Bill Text: IL HB4343 | 2021-2022 | 102nd General Assembly | Chaptered

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Bill Title: Reinserts the provisions of the engrossed bill with the following changes: Creates the Wellness Checks in Schools Program Act. Provides that subject to appropriation, the Department of Healthcare and Family Services shall establish the Wellness Checks in Schools Collaborative for school districts that wish to implement wellness checks to identify students in grades 7 through 12 who are at risk of mental health conditions, including depression or other mental health issues. Requires the Department to work with school districts that have a high percentage of students enrolled in Medicaid and a high number of referrals to the State's Crisis and Referral Entry Services (CARES) hotline. Provides that subject to appropriation, the Department shall establish and implement a program to provide wellness checks in public schools in accordance with the Act. Amends the Illinois Public Aid Code. In the Hospital Services Trust Fund Article, provides that 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. In the Medical Assistance Article, provides that beginning January 1, 2023, licensed certified professional midwife services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance. Requires the Department of Healthcare and Family Services to consult with midwives on reimbursement rates for midwifery services. Provides that subject to federal approval, beginning January 1, 2023, the community spouse resource allowance shall be established and maintained at a base amount of $109,560 plus an additional amount of $2,784 added to the base amount each year for a period of 10 years commencing with calendar year 2024 through calendar year 2034. Requires yearly increases up to the maximum resource allowance permitted under the Social Security Act. Provides that subject to federal approval, beginning January 1, 2034 the community spouse resource allowance shall be established and maintained at the maximum amount permitted under the Social Security Act, or an amount set after a fair hearing. Provides that subject to federal approval, beginning January 1, 2023 the monthly maintenance allowance for the community spouse shall be established and maintained at the maximum amount higher of $2,739 per month or the minimum level permitted under the Social Security Act. Contains provisions requiring the Department of Human Services to develop a program designed to provide behavioral health providers with academic detailing and clinical consultation over the phone on how to best care for patients with severe mental illness or a developmental disability. Contains provisions requiring the Department of Human Services to track the availability of beds for withdrawal management services that are licensed by the Department and are available to medical assistance beneficiaries. Contains provisions concerning coverage for peer recovery support services under the medical assistance program; the alignment of substance use prevention and recovery and mental health policy; increased rates for prenatal and postpartum care; the external cephalic version rate; increased funding for dental services; and coverage for acupuncture services under the medical assistance program. Amends the Department of Public Health Powers and Duties Law. Requires the Department of Public Health to establish or approve a Certified Nursing Assistant Intern Program to address the increasing need for trained health care workers and provide additional pathways for individuals to become certified nursing assistants. Amends the Assisted Living and Shared Housing Act, the Nursing Home Care Act, the MC/DD Act, and the ID/DD Community Care Act to establish certain employment requirements for certified nursing assistant interns and establishments that employ certified nursing assistant interns. Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to establish or approve a Certified Nursing Assistant Intern Program to address the increasing need for trained health care workers for the supporting living facilities program. Sets forth classroom and on-the-job training requirements for certified nursing assistant interns. Provides that the Certified Nursing Assistant Intern Program shall end upon the termination of the Secretary of Health and Human Services' public health emergency declaration for COVID-19 or 3 years after the date that the Program becomes operational, whichever occurs later. Grants the Departments of Public Health and Healthcare and Family Services emergency rulemaking authority. Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that by July 1, 2022, the Department of Healthcare and Family Services shall seek a State Plan amendment or any federal waivers or approvals necessary to make changes to the medical assistance redetermination process by allowing all people without income to be considered for ex parte redetermination. Requires the Department of Healthcare and Family Services to waive estate recovery under the medical assistance program where recovery would not be cost-effective, would work an undue hardship, or for any other just reason. Requires the Department of Human Services to compile on a monthly basis data on the percentage of medical assistance beneficiaries whose eligibility is renewed through ex parte redeterminations. Requires the Department of Healthcare and Family Services to seek a State Plan amendment by July 1, 2022 that permits the use of its asset verification system to assist in determining whether the ex parte process can be used to renew the medical assistance coverage of a senior or a person with a disability. Contains provisions concerning streamlining enrollment into the Medicare Savings Program. Repeals provisions under the Aid to the Aged, Blind or Disabled Article of the Illinois Public Aid Code concerning liens on recipients real property interests. In a provision requiring the Department of Healthcare and Family Services to pay the DCFS per diem rate for inpatient psychiatric stays at free-standing psychiatric hospitals or hospitals with a pediatric or adolescent inpatient psychiatric unit, removes language making the provision operative only through July 1, 2023. Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning ground ambulance services, provides that, within 90 days after the effective date of the amendatory Act, the Department of Healthcare and Family Services 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. Provides that beginning no later than January 1, 2023 and subject to federal approval, the amount allocated to fund rates for medi-car, service car, and attendant services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $24,000,000. Amends the Illinois Public Aid Code. Provides that by May 1, 2023, 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 the Code due to their not meeting the otherwise applicable provisions of the Code concerning citizenship 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. Amends the Illinois Administrative Procedure Act. Grants the Department of Healthcare and Family Services emergency rulemaking authority to provide medical services to noncitizens 42 years of age through 54 years of age. Effective immediately.

Spectrum: Partisan Bill (Democrat 26-0)

Status: (Passed) 2022-06-02 - Public Act . . . . . . . . . 102-1037 [HB4343 Detail]

Download: Illinois-2021-HB4343-Chaptered.html

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Public Act 102-1037
HB4343 Enrolled LRB102 22609 KTG 31752 b
AN ACT concerning public aid.
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
Wellness Checks in Schools Program Act. References in this
Article to "this Act" mean this Article.
Section 1-5. Findings. The General Assembly finds that:
(1) Depression is the most common mental health
disorder among American teens and adults, with over
2,800,000 young people between the ages of 12 and 17
experiencing at least one major depressive episode each
year, approximately 10-15% of teenagers exhibiting at
least one symptom of depression at any time, and roughly
5% of teenagers suffering from major depression at any
time. Teenage depression is 2 to 3 times more common in
females than in males.
(2) Various biological, psychological, and
environmental risk factors may contribute to teenage
depression, which can lead to substance and alcohol abuse,
social isolation, poor academic and workplace performance,
unnecessary risk taking, early pregnancy, and suicide,

which is the second leading cause of death among
teenagers. Approximately 20% of teens with depression
seriously consider suicide, and one in 12 attempt suicide.
Untreated teenage depression can also result in adverse
consequences throughout adulthood.
(3) Most teens who experience depression suffer from
more than one episode. It is estimated that, although
teenage depression is highly treatable through
combinations of therapy, individual and group counseling,
and certain medications, fewer than one-third of teenagers
experiencing depression seek help or treatment.
(4) The proper detection and diagnosis of mental
health conditions, including depression, is a key element
in reducing the risk of teenage suicide and improving
physical and mental health outcomes for young people. It
is therefore fitting and appropriate to establish
school-based mental health screenings to help identify the
symptoms of mental health conditions and facilitate access
to appropriate treatment.
Section 1-10. Wellness Checks in Schools Collaborative.
(a) Subject to appropriation, the Department of Healthcare
and Family Services shall establish the Wellness Checks in
Schools Collaborative for school districts that wish to
implement wellness checks to identify students in grades 7
through 12 who are at risk of mental health conditions,

