in this paragraph for all reported CNA employee

hours compensated according to a posted schedule
consisting of increments at least as large as those
specified in this paragraph. The increments are as
follows: an additional $1.50 per hour for CNAs with at
least one and less than 2 years' experience plus another
$1 per hour for each additional year of experience up to a
maximum of $6.50 for CNAs with at least 6 years of
experience. For purposes of this paragraph, Medicaid's
share shall be the ratio determined by paid Medicaid bed
days divided by total bed days for the applicable time
period used in the calculation. In addition, and additive
to any tenure increments paid as specified in this
paragraph, the Department shall establish, by rule,
payments supporting Medicaid's share of the
promotion-based wage increments for CNA employee hours
compensated for that promotion with at least a $1.50
hourly increase. Medicaid's share shall be established as
it is for the tenure increments described in this
paragraph. Qualifying promotions shall be defined by the
Department in rules for an expected 10-15% subset of CNAs
assigned intermediate, specialized, or added roles such as
CNA trainers, CNA scheduling "captains", and CNA
specialists for resident conditions like dementia or
memory care or behavioral health.
(m) The Department shall work with nursing facility
industry representatives to design policies and procedures to

permit facilities to address the integrity of data from
federal reporting sites used by the Department in setting
facility rates.
(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff.
5-31-22; 102-1118, eff. 1-18-23.)
ARTICLE 55.
Section 55-5. The Illinois Public Aid Code is amended by
adding Section 5-5i as follows:
(305 ILCS 5/5-5i new)
Sec. 5-5i. Rate increase for speech, physical, and
occupational therapy services. Subject to federal approval,
beginning January 1, 2024, the Department shall increase
reimbursement rates for speech therapy services, physical
therapy services, and occupational therapy services provided
by licensed speech-language pathologists and speech-language
pathology assistants, physical therapists and physical therapy
assistants, and occupational therapists and certified
occupational therapy assistants, including those in their
clinical fellowship, by 14.2%.
ARTICLE 60.

Section 60-5. The Illinois Public Aid Code is amended by
adding Section 5-35.5 as follows:
(305 ILCS 5/5-35.5 new)
Sec. 5-35.5. Personal needs allowance; nursing home
residents. Subject to federal approval, on and after January
1, 2024, for a person who is a resident in a facility licensed
under the Nursing Home Care Act for whom payments are made
under this Article throughout a month and who is determined to
be eligible for medical assistance under this Article, the
monthly personal needs allowance shall be $60.
ARTICLE 65.
Section 65-5. The Rebuild Illinois Mental Health Workforce
Act is amended by changing Sections 20-10 and 20-20 and by
adding Section 20-22 as follows:
(305 ILCS 66/20-10)
Sec. 20-10. Medicaid funding for community mental health
services. Medicaid funding for the specific community mental
health services listed in this Act shall be adjusted and paid
as set forth in this Act. Such payments shall be paid in
addition to the base Medicaid reimbursement rate and add-on
payment rates per service unit.
(a) The payment adjustments shall begin on July 1, 2022

for State Fiscal Year 2023 and shall continue for every State
fiscal year thereafter.
(1) Individual Therapy Medicaid Payment rate for
services provided under the H0004 Code:
(A) The Medicaid total payment rate for individual
therapy provided by a qualified mental health
professional shall be increased by no less than $9 per
service unit.
(B) The Medicaid total payment rate for individual
therapy provided by a mental health professional shall
be increased by no less than then $9 per service unit.
(2) Community Support - Individual Medicaid Payment
rate for services provided under the H2015 Code: All
community support - individual services shall be increased
by no less than $15 per service unit.
(3) Case Management Medicaid Add-on Payment for
services provided under the T1016 code: All case
management services rates shall be increased by no less
than $15 per service unit.
(4) Assertive Community Treatment Medicaid Add-on
Payment for services provided under the H0039 code: The
Medicaid total payment rate for assertive community
treatment services shall increase by no less than $8 per
service unit.
(5) Medicaid user-based directed payments.
(A) For each State fiscal year, a monthly directed

payment shall be paid to a community mental health
provider of community support team services based on
the number of Medicaid users of community support team
services documented by Medicaid fee-for-service and
managed care encounter claims delivered by that
provider in the base year. The Department of
Healthcare and Family Services shall make the monthly
directed payment to each provider entitled to directed
payments under this Act by no later than the last day
of each month throughout each State fiscal year.
(i) The monthly directed payment for a
community support team provider shall be
calculated as follows: The sum total number of
individual Medicaid users of community support
team services delivered by that provider
throughout the base year, multiplied by $4,200 per
Medicaid user, divided into 12 equal monthly
payments for the State fiscal year.
(ii) As used in this subparagraph, "user"
means an individual who received at least 200
units of community support team services (H2016)
during the base year.
(B) For each State fiscal year, a monthly directed
payment shall be paid to each community mental health
provider of assertive community treatment services
based on the number of Medicaid users of assertive

community treatment services documented by Medicaid
fee-for-service and managed care encounter claims
delivered by the provider in the base year.
(i) The monthly direct payment for an
assertive community treatment provider shall be
calculated as follows: The sum total number of
Medicaid users of assertive community treatment
services provided by that provider throughout the
base year, multiplied by $6,000 per Medicaid user,
divided into 12 equal monthly payments for that
State fiscal year.
(ii) As used in this subparagraph, "user"
means an individual that received at least 300
units of assertive community treatment services
during the base year.
(C) The base year for directed payments under this
Section shall be calendar year 2019 for State Fiscal
Year 2023 and State Fiscal Year 2024. For the State
fiscal year beginning on July 1, 2024, and for every
State fiscal year thereafter, the base year shall be
the calendar year that ended 18 months prior to the
start of the State fiscal year in which payments are
made.
(b) Subject to federal approval, a one-time directed
payment must be made in calendar year 2023 for community
mental health services provided by community mental health

providers. The one-time directed payment shall be for an
amount appropriated for these purposes. The one-time directed
payment shall be for services for Integrated Assessment and
Treatment Planning and other intensive services, including,
but not limited to, services for Mobile Crisis Response,
crisis intervention, and medication monitoring. The amounts
and services used for designing and distributing these
one-time directed payments shall not be construed to require
any future rate or funding increases for the same or other
mental health services.
(c) The following payment adjustments shall be made:
(1) Subject to federal approval, beginning on January
1, 2024, the Department shall introduce rate increases to
behavioral health services no less than by the following
targeted pool for the specified services provided by
community mental health centers:
(A) Mobile Crisis Response, $6,800,000;
(B) Crisis Intervention, $4,000,000;
(C) Integrative Assessment and Treatment Planning
services, $10,500,000;
(D) Group Therapy, $1,200,000;
(E) Family Therapy, $500,000;
(F) Community Support Group, $4,000,000; and
(G) Medication Monitoring, $3,000,000.
(2) Rate increases shall be determined with
significant input from Illinois behavioral health trade

associations and advocates. The Department must use
service units delivered under the fee-for-service and
managed care programs by community mental health centers
during State Fiscal Year 2022. These services are used for
distributing the targeted pools and setting rates but do
not prohibit the Department from paying providers not
enrolled as community mental health centers the same rate
if providing the same services.
(d) Rate simplification for team-based services.
(1) The Department shall work with stakeholders to
redesign reimbursement rates for behavioral health
team-based services established under the Rehabilitation
Option of the Illinois Medicaid State Plan supporting
individuals with chronic or complex behavioral health
conditions and crisis services. Subject to federal
approval, the redesigned rates shall seek to introduce
bundled payment systems that minimize provider claiming
activities while transitioning the focus of treatment
towards metrics and outcomes. Federally approved rate
models shall seek to ensure reimbursement levels are no
less than the State's total reimbursement for similar
services in calendar year 2023, including all service
level payments, add-ons, and all other payments specified
in this Section.
(2) In State Fiscal Year 2024, the Department shall
identify an existing, or establish a new, Behavioral

Health Outcomes Stakeholder Workgroup to help inform the
identification of metrics and outcomes for team-based
services.
(3) In State Fiscal Year 2025, subject to federal
approval, the Department shall introduce a
pay-for-performance model for team-based services to be
informed by the Behavioral Health Outcomes Stakeholder
Workgroup.
(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23;
revised 1-23-23.)
(305 ILCS 66/20-20)
Sec. 20-20. Base Medicaid rates or add-on payments.
(a) For services under subsection (a) of Section 20-10: .
No base Medicaid rate or Medicaid rate add-on payment or
any other payment for the provision of Medicaid community
mental health services in place on July 1, 2021 shall be
diminished or changed to make the reimbursement changes
required by this Act. Any payments required under this Act
that are delayed due to implementation challenges or federal
approval shall be made retroactive to July 1, 2022 for the full
amount required by this Act.
(b) For directed payments under subsection (b) of Section
20-10: .
No base Medicaid rate payment or any other payment for the
provision of Medicaid community mental health services in

place on January 1, 2023 shall be diminished or changed to make
the reimbursement changes required by this Act. The Department
of Healthcare and Family Services must pay the directed
payment in one installment within 60 days of receiving federal
approval.
(c) For directed payments under subsection (c) of Section
20-10:
No base Medicaid rate payment or any other payment for the
provision of Medicaid community mental health services in
place on January 1, 2023 shall be diminished or changed to make
the reimbursement changes required by this amendatory Act of
the 103rd General Assembly. Any payments required under this
amendatory Act of the 103rd General Assembly that are delayed
due to implementation challenges or federal approval shall be
made retroactive to no later than January 1, 2024 for the full
amount required by this amendatory Act of the 103rd General
Assembly.
(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23.)
(305 ILCS 66/20-22 new)
Sec. 20-22. Implementation plan for cost reporting.
(a) For the purpose of understanding behavioral health
services cost structures and their impact on the Illinois
Medical Assistance Program, the Department shall engage
stakeholders to develop a plan for the regular collection of
cost reporting for all entity-based providers of behavioral

health services reimbursed under the Rehabilitation or
Prevention authorities of the Illinois Medicaid State Plan.
Data shall be used to inform on the effectiveness and
efficiency of Illinois Medicaid rates. The plan at minimum
should consider the following:
(1) alignment with certified community behavioral
health clinic requirements, standards, policies, and
procedures;
(2) inclusion of prospective costs to measure what is
needed to increase services and capacity;
(3) consideration of differences in collection and
policies based on the size of providers;
(4) consideration of additional administrative time
and costs;
(5) goals, purposes, and usage of data collected from
cost reports;
(6) inclusion of qualitative data in addition to
quantitative data;
(7) technical assistance for providers for completing
cost reports including initial training by the Department
for providers; and
(8) an implementation timeline that allows an initial
grace period for providers to adjust internal procedures
and data collection.
Details from collected cost reports shall be made publicly
available on the Department's website and costs shall be used

to ensure the effectiveness and efficiency of Illinois
Medicaid rates.
(b) The Department and stakeholders shall develop a plan
by April 1, 2024. The Department shall engage stakeholders on
implementation of the plan.
ARTICLE 70.
Section 70-5. The Illinois Public Aid Code is amended by
changing Section 5-4.2 as follows:
(305 ILCS 5/5-4.2)
Sec. 5-4.2. Ambulance services payments.
(a) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1993, the Illinois
Department shall reimburse ambulance service providers at
rates calculated in accordance with this Section. It is the
intent of the General Assembly to provide adequate
reimbursement for ambulance services so as to ensure adequate
access to services for recipients of aid under this Article
and to provide appropriate incentives to ambulance service
providers to provide services in an efficient and
cost-effective manner. Thus, it is the intent of the General
Assembly that the Illinois Department implement a
reimbursement system for ambulance services that, to the
extent practicable and subject to the availability of funds

appropriated by the General Assembly for this purpose, is
consistent with the payment principles of Medicare. To ensure
uniformity between the payment principles of Medicare and
Medicaid, the Illinois Department shall follow, to the extent
necessary and practicable and subject to the availability of
funds appropriated by the General Assembly for this purpose,
the statutes, laws, regulations, policies, procedures,
principles, definitions, guidelines, and manuals used to
determine the amounts paid to ambulance service providers
under Title XVIII of the Social Security Act (Medicare).
(b) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1996, the Illinois
Department shall reimburse ambulance service providers based
upon the actual distance traveled if a natural disaster,
weather conditions, road repairs, or traffic congestion
necessitates the use of a route other than the most direct
route.
(c) For purposes of this Section, "ambulance services"
includes medical transportation services provided by means of
an ambulance, air ambulance, medi-car, service car, or taxi.
(c-1) For purposes of this Section, "ground ambulance
service" means medical transportation services that are
described as ground ambulance services by the Centers for
Medicare and Medicaid Services and provided in a vehicle that
is licensed as an ambulance by the Illinois Department of
Public Health pursuant to the Emergency Medical Services (EMS)

Systems Act.
(c-2) For purposes of this Section, "ground ambulance
service provider" means a vehicle service provider as
described in the Emergency Medical Services (EMS) Systems Act
that operates licensed ambulances for the purpose of providing
emergency ambulance services, or non-emergency ambulance
services, or both. For purposes of this Section, this includes
both ambulance providers and ambulance suppliers as described
by the Centers for Medicare and Medicaid Services.
(c-3) For purposes of this Section, "medi-car" means
transportation services provided to a patient who is confined
to a wheelchair and requires the use of a hydraulic or electric
lift or ramp and wheelchair lockdown when the patient's
condition does not require medical observation, medical
supervision, medical equipment, the administration of
medications, or the administration of oxygen.
(c-4) For purposes of this Section, "service car" means
transportation services provided to a patient by a passenger
vehicle where that patient does not require the specialized
modes described in subsection (c-1) or (c-3).
(c-5) For purposes of this Section, "air ambulance
service" means medical transport by helicopter or airplane for
patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
that is described as an air ambulance service by the federal
Centers for Medicare and Medicaid Services.
(d) This Section does not prohibit separate billing by

ambulance service providers for oxygen furnished while
providing advanced life support services.
(e) Beginning with services rendered on or after July 1,
2008, all providers of non-emergency medi-car and service car
transportation must certify that the driver and employee
attendant, as applicable, have completed a safety program
approved by the Department to protect both the patient and the
driver, prior to transporting a patient. The provider must
maintain this certification in its records. The provider shall
produce such documentation upon demand by the Department or
its representative. Failure to produce documentation of such
training shall result in recovery of any payments made by the
Department for services rendered by a non-certified driver or
employee attendant. Medi-car and service car providers must
maintain legible documentation in their records of the driver
and, as applicable, employee attendant that actually
transported the patient. Providers must recertify all drivers
and employee attendants every 3 years. If they meet the
established training components set forth by the Department,
providers of non-emergency medi-car and service car
transportation that are either directly or through an
affiliated company licensed by the Department of Public Health
shall be approved by the Department to have in-house safety
programs for training their own staff.
Notwithstanding the requirements above, any public
transportation provider of medi-car and service car

transportation that receives federal funding under 49 U.S.C.
5307 and 5311 need not certify its drivers and employee
attendants under this Section, since safety training is
already federally mandated.
(f) With respect to any policy or program administered by
the Department or its agent regarding approval of
non-emergency medical transportation by ground ambulance
service providers, including, but not limited to, the
Non-Emergency Transportation Services Prior Approval Program
(NETSPAP), the Department shall establish by rule a process by
which ground ambulance service providers of non-emergency
medical transportation may appeal any decision by the
Department or its agent for which no denial was received prior
to the time of transport that either (i) denies a request for
approval for payment of non-emergency transportation by means
of ground ambulance service or (ii) grants a request for
approval of non-emergency transportation by means of ground
ambulance service at a level of service that entitles the
ground ambulance service provider to a lower level of
compensation from the Department than the ground ambulance
service provider would have received as compensation for the
level of service requested. The rule shall be filed by
December 15, 2012 and shall provide that, for any decision
rendered by the Department or its agent on or after the date
the rule takes effect, the ground ambulance service provider
shall have 60 days from the date the decision is received to

file an appeal. The rule established by the Department shall
be, insofar as is practical, consistent with the Illinois
Administrative Procedure Act. The Director's decision on an
appeal under this Section shall be a final administrative
decision subject to review under the Administrative Review
Law.
(f-5) Beginning 90 days after July 20, 2012 (the effective
date of Public Act 97-842), (i) no denial of a request for
approval for payment of non-emergency transportation by means
of ground ambulance service, and (ii) no approval of
non-emergency transportation by means of ground ambulance
service at a level of service that entitles the ground
ambulance service provider to a lower level of compensation
from the Department than would have been received at the level
of service submitted by the ground ambulance service provider,
may be issued by the Department or its agent unless the
Department has submitted the criteria for determining the
appropriateness of the transport for first notice publication
in the Illinois Register pursuant to Section 5-40 of the
Illinois Administrative Procedure Act.
(f-6) Within 90 days after the effective date of this
amendatory Act of the 102nd General Assembly and subject to
federal approval, the Department shall file rules to allow for
the approval of ground ambulance services when the sole
purpose of the transport is for the navigation of stairs or the
assisting or lifting of a patient at a medical facility or

during a medical appointment in instances where the Department
or a contracted Medicaid managed care organization or their
transportation broker is unable to secure transportation
through any other transportation provider.
(f-7) For non-emergency ground ambulance claims properly
denied under Department policy at the time the claim is filed
due to failure to submit a valid Medical Certification for
Non-Emergency Ambulance on and after December 15, 2012 and
prior to January 1, 2021, the Department shall allot
$2,000,000 to a pool to reimburse such claims if the provider
proves medical necessity for the service by other means.
Providers must submit any such denied claims for which they
seek compensation to the Department no later than December 31,
2021 along with documentation of medical necessity. No later
than May 31, 2022, the Department shall determine for which
claims medical necessity was established. Such claims for
which medical necessity was established shall be paid at the
rate in effect at the time of the service, provided the
$2,000,000 is sufficient to pay at those rates. If the pool is
not sufficient, claims shall be paid at a uniform percentage
of the applicable rate such that the pool of $2,000,000 is
exhausted. The appeal process described in subsection (f)
shall not be applicable to the Department's determinations
made in accordance with this subsection.
(g) Whenever a patient covered by a medical assistance
program under this Code or by another medical program

administered by the Department, including a patient covered
under the State's Medicaid managed care program, is being
transported from a facility and requires non-emergency
transportation including ground ambulance, medi-car, or
service car transportation, a Physician Certification
Statement as described in this Section shall be required for
each patient. Facilities shall develop procedures for a
licensed medical professional to provide a written and signed
Physician Certification Statement. The Physician Certification
Statement shall specify the level of transportation services
needed and complete a medical certification establishing the
criteria for approval of non-emergency ambulance
transportation, as published by the Department of Healthcare
and Family Services, that is met by the patient. This
certification shall be completed prior to ordering the
transportation service and prior to patient discharge. The
Physician Certification Statement is not required prior to
transport if a delay in transport can be expected to
negatively affect the patient outcome. If the ground ambulance
provider, medi-car provider, or service car provider is unable
to obtain the required Physician Certification Statement
within 10 calendar days following the date of the service, the
ground ambulance provider, medi-car provider, or service car
provider must document its attempt to obtain the requested
certification and may then submit the claim for payment.
Acceptable documentation includes a signed return receipt from

the U.S. Postal Service, facsimile receipt, email receipt, or
other similar service that evidences that the ground ambulance
provider, medi-car provider, or service car provider attempted
to obtain the required Physician Certification Statement.
The medical certification specifying the level and type of
non-emergency transportation needed shall be in the form of
the Physician Certification Statement on a standardized form
prescribed by the Department of Healthcare and Family
Services. Within 75 days after July 27, 2018 (the effective
date of Public Act 100-646), the Department of Healthcare and
Family Services shall develop a standardized form of the
Physician Certification Statement specifying the level and
type of transportation services needed in consultation with
the Department of Public Health, Medicaid managed care
organizations, a statewide association representing ambulance
providers, a statewide association representing hospitals, 3
statewide associations representing nursing homes, and other
stakeholders. The Physician Certification Statement shall
include, but is not limited to, the criteria necessary to
demonstrate medical necessity for the level of transport
needed as required by (i) the Department of Healthcare and
Family Services and (ii) the federal Centers for Medicare and
Medicaid Services as outlined in the Centers for Medicare and
Medicaid Services' Medicare Benefit Policy Manual, Pub.
100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
Certification Statement shall satisfy the obligations of

hospitals under Section 6.22 of the Hospital Licensing Act and
nursing homes under Section 2-217 of the Nursing Home Care
Act. Implementation and acceptance of the Physician
Certification Statement shall take place no later than 90 days
after the issuance of the Physician Certification Statement by
the Department of Healthcare and Family Services.
Pursuant to subsection (E) of Section 12-4.25 of this
Code, the Department is entitled to recover overpayments paid
to a provider or vendor, including, but not limited to, from
the discharging physician, the discharging facility, and the
ground ambulance service provider, in instances where a
non-emergency ground ambulance service is rendered as the
result of improper or false certification.
Beginning October 1, 2018, the Department of Healthcare
and Family Services shall collect data from Medicaid managed
care organizations and transportation brokers, including the
Department's NETSPAP broker, regarding denials and appeals
related to the missing or incomplete Physician Certification
Statement forms and overall compliance with this subsection.
The Department of Healthcare and Family Services shall publish
quarterly results on its website within 15 days following the
end of each quarter.
(h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in

accordance with Section 5-5e.
(i) On and after July 1, 2018, the Department shall
increase the base rate of reimbursement for both base charges
and mileage charges for ground ambulance service providers for
medical transportation services provided by means of a ground
ambulance to a level not lower than 112% of the base rate in
effect as of June 30, 2018.
(j) Subject to federal approval, beginning on January 1,
2024, the Department shall increase the base rate of
reimbursement for both base charges and mileage charges for
medical transportation services provided by means of an air
ambulance to a level not lower than 50% of the Medicare
ambulance fee schedule rates, by designated Medicare locality,
in effect on January 1, 2023.
(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff.
5-13-22; 102-1037, eff. 6-2-22.)
ARTICLE 75.
Section 75-5. The Illinois Public Aid Code is amended by
changing Section 5-5.4h as follows:
(305 ILCS 5/5-5.4h)
Sec. 5-5.4h. Medicaid reimbursement for medically complex
for the developmentally disabled facilities licensed under the

