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.