including depression or other mental health issues. The
Department shall work with school districts that have a high
percentage of students enrolled in Medicaid and a high number
of referrals to the State's Crisis and Referral Entry Services
(CARES) hotline.
(b) The Collaborative shall focus on the identification of
research-based screening tools validated to screen for mental
health conditions in adolescents and identification of staff
who will be responsible for completion of the screening tool.
Nothing in this Act prohibits a school district from using a
self-administered screening tool as part of the wellness
check. To assist school districts in selecting research-based
screening tools to use in their wellness check programs, the
Department of Healthcare and Family Services may develop a
list of preapproved research-based screening tools that are
validated to screen adolescents for mental health concerns and
are appropriate for use in a school setting. The list shall be
posted on the websites of the Department of Healthcare and
Family Services and the State Board of Education.
(c) The Collaborative shall also focus on assisting
participating school districts in establishing a referral
process for immediate intervention for students who are
identified as having a behavioral health issue that requires
intervention.
(d) The Department shall publish a public notice regarding
the establishment of the Collaborative with school districts

and shall conduct regular meetings with interested school
districts.
(e) Subject to appropriation, the Department shall
establish and implement a program to provide wellness checks
in public schools in accordance with this Section.
ARTICLE 5.
Section 5-5. The Illinois Public Aid Code is amended by
changing Section 14-12 as follows:
(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 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 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. 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
the effective date of 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.
(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.)
ARTICLE 10.
Section 10-5. The Illinois Public Aid Code is amended by
changing Section 5-18.5 as follows:

(305 ILCS 5/5-18.5)
Sec. 5-18.5. Perinatal doula and evidence-based home
visiting services.
(a) As used in this Section:
"Home visiting" means a voluntary, evidence-based strategy
used to support pregnant people, infants, and young children
and their caregivers to promote infant, child, and maternal
health, to foster educational development and school
readiness, and to help prevent child abuse and neglect. Home
visitors are trained professionals whose visits and activities
focus on promoting strong parent-child attachment to foster
healthy child development.
"Perinatal doula" means a trained provider who provides
regular, voluntary physical, emotional, and educational
support, but not medical or midwife care, to pregnant and
birthing persons before, during, and after childbirth,
otherwise known as the perinatal period.
"Perinatal doula training" means any doula training that
focuses on providing support throughout the prenatal, labor
and delivery, or postpartum period, and reflects the type of
doula care that the doula seeks to provide.
(b) Notwithstanding any other provision of this Article,
perinatal doula services and evidence-based home visiting
services shall be covered under the medical assistance
program, subject to appropriation, for persons who are

otherwise eligible for medical assistance under this Article.
Perinatal doula services include regular visits beginning in
the prenatal period and continuing into the postnatal period,
inclusive of continuous support during labor and delivery,
that support healthy pregnancies and positive birth outcomes.
Perinatal doula services may be embedded in an existing
program, such as evidence-based home visiting. Perinatal doula
services provided during the prenatal period may be provided
weekly, services provided during the labor and delivery period
may be provided for the entire duration of labor and the time
immediately following birth, and services provided during the
postpartum period may be provided up to 12 months postpartum.
(b-5) Notwithstanding any other provision of this Article,
beginning January 1, 2023, licensed certified professional
midwife services shall be covered under the medical assistance
program, subject to appropriation, for persons who are
otherwise eligible for medical assistance under this Article.
The Department shall consult with midwives on reimbursement
rates for midwifery services.
(c) The Department of Healthcare and Family Services shall
adopt rules to administer this Section. In this rulemaking,
the Department shall consider the expertise of and consult
with doula program experts, doula training providers,
practicing doulas, and home visiting experts, along with State
agencies implementing perinatal doula services and relevant
bodies under the Illinois Early Learning Council. This body of

experts shall inform the Department on the credentials
necessary for perinatal doula and home visiting services to be
eligible for Medicaid reimbursement and the rate of
reimbursement for home visiting and perinatal doula services
in the prenatal, labor and delivery, and postpartum periods.
Every 2 years, the Department shall assess the rates of
reimbursement for perinatal doula and home visiting services
and adjust rates accordingly.
(d) The Department shall seek such State plan amendments
or waivers as may be necessary to implement this Section and
shall secure federal financial participation for expenditures
made by the Department in accordance with this Section.
(Source: P.A. 102-4, eff. 4-27-21.)
ARTICLE 15.
Section 15-5. The Illinois Public Aid Code is amended by
changing Section 5-4 as follows:
(305 ILCS 5/5-4) (from Ch. 23, par. 5-4)
Sec. 5-4. Amount and nature of medical assistance.
(a) The amount and nature of medical assistance shall be
determined in accordance with the standards, rules, and
regulations of the Department of Healthcare and Family
Services, with due regard to the requirements and conditions
in each case, including contributions available from legally

responsible relatives. However, the amount and nature of such
medical assistance shall not be affected by the payment of any
grant under the Senior Citizens and Persons with Disabilities
Property Tax Relief Act or any distributions or items of
income described under subparagraph (X) of paragraph (2) of
subsection (a) of Section 203 of the Illinois Income Tax Act.
The amount and nature of medical assistance shall not be
affected by the receipt of donations or benefits from
fundraisers in cases of serious illness, as long as neither
the person nor members of the person's family have actual
control over the donations or benefits or the disbursement of
the donations or benefits.
In determining the income and resources available to the
institutionalized spouse and to the community spouse, the
Department of Healthcare and Family Services shall follow the
procedures established by federal law. If an institutionalized
spouse or community spouse refuses to comply with the
requirements of Title XIX of the federal Social Security Act
and the regulations duly promulgated thereunder by failing to
provide the total value of assets, including income and
resources, to the extent either the institutionalized spouse
or community spouse has an ownership interest in them pursuant
to 42 U.S.C. 1396r-5, such refusal may result in the
institutionalized spouse being denied eligibility and
continuing to remain ineligible for the medical assistance
program based on failure to cooperate.

Subject to federal approval, beginning January 1, 2023,
the community spouse resource allowance shall be established
and maintained as follows: a base amount of $109,560 plus an
additional amount of $2,784 added to the base amount each year
for a period of 10 years commencing with calendar year 2024
through calendar year 2034. In addition to the base amount and
the additional amount shall be any increase each year from the
prior year to the maximum resource allowance permitted under
Section 1924(f)(2)(A)(ii)(II) of the Social Security Act.
Subject to federal approval, beginning January 1, 2034 the
community spouse resource allowance shall be established and
maintained at the maximum amount permitted under Section
1924(f)(2)(A)(ii)(II) of the Social Security Act, as now or
hereafter amended, or an amount set after a fair hearing.
Subject to federal approval, beginning January 1, 2023 the the
community spouse resource allowance shall be established and
maintained at the higher of $109,560 or the minimum level
permitted pursuant to Section 1924(f)(2) of the Social
Security Act, as now or hereafter amended, or an amount set
after a fair hearing, whichever is greater. The monthly
maintenance allowance for the community spouse shall be
established and maintained at the maximum amount higher of
$2,739 per month or the minimum level permitted pursuant to
Section 1924(d)(3)(C) of the Social Security Act, as now or
hereafter amended, or an amount set after a fair hearing,
whichever is greater. Subject to the approval of the Secretary