MC/DD Act.
(a) Facilities licensed as medically complex for the
developmentally disabled facilities that serve severely and
chronically ill patients shall have a specific reimbursement
system designed to recognize the characteristics and needs of
the patients they serve.
(b) For dates of services starting July 1, 2013 and until a
new reimbursement system is designed, medically complex for
the developmentally disabled facilities that meet the
following criteria:
(1) serve exceptional care patients; and
(2) have 30% or more of their patients receiving
ventilator care;
shall receive Medicaid reimbursement on a 30-day expedited
schedule.
(c) Subject to federal approval of changes to the Title
XIX State Plan, for dates of services starting July 1, 2014
through March 31, 2019, medically complex for the
developmentally disabled facilities which meet the criteria in
subsection (b) of this Section shall receive a per diem rate
for clinically complex residents of $304. Clinically complex
residents on a ventilator shall receive a per diem rate of
$669. Subject to federal approval of changes to the Title XIX
State Plan, for dates of services starting April 1, 2019,
medically complex for the developmentally disabled facilities
must be reimbursed an exceptional care per diem rate, instead

of the base rate, for services to residents with complex or
extensive medical needs. Exceptional care per diem rates must
be paid for the conditions or services specified under
subsection (f) at the following per diem rates: Tier 1 $326,
Tier 2 $546, and Tier 3 $735. Subject to federal approval, on
and after January 1, 2024, each tier rate shall be increased 6%
over the amount in effect on the effective date of this
amendatory Act of the 103rd General Assembly. Any
reimbursement increases applied to the base rate to providers
licensed under the ID/DD Community Care Act must also be
applied in an equivalent manner to each tier of exceptional
care per diem rates for medically complex for the
developmentally disabled facilities.
(d) For residents on a ventilator pursuant to subsection
(c) or subsection (f), facilities shall have a policy
documenting their method of routine assessment of a resident's
weaning potential with interventions implemented noted in the
resident's medical record.
(e) For services provided prior to April 1, 2019 and for
the purposes of this Section, a resident is considered
clinically complex if the resident requires at least one of
the following medical services:
(1) Tracheostomy care with dependence on mechanical
ventilation for a minimum of 6 hours each day.
(2) Tracheostomy care requiring suctioning at least
every 6 hours, room air mist or oxygen as needed, and

dependence on one of the treatment procedures listed under
paragraph (4) excluding the procedure listed in
subparagraph (A) of paragraph (4).
(3) Total parenteral nutrition or other intravenous
nutritional support and one of the treatment procedures
listed under paragraph (4).
(4) The following treatment procedures apply to the
conditions in paragraphs (2) and (3) of this subsection:
(A) Intermittent suctioning at least every 8 hours
and room air mist or oxygen as needed.
(B) Continuous intravenous therapy including
administration of therapeutic agents necessary for
hydration or of intravenous pharmaceuticals; or
intravenous pharmaceutical administration of more than
one agent via a peripheral or central line, without
continuous infusion.
(C) Peritoneal dialysis treatments requiring at
least 4 exchanges every 24 hours.
(D) Tube feeding via nasogastric or gastrostomy
tube.
(E) Other medical technologies required
continuously, which in the opinion of the attending
physician require the services of a professional
nurse.
(f) Complex or extensive medical needs for exceptional
care reimbursement. The conditions and services used for the

purposes of this Section have the same meanings as ascribed to
those conditions and services under the Minimum Data Set (MDS)
Resident Assessment Instrument (RAI) and specified in the most
recent manual. Instead of submitting minimum data set
assessments to the Department, medically complex for the
developmentally disabled facilities must document within each
resident's medical record the conditions or services using the
minimum data set documentation standards and requirements to
qualify for exceptional care reimbursement.
(1) Tier 1 reimbursement is for residents who are
receiving at least 51% of their caloric intake via a
feeding tube.
(2) Tier 2 reimbursement is for residents who are
receiving tracheostomy care without a ventilator.
(3) Tier 3 reimbursement is for residents who are
receiving tracheostomy care and ventilator care.
(g) For dates of services starting April 1, 2019,
reimbursement calculations and direct payment for services
provided by medically complex for the developmentally disabled
facilities are the responsibility of the Department of
Healthcare and Family Services instead of the Department of
Human Services. Appropriations for medically complex for the
developmentally disabled facilities must be shifted from the
Department of Human Services to the Department of Healthcare
and Family Services. Nothing in this Section prohibits the
Department of Healthcare and Family Services from paying more

than the rates specified in this Section. The rates in this
Section must be interpreted as a minimum amount. Any
reimbursement increases applied to providers licensed under
the ID/DD Community Care Act must also be applied in an
equivalent manner to medically complex for the developmentally
disabled facilities.
(h) The Department of Healthcare and Family Services shall
pay the rates in effect on March 31, 2019 until the changes
made to this Section by this amendatory Act of the 100th
General Assembly have been approved by the Centers for
Medicare and Medicaid Services of the U.S. Department of
Health and Human Services.
(i) The Department of Healthcare and Family Services may
adopt rules as allowed by the Illinois Administrative
Procedure Act to implement this Section; however, the
requirements of this Section must be implemented by the
Department of Healthcare and Family Services even if the
Department of Healthcare and Family Services has not adopted
rules by the implementation date of April 1, 2019.
(Source: P.A. 100-646, eff. 7-27-18.)
ARTICLE 80.
Section 80-5. The Illinois Public Aid Code is amended by
changing Section 5-4.2 as follows:

(305 ILCS 5/5-4.2)
Sec. 5-4.2. Ambulance services payments.
(a) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1993, the Illinois
Department shall reimburse ambulance service providers at
rates calculated in accordance with this Section. It is the
intent of the General Assembly to provide adequate
reimbursement for ambulance services so as to ensure adequate
access to services for recipients of aid under this Article
and to provide appropriate incentives to ambulance service
providers to provide services in an efficient and
cost-effective manner. Thus, it is the intent of the General
Assembly that the Illinois Department implement a
reimbursement system for ambulance services that, to the
extent practicable and subject to the availability of funds
appropriated by the General Assembly for this purpose, is
consistent with the payment principles of Medicare. To ensure
uniformity between the payment principles of Medicare and
Medicaid, the Illinois Department shall follow, to the extent
necessary and practicable and subject to the availability of
funds appropriated by the General Assembly for this purpose,
the statutes, laws, regulations, policies, procedures,
principles, definitions, guidelines, and manuals used to
determine the amounts paid to ambulance service providers
under Title XVIII of the Social Security Act (Medicare).
(b) For ambulance services provided to a recipient of aid

under this Article on or after January 1, 1996, the Illinois
Department shall reimburse ambulance service providers based
upon the actual distance traveled if a natural disaster,
weather conditions, road repairs, or traffic congestion
necessitates the use of a route other than the most direct
route.
(c) For purposes of this Section, "ambulance services"
includes medical transportation services provided by means of
an ambulance, medi-car, service car, or taxi.
(c-1) For purposes of this Section, "ground ambulance
service" means medical transportation services that are
described as ground ambulance services by the Centers for
Medicare and Medicaid Services and provided in a vehicle that
is licensed as an ambulance by the Illinois Department of
Public Health pursuant to the Emergency Medical Services (EMS)
Systems Act.
(c-2) For purposes of this Section, "ground ambulance
service provider" means a vehicle service provider as
described in the Emergency Medical Services (EMS) Systems Act
that operates licensed ambulances for the purpose of providing
emergency ambulance services, or non-emergency ambulance
services, or both. For purposes of this Section, this includes
both ambulance providers and ambulance suppliers as described
by the Centers for Medicare and Medicaid Services.
(c-3) For purposes of this Section, "medi-car" means
transportation services provided to a patient who is confined

to a wheelchair and requires the use of a hydraulic or electric
lift or ramp and wheelchair lockdown when the patient's
condition does not require medical observation, medical
supervision, medical equipment, the administration of
medications, or the administration of oxygen.
(c-4) For purposes of this Section, "service car" means
transportation services provided to a patient by a passenger
vehicle where that patient does not require the specialized
modes described in subsection (c-1) or (c-3).
(d) This Section does not prohibit separate billing by
ambulance service providers for oxygen furnished while
providing advanced life support services.
(e) Beginning with services rendered on or after July 1,
2008, all providers of non-emergency medi-car and service car
transportation must certify that the driver and employee
attendant, as applicable, have completed a safety program
approved by the Department to protect both the patient and the
driver, prior to transporting a patient. The provider must
maintain this certification in its records. The provider shall
produce such documentation upon demand by the Department or
its representative. Failure to produce documentation of such
training shall result in recovery of any payments made by the
Department for services rendered by a non-certified driver or
employee attendant. Medi-car and service car providers must
maintain legible documentation in their records of the driver
and, as applicable, employee attendant that actually

transported the patient. Providers must recertify all drivers
and employee attendants every 3 years. If they meet the
established training components set forth by the Department,
providers of non-emergency medi-car and service car
transportation that are either directly or through an
affiliated company licensed by the Department of Public Health
shall be approved by the Department to have in-house safety
programs for training their own staff.
Notwithstanding the requirements above, any public
transportation provider of medi-car and service car
transportation that receives federal funding under 49 U.S.C.
5307 and 5311 need not certify its drivers and employee
attendants under this Section, since safety training is
already federally mandated.
(f) With respect to any policy or program administered by
the Department or its agent regarding approval of
non-emergency medical transportation by ground ambulance
service providers, including, but not limited to, the
Non-Emergency Transportation Services Prior Approval Program
(NETSPAP), the Department shall establish by rule a process by
which ground ambulance service providers of non-emergency
medical transportation may appeal any decision by the
Department or its agent for which no denial was received prior
to the time of transport that either (i) denies a request for
approval for payment of non-emergency transportation by means
of ground ambulance service or (ii) grants a request for

approval of non-emergency transportation by means of ground
ambulance service at a level of service that entitles the
ground ambulance service provider to a lower level of
compensation from the Department than the ground ambulance
service provider would have received as compensation for the
level of service requested. The rule shall be filed by
December 15, 2012 and shall provide that, for any decision
rendered by the Department or its agent on or after the date
the rule takes effect, the ground ambulance service provider
shall have 60 days from the date the decision is received to
file an appeal. The rule established by the Department shall
be, insofar as is practical, consistent with the Illinois
Administrative Procedure Act. The Director's decision on an
appeal under this Section shall be a final administrative
decision subject to review under the Administrative Review
Law.
(f-5) Beginning 90 days after July 20, 2012 (the effective
date of Public Act 97-842), (i) no denial of a request for
approval for payment of non-emergency transportation by means
of ground ambulance service, and (ii) no approval of
non-emergency transportation by means of ground ambulance
service at a level of service that entitles the ground
ambulance service provider to a lower level of compensation
from the Department than would have been received at the level
of service submitted by the ground ambulance service provider,
may be issued by the Department or its agent unless the

Department has submitted the criteria for determining the
appropriateness of the transport for first notice publication
in the Illinois Register pursuant to Section 5-40 of the
Illinois Administrative Procedure Act.
(f-6) Within 90 days after the effective date of this
amendatory Act of the 102nd General Assembly and subject to
federal approval, the Department shall file rules to allow for
the approval of ground ambulance services when the sole
purpose of the transport is for the navigation of stairs or the
assisting or lifting of a patient at a medical facility or
during a medical appointment in instances where the Department
or a contracted Medicaid managed care organization or their
transportation broker is unable to secure transportation
through any other transportation provider.
(f-7) For non-emergency ground ambulance claims properly
denied under Department policy at the time the claim is filed
due to failure to submit a valid Medical Certification for
Non-Emergency Ambulance on and after December 15, 2012 and
prior to January 1, 2021, the Department shall allot
$2,000,000 to a pool to reimburse such claims if the provider
proves medical necessity for the service by other means.
Providers must submit any such denied claims for which they
seek compensation to the Department no later than December 31,
2021 along with documentation of medical necessity. No later
than May 31, 2022, the Department shall determine for which
claims medical necessity was established. Such claims for

which medical necessity was established shall be paid at the
rate in effect at the time of the service, provided the
$2,000,000 is sufficient to pay at those rates. If the pool is
not sufficient, claims shall be paid at a uniform percentage
of the applicable rate such that the pool of $2,000,000 is
exhausted. The appeal process described in subsection (f)
shall not be applicable to the Department's determinations
made in accordance with this subsection.
(g) Whenever a patient covered by a medical assistance
program under this Code or by another medical program
administered by the Department, including a patient covered
under the State's Medicaid managed care program, is being
transported from a facility and requires non-emergency
transportation including ground ambulance, medi-car, or
service car transportation, a Physician Certification
Statement as described in this Section shall be required for
each patient. Facilities shall develop procedures for a
licensed medical professional to provide a written and signed
Physician Certification Statement. The Physician Certification
Statement shall specify the level of transportation services
needed and complete a medical certification establishing the
criteria for approval of non-emergency ambulance
transportation, as published by the Department of Healthcare
and Family Services, that is met by the patient. This
certification shall be completed prior to ordering the
transportation service and prior to patient discharge. The

Physician Certification Statement is not required prior to
transport if a delay in transport can be expected to
negatively affect the patient outcome. If the ground ambulance
provider, medi-car provider, or service car provider is unable
to obtain the required Physician Certification Statement
within 10 calendar days following the date of the service, the
ground ambulance provider, medi-car provider, or service car
provider must document its attempt to obtain the requested
certification and may then submit the claim for payment.
Acceptable documentation includes a signed return receipt from
the U.S. Postal Service, facsimile receipt, email receipt, or
other similar service that evidences that the ground ambulance
provider, medi-car provider, or service car provider attempted
to obtain the required Physician Certification Statement.
The medical certification specifying the level and type of
non-emergency transportation needed shall be in the form of
the Physician Certification Statement on a standardized form
prescribed by the Department of Healthcare and Family
Services. Within 75 days after July 27, 2018 (the effective
date of Public Act 100-646), the Department of Healthcare and
Family Services shall develop a standardized form of the
Physician Certification Statement specifying the level and
type of transportation services needed in consultation with
the Department of Public Health, Medicaid managed care
organizations, a statewide association representing ambulance
providers, a statewide association representing hospitals, 3

statewide associations representing nursing homes, and other
stakeholders. The Physician Certification Statement shall
include, but is not limited to, the criteria necessary to
demonstrate medical necessity for the level of transport
needed as required by (i) the Department of Healthcare and
Family Services and (ii) the federal Centers for Medicare and
Medicaid Services as outlined in the Centers for Medicare and
Medicaid Services' Medicare Benefit Policy Manual, Pub.
100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
Certification Statement shall satisfy the obligations of
hospitals under Section 6.22 of the Hospital Licensing Act and
nursing homes under Section 2-217 of the Nursing Home Care
Act. Implementation and acceptance of the Physician
Certification Statement shall take place no later than 90 days
after the issuance of the Physician Certification Statement by
the Department of Healthcare and Family Services.
Pursuant to subsection (E) of Section 12-4.25 of this
Code, the Department is entitled to recover overpayments paid
to a provider or vendor, including, but not limited to, from
the discharging physician, the discharging facility, and the
ground ambulance service provider, in instances where a
non-emergency ground ambulance service is rendered as the
result of improper or false certification.
Beginning October 1, 2018, the Department of Healthcare
and Family Services shall collect data from Medicaid managed
care organizations and transportation brokers, including the

Department's NETSPAP broker, regarding denials and appeals
related to the missing or incomplete Physician Certification
Statement forms and overall compliance with this subsection.
The Department of Healthcare and Family Services shall publish
quarterly results on its website within 15 days following the
end of each quarter.
(h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(i) Subject to federal approval, on and after January 1,
2024 through June 30, 2026, On and after July 1, 2018, the
Department shall increase the base rate of reimbursement for
both base charges and mileage charges for ground ambulance
service providers not participating in the Ground Emergency
Medical Transportation (GEMT) Program for medical
transportation services provided by means of a ground
ambulance to a level not lower than 140% 112% of the base rate
in effect as of January 1, 2023 June 30, 2018.
(j) For the purpose of understanding ground ambulance
transportation services cost structures and their impact on
the Medical Assistance Program, the Department shall engage
stakeholders, including, but not limited to, a statewide
association representing private ground ambulance service
providers in Illinois, to develop recommendations for a plan

for the regular collection of cost data for all ground
ambulance transportation providers reimbursed under the
Illinois Title XIX State Plan. Cost data obtained through this
process shall be used to inform on and to ensure the
effectiveness and efficiency of Illinois Medicaid rates. The
Department shall establish a process to limit public
availability of portions of the cost report data determined to
be proprietary. This process shall be concluded and
recommendations shall be provided no later than April 1, 2024.
(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff.
5-13-22; 102-1037, eff. 6-2-22.)
ARTICLE 85.
Section 85-5. The Illinois Act on the Aging is amended by
changing Sections 4.02 and 4.06 as follows:
(20 ILCS 105/4.02) (from Ch. 23, par. 6104.02)
Sec. 4.02. Community Care Program. The Department shall
establish a program of services to prevent unnecessary
institutionalization of persons age 60 and older in need of
long term care or who are established as persons who suffer
from Alzheimer's disease or a related disorder under the
Alzheimer's Disease Assistance Act, thereby enabling them to
remain in their own homes or in other living arrangements.