of the United States Department of Health and Human Services,
the provisions of this Section shall be extended to persons
who but for the provision of home or community-based services
under Section 4.02 of the Illinois Act on the Aging, would
require the level of care provided in an institution, as is
provided for in federal law.
(b) Spousal support for institutionalized spouses
receiving medical assistance.
(i) The Department may seek support for an
institutionalized spouse, who has assigned his or her
right of support from his or her spouse to the State, from
the resources and income available to the community
spouse.
(ii) The Department may bring an action in the circuit
court to establish support orders or itself establish
administrative support orders by any means and procedures
authorized in this Code, as applicable, except that the
standard and regulations for determining ability to
support in Section 10-3 shall not limit the amount of
support that may be ordered.
(iii) Proceedings may be initiated to obtain support,
or for the recovery of aid granted during the period such
support was not provided, or both, for the obtainment of
support and the recovery of the aid provided. Proceedings
for the recovery of aid may be taken separately or they may
be consolidated with actions to obtain support. Such

proceedings may be brought in the name of the person or
persons requiring support or may be brought in the name of
the Department, as the case requires.
(iv) The orders for the payment of moneys for the
support of the person shall be just and equitable and may
direct payment thereof for such period or periods of time
as the circumstances require, including support for a
period before the date the order for support is entered.
In no event shall the orders reduce the community spouse
resource allowance below the level established in
subsection (a) of this Section or an amount set after a
fair hearing, whichever is greater, or reduce the monthly
maintenance allowance for the community spouse below the
level permitted pursuant to subsection (a) of this
Section.
(Source: P.A. 98-104, eff. 7-22-13; 99-143, eff. 7-27-15.)
ARTICLE 20.
Section 20-5. The Illinois Public Aid Code is amended by
adding Sections 5-5.05d, 5-5.05e, 5-5.05f, 5-5.05g, 5-5.06c,
and 5-5.06d as follows:
(305 ILCS 5/5-5.05d new)
Sec. 5-5.05d. Academic detailing for behavioral health
providers. The Department shall develop, in collaboration with

associations representing behavioral health providers, a
program designed to provide behavioral health providers and
providers in academic medical settings who need assistance in
caring for patients with severe mental illness or a
developmental disability under the medical assistance program
with academic detailing and clinical consultation over the
phone from a qualified provider on how to best care for the
patient. The Department shall include the phone number on its
website and notify providers that the service is available.
The Department may create an in-person option if adequate
staff is available. To the extent practicable, the Department
shall build upon this service to address worker shortages and
the availability of specialty services.
(305 ILCS 5/5-5.05e new)
Sec. 5-5.05e. Tracking availability of beds for withdrawal
management services. The Department of Human Services shall
track, or contract with an organization to track, the
availability of beds for withdrawal management services that
are licensed by the Department and are available to medical
assistance beneficiaries. The Department of Human Services
shall update the tracking daily and publish the availability
of beds online or in another public format.
(305 ILCS 5/5-5.05f new)
Sec. 5-5.05f. Medicaid coverage for peer recovery support

services. On or before January 1, 2023, the Department shall
seek approval from the federal Centers for Medicare and
Medicaid Services to cover peer recovery support services
under the medical assistance program when rendered by
certified peer support specialists for the purposes of
supporting the recovery of individuals receiving substance use
disorder treatment. As used in this Section, "certified peer
support specialist" means an individual who:
(1) is a self-identified current or former recipient
of substance use disorder services who has the ability to
support other individuals diagnosed with a substance use
disorder;
(2) is affiliated with a substance use prevention and
recovery provider agency that is licensed by the
Department of Human Services' Division of Substance Use
Prevention and Recovery; and
(A) is certified in accordance with applicable
State law to provide peer recovery support services in
substance use disorder settings; or
(B) is certified as qualified to furnish peer
support services under a certification process
consistent with the National Practice Guidelines for
Peer Supporters and inclusive of the core competencies
identified by the Substance Abuse and Mental Health
Services Administration in the Core Competencies for
Peer Workers in Behavioral Health Services.

(305 ILCS 5/5-5.05g new)
Sec. 5-5.05g. Alignment of substance use prevention and
recovery and mental health policy. The Department and the
Department of Human Services shall collaborate to review
coverage and billing requirements for substance use prevention
and recovery and mental health services with the goal of
identifying disparities and streamlining coverage and billing
requirements to reduce the administrative burden for providers
and medical assistance beneficiaries.
(305 ILCS 5/5-5.06c new)
Sec. 5-5.06c. Access to prenatal and postpartum care. To
ensure access to high quality prenatal and postpartum care and
to promote continuity of care for pregnant individuals, the
Department shall increase the rate for prenatal and postpartum
visits to no less than the rate for an adult well visit,
including any applicable add-ons, beginning on January 1,
2023. Bundled rates that include prenatal or postpartum visits
shall incorporate this increased rate, beginning on January 1,
2023.
(305 ILCS 5/5-5.06d new)
Sec. 5-5.06d. External cephalic version rate. To encourage
provider use of external cephalic versions and decrease the
rates of caesarean sections in Illinois, the Department shall

evaluate the rate for external cephalic versions and increase
the rate by an amount determined by the Department to promote
safer birthing options for pregnant individuals, beginning on
January 1, 2023.
ARTICLE 25.
Section 25-5. The Illinois Public Aid Code is amended by
adding Section 5-5.06e as follows:
(305 ILCS 5/5-5.06e new)
Sec. 5-5.06e. Increased funding for dental services.
Beginning January 1, 2023, the amount allocated to fund rates
for dental services provided to adults and children under the
medical assistance program shall be increased by an
approximate amount of $10,000,000.
ARTICLE 30.
Section 30-5. 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.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall

establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program

site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
On or after July 1, 2022, individuals who are otherwise
eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be
conditioned on the use of a screening instrument approved by
the Department.
Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided

prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information
from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Department of Healthcare and Family Services

nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined

necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior

written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for

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

updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or

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

the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received

by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final

adjudication by the primary payer.
In the case of long term care facilities, within 120
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not

limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department

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

or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's

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

State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in

compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(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.
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) this amendatory Act of the 102nd
General Assembly, the Department shall seek federal approval
of a State Plan amendment to expand coverage for family
planning services that includes presumptive eligibility to
individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.

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

(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
1-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)
ARTICLE 35.
Section 35-5. The Department of Public Health Powers and
Duties Law of the Civil Administrative Code of Illinois is
amended by adding Section 2310-434 as follows:
(20 ILCS 2310/2310-434 new)
Sec. 2310-434. Certified Nursing Assistant Intern Program.
(a) As used in this Section, "facility" means a facility
licensed by the Department under the Nursing Home Care Act,
the MC/DD Act, or the ID/DD Community Care Act or an
establishment licensed under the Assisted Living and Shared
Housing Act.
(b) The Department shall establish or approve a Certified
Nursing Assistant Intern Program to address the increasing
need for trained health care workers and provide additional
pathways for individuals to become certified nursing
assistants. Upon successful completion of the classroom
education and on-the-job training requirements of the Program

required under this Section, an individual may provide, at a
facility, the patient and resident care services determined
under the Program and may perform the procedures listed under
subsection (e).
(c) In order to qualify as a certified nursing assistant
intern, an individual shall successfully complete at least 8
hours of classroom education on the services and procedures
determined under the Program and listed under subsection (e).
The classroom education shall be:
(1) taken within the facility where the certified
nursing assistant intern will be employed;
(2) proctored by either an advanced practice
registered nurse or a registered nurse who holds a
bachelor's degree in nursing, has a minimum of 3 years of
continuous experience in geriatric care, or is certified
as a nursing assistant instructor; and
(3) satisfied by the successful completion of an
approved 8-hour online training course or in-person group
training.
(d) In order to qualify as a certified nursing assistant
intern, an individual shall successfully complete at least 24
hours of on-the-job training in the services and procedures
determined under the Program and listed under subsection (e),
as follows:
(1) The training program instructor shall be either an
advanced practice registered nurse or a registered nurse

who holds a bachelor's degree in nursing, has a minimum of
3 years of continuous experience in geriatric care, or is
certified as a nursing assistant instructor.
(2) The training program instructor shall ensure that
the student meets the competencies determined under the
Program and those listed under subsection (e). The
instructor shall document the successful completion or
failure of the competencies and any remediation that may
allow for the successful completion of the competencies.
(3) All on-the-job training shall be under the direct
observation of either an advanced practice registered
nurse or a registered nurse who holds a bachelor's degree
in nursing, has a minimum of 3 years of continuous
experience in geriatric care, or is certified as a nursing
assistant instructor.
(4) All on-the-job training shall be conducted at a
facility that is licensed by the State of Illinois and
that is the facility where the certified nursing assistant
intern will be working.
(e) A certified nursing assistant intern shall receive
classroom and on-the-job training on how to provide the
patient or resident care services and procedures, as
determined under the Program, that are required of a certified
nursing assistant's performance skills, including, but not
limited to, all of the following:
(1) Successful completion and maintenance of active

certification in both first aid and the American Red
Cross' courses on cardiopulmonary resuscitation.
(2) Infection control and in-service training required
at the facility.
(3) Washing a resident's hands.
(4) Performing oral hygiene on a resident.
(5) Shaving a resident with an electric razor.
(6) Giving a resident a partial bath.
(7) Making a bed that is occupied.
(8) Dressing a resident.
(9) Transferring a resident to a wheelchair using a
gait belt or transfer belt.
(10) Ambulating a resident with a gait belt or
transfer belt.
(11) Feeding a resident.
(12) Calculating a resident's intake and output.
(13) Placing a resident in a side-lying position.
(14) The Heimlich maneuver.
(f) A certified nursing assistant intern may not perform
any of the following on a resident:
(1) Shaving with a nonelectric razor.
(2) Nail care.
(3) Perineal care.
(4) Transfer using a mechanical lift.
(5) Passive range of motion.
(g) A certified nursing assistant intern may only provide

the patient or resident care services and perform the
procedures that he or she is deemed qualified to perform that
are listed under subsection (e). A certified nursing assistant
intern may not provide the procedures excluded under
subsection (f).
(h) The Program is subject to the Health Care Worker
Background Check Act and the Health Care Worker Background
Check Code under 77 Ill. Adm. Code 955. Program participants
and personnel shall be included on the Health Care Worker
Registry.
(i) A Program participant who has completed the training
required under paragraph (5) of subsection (a) of Section
3-206 of the Nursing Home Care Act, has completed the Program
from April 21, 2020 through September 18, 2020, and has shown
competency in all of the performance skills listed under
subsection (e) may be considered a certified nursing assistant
intern once the observing advanced practice registered nurse
or registered nurse educator has confirmed the Program
participant's competency in all of those performance skills.
(j) The requirement under subsection (b) of Section
395.400 of Title 77 of the Illinois Administrative Code that a
student must pass a BNATP written competency examination
within 12 months after the completion of the BNATP does not
apply to a certified nursing assistant intern under this
Section. However, upon a Program participant's enrollment in a
certified nursing assistant course, the requirement under

subsection (b) of Section 395.400 of Title 77 of the Illinois
Administrative Code that a student pass a BNATP written
competency examination within 12 months after completion of
the BNATP program applies.
(k) A certified nursing assistant intern shall enroll in a
certified nursing assistant program within 6 months after
completing his or her certified nursing assistant intern
training under the Program. The individual may continue to
work as a certified nursing assistant intern during his or her
certified nursing assistant training. If the scope of work for
a nurse assistant in training pursuant to 77 Ill. Adm. Code
300.660 is broader in scope than the work permitted to be
performed by a certified nursing assistant intern, then the
certified nursing assistant intern enrolled in certified
nursing assistant training may perform the work allowed under
77. Ill. Adm. Code 300.660 with written documentation that the
certified nursing assistant intern has successfully passed the
competencies necessary to perform such skills. The facility
shall maintain documentation as to the additional jobs and
duties the certified nursing assistant intern is authorized to
perform, which shall be made available to the Department upon
request. The individual shall receive one hour of credit for
every hour employed as a certified nursing assistant intern or
as a temporary nurse assistant, not to exceed 30 hours of
credit, subject to the approval of an accredited certified
nursing assistant training program.

(l) A facility that seeks to train and employ a certified
nursing assistant intern at the facility must:
(1) not have received or applied for a registered
nurse waiver under Section 3-303.1 of the Nursing Home
Care Act, if applicable;
(2) not have been cited for a violation, except a
citation for noncompliance with COVID-19 reporting
requirements, that has caused severe harm to or the death
of a resident within the 2 years prior to employing a
certified nursing assistant; for purposes of this
paragraph, the revocation of the facility's ability to
hire and train a certified nursing assistant intern shall
only occur if the underlying federal citation for the
revocation remains substantiated following an informal
dispute resolution or independent informal dispute
resolution;
(3) not have been cited for a violation that resulted
in a pattern of certified nursing assistants being removed
from the Health Care Worker Registry as a result of
resident abuse, neglect, or exploitation within the 2
years prior to employing a certified nursing assistant
intern;
(4) if the facility is a skilled nursing facility,
meet a minimum staffing ratio of 3.8 hours of nursing and
personal care time, as those terms are used in subsection
(e) of Section 3-202.05 of the Nursing Home Care Act, each

day for a resident needing skilled care and 2.5 hours of
nursing and personal care time each day for a resident
needing intermediate care;
(5) not have lost the ability to offer a Nursing
Assistant Training and Competency Evaluation Program as a
result of an enforcement action;
(6) establish a certified nursing assistant intern
mentoring program within the facility for the purposes of
increasing education and retention, which must include an
experienced certified nurse assistant who has at least 3
years of active employment and is employed by the
facility;
(7) not have a monitor or temporary management placed
upon the facility by the Department;
(8) not have provided the Department with a notice of
imminent closure; and
(9) not have had a termination action initiated by the
federal Centers for Medicare and Medicaid Services or the
Department for failing to comply with minimum regulatory
or licensure requirements.
(m) A facility that does not meet the requirements of
subsection (l) shall cease its new employment training,
education, or onboarding of any employee under the Program.
The facility may resume its new employment training,
education, or onboarding of an employee under the Program once
the Department determines that the facility is in compliance