Such preventive services, which may be coordinated with other
programs for the aged and monitored by area agencies on aging
in cooperation with the Department, may include, but are not
limited to, any or all of the following:
(a) (blank);
(b) (blank);
(c) home care aide services;
(d) personal assistant services;
(e) adult day services;
(f) home-delivered meals;
(g) education in self-care;
(h) personal care services;
(i) adult day health services;
(j) habilitation services;
(k) respite care;
(k-5) community reintegration services;
(k-6) flexible senior services;
(k-7) medication management;
(k-8) emergency home response;
(l) other nonmedical social services that may enable
the person to become self-supporting; or
(m) clearinghouse for information provided by senior
citizen home owners who want to rent rooms to or share
living space with other senior citizens.
The Department shall establish eligibility standards for
such services. In determining the amount and nature of

services for which a person may qualify, consideration shall
not be given to the value of cash, property or other assets
held in the name of the person's spouse pursuant to a written
agreement dividing marital property into equal but separate
shares or pursuant to a transfer of the person's interest in a
home to his spouse, provided that the spouse's share of the
marital property is not made available to the person seeking
such services.
Beginning January 1, 2008, the Department shall require as
a condition of eligibility that all new financially eligible
applicants apply for and enroll in medical assistance under
Article V of the Illinois Public Aid Code in accordance with
rules promulgated by the Department.
The Department shall, in conjunction with the Department
of Public Aid (now Department of Healthcare and Family
Services), seek appropriate amendments under Sections 1915 and
1924 of the Social Security Act. The purpose of the amendments
shall be to extend eligibility for home and community based
services under Sections 1915 and 1924 of the Social Security
Act to persons who transfer to or for the benefit of a spouse
those amounts of income and resources allowed under Section
1924 of the Social Security Act. Subject to the approval of
such amendments, the Department shall extend the provisions of
Section 5-4 of the Illinois Public Aid Code to persons who, but
for the provision of home or community-based services, would
require the level of care provided in an institution, as is

provided for in federal law. Those persons no longer found to
be eligible for receiving noninstitutional services due to
changes in the eligibility criteria shall be given 45 days
notice prior to actual termination. Those persons receiving
notice of termination may contact the Department and request
the determination be appealed at any time during the 45 day
notice period. The target population identified for the
purposes of this Section are persons age 60 and older with an
identified service need. Priority shall be given to those who
are at imminent risk of institutionalization. The services
shall be provided to eligible persons age 60 and older to the
extent that the cost of the services together with the other
personal maintenance expenses of the persons are reasonably
related to the standards established for care in a group
facility appropriate to the person's condition. These
non-institutional services, pilot projects or experimental
facilities may be provided as part of or in addition to those
authorized by federal law or those funded and administered by
the Department of Human Services. The Departments of Human
Services, Healthcare and Family Services, Public Health,
Veterans' Affairs, and Commerce and Economic Opportunity and
other appropriate agencies of State, federal and local
governments shall cooperate with the Department on Aging in
the establishment and development of the non-institutional
services. The Department shall require an annual audit from
all personal assistant and home care aide vendors contracting

with the Department under this Section. The annual audit shall
assure that each audited vendor's procedures are in compliance
with Department's financial reporting guidelines requiring an
administrative and employee wage and benefits cost split as
defined in administrative rules. The audit is a public record
under the Freedom of Information Act. The Department shall
execute, relative to the nursing home prescreening project,
written inter-agency agreements with the Department of Human
Services and the Department of Healthcare and Family Services,
to effect the following: (1) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (2) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped. On and after July 1, 1996, all nursing home
prescreenings for individuals 60 years of age or older shall
be conducted by the Department.
As part of the Department on Aging's routine training of
case managers and case manager supervisors, the Department may
include information on family futures planning for persons who
are age 60 or older and who are caregivers of their adult
children with developmental disabilities. The content of the
training shall be at the Department's discretion.
The Department is authorized to establish a system of
recipient copayment for services provided under this Section,
such copayment to be based upon the recipient's ability to pay

but in no case to exceed the actual cost of the services
provided. Additionally, any portion of a person's income which
is equal to or less than the federal poverty standard shall not
be considered by the Department in determining the copayment.
The level of such copayment shall be adjusted whenever
necessary to reflect any change in the officially designated
federal poverty standard.
The Department, or the Department's authorized
representative, may recover the amount of moneys expended for
services provided to or in behalf of a person under this
Section by a claim against the person's estate or against the
estate of the person's surviving spouse, but no recovery may
be had until after the death of the surviving spouse, if any,
and then only at such time when there is no surviving child who
is under age 21 or blind or who has a permanent and total
disability. This paragraph, however, shall not bar recovery,
at the death of the person, of moneys for services provided to
the person or in behalf of the person under this Section to
which the person was not entitled; provided that such recovery
shall not be enforced against any real estate while it is
occupied as a homestead by the surviving spouse or other
dependent, if no claims by other creditors have been filed
against the estate, or, if such claims have been filed, they
remain dormant for failure of prosecution or failure of the
claimant to compel administration of the estate for the
purpose of payment. This paragraph shall not bar recovery from

the estate of a spouse, under Sections 1915 and 1924 of the
Social Security Act and Section 5-4 of the Illinois Public Aid
Code, who precedes a person receiving services under this
Section in death. All moneys for services paid to or in behalf
of the person under this Section shall be claimed for recovery
from the deceased spouse's estate. "Homestead", as used in
this paragraph, means the dwelling house and contiguous real
estate occupied by a surviving spouse or relative, as defined
by the rules and regulations of the Department of Healthcare
and Family Services, regardless of the value of the property.
The Department shall increase the effectiveness of the
existing Community Care Program by:
(1) ensuring that in-home services included in the
care plan are available on evenings and weekends;
(2) ensuring that care plans contain the services that
eligible participants need based on the number of days in
a month, not limited to specific blocks of time, as
identified by the comprehensive assessment tool selected
by the Department for use statewide, not to exceed the
total monthly service cost maximum allowed for each
service; the Department shall develop administrative rules
to implement this item (2);
(3) ensuring that the participants have the right to
choose the services contained in their care plan and to
direct how those services are provided, based on
administrative rules established by the Department;

(4) ensuring that the determination of need tool is
accurate in determining the participants' level of need;
to achieve this, the Department, in conjunction with the
Older Adult Services Advisory Committee, shall institute a
study of the relationship between the Determination of
Need scores, level of need, service cost maximums, and the
development and utilization of service plans no later than
May 1, 2008; findings and recommendations shall be
presented to the Governor and the General Assembly no
later than January 1, 2009; recommendations shall include
all needed changes to the service cost maximums schedule
and additional covered services;
(5) ensuring that homemakers can provide personal care
services that may or may not involve contact with clients,
including but not limited to:
(A) bathing;
(B) grooming;
(C) toileting;
(D) nail care;
(E) transferring;
(F) respiratory services;
(G) exercise; or
(H) positioning;
(6) ensuring that homemaker program vendors are not
restricted from hiring homemakers who are family members
of clients or recommended by clients; the Department may

not, by rule or policy, require homemakers who are family
members of clients or recommended by clients to accept
assignments in homes other than the client;
(7) ensuring that the State may access maximum federal
matching funds by seeking approval for the Centers for
Medicare and Medicaid Services for modifications to the
State's home and community based services waiver and
additional waiver opportunities, including applying for
enrollment in the Balance Incentive Payment Program by May
1, 2013, in order to maximize federal matching funds; this
shall include, but not be limited to, modification that
reflects all changes in the Community Care Program
services and all increases in the services cost maximum;
(8) ensuring that the determination of need tool
accurately reflects the service needs of individuals with
Alzheimer's disease and related dementia disorders;
(9) ensuring that services are authorized accurately
and consistently for the Community Care Program (CCP); the
Department shall implement a Service Authorization policy
directive; the purpose shall be to ensure that eligibility
and services are authorized accurately and consistently in
the CCP program; the policy directive shall clarify
service authorization guidelines to Care Coordination
Units and Community Care Program providers no later than
May 1, 2013;
(10) working in conjunction with Care Coordination

Units, the Department of Healthcare and Family Services,
the Department of Human Services, Community Care Program
providers, and other stakeholders to make improvements to
the Medicaid claiming processes and the Medicaid
enrollment procedures or requirements as needed,
including, but not limited to, specific policy changes or
rules to improve the up-front enrollment of participants
in the Medicaid program and specific policy changes or
rules to insure more prompt submission of bills to the
federal government to secure maximum federal matching
dollars as promptly as possible; the Department on Aging
shall have at least 3 meetings with stakeholders by
January 1, 2014 in order to address these improvements;
(11) requiring home care service providers to comply
with the rounding of hours worked provisions under the
federal Fair Labor Standards Act (FLSA) and as set forth
in 29 CFR 785.48(b) by May 1, 2013;
(12) implementing any necessary policy changes or
promulgating any rules, no later than January 1, 2014, to
assist the Department of Healthcare and Family Services in
moving as many participants as possible, consistent with
federal regulations, into coordinated care plans if a care
coordination plan that covers long term care is available
in the recipient's area; and
(13) maintaining fiscal year 2014 rates at the same
level established on January 1, 2013.

By January 1, 2009 or as soon after the end of the Cash and
Counseling Demonstration Project as is practicable, the
Department may, based on its evaluation of the demonstration
project, promulgate rules concerning personal assistant
services, to include, but need not be limited to,
qualifications, employment screening, rights under fair labor
standards, training, fiduciary agent, and supervision
requirements. All applicants shall be subject to the
provisions of the Health Care Worker Background Check Act.
The Department shall develop procedures to enhance
availability of services on evenings, weekends, and on an
emergency basis to meet the respite needs of caregivers.
Procedures shall be developed to permit the utilization of
services in successive blocks of 24 hours up to the monthly
maximum established by the Department. Workers providing these
services shall be appropriately trained.
Beginning on the effective date of this amendatory Act of
1991, no person may perform chore/housekeeping and home care
aide services under a program authorized by this Section
unless that person has been issued a certificate of
pre-service to do so by his or her employing agency.
Information gathered to effect such certification shall
include (i) the person's name, (ii) the date the person was
hired by his or her current employer, and (iii) the training,
including dates and levels. Persons engaged in the program
authorized by this Section before the effective date of this

amendatory Act of 1991 shall be issued a certificate of all
pre- and in-service training from his or her employer upon
submitting the necessary information. The employing agency
shall be required to retain records of all staff pre- and
in-service training, and shall provide such records to the
Department upon request and upon termination of the employer's
contract with the Department. In addition, the employing
agency is responsible for the issuance of certifications of
in-service training completed to their employees.
The Department is required to develop a system to ensure
that persons working as home care aides and personal
assistants receive increases in their wages when the federal
minimum wage is increased by requiring vendors to certify that
they are meeting the federal minimum wage statute for home
care aides and personal assistants. An employer that cannot
ensure that the minimum wage increase is being given to home
care aides and personal assistants shall be denied any
increase in reimbursement costs.
The Community Care Program Advisory Committee is created
in the Department on Aging. The Director shall appoint
individuals to serve in the Committee, who shall serve at
their own expense. Members of the Committee must abide by all
applicable ethics laws. The Committee shall advise the
Department on issues related to the Department's program of
services to prevent unnecessary institutionalization. The
Committee shall meet on a bi-monthly basis and shall serve to

identify and advise the Department on present and potential
issues affecting the service delivery network, the program's
clients, and the Department and to recommend solution
strategies. Persons appointed to the Committee shall be
appointed on, but not limited to, their own and their agency's
experience with the program, geographic representation, and
willingness to serve. The Director shall appoint members to
the Committee to represent provider, advocacy, policy
research, and other constituencies committed to the delivery
of high quality home and community-based services to older
adults. Representatives shall be appointed to ensure
representation from community care providers including, but
not limited to, adult day service providers, homemaker
providers, case coordination and case management units,
emergency home response providers, statewide trade or labor
unions that represent home care aides and direct care staff,
area agencies on aging, adults over age 60, membership
organizations representing older adults, and other
organizational entities, providers of care, or individuals
with demonstrated interest and expertise in the field of home
and community care as determined by the Director.
Nominations may be presented from any agency or State
association with interest in the program. The Director, or his
or her designee, shall serve as the permanent co-chair of the
advisory committee. One other co-chair shall be nominated and
approved by the members of the committee on an annual basis.

Committee members' terms of appointment shall be for 4 years
with one-quarter of the appointees' terms expiring each year.
A member shall continue to serve until his or her replacement
is named. The Department shall fill vacancies that have a
remaining term of over one year, and this replacement shall
occur through the annual replacement of expiring terms. The
Director shall designate Department staff to provide technical
assistance and staff support to the committee. Department
representation shall not constitute membership of the
committee. All Committee papers, issues, recommendations,
reports, and meeting memoranda are advisory only. The
Director, or his or her designee, shall make a written report,
as requested by the Committee, regarding issues before the
Committee.
The Department on Aging and the Department of Human
Services shall cooperate in the development and submission of
an annual report on programs and services provided under this
Section. Such joint report shall be filed with the Governor
and the General Assembly on or before March 31 September 30
each year.
The requirement for reporting to the General Assembly
shall be satisfied by filing copies of the report as required
by Section 3.1 of the General Assembly Organization Act and
filing such additional copies with the State Government Report
Distribution Center for the General Assembly as is required
under paragraph (t) of Section 7 of the State Library Act.

Those persons previously found eligible for receiving
non-institutional services whose services were discontinued
under the Emergency Budget Act of Fiscal Year 1992, and who do
not meet the eligibility standards in effect on or after July
1, 1992, shall remain ineligible on and after July 1, 1992.
Those persons previously not required to cost-share and who
were required to cost-share effective March 1, 1992, shall
continue to meet cost-share requirements on and after July 1,
1992. Beginning July 1, 1992, all clients will be required to
meet eligibility, cost-share, and other requirements and will
have services discontinued or altered when they fail to meet
these requirements.
For the purposes of this Section, "flexible senior
services" refers to services that require one-time or periodic
expenditures including, but not limited to, respite care, home
modification, assistive technology, housing assistance, and
transportation.
The Department shall implement an electronic service
verification based on global positioning systems or other
cost-effective technology for the Community Care Program no
later than January 1, 2014.
The Department shall require, as a condition of
eligibility, enrollment in the medical assistance program
under Article V of the Illinois Public Aid Code (i) beginning
August 1, 2013, if the Auditor General has reported that the
Department has failed to comply with the reporting

requirements of Section 2-27 of the Illinois State Auditing
Act; or (ii) beginning June 1, 2014, if the Auditor General has
reported that the Department has not undertaken the required
actions listed in the report required by subsection (a) of
Section 2-27 of the Illinois State Auditing Act.
The Department shall delay Community Care Program services
until an applicant is determined eligible for medical
assistance under Article V of the Illinois Public Aid Code (i)
beginning August 1, 2013, if the Auditor General has reported
that the Department has failed to comply with the reporting
requirements of Section 2-27 of the Illinois State Auditing
Act; or (ii) beginning June 1, 2014, if the Auditor General has
reported that the Department has not undertaken the required
actions listed in the report required by subsection (a) of
Section 2-27 of the Illinois State Auditing Act.
The Department shall implement co-payments for the
Community Care Program at the federally allowable maximum
level (i) beginning August 1, 2013, if the Auditor General has
reported that the Department has failed to comply with the
reporting requirements of Section 2-27 of the Illinois State
Auditing Act; or (ii) beginning June 1, 2014, if the Auditor
General has reported that the Department has not undertaken
the required actions listed in the report required by
subsection (a) of Section 2-27 of the Illinois State Auditing
Act.
The Department shall continue to provide other Community

Care Program reports as required by statute.
The Department shall conduct a quarterly review of Care
Coordination Unit performance and adherence to service
guidelines. The quarterly review shall be reported to the
Speaker of the House of Representatives, the Minority Leader
of the House of Representatives, the President of the Senate,
and the Minority Leader of the Senate. The Department shall
collect and report longitudinal data on the performance of
each care coordination unit. Nothing in this paragraph shall
be construed to require the Department to identify specific
care coordination units.
In regard to community care providers, failure to comply
with Department on Aging policies shall be cause for
disciplinary action, including, but not limited to,
disqualification from serving Community Care Program clients.
Each provider, upon submission of any bill or invoice to the
Department for payment for services rendered, shall include a
notarized statement, under penalty of perjury pursuant to
Section 1-109 of the Code of Civil Procedure, that the
provider has complied with all Department policies.
The Director of the Department on Aging shall make
information available to the State Board of Elections as may
be required by an agreement the State Board of Elections has
entered into with a multi-state voter registration list
maintenance system.
Within 30 days after July 6, 2017 (the effective date of

Public Act 100-23), rates shall be increased to $18.29 per
hour, for the purpose of increasing, by at least $.72 per hour,
the wages paid by those vendors to their employees who provide
homemaker services. The Department shall pay an enhanced rate
under the Community Care Program to those in-home service
provider agencies that offer health insurance coverage as a
benefit to their direct service worker employees consistent
with the mandates of Public Act 95-713. For State fiscal years
2018 and 2019, the enhanced rate shall be $1.77 per hour. The
rate shall be adjusted using actuarial analysis based on the
cost of care, but shall not be set below $1.77 per hour. The
Department shall adopt rules, including emergency rules under
subsections (y) and (bb) of Section 5-45 of the Illinois
Administrative Procedure Act, to implement the provisions of
this paragraph.
Subject to federal approval, beginning on January 1, 2024,
rates for adult day services shall be increased to $16.84 per
hour and rates for each way transportation services for adult
day services shall be increased to $12.44 per unit
transportation.
The General Assembly finds it necessary to authorize an
aggressive Medicaid enrollment initiative designed to maximize
federal Medicaid funding for the Community Care Program which
produces significant savings for the State of Illinois. The
Department on Aging shall establish and implement a Community
Care Program Medicaid Initiative. Under the Initiative, the

Department on Aging shall, at a minimum: (i) provide an
enhanced rate to adequately compensate care coordination units
to enroll eligible Community Care Program clients into
Medicaid; (ii) use recommendations from a stakeholder
committee on how best to implement the Initiative; and (iii)
establish requirements for State agencies to make enrollment
in the State's Medical Assistance program easier for seniors.
The Community Care Program Medicaid Enrollment Oversight
Subcommittee is created as a subcommittee of the Older Adult
Services Advisory Committee established in Section 35 of the
Older Adult Services Act to make recommendations on how best
to increase the number of medical assistance recipients who
are enrolled in the Community Care Program. The Subcommittee
shall consist of all of the following persons who must be
appointed within 30 days after the effective date of this
amendatory Act of the 100th General Assembly:
(1) The Director of Aging, or his or her designee, who
shall serve as the chairperson of the Subcommittee.
(2) One representative of the Department of Healthcare
and Family Services, appointed by the Director of
Healthcare and Family Services.
(3) One representative of the Department of Human
Services, appointed by the Secretary of Human Services.
(4) One individual representing a care coordination
unit, appointed by the Director of Aging.
(5) One individual from a non-governmental statewide

organization that advocates for seniors, appointed by the
Director of Aging.
(6) One individual representing Area Agencies on
Aging, appointed by the Director of Aging.
(7) One individual from a statewide association
dedicated to Alzheimer's care, support, and research,
appointed by the Director of Aging.
(8) One individual from an organization that employs
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(9) One member of a trade or labor union representing
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(10) One member of the Senate, who shall serve as
co-chairperson, appointed by the President of the Senate.
(11) One member of the Senate, who shall serve as
co-chairperson, appointed by the Minority Leader of the
Senate.
(12) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Speaker of
the House of Representatives.
(13) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Minority
Leader of the House of Representatives.
(14) One individual appointed by a labor organization
representing frontline employees at the Department of

Human Services.
The Subcommittee shall provide oversight to the Community
Care Program Medicaid Initiative and shall meet quarterly. At
each Subcommittee meeting the Department on Aging shall
provide the following data sets to the Subcommittee: (A) the
number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are enrolled in the State's Medical
Assistance Program; (B) the number of Illinois residents,
categorized by planning and service area, who are receiving
services under the Community Care Program, but are not
enrolled in the State's Medical Assistance Program; and (C)
the number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are eligible for benefits under the State's
Medical Assistance Program, but are not enrolled in the
State's Medical Assistance Program. In addition to this data,
the Department on Aging shall provide the Subcommittee with
plans on how the Department on Aging will reduce the number of
Illinois residents who are not enrolled in the State's Medical
Assistance Program but who are eligible for medical assistance
benefits. The Department on Aging shall enroll in the State's
Medical Assistance Program those Illinois residents who
receive services under the Community Care Program and are
eligible for medical assistance benefits but are not enrolled
in the State's Medicaid Assistance Program. The data provided

to the Subcommittee shall be made available to the public via
the Department on Aging's website.
The Department on Aging, with the involvement of the
Subcommittee, shall collaborate with the Department of Human
Services and the Department of Healthcare and Family Services
on how best to achieve the responsibilities of the Community
Care Program Medicaid Initiative.
The Department on Aging, the Department of Human Services,
and the Department of Healthcare and Family Services shall
coordinate and implement a streamlined process for seniors to
access benefits under the State's Medical Assistance Program.
The Subcommittee shall collaborate with the Department of
Human Services on the adoption of a uniform application
submission process. The Department of Human Services and any
other State agency involved with processing the medical
assistance application of any person enrolled in the Community
Care Program shall include the appropriate care coordination
unit in all communications related to the determination or
status of the application.
The Community Care Program Medicaid Initiative shall
provide targeted funding to care coordination units to help
seniors complete their applications for medical assistance
benefits. On and after July 1, 2019, care coordination units
shall receive no less than $200 per completed application,
which rate may be included in a bundled rate for initial intake
services when Medicaid application assistance is provided in

conjunction with the initial intake process for new program
participants.
The Community Care Program Medicaid Initiative shall cease
operation 5 years after the effective date of this amendatory
Act of the 100th General Assembly, after which the
Subcommittee shall dissolve.
(Source: P.A. 101-10, eff. 6-5-19; 102-1071, eff. 6-10-22.)
(20 ILCS 105/4.06)
Sec. 4.06. Coordinated services for minority senior
citizens Minority Senior Citizen Program. The Department shall
develop strategies a program to identify the special needs and
problems of minority senior citizens and evaluate the adequacy
and accessibility of existing services programs and
information for minority senior citizens. The Department shall
coordinate services for minority senior citizens through the
Department of Public Health, the Department of Healthcare and
Family Services, and the Department of Human Services.
The Department shall develop procedures to enhance and
identify availability of services and shall promulgate
administrative rules to establish the responsibilities of the
Department.
The Department on Aging, the Department of Public Health,
the Department of Healthcare and Family Services, and the
Department of Human Services shall cooperate in the
development and submission of an annual report on programs and

services provided under this Section. The joint report shall
be filed with the Governor and the General Assembly on or
before September 30 of each year.
(Source: P.A. 95-331, eff. 8-21-07.)
ARTICLE 90.
Section 90-5. The Illinois Act on the Aging is amended by
changing Sections 4.02 and 4.07 as follows:
(20 ILCS 105/4.02) (from Ch. 23, par. 6104.02)
Sec. 4.02. Community Care Program. The Department shall
establish a program of services to prevent unnecessary
institutionalization of persons age 60 and older in need of
long term care or who are established as persons who suffer
from Alzheimer's disease or a related disorder under the
Alzheimer's Disease Assistance Act, thereby enabling them to
remain in their own homes or in other living arrangements.
Such preventive services, which may be coordinated with other
programs for the aged and monitored by area agencies on aging
in cooperation with the Department, may include, but are not
limited to, any or all of the following:
(a) (blank);
(b) (blank);
(c) home care aide services;
(d) personal assistant services;

(e) adult day services;
(f) home-delivered meals;
(g) education in self-care;
(h) personal care services;
(i) adult day health services;
(j) habilitation services;
(k) respite care;
(k-5) community reintegration services;
(k-6) flexible senior services;
(k-7) medication management;
(k-8) emergency home response;
(l) other nonmedical social services that may enable
the person to become self-supporting; or
(m) clearinghouse for information provided by senior
citizen home owners who want to rent rooms to or share
living space with other senior citizens.
The Department shall establish eligibility standards for
such services. In determining the amount and nature of
services for which a person may qualify, consideration shall
not be given to the value of cash, property or other assets
held in the name of the person's spouse pursuant to a written
agreement dividing marital property into equal but separate
shares or pursuant to a transfer of the person's interest in a
home to his spouse, provided that the spouse's share of the
marital property is not made available to the person seeking
such services.