with subsection (l).
(n) To study the effectiveness of the Program, the
Department shall collect data from participating facilities
and publish a report on the extent to which the Program brought
individuals into continuing employment as certified nursing
assistants in long-term care. Data collected from facilities
shall include, but shall not be limited to, the number of
certified nursing assistants employed, the number of persons
who began participation in the Program, the number of persons
who successfully completed the Program, and the number of
persons who continue employment in a long-term care service or
facility. The report shall be published no later than 6 months
after the Program end date determined under subsection (p). A
facility participating in the Program shall, twice annually,
submit data under this subsection in a manner and time
determined by the Department. Failure to submit data under
this subsection shall result in suspension of the facility's
Program.
(o) The Department may adopt emergency rules in accordance
with Section 5-45.21 of the Illinois Administrative Procedure
Act.
(p) The Program shall end upon the termination of the
Secretary of Health and Human Services' public health
emergency declaration for COVID-19 or 3 years after the date
that the Program becomes operational, whichever occurs later.
(q) This Section is inoperative 18 months after the

Program end date determined under subsection (p).
Section 35-10. The Assisted Living and Shared Housing Act
is amended by adding Section 77 as follows:
(210 ILCS 9/77 new)
Sec. 77. Certified nursing assistant interns.
(a) A certified nursing assistant intern shall report to
an establishment's charge nurse or nursing supervisor and may
only be assigned duties authorized in Section 2310-434 of the
Department of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois by a supervising nurse.
(b) An establishment shall notify its certified and
licensed staff members, in writing, that a certified nursing
assistant intern may only provide the services and perform the
procedures permitted under Section 2310-434 of the Department
of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois. The notification shall detail
which duties may be delegated to a certified nursing assistant
intern. The establishment shall establish a policy describing
the authorized duties, supervision, and evaluation of
certified nursing assistant interns available upon request of
the Department and any surveyor.
(c) If an establishment learns that a certified nursing
assistant intern is performing work outside the scope of the
Certified Nursing Assistant Intern Program's training, the

establishment shall:
(1) stop the certified nursing assistant intern from
performing the work;
(2) inspect the work and correct mistakes, if the work
performed was done improperly;
(3) assign the work to the appropriate personnel; and
(4) ensure that a thorough assessment of any resident
involved in the work performed is completed by a
registered nurse.
(d) An establishment that employs a certified nursing
assistant intern in violation of this Section shall be subject
to civil penalties or fines under subsection (a) of Section
135.
Section 35-15. The Nursing Home Care Act is amended by
adding Section 3-613 as follows:
(210 ILCS 45/3-613 new)
Sec. 3-613. Certified nursing assistant interns.
(a) A certified nursing assistant intern shall report to a
facility's charge nurse or nursing supervisor and may only be
assigned duties authorized in Section 2310-434 of the
Department of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois by a supervising nurse.
(b) A facility shall notify its certified and licensed
staff members, in writing, that a certified nursing assistant

intern may only provide the services and perform the
procedures permitted under Section 2310-434 of the Department
of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois. The notification shall detail
which duties may be delegated to a certified nursing assistant
intern. The facility shall establish a policy describing the
authorized duties, supervision, and evaluation of certified
nursing assistant interns available upon request of the
Department and any surveyor.
(c) If a facility learns that a certified nursing
assistant intern is performing work outside the scope of the
Certified Nursing Assistant Intern Program's training, the
facility shall:
(1) stop the certified nursing assistant intern from
performing the work;
(2) inspect the work and correct mistakes, if the work
performed was done improperly;
(3) assign the work to the appropriate personnel; and
(4) ensure that a thorough assessment of any resident
involved in the work performed is completed by a
registered nurse.
(d) A facility that employs a certified nursing assistant
intern in violation of this Section shall be subject to civil
penalties or fines under Section 3-305.
(e) A minimum of 50% of nursing and personal care time
shall be provided by a certified nursing assistant, but no

more than 15% of nursing and personal care time may be provided
by a certified nursing assistant intern.
Section 35-20. The MC/DD Act is amended by adding Section
3-613 as follows:
(210 ILCS 46/3-613 new)
Sec. 3-613. Certified nursing assistant interns.
(a) A certified nursing assistant intern shall report to a
facility's charge nurse or nursing supervisor and may only be
assigned duties authorized in Section 2310-434 of the
Department of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois by a supervising nurse.
(b) A facility shall notify its certified and licensed
staff members, in writing, that a certified nursing assistant
intern may only provide the services and perform the
procedures permitted under Section 2310-434 of the Department
of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois. The notification shall detail
which duties may be delegated to a certified nursing assistant
intern. The facility shall establish a policy describing the
authorized duties, supervision, and evaluation of certified
nursing assistant interns available upon request of the
Department and any surveyor.
(c) If a facility learns that a certified nursing
assistant intern is performing work outside the scope of the

Certified Nursing Assistant Intern Program's training, the
facility shall:
(1) stop the certified nursing assistant intern from
performing the work;
(2) inspect the work and correct mistakes, if the work
performed was done improperly;
(3) assign the work to the appropriate personnel; and
(4) ensure that a thorough assessment of any resident
involved in the work performed is completed by a
registered nurse.
(d) A facility that employs a certified nursing assistant
intern in violation of this Section shall be subject to civil
penalties or fines under Section 3-305.
Section 35-25. The ID/DD Community Care Act is amended by
adding Section 3-613 as follows:
(210 ILCS 47/3-613 new)
Sec. 3-613. Certified nursing assistant interns.
(a) A certified nursing assistant intern shall report to a
facility's charge nurse or nursing supervisor and may only be
assigned duties authorized in Section 2310-434 of the
Department of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois by a supervising nurse.
(b) A facility shall notify its certified and licensed
staff members, in writing, that a certified nursing assistant

intern may only provide the services and perform the
procedures permitted under Section 2310-434 of the Department
of Public Health Powers and Duties Law of the Civil
Administrative Code of Illinois. The notification shall detail
which duties may be delegated to a certified nursing assistant
intern. The facility shall establish a policy describing the
authorized duties, supervision, and evaluation of certified
nursing assistant interns available upon request of the
Department and any surveyor.
(c) If a facility learns that a certified nursing
assistant intern is performing work outside the scope of the
Certified Nursing Assistant Intern Program's training, the
facility shall:
(1) stop the certified nursing assistant intern from
performing the work;
(2) inspect the work and correct mistakes, if the work
performed was done improperly;
(3) assign the work to the appropriate personnel; and
(4) ensure that a thorough assessment of any resident
involved in the work performed is completed by a
registered nurse.
(d) A facility that employs a certified nursing assistant
intern in violation of this Section shall be subject to civil
penalties or fines under Section 3-305.
Section 35-30. The Illinois Public Aid Code is amended by