Beginning January 1, 2008, the Department shall require as
a condition of eligibility that all new financially eligible
applicants apply for and enroll in medical assistance under
Article V of the Illinois Public Aid Code in accordance with
rules promulgated by the Department.
The Department shall, in conjunction with the Department
of Public Aid (now Department of Healthcare and Family
Services), seek appropriate amendments under Sections 1915 and
1924 of the Social Security Act. The purpose of the amendments
shall be to extend eligibility for home and community based
services under Sections 1915 and 1924 of the Social Security
Act to persons who transfer to or for the benefit of a spouse
those amounts of income and resources allowed under Section
1924 of the Social Security Act. Subject to the approval of
such amendments, the Department shall extend the provisions of
Section 5-4 of the Illinois Public Aid Code to persons who, but
for the provision of home or community-based services, would
require the level of care provided in an institution, as is
provided for in federal law. Those persons no longer found to
be eligible for receiving noninstitutional services due to
changes in the eligibility criteria shall be given 45 days
notice prior to actual termination. Those persons receiving
notice of termination may contact the Department and request
the determination be appealed at any time during the 45 day
notice period. The target population identified for the
purposes of this Section are persons age 60 and older with an

identified service need. Priority shall be given to those who
are at imminent risk of institutionalization. The services
shall be provided to eligible persons age 60 and older to the
extent that the cost of the services together with the other
personal maintenance expenses of the persons are reasonably
related to the standards established for care in a group
facility appropriate to the person's condition. These
non-institutional services, pilot projects or experimental
facilities may be provided as part of or in addition to those
authorized by federal law or those funded and administered by
the Department of Human Services. The Departments of Human
Services, Healthcare and Family Services, Public Health,
Veterans' Affairs, and Commerce and Economic Opportunity and
other appropriate agencies of State, federal and local
governments shall cooperate with the Department on Aging in
the establishment and development of the non-institutional
services. The Department shall require an annual audit from
all personal assistant and home care aide vendors contracting
with the Department under this Section. The annual audit shall
assure that each audited vendor's procedures are in compliance
with Department's financial reporting guidelines requiring an
administrative and employee wage and benefits cost split as
defined in administrative rules. The audit is a public record
under the Freedom of Information Act. The Department shall
execute, relative to the nursing home prescreening project,
written inter-agency agreements with the Department of Human

Services and the Department of Healthcare and Family Services,
to effect the following: (1) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (2) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped. On and after July 1, 1996, all nursing home
prescreenings for individuals 60 years of age or older shall
be conducted by the Department.
As part of the Department on Aging's routine training of
case managers and case manager supervisors, the Department may
include information on family futures planning for persons who
are age 60 or older and who are caregivers of their adult
children with developmental disabilities. The content of the
training shall be at the Department's discretion.
The Department is authorized to establish a system of
recipient copayment for services provided under this Section,
such copayment to be based upon the recipient's ability to pay
but in no case to exceed the actual cost of the services
provided. Additionally, any portion of a person's income which
is equal to or less than the federal poverty standard shall not
be considered by the Department in determining the copayment.
The level of such copayment shall be adjusted whenever
necessary to reflect any change in the officially designated
federal poverty standard.
The Department, or the Department's authorized

representative, may recover the amount of moneys expended for
services provided to or in behalf of a person under this
Section by a claim against the person's estate or against the
estate of the person's surviving spouse, but no recovery may
be had until after the death of the surviving spouse, if any,
and then only at such time when there is no surviving child who
is under age 21 or blind or who has a permanent and total
disability. This paragraph, however, shall not bar recovery,
at the death of the person, of moneys for services provided to
the person or in behalf of the person under this Section to
which the person was not entitled; provided that such recovery
shall not be enforced against any real estate while it is
occupied as a homestead by the surviving spouse or other
dependent, if no claims by other creditors have been filed
against the estate, or, if such claims have been filed, they
remain dormant for failure of prosecution or failure of the
claimant to compel administration of the estate for the
purpose of payment. This paragraph shall not bar recovery from
the estate of a spouse, under Sections 1915 and 1924 of the
Social Security Act and Section 5-4 of the Illinois Public Aid
Code, who precedes a person receiving services under this
Section in death. All moneys for services paid to or in behalf
of the person under this Section shall be claimed for recovery
from the deceased spouse's estate. "Homestead", as used in
this paragraph, means the dwelling house and contiguous real
estate occupied by a surviving spouse or relative, as defined

by the rules and regulations of the Department of Healthcare
and Family Services, regardless of the value of the property.
The Department shall increase the effectiveness of the
existing Community Care Program by:
(1) ensuring that in-home services included in the
care plan are available on evenings and weekends;
(2) ensuring that care plans contain the services that
eligible participants need based on the number of days in
a month, not limited to specific blocks of time, as
identified by the comprehensive assessment tool selected
by the Department for use statewide, not to exceed the
total monthly service cost maximum allowed for each
service; the Department shall develop administrative rules
to implement this item (2);
(3) ensuring that the participants have the right to
choose the services contained in their care plan and to
direct how those services are provided, based on
administrative rules established by the Department;
(4) ensuring that the determination of need tool is
accurate in determining the participants' level of need;
to achieve this, the Department, in conjunction with the
Older Adult Services Advisory Committee, shall institute a
study of the relationship between the Determination of
Need scores, level of need, service cost maximums, and the
development and utilization of service plans no later than
May 1, 2008; findings and recommendations shall be

presented to the Governor and the General Assembly no
later than January 1, 2009; recommendations shall include
all needed changes to the service cost maximums schedule
and additional covered services;
(5) ensuring that homemakers can provide personal care
services that may or may not involve contact with clients,
including but not limited to:
(A) bathing;
(B) grooming;
(C) toileting;
(D) nail care;
(E) transferring;
(F) respiratory services;
(G) exercise; or
(H) positioning;
(6) ensuring that homemaker program vendors are not
restricted from hiring homemakers who are family members
of clients or recommended by clients; the Department may
not, by rule or policy, require homemakers who are family
members of clients or recommended by clients to accept
assignments in homes other than the client;
(7) ensuring that the State may access maximum federal
matching funds by seeking approval for the Centers for
Medicare and Medicaid Services for modifications to the
State's home and community based services waiver and
additional waiver opportunities, including applying for

enrollment in the Balance Incentive Payment Program by May
1, 2013, in order to maximize federal matching funds; this
shall include, but not be limited to, modification that
reflects all changes in the Community Care Program
services and all increases in the services cost maximum;
(8) ensuring that the determination of need tool
accurately reflects the service needs of individuals with
Alzheimer's disease and related dementia disorders;
(9) ensuring that services are authorized accurately
and consistently for the Community Care Program (CCP); the
Department shall implement a Service Authorization policy
directive; the purpose shall be to ensure that eligibility
and services are authorized accurately and consistently in
the CCP program; the policy directive shall clarify
service authorization guidelines to Care Coordination
Units and Community Care Program providers no later than
May 1, 2013;
(10) working in conjunction with Care Coordination
Units, the Department of Healthcare and Family Services,
the Department of Human Services, Community Care Program
providers, and other stakeholders to make improvements to
the Medicaid claiming processes and the Medicaid
enrollment procedures or requirements as needed,
including, but not limited to, specific policy changes or
rules to improve the up-front enrollment of participants
in the Medicaid program and specific policy changes or

rules to insure more prompt submission of bills to the
federal government to secure maximum federal matching
dollars as promptly as possible; the Department on Aging
shall have at least 3 meetings with stakeholders by
January 1, 2014 in order to address these improvements;
(11) requiring home care service providers to comply
with the rounding of hours worked provisions under the
federal Fair Labor Standards Act (FLSA) and as set forth
in 29 CFR 785.48(b) by May 1, 2013;
(12) implementing any necessary policy changes or
promulgating any rules, no later than January 1, 2014, to
assist the Department of Healthcare and Family Services in
moving as many participants as possible, consistent with
federal regulations, into coordinated care plans if a care
coordination plan that covers long term care is available
in the recipient's area; and
(13) maintaining fiscal year 2014 rates at the same
level established on January 1, 2013.
By January 1, 2009 or as soon after the end of the Cash and
Counseling Demonstration Project as is practicable, the
Department may, based on its evaluation of the demonstration
project, promulgate rules concerning personal assistant
services, to include, but need not be limited to,
qualifications, employment screening, rights under fair labor
standards, training, fiduciary agent, and supervision
requirements. All applicants shall be subject to the

provisions of the Health Care Worker Background Check Act.
The Department shall develop procedures to enhance
availability of services on evenings, weekends, and on an
emergency basis to meet the respite needs of caregivers.
Procedures shall be developed to permit the utilization of
services in successive blocks of 24 hours up to the monthly
maximum established by the Department. Workers providing these
services shall be appropriately trained.
Beginning on the effective date of this amendatory Act of
1991, no person may perform chore/housekeeping and home care
aide services under a program authorized by this Section
unless that person has been issued a certificate of
pre-service to do so by his or her employing agency.
Information gathered to effect such certification shall
include (i) the person's name, (ii) the date the person was
hired by his or her current employer, and (iii) the training,
including dates and levels. Persons engaged in the program
authorized by this Section before the effective date of this
amendatory Act of 1991 shall be issued a certificate of all
pre- and in-service training from his or her employer upon
submitting the necessary information. The employing agency
shall be required to retain records of all staff pre- and
in-service training, and shall provide such records to the
Department upon request and upon termination of the employer's
contract with the Department. In addition, the employing
agency is responsible for the issuance of certifications of

in-service training completed to their employees.
The Department is required to develop a system to ensure
that persons working as home care aides and personal
assistants receive increases in their wages when the federal
minimum wage is increased by requiring vendors to certify that
they are meeting the federal minimum wage statute for home
care aides and personal assistants. An employer that cannot
ensure that the minimum wage increase is being given to home
care aides and personal assistants shall be denied any
increase in reimbursement costs.
The Community Care Program Advisory Committee is created
in the Department on Aging. The Director shall appoint
individuals to serve in the Committee, who shall serve at
their own expense. Members of the Committee must abide by all
applicable ethics laws. The Committee shall advise the
Department on issues related to the Department's program of
services to prevent unnecessary institutionalization. The
Committee shall meet on a bi-monthly basis and shall serve to
identify and advise the Department on present and potential
issues affecting the service delivery network, the program's
clients, and the Department and to recommend solution
strategies. Persons appointed to the Committee shall be
appointed on, but not limited to, their own and their agency's
experience with the program, geographic representation, and
willingness to serve. The Director shall appoint members to
the Committee to represent provider, advocacy, policy

research, and other constituencies committed to the delivery
of high quality home and community-based services to older
adults. Representatives shall be appointed to ensure
representation from community care providers including, but
not limited to, adult day service providers, homemaker
providers, case coordination and case management units,
emergency home response providers, statewide trade or labor
unions that represent home care aides and direct care staff,
area agencies on aging, adults over age 60, membership
organizations representing older adults, and other
organizational entities, providers of care, or individuals
with demonstrated interest and expertise in the field of home
and community care as determined by the Director.
Nominations may be presented from any agency or State
association with interest in the program. The Director, or his
or her designee, shall serve as the permanent co-chair of the
advisory committee. One other co-chair shall be nominated and
approved by the members of the committee on an annual basis.
Committee members' terms of appointment shall be for 4 years
with one-quarter of the appointees' terms expiring each year.
A member shall continue to serve until his or her replacement
is named. The Department shall fill vacancies that have a
remaining term of over one year, and this replacement shall
occur through the annual replacement of expiring terms. The
Director shall designate Department staff to provide technical
assistance and staff support to the committee. Department

representation shall not constitute membership of the
committee. All Committee papers, issues, recommendations,
reports, and meeting memoranda are advisory only. The
Director, or his or her designee, shall make a written report,
as requested by the Committee, regarding issues before the
Committee.
The Department on Aging and the Department of Human
Services shall cooperate in the development and submission of
an annual report on programs and services provided under this
Section. Such joint report shall be filed with the Governor
and the General Assembly on or before March 31 of the following
fiscal year September 30 each year.
The requirement for reporting to the General Assembly
shall be satisfied by filing copies of the report as required
by Section 3.1 of the General Assembly Organization Act and
filing such additional copies with the State Government Report
Distribution Center for the General Assembly as is required
under paragraph (t) of Section 7 of the State Library Act.
Those persons previously found eligible for receiving
non-institutional services whose services were discontinued
under the Emergency Budget Act of Fiscal Year 1992, and who do
not meet the eligibility standards in effect on or after July
1, 1992, shall remain ineligible on and after July 1, 1992.
Those persons previously not required to cost-share and who
were required to cost-share effective March 1, 1992, shall
continue to meet cost-share requirements on and after July 1,

1992. Beginning July 1, 1992, all clients will be required to
meet eligibility, cost-share, and other requirements and will
have services discontinued or altered when they fail to meet
these requirements.
For the purposes of this Section, "flexible senior
services" refers to services that require one-time or periodic
expenditures including, but not limited to, respite care, home
modification, assistive technology, housing assistance, and
transportation.
The Department shall implement an electronic service
verification based on global positioning systems or other
cost-effective technology for the Community Care Program no
later than January 1, 2014.
The Department shall require, as a condition of
eligibility, enrollment in the medical assistance program
under Article V of the Illinois Public Aid Code (i) beginning
August 1, 2013, if the Auditor General has reported that the
Department has failed to comply with the reporting
requirements of Section 2-27 of the Illinois State Auditing
Act; or (ii) beginning June 1, 2014, if the Auditor General has
reported that the Department has not undertaken the required
actions listed in the report required by subsection (a) of
Section 2-27 of the Illinois State Auditing Act.
The Department shall delay Community Care Program services
until an applicant is determined eligible for medical
assistance under Article V of the Illinois Public Aid Code (i)

beginning August 1, 2013, if the Auditor General has reported
that the Department has failed to comply with the reporting
requirements of Section 2-27 of the Illinois State Auditing
Act; or (ii) beginning June 1, 2014, if the Auditor General has
reported that the Department has not undertaken the required
actions listed in the report required by subsection (a) of
Section 2-27 of the Illinois State Auditing Act.
The Department shall implement co-payments for the
Community Care Program at the federally allowable maximum
level (i) beginning August 1, 2013, if the Auditor General has
reported that the Department has failed to comply with the
reporting requirements of Section 2-27 of the Illinois State
Auditing Act; or (ii) beginning June 1, 2014, if the Auditor
General has reported that the Department has not undertaken
the required actions listed in the report required by
subsection (a) of Section 2-27 of the Illinois State Auditing
Act.
The Department shall continue to provide other Community
Care Program reports as required by statute.
The Department shall conduct a quarterly review of Care
Coordination Unit performance and adherence to service
guidelines. The quarterly review shall be reported to the
Speaker of the House of Representatives, the Minority Leader
of the House of Representatives, the President of the Senate,
and the Minority Leader of the Senate. The Department shall
collect and report longitudinal data on the performance of

each care coordination unit. Nothing in this paragraph shall
be construed to require the Department to identify specific
care coordination units.
In regard to community care providers, failure to comply
with Department on Aging policies shall be cause for
disciplinary action, including, but not limited to,
disqualification from serving Community Care Program clients.
Each provider, upon submission of any bill or invoice to the
Department for payment for services rendered, shall include a
notarized statement, under penalty of perjury pursuant to
Section 1-109 of the Code of Civil Procedure, that the
provider has complied with all Department policies.
The Director of the Department on Aging shall make
information available to the State Board of Elections as may
be required by an agreement the State Board of Elections has
entered into with a multi-state voter registration list
maintenance system.
Within 30 days after July 6, 2017 (the effective date of
Public Act 100-23), rates shall be increased to $18.29 per
hour, for the purpose of increasing, by at least $.72 per hour,
the wages paid by those vendors to their employees who provide
homemaker services. The Department shall pay an enhanced rate
under the Community Care Program to those in-home service
provider agencies that offer health insurance coverage as a
benefit to their direct service worker employees consistent
with the mandates of Public Act 95-713. For State fiscal years

2018 and 2019, the enhanced rate shall be $1.77 per hour. The
rate shall be adjusted using actuarial analysis based on the
cost of care, but shall not be set below $1.77 per hour. The
Department shall adopt rules, including emergency rules under
subsections (y) and (bb) of Section 5-45 of the Illinois
Administrative Procedure Act, to implement the provisions of
this paragraph.
The General Assembly finds it necessary to authorize an
aggressive Medicaid enrollment initiative designed to maximize
federal Medicaid funding for the Community Care Program which
produces significant savings for the State of Illinois. The
Department on Aging shall establish and implement a Community
Care Program Medicaid Initiative. Under the Initiative, the
Department on Aging shall, at a minimum: (i) provide an
enhanced rate to adequately compensate care coordination units
to enroll eligible Community Care Program clients into
Medicaid; (ii) use recommendations from a stakeholder
committee on how best to implement the Initiative; and (iii)
establish requirements for State agencies to make enrollment
in the State's Medical Assistance program easier for seniors.
The Community Care Program Medicaid Enrollment Oversight
Subcommittee is created as a subcommittee of the Older Adult
Services Advisory Committee established in Section 35 of the
Older Adult Services Act to make recommendations on how best
to increase the number of medical assistance recipients who
are enrolled in the Community Care Program. The Subcommittee

shall consist of all of the following persons who must be
appointed within 30 days after the effective date of this
amendatory Act of the 100th General Assembly:
(1) The Director of Aging, or his or her designee, who
shall serve as the chairperson of the Subcommittee.
(2) One representative of the Department of Healthcare
and Family Services, appointed by the Director of
Healthcare and Family Services.
(3) One representative of the Department of Human
Services, appointed by the Secretary of Human Services.
(4) One individual representing a care coordination
unit, appointed by the Director of Aging.
(5) One individual from a non-governmental statewide
organization that advocates for seniors, appointed by the
Director of Aging.
(6) One individual representing Area Agencies on
Aging, appointed by the Director of Aging.
(7) One individual from a statewide association
dedicated to Alzheimer's care, support, and research,
appointed by the Director of Aging.
(8) One individual from an organization that employs
persons who provide services under the Community Care
Program, appointed by the Director of Aging.
(9) One member of a trade or labor union representing
persons who provide services under the Community Care
Program, appointed by the Director of Aging.