adding Section 5-5.01b as follows:
(305 ILCS 5/5-5.01b new)
Sec. 5-5.01b. Certified Nursing Assistant Intern Program.
(a) The Department shall establish or approve a Certified
Nursing Assistant Intern Program to address the increasing
need for trained health care workers for the supporting living
facilities program established under Section 5-5.01a. Upon
successful completion of the classroom education and
on-the-job training requirements of the Program under this
Section, an individual may provide, at a facility certified
under this Act, the patient and resident care services
determined under the Program and may perform the procedures
listed under subsection (d).
(b) In order to qualify as a certified nursing assistant
intern, an individual shall successfully complete at least 8
hours of classroom education on the services and procedures
listed under subsection (d). The classroom education shall be:
(1) taken within the facility where the certified
nursing assistant intern will be employed;
(2) proctored by either an advanced practice
registered nurse or a registered nurse who holds a
bachelor's degree in nursing, has a minimum of 3 years of
continuous experience in geriatric care, or is certified
as a nursing assistant instructor; and
(3) satisfied by the successful completion of an

approved 8-hour online training course or in-person group
training.
(c) In order to qualify as a certified nursing assistant
intern, an individual shall successfully complete at least 24
hours of on-the-job training in the services and procedures
determined under the Program and listed under subsection (d),
as follows:
(1) The training program instructor shall be either an
advanced practice registered nurse or a registered nurse
who holds a bachelor's degree in nursing, has a minimum of
3 years of continuous experience in geriatric care, or is
certified as a nursing assistant instructor.
(2) The training program instructor shall ensure that
the student meets the competencies determined under the
Program and those listed under subsection (d). The
instructor shall document the successful completion or
failure of the competencies and any remediation that may
allow for the successful completion of the competencies.
(3) All on-the-job training shall be under the direct
observation of either an advanced practice registered
nurse or a registered nurse who holds a bachelor's degree
in nursing, has a minimum of 3 years of continuous
experience in geriatric care, or is certified as a nursing
assistant instructor.
(4) All on-the-job training shall be conducted at a
facility that is licensed by the State of Illinois and

that is the facility where the certified nursing assistant
intern will be working.
(d) A certified nursing assistant intern shall receive
classroom and on-the-job training on how to provide the
patient or resident care services and procedures, as
determined under the Program, that are required of a certified
nursing assistant's performance skills, including, but not
limited to, all of the following:
(1) Successful completion and maintenance of active
certification in both first aid and the American Red
Cross' courses on cardiopulmonary resuscitation.
(2) Infection control and in-service training required
at the facility.
(3) Washing a resident's hands.
(4) Performing oral hygiene on a resident.
(5) Shaving a resident with an electric razor.
(6) Giving a resident a partial bath.
(7) Making a bed that is occupied.
(8) Dressing a resident.
(9) Transferring a resident to a wheelchair using a
gait belt or transfer belt.
(10) Ambulating a resident with a gait belt or
transfer belt.
(11) Feeding a resident.
(12) Calculating a resident's intake and output.
(13) Placing a resident in a side-lying position.

(14) The Heimlich maneuver.
(e) A certified nursing assistant intern may not perform
any of the following on a resident:
(1) Shaving with a nonelectric razor.
(2) Nail care.
(3) Perineal care.
(4) Transfer using a mechanical lift.
(5) Passive range of motion.
(f) A certified nursing assistant intern may only provide
the patient or resident care services and perform the
procedures that he or she is deemed qualified to perform that
are listed under subsection (d). A certified nursing assistant
intern may not provide the procedures excluded under
subsection (e).
(g) A certified nursing assistant intern shall report to a
facility's charge nurse or nursing supervisor and may only be
assigned duties authorized in this Section by a supervising
nurse.
(h) A facility shall notify its certified and licensed
staff members, in writing, that a certified nursing assistant
intern may only provide the services and perform the
procedures listed under subsection (d). The notification shall
detail which duties may be delegated to a certified nursing
assistant intern.
(i) If a facility learns that a certified nursing
assistant intern is performing work outside of the scope of

the Program's training, the facility shall:
(1) stop the certified nursing assistant intern from
performing the work;
(2) inspect the work and correct mistakes, if the work
performed was done improperly;
(3) assign the work to the appropriate personnel; and
(4) ensure that a thorough assessment of any resident
involved in the work performed is completed by a
registered nurse.
(j) The Program is subject to the Health Care Worker
Background Check Act and the Health Care Worker Background
Check Code under 77 Ill. Adm. Code 955. Program participants
and personnel shall be included on the Health Care Worker
Registry.
(k) A Program participant who has completed the training
required under paragraph (5) of subsection (a) of Section
3-206 of the Nursing Home Care Act, has completed the Program
from April 21, 2020 through September 18, 2020, and has shown
competency in all of the performance skills listed under
subsection (d) shall be considered a certified nursing
assistant intern.
(l) The requirement under subsection (b) of Section
395.400 of Title 77 of the Illinois Administrative Code that a
student must pass a BNATP written competency examination
within 12 months after the completion of the BNATP does not
apply to a certified nursing assistant intern under this

Section. However, upon a Program participant's enrollment in a
certified nursing assistant course, the requirement under
subsection (b) of Section 395.400 of Title 77 of the Illinois
Administrative Code that a student pass a BNATP written
competency examination within 12 months after completion of
the BNATP program applies.
(m) A certified nursing assistant intern shall enroll in a
certified nursing assistant program within 6 months after
completing his or her certified nursing assistant intern
training under the Program. The individual may continue to
work as a certified nursing assistant intern during his or her
certified nursing assistant training. If the scope of work for
a nurse assistant in training pursuant to 77 Ill. Adm. Code
300.660 is broader in scope than the work permitted to be
performed by a certified nursing assistant intern, then the
certified nursing assistant intern enrolled in certified
nursing assistant training may perform the work allowed under
77. Ill. Adm. Code 300.660. The individual shall receive one
hour of credit for every hour employed as a certified nursing
assistant intern or as a temporary nurse assistant, not to
exceed 30 hours of credit, subject to the approval of an
accredited certified nursing assistant training program.
(n) A facility that seeks to train and employ a certified
nursing assistant intern at the facility must:
(1) not have received a substantiated citation, that
the facility has the right to the appeal, for a violation

that has caused severe harm to or the death of a resident
within the 2 years prior to employing a certified nursing
assistant intern; and
(2) establish a certified nursing assistant intern
mentoring program within the facility for the purposes of
increasing education and retention, which must include an
experienced certified nurse assistant who has at least 3
years of active employment and is employed by the
facility.
(o) A facility that does not meet the requirements of
subsection (n) shall cease its new employment training,
education, or onboarding of any employee under the Program.
The facility may resume its new employment training,
education, or onboarding of an employee under the Program once
the Department determines that the facility is in compliance
with subsection (n).
(p) To study the effectiveness of the Program, the
Department shall collect data from participating facilities
and publish a report on the extent to which the Program brought
individuals into continuing employment as certified nursing
assistants in long-term care. Data collected from facilities
shall include, but shall not be limited to, the number of
certified nursing assistants employed, the number of persons
who began participation in the Program, the number of persons
who successfully completed the Program, and the number of
persons who continue employment in a long-term care service or

facility. The report shall be published no later than 6 months
after the Program end date determined under subsection (r). A
facility participating in the Program shall, twice annually,
submit data under this subsection in a manner and time
determined by the Department. Failure to submit data under
this subsection shall result in suspension of the facility's
Program.
(q) The Department may adopt emergency rules in accordance
with Section 5-45.22 of the Illinois Administrative Procedure
Act.
(r) The Program shall end upon the termination of the
Secretary of Health and Human Services' public health
emergency declaration for COVID-19 or 3 years after the date
that the Program becomes operational, whichever occurs later.
(s) This Section is inoperative 18 months after the
Program end date determined under subsection (r).
Section 35-35. The Illinois Administrative Procedure Act
is amended by adding Sections 5-45.21 and 5-45.22 as follows:
(5 ILCS 100/5-45.21 new)
Sec. 5-45.21. Emergency rulemaking; Certified Nursing
Assistant Intern Program; Department of Public Health. To
provide for the expeditious and timely implementation of this
amendatory Act of the 102nd General Assembly, emergency rules
implementing Section 2310-434 of the Department of Public

Health Powers and Duties Law of the Civil Administrative Code
of Illinois may be adopted in accordance with Section 5-45 by
the Department of Public Health. 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 102nd General Assembly.
(5 ILCS 100/5-45.22 new)
Sec. 5-45.22. Emergency rulemaking; Certified Nursing
Assistant Intern Program; Department of Healthcare and Family
Services. To provide for the expeditious and timely
implementation of this amendatory Act of the 102nd General
Assembly, emergency rules implementing Section 5-5.01b 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 102nd General Assembly.
ARTICLE 40.
Section 40-5. The Illinois Public Aid Code is amended by
changing Section 11-5.1 and by adding Sections 5-1.6, 5-13.1

and 11-5.5 as follows:
(305 ILCS 5/5-1.6 new)
Sec. 5-1.6. Continuous eligibility; ex parte
redeterminations.
(a) By July 1, 2022, the Department of Healthcare and
Family Services shall seek a State Plan amendment or any
federal waivers necessary to make changes to the medical
assistance program. The Department shall apply for federal
approval to implement 12 months of continuous eligibility for
adults participating in the medical assistance program. The
Department shall secure federal financial participation in
accordance with this Section for expenditures made by the
Department in State Fiscal Year 2023 and every State fiscal
year thereafter.
(b) By July 1, 2022, the Department of Healthcare and
Family Services shall seek a State Plan amendment or any
federal waivers or approvals necessary to make changes to the
medical assistance redetermination process for people without
any income at the time of redetermination. These changes shall
seek to allow all people without income to be considered for ex
parte redetermination. If there is no non-income related
disqualifying information for medical assistance recipients
without any income, then a person without any income shall be
redetermined ex parte. Within 60 days after receiving federal
approval or guidance, the Department of Healthcare and Family

Services and the Department of Human Services shall make
necessary technical and rule changes to implement changes to
the redetermination process. The percentage of medical
assistance recipients whose eligibility is renewed through the
ex parte redetermination process shall be reported monthly by
the Department of Healthcare and Family Services on its
website in accordance with subsection (d) of Section 11-5.1 of
this Code as well as shared in all Medicaid Advisory Committee
meetings and Medicaid Advisory Committee Public Education
Subcommittee meetings.
(305 ILCS 5/5-13.1 new)
Sec. 5-13.1. Cost-effectiveness waiver, hardship waivers,
and making information about waivers more accessible.
(a) It is the intent of the General Assembly to ease the
burden of liens and estate recovery for correctly paid
benefits for participants, applicants, and their families and
heirs, and to make information about waivers more widely
available.
(b) The Department shall waive estate recovery under
Sections 3-9 and 5-13 where recovery would not be
cost-effective, would work an undue hardship, or for any other
just reason, and shall make information about waivers and
estate recovery easily accessible.
(1) Cost-effectiveness waiver. Subject to federal
approval, the Department shall waive any claim against the

first $25,000 of any estate to prevent substantial and
unreasonable hardship. The Department shall consider the
gross assets in the estate, including, but not limited to,
the net value of real estate less mortgages or liens with
priority over the Department's claims. The Department may
increase the cost-effectiveness threshold in the future.
(2) Undue hardship waiver. The Department may develop
additional hardship waiver standards in addition to those
already employed, including, but not limited to, waivers
aimed at preserving income-producing real property or a
modest home as defined by rule.
(3) Accessible information. The Department shall make
information about estate recovery and hardship waivers
easily accessible. The Department shall maintain
information about how to request a hardship waiver on its
website in English, Spanish, and the next 4 most commonly
used languages, including a short guide and simple form to
facilitate requesting hardship exemptions in each
language. On an annual basis, the Department shall
publicly report on the number of estate recovery cases
that are pursued and the number of undue hardship
exemptions granted, including demographic data of the
deceased beneficiaries where available.
(305 ILCS 5/11-5.1)
Sec. 11-5.1. Eligibility verification. Notwithstanding any

other provision of this Code, with respect to applications for
medical assistance provided under Article V of this Code,
eligibility shall be determined in a manner that ensures
program integrity and complies with federal laws and
regulations while minimizing unnecessary barriers to
enrollment. To this end, as soon as practicable, and unless
the Department receives written denial from the federal
government, this Section shall be implemented:
(a) The Department of Healthcare and Family Services or
its designees shall:
(1) By no later than July 1, 2011, require
verification of, at a minimum, one month's income from all
sources required for determining the eligibility of
applicants for medical assistance under this Code. Such
verification shall take the form of pay stubs, business or
income and expense records for self-employed persons,
letters from employers, and any other valid documentation
of income including data obtained electronically by the
Department or its designees from other sources as
described in subsection (b) of this Section. A month's
income may be verified by a single pay stub with the
monthly income extrapolated from the time period covered
by the pay stub.
(2) By no later than October 1, 2011, require
verification of, at a minimum, one month's income from all
sources required for determining the continued eligibility

of recipients at their annual review of eligibility for
medical assistance under this Code. Information the
Department receives prior to the annual review, including
information available to the Department as a result of the
recipient's application for other non-Medicaid benefits,
that is sufficient to make a determination of continued
Medicaid eligibility may be reviewed and verified, and
subsequent action taken including client notification of
continued Medicaid eligibility. The date of client
notification establishes the date for subsequent annual
Medicaid eligibility reviews. Such verification shall take
the form of pay stubs, business or income and expense
records for self-employed persons, letters from employers,
and any other valid documentation of income including data
obtained electronically by the Department or its designees
from other sources as described in subsection (b) of this
Section. A month's income may be verified by a single pay
stub with the monthly income extrapolated from the time
period covered by the pay stub. The Department shall send
a notice to recipients at least 60 days prior to the end of
their period of eligibility that informs them of the
requirements for continued eligibility. If a recipient
does not fulfill the requirements for continued
eligibility by the deadline established in the notice a
notice of cancellation shall be issued to the recipient
and coverage shall end no later than the last day of the