(10) One member of the Senate, who shall serve as
co-chairperson, appointed by the President of the Senate.
(11) One member of the Senate, who shall serve as
co-chairperson, appointed by the Minority Leader of the
Senate.
(12) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Speaker of
the House of Representatives.
(13) One member of the House of Representatives, who
shall serve as co-chairperson, appointed by the Minority
Leader of the House of Representatives.
(14) One individual appointed by a labor organization
representing frontline employees at the Department of
Human Services.
The Subcommittee shall provide oversight to the Community
Care Program Medicaid Initiative and shall meet quarterly. At
each Subcommittee meeting the Department on Aging shall
provide the following data sets to the Subcommittee: (A) the
number of Illinois residents, categorized by planning and
service area, who are receiving services under the Community
Care Program and are enrolled in the State's Medical
Assistance Program; (B) the number of Illinois residents,
categorized by planning and service area, who are receiving
services under the Community Care Program, but are not
enrolled in the State's Medical Assistance Program; and (C)
the number of Illinois residents, categorized by planning and

service area, who are receiving services under the Community
Care Program and are eligible for benefits under the State's
Medical Assistance Program, but are not enrolled in the
State's Medical Assistance Program. In addition to this data,
the Department on Aging shall provide the Subcommittee with
plans on how the Department on Aging will reduce the number of
Illinois residents who are not enrolled in the State's Medical
Assistance Program but who are eligible for medical assistance
benefits. The Department on Aging shall enroll in the State's
Medical Assistance Program those Illinois residents who
receive services under the Community Care Program and are
eligible for medical assistance benefits but are not enrolled
in the State's Medicaid Assistance Program. The data provided
to the Subcommittee shall be made available to the public via
the Department on Aging's website.
The Department on Aging, with the involvement of the
Subcommittee, shall collaborate with the Department of Human
Services and the Department of Healthcare and Family Services
on how best to achieve the responsibilities of the Community
Care Program Medicaid Initiative.
The Department on Aging, the Department of Human Services,
and the Department of Healthcare and Family Services shall
coordinate and implement a streamlined process for seniors to
access benefits under the State's Medical Assistance Program.
The Subcommittee shall collaborate with the Department of
Human Services on the adoption of a uniform application

submission process. The Department of Human Services and any
other State agency involved with processing the medical
assistance application of any person enrolled in the Community
Care Program shall include the appropriate care coordination
unit in all communications related to the determination or
status of the application.
The Community Care Program Medicaid Initiative shall
provide targeted funding to care coordination units to help
seniors complete their applications for medical assistance
benefits. On and after July 1, 2019, care coordination units
shall receive no less than $200 per completed application,
which rate may be included in a bundled rate for initial intake
services when Medicaid application assistance is provided in
conjunction with the initial intake process for new program
participants.
The Community Care Program Medicaid Initiative shall cease
operation 5 years after the effective date of this amendatory
Act of the 100th General Assembly, after which the
Subcommittee shall dissolve.
(Source: P.A. 101-10, eff. 6-5-19; 102-1071, eff. 6-10-22.)
(20 ILCS 105/4.07)
Sec. 4.07. Home-delivered meals.
(a) Every citizen of the State of Illinois who qualifies
for home-delivered meals under the federal Older Americans Act
shall be provided services, subject to appropriation. The

Department shall file a report with the General Assembly and
the Illinois Council on Aging by March 31 of the following
fiscal year January 1 of each year. The report shall include,
but not be limited to, the following information: (i)
estimates, by county, of citizens denied service due to
insufficient funds during the preceding fiscal year and the
potential impact on service delivery of any additional funds
appropriated for the current fiscal year; (ii) geographic
areas and special populations unserved and underserved in the
preceding fiscal year; (iii) estimates of additional funds
needed to permit the full funding of the program and the
statewide provision of services in the next fiscal year,
including staffing and equipment needed to prepare and deliver
meals; (iv) recommendations for increasing the amount of
federal funding captured for the program; (v) recommendations
for serving unserved and underserved areas and special
populations, to include rural areas, dietetic meals, weekend
meals, and 2 or more meals per day; and (vi) any other
information needed to assist the General Assembly and the
Illinois Council on Aging in developing a plan to address
unserved and underserved areas of the State.
(b) Subject to appropriation, on an annual basis each
recipient of home-delivered meals shall receive a fact sheet
developed by the Department on Aging with a current list of
toll-free numbers to access information on various health
conditions, elder abuse, and programs for persons 60 years of

age and older. The fact sheet shall be written in a language
that the client understands, if possible. In addition, each
recipient of home-delivered meals shall receive updates on any
new program for which persons 60 years of age and older may be
eligible.
(Source: P.A. 102-253, eff. 8-6-21.)
Section 90-10. The Respite Program Act is amended by
changing Section 12 as follows:
(320 ILCS 10/12) (from Ch. 23, par. 6212)
Sec. 12. Annual report. The Director shall submit a report
by March 31 of the following fiscal year each year to the
Governor and the General Assembly detailing the progress of
the respite care services provided under this Act and shall
also include an estimate of the demand for respite care
services over the next 10 years.
(Source: P.A. 100-972, eff. 1-1-19.)
ARTICLE 95.
Section 95-5. The Hospital Licensing Act is amended by
changing Section 6.09 as follows:
(210 ILCS 85/6.09) (from Ch. 111 1/2, par. 147.09)
Sec. 6.09. (a) In order to facilitate the orderly

transition of aged patients and patients with disabilities
from hospitals to post-hospital care, whenever a patient who
qualifies for the federal Medicare program is hospitalized,
the patient shall be notified of discharge at least 24 hours
prior to discharge from the hospital. With regard to pending
discharges to a skilled nursing facility, the hospital must
notify the case coordination unit, as defined in 89 Ill. Adm.
Code 240.260, at least 24 hours prior to discharge. When the
assessment is completed in the hospital, the case coordination
unit shall provide a copy of the required assessment
documentation directly to the nursing home to which the
patient is being discharged prior to discharge. The Department
on Aging shall provide notice of this requirement to case
coordination units. When a case coordination unit is unable to
complete an assessment in a hospital prior to the discharge of
a patient, 60 years of age or older, to a nursing home, the
case coordination unit shall notify the Department on Aging
which shall notify the Department of Healthcare and Family
Services. The Department of Healthcare and Family Services and
the Department on Aging shall adopt rules to address these
instances to ensure that the patient is able to access nursing
home care, the nursing home is not penalized for accepting the
admission, and the patient's timely discharge from the
hospital is not delayed, to the extent permitted under federal
law or regulation. Nothing in this subsection shall preclude
federal requirements for a pre-admission screening/mental

health (PAS/MH) as required under Section 2-201.5 of the
Nursing Home Care Act or State or federal law or regulation. If
home health services are ordered, the hospital must inform its
designated case coordination unit, as defined in 89 Ill. Adm.
Code 240.260, of the pending discharge and must provide the
patient with the case coordination unit's telephone number and
other contact information.
(b) Every hospital shall develop procedures for a
physician with medical staff privileges at the hospital or any
appropriate medical staff member to provide the discharge
notice prescribed in subsection (a) of this Section. The
procedures must include prohibitions against discharging or
referring a patient to any of the following if unlicensed,
uncertified, or unregistered: (i) a board and care facility,
as defined in the Board and Care Home Act; (ii) an assisted
living and shared housing establishment, as defined in the
Assisted Living and Shared Housing Act; (iii) a facility
licensed under the Nursing Home Care Act, the Specialized
Mental Health Rehabilitation Act of 2013, the ID/DD Community
Care Act, or the MC/DD Act; (iv) a supportive living facility,
as defined in Section 5-5.01a of the Illinois Public Aid Code;
or (v) a free-standing hospice facility licensed under the
Hospice Program Licensing Act if licensure, certification, or
registration is required. The Department of Public Health
shall annually provide hospitals with a list of licensed,
certified, or registered board and care facilities, assisted

living and shared housing establishments, nursing homes,
supportive living facilities, facilities licensed under the
ID/DD Community Care Act, the MC/DD Act, or the Specialized
Mental Health Rehabilitation Act of 2013, and hospice
facilities. Reliance upon this list by a hospital shall
satisfy compliance with this requirement. The procedure may
also include a waiver for any case in which a discharge notice
is not feasible due to a short length of stay in the hospital
by the patient, or for any case in which the patient
voluntarily desires to leave the hospital before the
expiration of the 24 hour period.
(c) At least 24 hours prior to discharge from the
hospital, the patient shall receive written information on the
patient's right to appeal the discharge pursuant to the
federal Medicare program, including the steps to follow to
appeal the discharge and the appropriate telephone number to
call in case the patient intends to appeal the discharge.
(d) Before transfer of a patient to a long term care
facility licensed under the Nursing Home Care Act where
elderly persons reside, a hospital shall as soon as
practicable initiate a name-based criminal history background
check by electronic submission to the Illinois State Police
for all persons between the ages of 18 and 70 years; provided,
however, that a hospital shall be required to initiate such a
background check only with respect to patients who:
(1) are transferring to a long term care facility for

the first time;
(2) have been in the hospital more than 5 days;
(3) are reasonably expected to remain at the long term
care facility for more than 30 days;
(4) have a known history of serious mental illness or
substance abuse; and
(5) are independently ambulatory or mobile for more
than a temporary period of time.
A hospital may also request a criminal history background
check for a patient who does not meet any of the criteria set
forth in items (1) through (5).
A hospital shall notify a long term care facility if the
hospital has initiated a criminal history background check on
a patient being discharged to that facility. In all
circumstances in which the hospital is required by this
subsection to initiate the criminal history background check,
the transfer to the long term care facility may proceed
regardless of the availability of criminal history results.
Upon receipt of the results, the hospital shall promptly
forward the results to the appropriate long term care
facility. If the results of the background check are
inconclusive, the hospital shall have no additional duty or
obligation to seek additional information from, or about, the
patient.
(Source: P.A. 102-538, eff. 8-20-21.)

Section 95-10. The Illinois Insurance Code is amended by
changing Section 5.5 as follows:
(215 ILCS 5/5.5)
Sec. 5.5. Compliance with the Department of Healthcare and
Family Services. A company authorized to do business in this
State or accredited by the State to issue policies of health
insurance, including but not limited to, self-insured plans,
group health plans (as defined in Section 607(1) of the
Employee Retirement Income Security Act of 1974), service
benefit plans, managed care organizations, pharmacy benefit
managers, or other parties that are by statute, contract, or
agreement legally responsible for payment of a claim for a
health care item or service as a condition of doing business in
the State must:
(1) provide to the Department of Healthcare and Family
Services, or any successor agency, on at least a quarterly
basis if so requested by the Department, information to
determine during what period any individual may be, or may
have been, covered by a health insurer and the nature of
the coverage that is or was provided by the health
insurer, including the name, address, and identifying
number of the plan;
(2) accept the State's right of recovery and the
assignment to the State of any right of an individual or
other entity to payment from the party for an item or

service for which payment has been made under the medical
programs of the Department of Healthcare and Family
Services, or any successor or authorized agency, under
this Code, or the Illinois Public Aid Code, or any other
applicable law; and (other than parties expressly excluded
under 42 U.S.C. 1396a(a)(25)(I)(ii)(II)) accept
authorization provided by the State that the item or
service is covered under such medical programs for the
individual, as if the State's authorization was the prior
authorization made by the company for the item or service;
(3) not later than 60 days after receiving respond to
any inquiry by the Department of Healthcare and Family
Services regarding a claim for payment for any health care
item or service that is submitted not later than 3 years
after the date of the provision of such health care item or
service, respond to such inquiry; and
(4) agree not to deny a claim submitted by the
Department of Healthcare and Family Services solely on the
basis of the date of submission of the claim, the type or
format of the claim form, or a failure to present proper
documentation at the point-of-sale that is the basis of
the claim, or (other than parties expressly excluded under
42 U.S.C. 1396a(a)(25)(I)(iv)) a failure to obtain a prior
authorization for the item or service for which the claim
is being submitted if (i) the claim is submitted by the
Department of Healthcare and Family Services within the

3-year period beginning on the date on which the item or
service was furnished and (ii) any action by the
Department of Healthcare and Family Services to enforce
its rights with respect to such claim is commenced within
6 years of its submission of such claim.
The Department of Healthcare and Family Services may
impose an administrative penalty as provided under Section
12-4.45 of the Illinois Public Aid Code on entities that have
established a pattern of failure to provide the information
required under this Section, or in cases in which the
Department of Healthcare and Family Services has determined
that an entity that provides health insurance coverage has
established a pattern of failure to provide the information
required under this Section, and has subsequently certified
that determination, along with supporting documentation, to
the Director of the Department of Insurance, the Director of
the Department of Insurance, based upon the certification of
determination made by the Department of Healthcare and Family
Services, may commence regulatory proceedings in accordance
with all applicable provisions of the Illinois Insurance Code.
(Source: P.A. 98-130, eff. 8-2-13.)
Section 95-15. The Illinois Public Aid Code is amended by
changing Sections 5-5 and 12-8 as follows:
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)

Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant individuals, provided by an individual licensed
to practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use

disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; (16.5) services performed by
a chiropractic physician licensed under the Medical Practice
Act of 1987 and acting within the scope of his or her license,
including, but not limited to, chiropractic manipulative
treatment; and (17) any other medical care, and any other type
of remedial care recognized under the laws of this State. The
term "any other type of remedial care" shall include nursing
care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes

purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided
through the Illinois Tobacco Quitline shall be covered under
the medical assistance program for persons who are otherwise
eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable

Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of
understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients

of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever
the person may select.
On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the

supervision of a dentist in the practice of his or her
profession.
On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare

and Family Services shall administer and regulate a
school-based dental program that allows for the out-of-office
delivery of preventative dental services in a school setting
to children under 19 years of age. The Department shall
establish, by rule, guidelines for participation by providers
and set requirements for follow-up referral care based on the
requirements established in the Dental Office Reference Manual
published by the Department that establishes the requirements
for dentists participating in the All Kids Dental School
Program. Every effort shall be made by the Department when
developing the program requirements to consider the different
geographic differences of both urban and rural areas of the
State for initial treatment and necessary follow-up care. No
provider shall be charged a fee by any unit of local government
to participate in the school-based dental program administered
by the Department. Nothing in this paragraph shall be
construed to limit or preempt a home rule unit's or school
district's authority to establish, change, or administer a
school-based dental program in addition to, or independent of,
the school-based dental program administered by the
Department.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Department of Healthcare and Family Services must

provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for
individuals 35 years of age or older who are eligible for
medical assistance under this Article, as follows:
(A) A baseline mammogram for individuals 35 to 39
years of age.
(B) An annual mammogram for individuals 40 years of
age or older.
(C) A mammogram at the age and intervals considered
medically necessary by the individual's health care
provider for individuals 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 or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.

(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the

breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation

for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography and, after
January 1, 2023 (the effective date of Public Act 102-1018)
this amendatory Act of the 102nd General Assembly, breast
tomosynthesis.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including

representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers

who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
The Department shall provide coverage and reimbursement
for a human papillomavirus (HPV) vaccine that is approved for
marketing by the federal Food and Drug Administration for all

persons between the ages of 9 and 45. Subject to federal
approval, the Department shall provide coverage and
reimbursement for a human papillomavirus (HPV) vaccine for and
persons of the age of 46 and above who have been diagnosed with
cervical dysplasia with a high risk of recurrence or
progression. The Department shall disallow any
preauthorization requirements for the administration of the
human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise
eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be
conditioned on the use of a screening instrument approved by
the Department.
Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department

of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information
from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,

information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by

the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between

service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and

eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the

viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical

assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon the category of risk
of the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,

certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.

(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 120
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission

documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with

State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre-adjudicated pre-
or post-adjudicated predictive modeling with an integrated

case management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
The Department shall require, by rule, all providers of

durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care

settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of the same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings

amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(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 shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate

of reimbursement for services or other payments in accordance
with Section 5-5e.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee for service and managed care medical
assistance programs for persons who are otherwise eligible for
medical assistance under this Article and shall not be subject
to any (1) utilization control, other than those established

under the American Society of Addiction Medicine patient
placement criteria, (2) prior authorization mandate, or (3)
lifetime restriction limit mandate.
On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees or hospital fees related to the dispensing, distribution,
and administration of the opioid antagonist, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
As used in this Section, "opioid antagonist" means a drug that
binds to opioid receptors and blocks or inhibits the effect of
opioids acting on those receptors, including, but not limited
to, naloxone hydrochloride or any other similarly acting drug
approved by the U.S. Food and Drug Administration. The
Department shall not impose a copayment on the coverage
provided for naloxone hydrochloride under the medical
assistance program.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually

transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date
of Public Act 102-665), the Department shall seek federal
approval of a State Plan amendment to expand coverage for
family planning services that includes presumptive eligibility
to individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare
and Medicaid Services of a Title XIX State Plan amendment
electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of

the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,
subject to criteria established in accordance with all
applicable laws.
Notwithstanding any other provision of this Code,
community-based pediatric palliative care from a trained
interdisciplinary team shall be covered under the medical
assistance program as provided in Section 15 of the Pediatric
Palliative Care Act.
Notwithstanding any other provision of this Code, within
12 months after June 2, 2022 (the effective date of Public Act
102-1037) this amendatory Act of the 102nd General Assembly
and subject to federal approval, acupuncture services
performed by an acupuncturist licensed under the Acupuncture
Practice Act who is acting within the scope of his or her
license shall be covered under the medical assistance program.
The Department shall apply for any federal waiver or State
Plan amendment, if required, to implement this paragraph. The
Department may adopt any rules, including standards and
criteria, necessary to implement this paragraph.
(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22;

102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff.
1-1-23; revised 2-5-23.)
(305 ILCS 5/12-8) (from Ch. 23, par. 12-8)
Sec. 12-8. Public Assistance Emergency Revolving Fund -
Uses. The Public Assistance Emergency Revolving Fund,
established by Act approved July 8, 1955 shall be held by the
Illinois Department and shall be used for the following
purposes:
1. To provide immediate financial aid to applicants in
acute need who have been determined eligible for aid under
Articles III, IV, or V.
2. To provide emergency aid to recipients under said
Articles who have failed to receive their grants because
of mail box or other thefts, or who are victims of a
burnout, eviction, or other circumstances causing
privation, in which cases the delays incident to the
issuance of grants from appropriations would cause
hardship and suffering.
3. To provide emergency aid for transportation, meals
and lodging to applicants who are referred to cities other
than where they reside for physical examinations to
establish blindness or disability, or to determine the
incapacity of the parent of a dependent child.
4. To provide emergency transportation expense
allowances to recipients engaged in vocational training

and rehabilitation projects.
5. To assist public aid applicants in obtaining copies
of birth certificates, death certificates, marriage
licenses or other similar legal documents which may
facilitate the verification of eligibility for public aid
under this Code.
6. To provide immediate payments to current or former
recipients of child support enforcement services, or
refunds to responsible relatives, for child support made
to the Illinois Department under Title IV-D of the Social
Security Act when such recipients of services or
responsible relatives are legally entitled to all or part
of such child support payments under applicable State or
federal law.
7. To provide payments to individuals or providers of
transportation to and from medical care for the benefit of
recipients under Articles III, IV, V, and VI.
8. To provide immediate payment of fees, as follows:
(A) To sheriffs and other public officials
authorized by law to serve process in judicial and
administrative child support actions in the State of
Illinois and other states.
(B) To county clerks, recorders of deeds, and
other public officials and keepers of real property
records in order to perfect and release real property
liens.

(C) To State and local officials in connection
with the processing of Qualified Illinois Domestic
Relations Orders.
(D) To the State Registrar of Vital Records, local
registrars of vital records, or other public officials
and keepers of voluntary acknowledgment of paternity
forms.
Disbursements from the Public Assistance Emergency
Revolving Fund shall be made by the Illinois Department.
Expenditures from the Public Assistance Emergency
Revolving Fund shall be for purposes which are properly
chargeable to appropriations made to the Illinois Department,
or, in the case of payments under subparagraphs 6 and 8, to the
Child Support Enforcement Trust Fund or the Child Support
Administrative Fund, except that no expenditure, other than
payment of the fees provided for under subparagraph 8 of this
Section, shall be made for purposes which are properly
chargeable to appropriations for the following objects:
personal services; extra help; state contributions to
retirement system; state contributions to Social Security;
state contributions for employee group insurance; contractual
services; travel; commodities; printing; equipment; electronic
data processing; operation of auto equipment;
telecommunications services; library books; and refunds. The
Illinois Department shall reimburse the Public Assistance
Emergency Revolving Fund by warrants drawn by the State

Comptroller on the appropriation or appropriations which are
so chargeable, or, in the case of payments under subparagraphs
6 and 8, by warrants drawn on the Child Support Enforcement
Trust Fund or the Child Support Administrative Fund, payable
to the Revolving Fund.
(Source: P.A. 97-735, eff. 7-3-12.)
ARTICLE 100.
Section 100-5. The Illinois Public Aid Code is amended by
changing Section 5-5.01a as follows:
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program.
(a) The Department shall establish and provide oversight
for a program of supportive living facilities that seek to
promote resident independence, dignity, respect, and
well-being in the most cost-effective manner.
A supportive living facility is (i) a free-standing
facility or (ii) a distinct physical and operational entity
within a mixed-use building that meets the criteria
established in subsection (d). A supportive living facility
integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents
their own separate, private, and distinct living units.
Sites for the operation of the program shall be selected

by the Department based upon criteria that may include the
need for services in a geographic area, the availability of
funding, and the site's ability to meet the standards.
(b) Beginning July 1, 2014, subject to federal approval,
the Medicaid rates for supportive living facilities shall be
equal to the supportive living facility Medicaid rate
effective on June 30, 2014 increased by 8.85%. Once the
assessment imposed at Article V-G of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act, the Department shall increase the Medicaid rates for
supportive living facilities effective on July 1, 2014 by
9.09%. The Department shall apply this increase retroactively
to coincide with the imposition of the assessment in Article
V-G of this Code in accordance with the approval for federal
financial participation by the Centers for Medicare and
Medicaid Services.
The Medicaid rates for supportive living facilities
effective on July 1, 2017 must be equal to the rates in effect
for supportive living facilities on June 30, 2017 increased by
2.8%.
The Medicaid rates for supportive living facilities
effective on July 1, 2018 must be equal to the rates in effect
for supportive living facilities on June 30, 2018.
Subject to federal approval, the Medicaid rates for
supportive living services on and after July 1, 2019 must be at
least 54.3% of the average total nursing facility services per

diem for the geographic areas defined by the Department while
maintaining the rate differential for dementia care and must
be updated whenever the total nursing facility service per
diems are updated. Beginning July 1, 2022, upon the
implementation of the Patient Driven Payment Model, Medicaid
rates for supportive living services must be at least 54.3% of
the average total nursing services per diem rate for the
geographic areas. For purposes of this provision, the average
total nursing services per diem rate shall include all add-ons
for nursing facilities for the geographic area provided for in
Section 5-5.2. The rate differential for dementia care must be
maintained in these rates and the rates shall be updated
whenever nursing facility per diem rates are updated.
(c) The Department may adopt rules to implement this
Section. Rules that establish or modify the services,
standards, and conditions for participation in the program
shall be adopted by the Department in consultation with the
Department on Aging, the Department of Rehabilitation
Services, and the Department of Mental Health and
Developmental Disabilities (or their successor agencies).
(d) Subject to federal approval by the Centers for
Medicare and Medicaid Services, the Department shall accept
for consideration of certification under the program any
application for a site or building where distinct parts of the
site or building are designated for purposes other than the
provision of supportive living services, but only if:

(1) those distinct parts of the site or building are
not designated for the purpose of providing assisted
living services as required under the Assisted Living and
Shared Housing Act;
(2) those distinct parts of the site or building are
completely separate from the part of the building used for
the provision of supportive living program services,
including separate entrances;
(3) those distinct parts of the site or building do
not share any common spaces with the part of the building
used for the provision of supportive living program
services; and
(4) those distinct parts of the site or building do
not share staffing with the part of the building used for
the provision of supportive living program services.
(e) Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good
standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois
Health Facilities Planning Act.
(f) Section 9817 of the American Rescue Plan Act of 2021
(Public Law 117-2) authorizes a 10% enhanced federal medical
assistance percentage for supportive living services for a
12-month period from April 1, 2021 through March 31, 2022.
Subject to federal approval, including the approval of any
necessary waiver amendments or other federally required

documents or assurances, for a 12-month period the Department
must pay a supplemental $26 per diem rate to all supportive
living facilities with the additional federal financial
participation funds that result from the enhanced federal
medical assistance percentage from April 1, 2021 through March
31, 2022. The Department may issue parameters around how the
supplemental payment should be spent, including quality
improvement activities. The Department may alter the form,
methods, or timeframes concerning the supplemental per diem
rate to comply with any subsequent changes to federal law,
changes made by guidance issued by the federal Centers for
Medicare and Medicaid Services, or other changes necessary to
receive the enhanced federal medical assistance percentage.
(g) All applications for the expansion of supportive
living dementia care settings involving sites not approved by
the Department on the effective date of this amendatory Act of
the 103rd General Assembly may allow new elderly non-dementia
units in addition to new dementia care units. The Department
may approve such applications only if the application has: (1)
no more than one non-dementia care unit for each dementia care
unit and (2) the site is not located within 4 miles of an
existing supportive living program site in Cook County
(including the City of Chicago), not located within 12 miles
of an existing supportive living program site in DuPage
County, Kane County, Lake County, McHenry County, or Will
County, or not located within 25 miles of an existing

supportive living program site in any other county.
(Source: P.A. 101-10, eff. 6-5-19; 102-43, eff. 7-6-21;
102-699, eff. 4-19-22.)
ARTICLE 105.
Section 105-5. The Illinois Public Aid Code is amended by
changing Section 5A-2 as follows:
(305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2)
(Section scheduled to be repealed on December 31, 2026)
Sec. 5A-2. Assessment.
(a)(1) Subject to Sections 5A-3 and 5A-10, for State
fiscal years 2009 through 2018, or as long as continued under
Section 5A-16, an annual assessment on inpatient services is
imposed on each hospital provider in an amount equal to
$218.38 multiplied by the difference of the hospital's
occupied bed days less the hospital's Medicare bed days,
provided, however, that the amount of $218.38 shall be
increased by a uniform percentage to generate an amount equal
to 75% of the State share of the payments authorized under
Section 5A-12.5, with such increase only taking effect upon
the date that a State share for such payments is required under
federal law. For the period of April through June 2015, the
amount of $218.38 used to calculate the assessment under this
paragraph shall, by emergency rule under subsection (s) of

Section 5-45 of the Illinois Administrative Procedure Act, be
increased by a uniform percentage to generate $20,250,000 in
the aggregate for that period from all hospitals subject to
the annual assessment under this paragraph.
(2) In addition to any other assessments imposed under
this Article, effective July 1, 2016 and semi-annually
thereafter through June 2018, or as provided in Section 5A-16,
in addition to any federally required State share as
authorized under paragraph (1), the amount of $218.38 shall be
increased by a uniform percentage to generate an amount equal
to 75% of the ACA Assessment Adjustment, as defined in
subsection (b-6) of this Section.
For State fiscal years 2009 through 2018, or as provided
in Section 5A-16, a hospital's occupied bed days and Medicare
bed days shall be determined using the most recent data
available from each hospital's 2005 Medicare cost report as
contained in the Healthcare Cost Report Information System
file, for the quarter ending on December 31, 2006, without
regard to any subsequent adjustments or changes to such data.
If a hospital's 2005 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the
Illinois Department may obtain the hospital provider's
occupied bed days and Medicare bed days from any source
available, including, but not limited to, records maintained
by the hospital provider, which may be inspected at all times
during business hours of the day by the Illinois Department or

its duly authorized agents and employees.
(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
fiscal years 2019 and 2020, an annual assessment on inpatient
services is imposed on each hospital provider in an amount
equal to $197.19 multiplied by the difference of the
hospital's occupied bed days less the hospital's Medicare bed
days. For State fiscal years 2019 and 2020, a hospital's
occupied bed days and Medicare bed days shall be determined
using the most recent data available from each hospital's 2015
Medicare cost report as contained in the Healthcare Cost
Report Information System file, for the quarter ending on
March 31, 2017, without regard to any subsequent adjustments
or changes to such data. If a hospital's 2015 Medicare cost
report is not contained in the Healthcare Cost Report
Information System, then the Illinois Department may obtain
the hospital provider's occupied bed days and Medicare bed
days from any source available, including, but not limited to,
records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Illinois Department or its duly authorized agents and
employees. Notwithstanding any other provision in this
Article, for a hospital provider that did not have a 2015
Medicare cost report, but paid an assessment in State fiscal
year 2018 on the basis of hypothetical data, that assessment
amount shall be used for State fiscal years 2019 and 2020.
(4) Subject to Sections 5A-3 and 5A-10 and to subsection

(b-8), for the period of July 1, 2020 through December 31, 2020
and calendar years 2021 through 2026, an annual assessment on
inpatient services is imposed on each hospital provider in an
amount equal to $221.50 multiplied by the difference of the
hospital's occupied bed days less the hospital's Medicare bed
days, provided however: for the period of July 1, 2020 through
December 31, 2020, (i) the assessment shall be equal to 50% of
the annual amount; and (ii) the amount of $221.50 shall be
retroactively adjusted by a uniform percentage to generate an
amount equal to 50% of the Assessment Adjustment, as defined
in subsection (b-7). For the period of July 1, 2020 through
December 31, 2020 and calendar years 2021 through 2026, a
hospital's occupied bed days and Medicare bed days shall be
determined using the most recent data available from each
hospital's 2015 Medicare cost report as contained in the
Healthcare Cost Report Information System file, for the
quarter ending on March 31, 2017, without regard to any
subsequent adjustments or changes to such data. If a
hospital's 2015 Medicare cost report is not contained in the
Healthcare Cost Report Information System, then the Illinois
Department may obtain the hospital provider's occupied bed
days and Medicare bed days from any source available,
including, but not limited to, records maintained by the
hospital provider, which may be inspected at all times during
business hours of the day by the Illinois Department or its
duly authorized agents and employees. Should the change in the

assessment methodology for fiscal years 2021 through December
31, 2022 not be approved on or before June 30, 2020, the
assessment and payments under this Article in effect for
fiscal year 2020 shall remain in place until the new
assessment is approved. If the assessment methodology for July
1, 2020 through December 31, 2022, is approved on or after July
1, 2020, it shall be retroactive to July 1, 2020, subject to
federal approval and provided that the payments authorized
under Section 5A-12.7 have the same effective date as the new
assessment methodology. In giving retroactive effect to the
assessment approved after June 30, 2020, credit toward the new
assessment shall be given for any payments of the previous
assessment for periods after June 30, 2020. Notwithstanding
any other provision of this Article, for a hospital provider
that did not have a 2015 Medicare cost report, but paid an
assessment in State Fiscal Year 2020 on the basis of
hypothetical data, the data that was the basis for the 2020
assessment shall be used to calculate the assessment under
this paragraph until December 31, 2023. Beginning July 1, 2022
and through December 31, 2024, a safety-net hospital that had
a change of ownership in calendar year 2021, and whose
inpatient utilization had decreased by 90% from the prior year
and prior to the change of ownership, may be eligible to pay a
tax based on hypothetical data based on a determination of
financial distress by the Department. Subject to federal
approval, the Department may, by January 1, 2024, develop a

hypothetical tax for a specialty cancer hospital which had a
structural change of ownership during calendar year 2022 from
a for-profit entity to a non-profit entity, and which has
experienced a decline of 60% or greater in inpatient days of
care as compared to the prior owners 2015 Medicare cost
report. This change of ownership may make the hospital
eligible for a hypothetical tax under the new hospital
provision of the assessment defined in this Section. This new
hypothetical tax may be applicable from January 1, 2024
through December 31, 2026.
(b) (Blank).
(b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
portion of State fiscal year 2012, beginning June 10, 2012
through June 30, 2012, and for State fiscal years 2013 through
2018, or as provided in Section 5A-16, an annual assessment on
outpatient services is imposed on each hospital provider in an
amount equal to .008766 multiplied by the hospital's
outpatient gross revenue, provided, however, that the amount
of .008766 shall be increased by a uniform percentage to
generate an amount equal to 25% of the State share of the
payments authorized under Section 5A-12.5, with such increase
only taking effect upon the date that a State share for such
payments is required under federal law. For the period
beginning June 10, 2012 through June 30, 2012, the annual
assessment on outpatient services shall be prorated by
multiplying the assessment amount by a fraction, the numerator

of which is 21 days and the denominator of which is 365 days.
For the period of April through June 2015, the amount of
.008766 used to calculate the assessment under this paragraph
shall, by emergency rule under subsection (s) of Section 5-45
of the Illinois Administrative Procedure Act, be increased by
a uniform percentage to generate $6,750,000 in the aggregate
for that period from all hospitals subject to the annual
assessment under this paragraph.
(2) In addition to any other assessments imposed under
this Article, effective July 1, 2016 and semi-annually
thereafter through June 2018, in addition to any federally
required State share as authorized under paragraph (1), the
amount of .008766 shall be increased by a uniform percentage
to generate an amount equal to 25% of the ACA Assessment
Adjustment, as defined in subsection (b-6) of this Section.
For the portion of State fiscal year 2012, beginning June
10, 2012 through June 30, 2012, and State fiscal years 2013
through 2018, or as provided in Section 5A-16, a hospital's
outpatient gross revenue shall be determined using the most
recent data available from each hospital's 2009 Medicare cost
report as contained in the Healthcare Cost Report Information
System file, for the quarter ending on June 30, 2011, without
regard to any subsequent adjustments or changes to such data.
If a hospital's 2009 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the
Department may obtain the hospital provider's outpatient gross

revenue from any source available, including, but not limited
to, records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Department or its duly authorized agents and employees.
(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
fiscal years 2019 and 2020, an annual assessment on outpatient
services is imposed on each hospital provider in an amount
equal to .01358 multiplied by the hospital's outpatient gross
revenue. For State fiscal years 2019 and 2020, a hospital's
outpatient gross revenue shall be determined using the most
recent data available from each hospital's 2015 Medicare cost
report as contained in the Healthcare Cost Report Information
System file, for the quarter ending on March 31, 2017, without
regard to any subsequent adjustments or changes to such data.
If a hospital's 2015 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the
Department may obtain the hospital provider's outpatient gross
revenue from any source available, including, but not limited
to, records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Department or its duly authorized agents and employees.
Notwithstanding any other provision in this Article, for a
hospital provider that did not have a 2015 Medicare cost
report, but paid an assessment in State fiscal year 2018 on the
basis of hypothetical data, that assessment amount shall be
used for State fiscal years 2019 and 2020.

(4) Subject to Sections 5A-3 and 5A-10 and to subsection
(b-8), for the period of July 1, 2020 through December 31, 2020
and calendar years 2021 through 2026, an annual assessment on
outpatient services is imposed on each hospital provider in an
amount equal to .01525 multiplied by the hospital's outpatient
gross revenue, provided however: (i) for the period of July 1,
2020 through December 31, 2020, the assessment shall be equal
to 50% of the annual amount; and (ii) the amount of .01525
shall be retroactively adjusted by a uniform percentage to
generate an amount equal to 50% of the Assessment Adjustment,
as defined in subsection (b-7). For the period of July 1, 2020
through December 31, 2020 and calendar years 2021 through
2026, a hospital's outpatient gross revenue shall be
determined using the most recent data available from each
hospital's 2015 Medicare cost report as contained in the
Healthcare Cost Report Information System file, for the
quarter ending on March 31, 2017, without regard to any
subsequent adjustments or changes to such data. If a
hospital's 2015 Medicare cost report is not contained in the
Healthcare Cost Report Information System, then the Illinois
Department may obtain the hospital provider's outpatient
revenue data from any source available, including, but not
limited to, records maintained by the hospital provider, which
may be inspected at all times during business hours of the day
by the Illinois Department or its duly authorized agents and
employees. Should the change in the assessment methodology

above for fiscal years 2021 through calendar year 2022 not be
approved prior to July 1, 2020, the assessment and payments
under this Article in effect for fiscal year 2020 shall remain
in place until the new assessment is approved. If the change in
the assessment methodology above for July 1, 2020 through
December 31, 2022, is approved after June 30, 2020, it shall
have a retroactive effective date of July 1, 2020, subject to
federal approval and provided that the payments authorized
under Section 12A-7 have the same effective date as the new
assessment methodology. In giving retroactive effect to the
assessment approved after June 30, 2020, credit toward the new
assessment shall be given for any payments of the previous
assessment for periods after June 30, 2020. Notwithstanding
any other provision of this Article, for a hospital provider
that did not have a 2015 Medicare cost report, but paid an
assessment in State Fiscal Year 2020 on the basis of
hypothetical data, the data that was the basis for the 2020
assessment shall be used to calculate the assessment under
this paragraph until December 31, 2023. Beginning July 1, 2022
and through December 31, 2024, a safety-net hospital that had
a change of ownership in calendar year 2021, and whose
inpatient utilization had decreased by 90% from the prior year
and prior to the change of ownership, may be eligible to pay a
tax based on hypothetical data based on a determination of
financial distress by the Department.
(b-6)(1) As used in this Section, "ACA Assessment

Adjustment" means:
(A) For the period of July 1, 2016 through December
31, 2016, the product of .19125 multiplied by the sum of
the fee-for-service payments to hospitals as authorized
under Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of April 2016 multiplied by 6.
(B) For the period of January 1, 2017 through June 30,
2017, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under
Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of October 2016 multiplied by 6, except that the
amount calculated under this subparagraph (B) shall be
adjusted, either positively or negatively, to account for
the difference between the actual payments issued under
Section 5A-12.5 for the period beginning July 1, 2016
through December 31, 2016 and the estimated payments due
and payable in the month of April 2016 multiplied by 6 as
described in subparagraph (A).
(C) For the period of July 1, 2017 through December
31, 2017, the product of .19125 multiplied by the sum of
the fee-for-service payments to hospitals as authorized
under Section 5A-12.5 and the adjustments authorized under

subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of April 2017 multiplied by 6, except that the
amount calculated under this subparagraph (C) shall be
adjusted, either positively or negatively, to account for
the difference between the actual payments issued under
Section 5A-12.5 for the period beginning January 1, 2017
through June 30, 2017 and the estimated payments due and
payable in the month of October 2016 multiplied by 6 as
described in subparagraph (B).
(D) For the period of January 1, 2018 through June 30,
2018, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under
Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of October 2017 multiplied by 6, except that:
(i) the amount calculated under this subparagraph
(D) shall be adjusted, either positively or
negatively, to account for the difference between the
actual payments issued under Section 5A-12.5 for the
period of July 1, 2017 through December 31, 2017 and
the estimated payments due and payable in the month of
April 2017 multiplied by 6 as described in
subparagraph (C); and
(ii) the amount calculated under this subparagraph

(D) shall be adjusted to include the product of .19125
multiplied by the sum of the fee-for-service payments,
if any, estimated to be paid to hospitals under
subsection (b) of Section 5A-12.5.
(2) The Department shall complete and apply a final
reconciliation of the ACA Assessment Adjustment prior to June
30, 2018 to account for:
(A) any differences between the actual payments issued
or scheduled to be issued prior to June 30, 2018 as
authorized in Section 5A-12.5 for the period of January 1,
2018 through June 30, 2018 and the estimated payments due
and payable in the month of October 2017 multiplied by 6 as
described in subparagraph (D); and
(B) any difference between the estimated
fee-for-service payments under subsection (b) of Section
5A-12.5 and the amount of such payments that are actually
scheduled to be paid.
The Department shall notify hospitals of any additional
amounts owed or reduction credits to be applied to the June
2018 ACA Assessment Adjustment. This is to be considered the
final reconciliation for the ACA Assessment Adjustment.
(3) Notwithstanding any other provision of this Section,
if for any reason the scheduled payments under subsection (b)
of Section 5A-12.5 are not issued in full by the final day of
the period authorized under subsection (b) of Section 5A-12.5,
funds collected from each hospital pursuant to subparagraph

(D) of paragraph (1) and pursuant to paragraph (2),
attributable to the scheduled payments authorized under
subsection (b) of Section 5A-12.5 that are not issued in full
by the final day of the period attributable to each payment
authorized under subsection (b) of Section 5A-12.5, shall be
refunded.
(4) The increases authorized under paragraph (2) of
subsection (a) and paragraph (2) of subsection (b-5) shall be
limited to the federally required State share of the total
payments authorized under Section 5A-12.5 if the sum of such
payments yields an annualized amount equal to or less than
$450,000,000, or if the adjustments authorized under
subsection (t) of Section 5A-12.2 are found not to be
actuarially sound; however, this limitation shall not apply to
the fee-for-service payments described in subsection (b) of
Section 5A-12.5.
(b-7)(1) As used in this Section, "Assessment Adjustment"
means:
(A) For the period of July 1, 2020 through December
31, 2020, the product of .3853 multiplied by the total of
the actual payments made under subsections (c) through (k)
of Section 5A-12.7 attributable to the period, less the
total of the assessment imposed under subsections (a) and
(b-5) of this Section for the period.
(B) For each calendar quarter beginning January 1,
2021 through December 31, 2022, the product of .3853

multiplied by the total of the actual payments made under
subsections (c) through (k) of Section 5A-12.7
attributable to the period, less the total of the
assessment imposed under subsections (a) and (b-5) of this
Section for the period.
(C) Beginning on January 1, 2023, and each subsequent
July 1 and January 1, the product of .3853 multiplied by
the total of the actual payments made under subsections
(c) through (j) of Section 5A-12.7 attributable to the
6-month period immediately preceding the period to which
the adjustment applies, less the total of the assessment
imposed under subsections (a) and (b-5) of this Section
for the 6-month period immediately preceding the period to
which the adjustment applies.
(2) The Department shall calculate and notify each
hospital of the total Assessment Adjustment and any additional
assessment owed by the hospital or refund owed to the hospital
on either a semi-annual or annual basis. Such notice shall be
issued at least 30 days prior to any period in which the
assessment will be adjusted. Any additional assessment owed by
the hospital or refund owed to the hospital shall be uniformly
applied to the assessment owed by the hospital in monthly
installments for the subsequent semi-annual period or calendar
year. If no assessment is owed in the subsequent year, any
amount owed by the hospital or refund due to the hospital,
shall be paid in a lump sum.

(3) The Department shall publish all details of the
Assessment Adjustment calculation performed each year on its
website within 30 days of completing the calculation, and also
submit the details of the Assessment Adjustment calculation as
part of the Department's annual report to the General
Assembly.
(b-8) Notwithstanding any other provision of this Article,
the Department shall reduce the assessments imposed on each
hospital under subsections (a) and (b-5) by the uniform
percentage necessary to reduce the total assessment imposed on
all hospitals by an aggregate amount of $240,000,000, with
such reduction being applied by June 30, 2022. The assessment
reduction required for each hospital under this subsection
shall be forever waived, forgiven, and released by the
Department.
(c) (Blank).
(d) Notwithstanding any of the other provisions of this
Section, the Department is authorized to adopt rules to reduce
the rate of any annual assessment imposed under this Section,
as authorized by Section 5-46.2 of the Illinois Administrative
Procedure Act.
(e) Notwithstanding any other provision of this Section,
any plan providing for an assessment on a hospital provider as
a permissible tax under Title XIX of the federal Social
Security Act and Medicaid-eligible payments to hospital
providers from the revenues derived from that assessment shall

be reviewed by the Illinois Department of Healthcare and
Family Services, as the Single State Medicaid Agency required
by federal law, to determine whether those assessments and
hospital provider payments meet federal Medicaid standards. If
the Department determines that the elements of the plan may
meet federal Medicaid standards and a related State Medicaid
Plan Amendment is prepared in a manner and form suitable for
submission, that State Plan Amendment shall be submitted in a
timely manner for review by the Centers for Medicare and
Medicaid Services of the United States Department of Health
and Human Services and subject to approval by the Centers for
Medicare and Medicaid Services of the United States Department
of Health and Human Services. No such plan shall become
effective without approval by the Illinois General Assembly by
the enactment into law of related legislation. Notwithstanding
any other provision of this Section, the Department is
authorized to adopt rules to reduce the rate of any annual
assessment imposed under this Section. Any such rules may be
adopted by the Department under Section 5-50 of the Illinois
Administrative Procedure Act.
(Source: P.A. 101-10, eff. 6-5-19; 101-650, eff. 7-7-20;
reenacted by P.A. 101-655, eff. 3-12-21; 102-886, eff.
5-17-22.)
ARTICLE 110.

Section 110-5. The Illinois Insurance Code is amended by
adding Section 513b7 as follows:
(215 ILCS 5/513b7 new)
Sec. 513b7. Pharmacy audits.
(a) As used in this Section:
"Audit" means any physical on-site, remote electronic, or
concurrent review of a pharmacist or pharmacy service
submitted to the pharmacy benefit manager or pharmacy benefit
manager affiliate by a pharmacist or pharmacy for payment.
"Auditing entity" means a person or company that performs
a pharmacy audit.
"Extrapolation" means the practice of inferring a
frequency of dollar amount of overpayments, underpayments,
nonvalid claims, or other errors on any portion of claims
submitted, based on the frequency of dollar amount of
overpayments, underpayments, nonvalid claims, or other errors
actually measured in a sample of claims.
"Misfill" means a prescription that was not dispensed; a
prescription that was dispensed but was an incorrect dose,
amount, or type of medication; a prescription that was
dispensed to the wrong person; a prescription in which the
prescriber denied the authorization request; or a prescription
in which an additional dispensing fee was charged.
"Pharmacy audit" means an audit conducted of any records
of a pharmacy for prescriptions dispensed or nonproprietary

drugs or pharmacist services provided by a pharmacy or
pharmacist to a covered person.
"Pharmacy record" means any record stored electronically
or as a hard copy by a pharmacy that relates to the provision
of a prescription or pharmacy services or other component of
pharmacist care that is included in the practice of pharmacy.
(b) Notwithstanding any other law, when conducting a
pharmacy audit, an auditing entity shall:
(1) not conduct an on-site audit of a pharmacy at any
time during the first 3 business days of a month or the
first 2 weeks and final 2 weeks of the calendar year or
during a declared State or federal public health
emergency;
(2) notify the pharmacy or its contracting agent no
later than 14 business days before the date of initial
on-site audit; the notification to the pharmacy or its
contracting agent shall be in writing and delivered
either:
(A) by mail or common carrier, return receipt
requested; or
(B) electronically, not including facsimile, with
electronic receipt confirmation and delivered during
normal business hours of operation, addressed to the
supervising pharmacist and pharmacy corporate office,
if applicable, at least 14 business days before the
date of an initial on-site audit;

(3) limit the audit period to 24 months after the date
a claim is submitted to or adjudicated by the pharmacy
benefit manager;
(4) provide in writing the list of specific
prescription numbers to be included in the audit 14
business days before the on-site audit that may or may not
include the final 2 digits of the prescription numbers;
(5) use the written and verifiable records of a
hospital, physician, or other authorized practitioner that
are transmitted by any means of communication to validate
the pharmacy records in accordance with State and federal
law;
(6) limit the number of prescriptions audited to no
more than 100 prescriptions per audit and an entity shall
not audit more than 200 prescriptions in any 12-month
period, except in cases of fraud or knowing and willful
misrepresentation; a refill shall not constitute a
separate prescription and a pharmacy shall not be audited
more than once every 6 months;
(7) provide the pharmacy or its contracting agent with
a copy of the preliminary audit report within 45 days
after the conclusion of the audit;
(8) be allowed to conduct a follow-up audit on site if
a remote or desk audit reveals the necessity for a review
of additional claims;
(9) accept invoice audits as validation invoices from

any wholesaler registered with the Department of Financial
and Professional Regulation from which the pharmacy has
purchased prescription drugs or, in the case of durable
medical equipment or sickroom supplies, invoices from an
authorized distributor other than a wholesaler;
(10) provide the pharmacy or its contracting agent
with the ability to provide documentation to address a
discrepancy or audit finding if the documentation is
received by the pharmacy benefit manager no later than the
45th day after the preliminary audit report was provided
to the pharmacy or its contracting agent; the pharmacy
benefit manager shall consider a reasonable request from
the pharmacy for an extension of time to submit
documentation to address or correct any findings in the
report;
(11) be required to provide the pharmacy or its
contracting agent with the final audit report no later
than 90 days after the initial audit report was provided
to the pharmacy or its contracting agent;
(12) conduct the audit in consultation with a
pharmacist in specific cases if the audit involves
clinical or professional judgment;
(13) not chargeback, recoup, or collect penalties from
a pharmacy until the time period to file an appeal of the
final pharmacy audit report has passed or the appeals
process has been exhausted, whichever is later, unless the

identified discrepancy is expected to exceed $25,000, in
which case the auditing entity may withhold future
payments in excess of that amount until the final
resolution of the audit;
(14) not compensate the employee or contractor
conducting the audit based on a percentage of the amount
claimed or recouped pursuant to the audit;
(15) not use extrapolation to calculate penalties or
amounts to be charged back or recouped unless otherwise
required by federal law or regulation; any amount to be
charged back or recouped due to overpayment may not exceed
the amount the pharmacy was overpaid;
(16) not include dispensing fees in the calculation of
overpayments unless a prescription is considered a
misfill, the medication is not delivered to the patient,
the prescription is not valid, or the prescriber denies
authorizing the prescription; and
(17) conduct a pharmacy audit under the same standards
and parameters as conducted for other similarly situated
pharmacies audited by the auditing entity.
(c) Except as otherwise provided by State or federal law,
an auditing entity conducting a pharmacy audit may have access
to a pharmacy's previous audit report only if the report was
prepared by that auditing entity.
(d) Information collected during a pharmacy audit shall be
confidential by law, except that the auditing entity

conducting the pharmacy audit may share the information with
the health benefit plan for which a pharmacy audit is being
conducted and with any regulatory agencies and law enforcement
agencies as required by law.
(e) A pharmacy may not be subject to a chargeback or
recoupment for a clerical or recordkeeping error in a required
document or record, including a typographical error or
computer error, unless the pharmacy benefit manager can
provide proof of intent to commit fraud or such error results
in actual financial harm to the pharmacy benefit manager, a
health plan managed by the pharmacy benefit manager, or a
consumer.
(f) A pharmacy shall have the right to file a written
appeal of a preliminary and final pharmacy audit report in
accordance with the procedures established by the entity
conducting the pharmacy audit.
(g) No interest shall accrue for any party during the
audit period, beginning with the notice of the pharmacy audit
and ending with the conclusion of the appeals process.
(h) An auditing entity must provide a copy to the plan
sponsor of its claims that were included in the audit, and any
recouped money shall be returned to the plan sponsor, unless
otherwise contractually agreed upon by the plan sponsor and
the pharmacy benefit manager.
(i) The parameters of an audit must comply with
manufacturer listings or recommendations, unless otherwise

prescribed by the treating provider, and must be covered under
the individual's health plan, for the following:
(1) the day supply for eye drops must be calculated so
that the consumer pays only one 30-day copayment if the
bottle of eye drops is intended by the manufacturer to be a
30-day supply;
(2) the day supply for insulin must be calculated so
that the highest dose prescribed is used to determine the
day supply and consumer copayment; and
(3) the day supply for topical product must be
determined by the judgment of the pharmacist or treating
provider upon the treated area.
(j) This Section shall not apply to:
(1) audits in which suspected fraud or knowing and
willful misrepresentation is evidenced by a physical
review, review of claims data or statements, or other
investigative methods;
(2) audits of claims paid for by federally funded
programs not applicable to health insurance coverage
regulated by the Department; or
(3) concurrent reviews or desk audits that occur
within 3 business days after transmission of a claim and
in which no chargeback or recoupment is demanded.
ARTICLE 115.

Section 115-5. The Illinois Public Aid Code is amended by
changing Section 5-30.11 as follows:
(305 ILCS 5/5-30.11)
Sec. 5-30.11. Treatment of autism spectrum disorder.
Treatment of autism spectrum disorder through applied behavior
analysis shall be covered under the medical assistance program
under this Article for children with a diagnosis of autism
spectrum disorder when (1) ordered by: (1) a physician
licensed to practice medicine in all its branches or a
psychologist licensed by the Department of Financial and
Professional Regulation and (2) and rendered by a licensed or
certified health care professional with expertise in applied
behavior analysis; or (2) when evaluated and treated by a
behavior analyst as recognized by the Department or licensed
by the Department of Financial and Professional Regulation to
practice applied behavior analysis in this State. Such
coverage may be limited to age ranges based on evidence-based
best practices. Appropriate State plan amendments as well as
rules regarding provision of services and providers will be
submitted by September 1, 2019. Pursuant to the flexibilities
allowed by the federal Centers for Medicare and Medicaid
Services to Illinois under the Medical Assistance Program, the
Department shall enroll and reimburse qualified staff to
perform applied behavior analysis services in advance of
Illinois licensure activities performed by the Department of

Financial and Professional Regulation. These services shall be
covered if they are provided in a home or community setting or
in an office-based setting. The Department may conduct annual
on-site reviews of the services authorized under this Section.
Provider enrollment shall occur no later than September 1,
2023.
(Source: P.A. 101-10, eff. 6-5-19; 102-558, eff. 8-20-21;
102-953, eff. 5-27-22.)
ARTICLE 120.
Section 120-5. The Illinois Public Aid Code is amended by
adding Section 5-5a.1 as follows:
(305 ILCS 5/5-5a.1 new)
Sec. 5-5a.1. Telehealth services for persons with
intellectual and developmental disabilities. The Department
shall file an amendment to the Home and Community-Based
Services Waiver Program for Adults with Developmental
Disabilities authorized under Section 1915(c) of the Social
Security Act to incorporate telehealth services administered
by a provider of telehealth services that demonstrates
knowledge and experience in providing medical and emergency
services for persons with intellectual and developmental
disabilities. The Department shall pay administrative fees
associated with implementing telehealth services for all

persons with intellectual and developmental disabilities who
are receiving services under the Home and Community-Based
Services Waiver Program for Adults with Developmental
Disabilities.
ARTICLE 125.
Section 125-5. The Illinois Public Aid Code is amended by
adding Section 5-48 as follows:
(305 ILCS 5/5-48 new)
Sec. 5-48. Increasing behavioral health service capacity
in federally qualified health centers. The Department of
Healthcare and Family Services shall develop policies and
procedures with the goal of increasing the capacity of
behavioral health services provided by federally qualified
health centers as defined in Section 1905(l)(2)(B) of the
federal Social Security Act. Subject to federal approval, the
Department shall develop, no later than January 1, 2024,
billing policies that provide reimbursement to federally
qualified health centers for services rendered by
graduate-level, sub-clinical behavioral health professionals
who deliver care under the supervision of a fully licensed
behavioral health clinician who is licensed as a clinical
social worker, clinical professional counselor, marriage and
family therapist, or clinical psychologist.

To be eligible for reimbursement as provided for in this
Section, a graduate-level, sub-clinical professional must meet
the educational requirements set forth by the Department of
Financial and Professional Regulation for licensed clinical
social workers, licensed clinical professional counselors,
licensed marriage and family therapists, or licensed clinical
psychologists. An individual seeking to fulfill post-degree
experience requirements in order to qualify for licensing as a
clinical social worker, clinical professional counselor,
marriage and family therapist, or clinical psychologist shall
also be eligible for reimbursement under this Section so long
as the individual is in compliance with all applicable laws
and regulations regarding supervision, including, but not
limited to, the requirement that the supervised experience be
under the order, control, and full professional responsibility
of the individual's supervisor or that the individual is
designated by a title that clearly indicates training status.
The Department shall work with a trade association
representing a majority of federally qualified health centers
operating in Illinois to develop the policies and procedures
required under this Section.
ARTICLE 130.
Section 130-5. The Illinois Insurance Code is amended by
changing Section 363 as follows:

(215 ILCS 5/363) (from Ch. 73, par. 975)
Sec. 363. Medicare supplement policies; minimum standards.
(1) Except as otherwise specifically provided therein,
this Section and Section 363a of this Code shall apply to:
(a) all Medicare supplement policies and subscriber
contracts delivered or issued for delivery in this State
on and after January 1, 1989; and
(b) all certificates issued under group Medicare
supplement policies or subscriber contracts, which
certificates are issued or issued for delivery in this
State on and after January 1, 1989.
This Section shall not apply to "Accident Only" or
"Specified Disease" types of policies. The provisions of this
Section are not intended to prohibit or apply to policies or
health care benefit plans, including group conversion
policies, provided to Medicare eligible persons, which
policies or plans are not marketed or purported or held to be
Medicare supplement policies or benefit plans.
(2) For the purposes of this Section and Section 363a, the
following terms have the following meanings:
(a) "Applicant" means:
(i) in the case of individual Medicare supplement
policy, the person who seeks to contract for insurance
benefits, and
(ii) in the case of a group Medicare policy or

subscriber contract, the proposed certificate holder.
(b) "Certificate" means any certificate delivered or
issued for delivery in this State under a group Medicare
supplement policy.
(c) "Medicare supplement policy" means an individual
policy of accident and health insurance, as defined in
paragraph (a) of subsection (2) of Section 355a of this
Code, or a group policy or certificate delivered or issued
for delivery in this State by an insurer, fraternal
benefit society, voluntary health service plan, or health
maintenance organization, other than a policy issued
pursuant to a contract under Section 1876 of the federal
Social Security Act (42 U.S.C. Section 1395 et seq.) or a
policy issued under a demonstration project specified in
42 U.S.C. Section 1395ss(g)(1), or any similar
organization, that is advertised, marketed, or designed
primarily as a supplement to reimbursements under Medicare
for the hospital, medical, or surgical expenses of persons
eligible for Medicare.
(d) "Issuer" includes insurance companies, fraternal
benefit societies, voluntary health service plans, health
maintenance organizations, or any other entity providing
Medicare supplement insurance, unless the context clearly
indicates otherwise.
(e) "Medicare" means the Health Insurance for the Aged
Act, Title XVIII of the Social Security Amendments of

1965.
(3) No Medicare supplement insurance policy, contract, or
certificate, that provides benefits that duplicate benefits
provided by Medicare, shall be issued or issued for delivery
in this State after December 31, 1988. No such policy,
contract, or certificate shall provide lesser benefits than
those required under this Section or the existing Medicare
Supplement Minimum Standards Regulation, except where
duplication of Medicare benefits would result.
(4) Medicare supplement policies or certificates shall
have a notice prominently printed on the first page of the
policy or attached thereto stating in substance that the
policyholder or certificate holder shall have the right to
return the policy or certificate within 30 days of its
delivery and to have the premium refunded directly to him or
her in a timely manner if, after examination of the policy or
certificate, the insured person is not satisfied for any
reason.
(5) A Medicare supplement policy or certificate may not
deny a claim for losses incurred more than 6 months from the
effective date of coverage for a preexisting condition. The
policy may not define a preexisting condition more
restrictively than a condition for which medical advice was
given or treatment was recommended by or received from a
physician within 6 months before the effective date of
coverage.

(6) An issuer of a Medicare supplement policy shall:
(a) not deny coverage to an applicant under 65 years
of age who meets any of the following criteria:
(i) becomes eligible for Medicare by reason of
disability if the person makes application for a
Medicare supplement policy within 6 months of the
first day on which the person enrolls for benefits
under Medicare Part B; for a person who is
retroactively enrolled in Medicare Part B due to a
retroactive eligibility decision made by the Social
Security Administration, the application must be
submitted within a 6-month period beginning with the
month in which the person received notice of
retroactive eligibility to enroll;
(ii) has Medicare and an employer group health
plan (either primary or secondary to Medicare) that
terminates or ceases to provide all such supplemental
health benefits;
(iii) is insured by a Medicare Advantage plan that
includes a Health Maintenance Organization, a
Preferred Provider Organization, and a Private
Fee-For-Service or Medicare Select plan and the
applicant moves out of the plan's service area; the
insurer goes out of business, withdraws from the
market, or has its Medicare contract terminated; or
the plan violates its contract provisions or is

misrepresented in its marketing; or
(iv) is insured by a Medicare supplement policy
and the insurer goes out of business, withdraws from
the market, or the insurance company or agents
misrepresent the plan and the applicant is without
coverage;
(b) make available to persons eligible for Medicare by
reason of disability each type of Medicare supplement
policy the issuer makes available to persons eligible for
Medicare by reason of age;
(c) not charge individuals who become eligible for
Medicare by reason of disability and who are under the age
of 65 premium rates for any medical supplemental insurance
benefit plan offered by the issuer that exceed the
issuer's highest rate on the current rate schedule filed
with the Division of Insurance for that plan to
individuals who are age 65 or older; and
(d) provide the rights granted by items (a) through
(d), for 6 months after the effective date of this
amendatory Act of the 95th General Assembly, to any person
who had enrolled for benefits under Medicare Part B prior
to this amendatory Act of the 95th General Assembly who
otherwise would have been eligible for coverage under item
(a).
(7) The Director shall issue reasonable rules and
regulations for the following purposes:

(a) To establish specific standards for policy
provisions of Medicare policies and certificates. The
standards shall be in accordance with the requirements of
this Code. No requirement of this Code relating to minimum
required policy benefits, other than the minimum standards
contained in this Section and Section 363a, shall apply to
Medicare supplement policies and certificates. The
standards may cover, but are not limited to the following:
(A) Terms of renewability.
(B) Initial and subsequent terms of eligibility.
(C) Non-duplication of coverage.
(D) Probationary and elimination periods.
(E) Benefit limitations, exceptions and
reductions.
(F) Requirements for replacement.
(G) Recurrent conditions.
(H) Definition of terms.
(I) Requirements for issuing rebates or credits to
policyholders if the policy's loss ratio does not
comply with subsection (7) of Section 363a.
(J) Uniform methodology for the calculating and
reporting of loss ratio information.
(K) Assuring public access to loss ratio
information of an issuer of Medicare supplement
insurance.
(L) Establishing a process for approving or

disapproving proposed premium increases.
(M) Establishing a policy for holding public
hearings prior to approval of premium increases.
(N) Establishing standards for Medicare Select
policies.
(O) Prohibited policy provisions not otherwise
specifically authorized by statute that, in the
opinion of the Director, are unjust, unfair, or
unfairly discriminatory to any person insured or
proposed for coverage under a medicare supplement
policy or certificate.
(b) To establish minimum standards for benefits and
claims payments, marketing practices, compensation
arrangements, and reporting practices for Medicare
supplement policies.
(c) To implement transitional requirements of Medicare
supplement insurance benefits and premiums of Medicare
supplement policies and certificates to conform to
Medicare program revisions.
(8) If an individual is at least 65 years of age but no
more than 75 years of age and has an existing Medicare
supplement policy, the individual is entitled to an annual
open enrollment period lasting 45 days, commencing with the
individual's birthday, and the individual may purchase any
Medicare supplement policy with the same issuer that offers
benefits equal to or lesser than those provided by the

previous coverage. During this open enrollment period, an
issuer of a Medicare supplement policy shall not deny or
condition the issuance or effectiveness of Medicare
supplemental coverage, nor discriminate in the pricing of
coverage, because of health status, claims experience, receipt
of health care, or a medical condition of the individual. An
issuer shall provide notice of this annual open enrollment
period for eligible Medicare supplement policyholders at the
time that the application is made for a Medicare supplement
policy or certificate. The notice shall be in a form that may
be prescribed by the Department.
(9) Without limiting an individual's eligibility under
Department rules implementing 42 U.S.C. 1395ss(s)(2)(A), for
at least 63 days after the later of the applicant's loss of
benefits or the notice of termination of benefits, including a
notice of claim denial due to termination of benefits, under
the State's medical assistance program under Article V of the
Illinois Public Aid Code, an issuer shall not deny or
condition the issuance or effectiveness of any Medicare
supplement policy or certificate that is offered and is
available for issuance to new enrollees by the issuer; shall
not discriminate in the pricing of such a Medicare supplement
policy because of health status, claims experience, receipt of
health care, or medical condition; and shall not include a
policy provision that imposes an exclusion of benefits based
on a preexisting condition under such a Medicare supplement

policy if the individual:
(a) is enrolled for Medicare Part B;
(b) was enrolled in the State's medical assistance
program during the COVID-19 Public Health Emergency
described in Section 5-1.5 of the Illinois Public Aid
Code;
(c) was terminated or disenrolled from the State's
medical assistance program after the COVID-19 Public
Health Emergency and the later of the date of termination
of benefits or the date of the notice of termination,
including a notice of a claim denial due to termination,
occurred on, after, or no more than 63 days before the end
of either, as applicable:
(A) the individual's Medicare supplement open
enrollment period described in Department rules
implementing 42 U.S.C. 1395ss(s)(2)(A); or
(B) the 6-month period described in Section
363(6)(a)(i) of this Code; and
(d) submits evidence of the date of termination of
benefits or notice of termination under the State's
medical assistance program with the application for a
Medicare supplement policy or certificate.
(10) Each Medicare supplement policy and certificate
available from an insurer on and after the effective date of
this amendatory Act of the 103rd General Assembly shall be
made available to all applicants who qualify under

subparagraph (i) of paragraph (a) of subsection (6) or
Department rules implementing 42 U.S.C. 1395ss(s)(2)(A)
without regard to age or applicability of a Medicare Part B
late enrollment penalty.
(Source: P.A. 102-142, eff. 1-1-22.)
ARTICLE 135.
Section 135-5. The Illinois Public Aid Code is amended by
adding Section 5-49 as follows:
(305 ILCS 5/5-49 new)
Sec. 5-49. Long-acting reversible contraception. Subject
to federal approval, the Department shall adopt policies and
rates for long-acting reversible contraception by January 1,
2024 to ensure that reimbursement is not reduced by 4.4% below
list price. The Department shall submit any necessary
application to the federal Centers for Medicare and Medicaid
Services for the purposes of implementing such policies and
rates.
ARTICLE 140.
Section 140-5. The Illinois Public Aid Code is amended by
changing Section 5-30.8 as follows:

(305 ILCS 5/5-30.8)
Sec. 5-30.8. Managed care organization rate transparency.
(a) For the establishment of managed care organization
(MCO) capitation base rate payments from the State, including,
but not limited to: (i) hospital fee schedule reforms and
updates, (ii) rates related to a single State-mandated
preferred drug list, (iii) rate updates related to the State's
preferred drug list, (iv) inclusion of coverage for children
with special needs, (v) inclusion of coverage for children
within the child welfare system, (vi) annual MCO capitation
rates, and (vii) any retroactive provider fee schedule
adjustments or other changes required by legislation or other
actions, the Department of Healthcare and Family Services
shall implement a capitation base rate setting process
beginning on July 27, 2018 (the effective date of Public Act
100-646) which shall include all of the following elements of
transparency:
(1) The Department shall include participating MCOs
and a statewide trade association representing a majority
of participating MCOs in meetings to discuss the impact to
base capitation rates as a result of any new or updated
hospital fee schedules or other provider fee schedules.
Additionally, the Department shall share any data or
reports used to develop MCO capitation rates with
participating MCOs. This data shall be comprehensive
enough for MCO actuaries to recreate and verify the

accuracy of the capitation base rate build-up.
(2) The Department shall not limit the number of
experts that each MCO is allowed to bring to the draft
capitation base rate meeting or the final capitation base
rate review meeting. Draft and final capitation base rate
review meetings shall be held in at least 2 locations.
(3) The Department and its contracted actuary shall
meet with all participating MCOs simultaneously and
together along with consulting actuaries contracted with
statewide trade association representing a majority of
Medicaid health plans at the request of the plans.
Participating MCOs shall additionally, at their request,
be granted individual capitation rate development meetings
with the Department.
(4) (Blank). Any quality incentive or other incentive
withholding of any portion of the actuarially certified
capitation rates must be budget-neutral. The entirety of
any aggregate withheld amounts must be returned to the
MCOs in proportion to their performance on the relevant
performance metric. No amounts shall be returned to the
Department if all performance measures are not achieved to
the extent allowable by federal law and regulations.
(4.5) Effective for calendar year 2024, a quality
withhold program may be established by the Department for
the HealthChoice Illinois Managed Care Program or any
successor program. If such program withholds a portion of

the actuarially certified capitation rates, the program
must meet the following criteria: (i) benchmarks must be
discussed publicly, based on predetermined quality
standards that align with the Department's federally
approved quality strategy, and set by publication on the
Department's website at least 4 months prior to the start
of the calendar year; (ii) incentive measures and
benchmarks must be reasonable and attainable within the
measurement year; and (iii) no less than 75% of the
metrics shall be tied to nationally recognized measures.
Any non-nationally recognized measures shall be in the
reporting category for at least 2 years of experience and
evaluation for consistency among MCOs prior to setting a
performance baseline. The Department shall provide MCOs
with biannual industry average data on the quality
withhold measures. If all the money withheld is not earned
back by individual MCOs, the Department shall reallocate
unearned funds among the MCOs in one or both of the
following manners: based upon their quality performance or
for quality and equity improvement projects. Nothing in
this paragraph prohibits the Department and the MCOs from
establishing any other quality performance program.
(5) Upon request, the Department shall provide written
responses to questions regarding MCO capitation base
rates, the capitation base development methodology, and
MCO capitation rate data, and all other requests regarding

capitation rates from MCOs. Upon request, the Department
shall also provide to the MCOs materials used in
incorporating provider fee schedules into base capitation
rates.
(b) For the development of capitation base rates for new
capitation rate years:
(1) The Department shall take into account emerging
experience in the development of the annual MCO capitation
base rates, including, but not limited to, current-year
cost and utilization trends observed by MCOs in an
actuarially sound manner and in accordance with federal
law and regulations.
(2) No later than January 1 of each year, the
Department shall release an agreed upon annual calendar
that outlines dates for capitation rate setting meetings
for that year. The calendar shall include at least the
following meetings and deadlines:
(A) An initial meeting for the Department to
review MCO data and draft rate assumptions to be used
in the development of capitation base rates for the
following year.
(B) A draft rate meeting after the Department
provides the MCOs with the draft capitation base rates
to discuss, review, and seek feedback regarding the
draft capitation base rates.
(3) Prior to the submission of final capitation rates

to the federal Centers for Medicare and Medicaid Services,
the Department shall provide the MCOs with a final
actuarial report including the final capitation base rates
for the following year and subsequently conduct a final
capitation base review meeting. Final capitation rates
shall be marked final.
(c) For the development of capitation base rates
reflecting policy changes:
(1) Unless contrary to federal law and regulation, the
Department must provide notice to MCOs of any significant
operational policy change no later than 60 days prior to
the effective date of an operational policy change in
order to give MCOs time to prepare for and implement the
operational policy change and to ensure that the quality
and delivery of enrollee health care is not disrupted.
"Operational policy change" means a change to operational
requirements such as reporting formats, encounter
submission definitional changes, or required provider
interfaces made at the sole discretion of the Department
and not required by legislation with a retroactive
effective date. Nothing in this Section shall be construed
as a requirement to delay or prohibit implementation of
policy changes that impact enrollee benefits as determined
in the sole discretion of the Department.
(2) No later than 60 days after the effective date of
the policy change or program implementation, the

Department shall meet with the MCOs regarding the initial
data collection needed to establish capitation base rates
for the policy change. Additionally, the Department shall
share with the participating MCOs what other data is
needed to estimate the change and the processes for
collection of that data that shall be utilized to develop
capitation base rates.
(3) No later than 60 days after the effective date of
the policy change or program implementation, the
Department shall meet with MCOs to review data and the
Department's written draft assumptions to be used in
development of capitation base rates for the policy
change, and shall provide opportunities for questions to
be asked and answered.
(4) No later than 60 days after the effective date of
the policy change or program implementation, the
Department shall provide the MCOs with draft capitation
base rates and shall also conduct a draft capitation base
rate meeting with MCOs to discuss, review, and seek
feedback regarding the draft capitation base rates.
(d) For the development of capitation base rates for
retroactive policy or fee schedule changes:
(1) The Department shall meet with the MCOs regarding
the initial data collection needed to establish capitation
base rates for the policy change. Additionally, the
Department shall share with the participating MCOs what

other data is needed to estimate the change and the
processes for collection of the data that shall be
utilized to develop capitation base rates.
(2) The Department shall meet with MCOs to review data
and the Department's written draft assumptions to be used
in development of capitation base rates for the policy
change. The Department shall provide opportunities for
questions to be asked and answered.
(3) The Department shall provide the MCOs with draft
capitation rates and shall also conduct a draft rate
meeting with MCOs to discuss, review, and seek feedback
regarding the draft capitation base rates.
(4) The Department shall inform MCOs no less than
quarterly of upcoming benefit and policy changes to the
Medicaid program.
(e) Meetings of the group established to discuss Medicaid
capitation rates under this Section shall be closed to the
public and shall not be subject to the Open Meetings Act.
Records and information produced by the group established to
discuss Medicaid capitation rates under this Section shall be
confidential and not subject to the Freedom of Information
Act.
(Source: P.A. 100-646, eff. 7-27-18; 101-81, eff. 7-12-19.)
ARTICLE 145.

Section 145-5. The Medical Practice Act of 1987 is amended
by changing Section 54.2 and by adding Section 15.5 as
follows:
(225 ILCS 60/15.5 new)
Sec. 15.5. International medical graduate physicians;
licensure. After January 1, 2025, an international medical
graduate physician may apply to the Department for a limited
license. The Department shall adopt rules establishing
qualifications and application fees for the limited licensure
of international medical graduate physicians and may adopt
other rules as may be necessary for the implementation of this
Section. The Department shall adopt rules that provide a
pathway to full licensure for limited license holders after
the licensee successfully completes a supervision period and
satisfies other qualifications as established by the
Department.
(225 ILCS 60/54.2)
(Section scheduled to be repealed on January 1, 2027)
Sec. 54.2. Physician delegation of authority.
(a) Nothing in this Act shall be construed to limit the
delegation of patient care tasks or duties by a physician, to a
licensed practical nurse, a registered professional nurse, or
other licensed person practicing within the scope of his or
her individual licensing Act. Delegation by a physician

licensed to practice medicine in all its branches to physician
assistants or advanced practice registered nurses is also
addressed in Section 54.5 of this Act. No physician may
delegate any patient care task or duty that is statutorily or
by rule mandated to be performed by a physician.
(b) In an office or practice setting and within a
physician-patient relationship, a physician may delegate
patient care tasks or duties to an unlicensed person who
possesses appropriate training and experience provided a
health care professional, who is practicing within the scope
of such licensed professional's individual licensing Act, is
on site to provide assistance.
(c) Any such patient care task or duty delegated to a
licensed or unlicensed person must be within the scope of
practice, education, training, or experience of the delegating
physician and within the context of a physician-patient
relationship.
(d) Nothing in this Section shall be construed to affect
referrals for professional services required by law.
(e) The Department shall have the authority to promulgate
rules concerning a physician's delegation, including but not
limited to, the use of light emitting devices for patient care
or treatment.
(f) Nothing in this Act shall be construed to limit the
method of delegation that may be authorized by any means,
including, but not limited to, oral, written, electronic,

standing orders, protocols, guidelines, or verbal orders.
(g) A physician licensed to practice medicine in all of
its branches under this Act may delegate any and all authority
prescribed to him or her by law to international medical
graduate physicians, so long as the tasks or duties are within
the scope of practice, education, training, or experience of
the delegating physician who is on site to provide assistance.
An international medical graduate working in Illinois pursuant
to this subsection is subject to all statutory and regulatory
requirements of this Act, as applicable, relating to the
standards of care. An international medical graduate physician
is limited to providing treatment under the supervision of a
physician licensed to practice medicine in all of its
branches. The supervising physician or employer must keep
record of and make available upon request by the Department
the following: (1) evidence of education certified by the
Educational Commission for Foreign Medical Graduates; (2)
evidence of passage of Step 1, Step 2 Clinical Knowledge, and
Step 3 of the United States Medical Licensing Examination as
required by this Act; and (3) evidence of an unencumbered
license from another country. This subsection does not apply
to any international medical graduate whose license as a
physician is revoked, suspended, or otherwise encumbered. This
subsection is inoperative upon the adoption of rules
implementing Section 15.5.
(Source: P.A. 103-1, eff. 4-27-23.)

ARTICLE 150.
Section 150-5. The Illinois Administrative Procedure Act
is amended by adding Section 5-45.37 as follows:
(5 ILCS 100/5-45.37 new)
Sec. 5-45.37. Emergency rulemaking; medical services for
certain noncitizens. To provide for the expeditious and
effective ongoing implementation of Section 12-4.35 of the
Illinois Public Aid Code, emergency rules implementing Section
12-4.35 of the Illinois Public Aid Code may be adopted in
accordance with Section 5-45 by the Department of Healthcare
and Family Services, except that the limitation on the number
of emergency rules that may be adopted in a 24-month period
shall not apply. The adoption of emergency rules authorized by
Section 5-45 and this Section is deemed to be necessary for the
public interest, safety, and welfare.
This Section is repealed 2 years after the effective date
of this amendatory Act of the 103rd General Assembly.
Section 150-10. The Illinois Public Aid Code is amended by
changing Section 12-4.35 as follows:
(305 ILCS 5/12-4.35)
Sec. 12-4.35. Medical services for certain noncitizens.

(a) Notwithstanding Section 1-11 of this Code or Section
20(a) of the Children's Health Insurance Program Act, the
Department of Healthcare and Family Services may provide
medical services to noncitizens who have not yet attained 19
years of age and who are not eligible for medical assistance
under Article V of this Code or under the Children's Health
Insurance Program created by the Children's Health Insurance
Program Act due to their not meeting the otherwise applicable
provisions of Section 1-11 of this Code or Section 20(a) of the
Children's Health Insurance Program Act. The medical services
available, standards for eligibility, and other conditions of
participation under this Section shall be established by rule
by the Department; however, any such rule shall be at least as
restrictive as the rules for medical assistance under Article
V of this Code or the Children's Health Insurance Program
created by the Children's Health Insurance Program Act.
(a-5) Notwithstanding Section 1-11 of this Code, the
Department of Healthcare and Family Services may provide
medical assistance in accordance with Article V of this Code
to noncitizens over the age of 65 years of age who are not
eligible for medical assistance under Article V of this Code
due to their not meeting the otherwise applicable provisions
of Section 1-11 of this Code, whose income is at or below 100%
of the federal poverty level after deducting the costs of
medical or other remedial care, and who would otherwise meet
the eligibility requirements in Section 5-2 of this Code. The

medical services available, standards for eligibility, and
other conditions of participation under this Section shall be
established by rule by the Department; however, any such rule
shall be at least as restrictive as the rules for medical
assistance under Article V of this Code.
(a-6) By May 30, 2022, notwithstanding Section 1-11 of
this Code, the Department of Healthcare and Family Services
may provide medical services to noncitizens 55 years of age
through 64 years of age who (i) are not eligible for medical
assistance under Article V of this Code due to their not
meeting the otherwise applicable provisions of Section 1-11 of
this Code and (ii) have income at or below 133% of the federal
poverty level plus 5% for the applicable family size as
determined under applicable federal law and regulations.
Persons eligible for medical services under Public Act 102-16
shall receive benefits identical to the benefits provided
under the Health Benefits Service Package as that term is
defined in subsection (m) of Section 5-1.1 of this Code.
(a-7) By July 1, 2022, notwithstanding Section 1-11 of
this Code, the Department of Healthcare and Family Services
may provide medical services to noncitizens 42 years of age
through 54 years of age who (i) are not eligible for medical
assistance under Article V of this Code due to their not
meeting the otherwise applicable provisions of Section 1-11 of
this Code and (ii) have income at or below 133% of the federal
poverty level plus 5% for the applicable family size as

determined under applicable federal law and regulations. The
medical services available, standards for eligibility, and
other conditions of participation under this Section shall be
established by rule by the Department; however, any such rule
shall be at least as restrictive as the rules for medical
assistance under Article V of this Code. In order to provide
for the timely and expeditious implementation of this
subsection, the Department may adopt rules necessary to
establish and implement this subsection through the use of
emergency rulemaking in accordance with Section 5-45 of the
Illinois Administrative Procedure Act. For purposes of the
Illinois Administrative Procedure Act, the General Assembly
finds that the adoption of rules to implement this subsection
is deemed necessary for the public interest, safety, and
welfare.
(a-10) Notwithstanding the provisions of Section 1-11, the
Department shall cover immunosuppressive drugs and related
services associated with post-kidney transplant management,
excluding long-term care costs, for noncitizens who: (i) are
not eligible for comprehensive medical benefits; (ii) meet the
residency requirements of Section 5-3; and (iii) would meet
the financial eligibility requirements of Section 5-2.
(b) The Department is authorized to take any action that
would not otherwise be prohibited by applicable law,
including, without limitation, cessation or limitation of
enrollment, reduction of available medical services, and

changing standards for eligibility, that is deemed necessary
by the Department during a State fiscal year to assure that
payments under this Section do not exceed available funds.
(c) (Blank).
(d) (Blank).
(e) In order to provide for the expeditious and effective
ongoing implementation of this Section, the Department may
adopt rules through the use of emergency rulemaking in
accordance with Section 5-45 of the Illinois Administrative
Procedure Act, except that the limitation on the number of
emergency rules that may be adopted in a 24-month period shall
not apply. For purposes of the Illinois Administrative
Procedure Act, the General Assembly finds that the adoption of
rules to implement this Section is deemed necessary for the
public interest, safety, and welfare. This subsection (e) is
inoperative on and after July 1, 2025.
(Source: P.A. 101-636, eff. 6-10-20; 102-16, eff. 6-17-21;
102-43, Article 25, Section 25-15, eff. 7-6-21; 102-43,
Article 45, Section 45-5, eff. 7-6-21; 102-813, eff. 5-13-22;
102-1037, eff. 6-2-22.)
ARTICLE 999.
Section 999-99. Effective date. This Article and Articles
1, 5, 10, 130, 145, and 150 take effect upon becoming law and
Articles 65, 115, 120, and 135 take effect July 1, 2023.