month following the last day of the eligibility period. A
recipient's eligibility may be reinstated without
requiring a new application if the recipient fulfills the
requirements for continued eligibility prior to the end of
the third month following the last date of coverage (or
longer period if required by federal regulations). Nothing
in this Section shall prevent an individual whose coverage
has been cancelled from reapplying for health benefits at
any time.
(3) By no later than July 1, 2011, require
verification of Illinois residency.
The Department, with federal approval, may choose to adopt
continuous financial eligibility for a full 12 months for
adults on Medicaid.
(b) The Department shall establish or continue cooperative
arrangements with the Social Security Administration, the
Illinois Secretary of State, the Department of Human Services,
the Department of Revenue, the Department of Employment
Security, and any other appropriate entity to gain electronic
access, to the extent allowed by law, to information available
to those entities that may be appropriate for electronically
verifying any factor of eligibility for benefits under the
Program. Data relevant to eligibility shall be provided for no
other purpose than to verify the eligibility of new applicants
or current recipients of health benefits under the Program.
Data shall be requested or provided for any new applicant or

current recipient only insofar as that individual's
circumstances are relevant to that individual's or another
individual's eligibility.
(c) Within 90 days of the effective date of this
amendatory Act of the 96th General Assembly, the Department of
Healthcare and Family Services shall send notice to current
recipients informing them of the changes regarding their
eligibility verification.
(d) As soon as practical if the data is reasonably
available, but no later than January 1, 2017, the Department
shall compile on a monthly basis data on eligibility
redeterminations of beneficiaries of medical assistance
provided under Article V of this Code. In addition to the other
data required under this subsection, the Department shall
compile on a monthly basis data on the percentage of
beneficiaries whose eligibility is renewed through ex parte
redeterminations as described in subsection (b) of Section
5-1.6 of this Code, subject to federal approval of the changes
made in subsection (b) of Section 5-1.6 by this amendatory Act
of the 102nd General Assembly. This data shall be posted on the
Department's website, and data from prior months shall be
retained and available on the Department's website. The data
compiled and reported shall include the following:
(1) The total number of redetermination decisions made
in a month and, of that total number, the number of
decisions to continue or change benefits and the number of

decisions to cancel benefits.
(2) A breakdown of enrollee language preference for
the total number of redetermination decisions made in a
month and, of that total number, a breakdown of enrollee
language preference for the number of decisions to
continue or change benefits, and a breakdown of enrollee
language preference for the number of decisions to cancel
benefits. The language breakdown shall include, at a
minimum, English, Spanish, and the next 4 most commonly
used languages.
(3) The percentage of cancellation decisions made in a
month due to each of the following:
(A) The beneficiary's ineligibility due to excess
income.
(B) The beneficiary's ineligibility due to not
being an Illinois resident.
(C) The beneficiary's ineligibility due to being
deceased.
(D) The beneficiary's request to cancel benefits.
(E) The beneficiary's lack of response after
notices mailed to the beneficiary are returned to the
Department as undeliverable by the United States
Postal Service.
(F) The beneficiary's lack of response to a
request for additional information when reliable
information in the beneficiary's account, or other

more current information, is unavailable to the
Department to make a decision on whether to continue
benefits.
(G) Other reasons tracked by the Department for
the purpose of ensuring program integrity.
(4) If a vendor is utilized to provide services in
support of the Department's redetermination decision
process, the total number of redetermination decisions
made in a month and, of that total number, the number of
decisions to continue or change benefits, and the number
of decisions to cancel benefits (i) with the involvement
of the vendor and (ii) without the involvement of the
vendor.
(5) Of the total number of benefit cancellations in a
month, the number of beneficiaries who return from
cancellation within one month, the number of beneficiaries
who return from cancellation within 2 months, and the
number of beneficiaries who return from cancellation
within 3 months. Of the number of beneficiaries who return
from cancellation within 3 months, the percentage of those
cancellations due to each of the reasons listed under
paragraph (3) of this subsection.
(e) The Department shall conduct a complete review of the
Medicaid redetermination process in order to identify changes
that can increase the use of ex parte redetermination
processing. This review shall be completed within 90 days

after the effective date of this amendatory Act of the 101st
General Assembly. Within 90 days of completion of the review,
the Department shall seek written federal approval of policy
changes the review recommended and implement once approved.
The review shall specifically include, but not be limited to,
use of ex parte redeterminations of the following populations:
(1) Recipients of developmental disabilities services.
(2) Recipients of benefits under the State's Aid to
the Aged, Blind, or Disabled program.
(3) Recipients of Medicaid long-term care services and
supports, including waiver services.
(4) All Modified Adjusted Gross Income (MAGI)
populations.
(5) Populations with no verifiable income.
(6) Self-employed people.
The report shall also outline populations and
circumstances in which an ex parte redetermination is not a
recommended option.
(f) The Department shall explore and implement, as
practical and technologically possible, roles that
stakeholders outside State agencies can play to assist in
expediting eligibility determinations and redeterminations
within 24 months after the effective date of this amendatory
Act of the 101st General Assembly. Such practical roles to be
explored to expedite the eligibility determination processes
shall include the implementation of hospital presumptive

eligibility, as authorized by the Patient Protection and
Affordable Care Act.
(g) The Department or its designee shall seek federal
approval to enhance the reasonable compatibility standard from
5% to 10%.
(h) Reporting. The Department of Healthcare and Family
Services and the Department of Human Services shall publish
quarterly reports on their progress in implementing policies
and practices pursuant to this Section as modified by this
amendatory Act of the 101st General Assembly.
(1) The reports shall include, but not be limited to,
the following:
(A) Medical application processing, including a
breakdown of the number of MAGI, non-MAGI, long-term
care, and other medical cases pending for various
incremental time frames between 0 to 181 or more days.
(B) Medical redeterminations completed, including:
(i) a breakdown of the number of households that were
redetermined ex parte and those that were not; (ii)
the reasons households were not redetermined ex parte;
and (iii) the relative percentages of these reasons.
(C) A narrative discussion on issues identified in
the functioning of the State's Integrated Eligibility
System and progress on addressing those issues, as
well as progress on implementing strategies to address
eligibility backlogs, including expanding ex parte

determinations to ensure timely eligibility
determinations and renewals.
(2) Initial reports shall be issued within 90 days
after the effective date of this amendatory Act of the
101st General Assembly.
(3) All reports shall be published on the Department's
website.
(i) It is the determination of the General Assembly that
the Department must include seniors and persons with
disabilities in ex parte renewals. It is the determination of
the General Assembly that the Department must use its asset
verification system to assist in the determination of whether
an individual's coverage can be renewed using the ex parte
process. If a State Plan amendment is required, the Department
shall pursue such State Plan amendment by July 1, 2022. Within
60 days after receiving federal approval or guidance, the
Department of Healthcare and Family Services and the
Department of Human Services shall make necessary technical
and rule changes to implement these changes to the
redetermination process.
(Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20.)
(305 ILCS 5/11-5.5 new)
Sec. 11-5.5. Streamlining enrollment into the Medicare
Savings Program.
(a) The Department shall investigate how to align the

Medicare Part D Low-Income Subsidy and Medicare Savings
Program eligibility criteria.
(b) The Department shall issue a report making
recommendations on how to streamline enrollment into Medicare
Savings Program benefits by July 1, 2022.
(c) Within 90 days after issuing its report, the
Department shall seek public feedback on those recommendations
and plans.
(d) By July 1, 2023, the Department shall implement the
necessary changes to streamline enrollment into the Medicare
Savings Program. The Department may adopt any rules necessary
to implement the provisions of this paragraph.
(305 ILCS 5/3-10 rep.)
(305 ILCS 5/3-10.1 rep.)
(305 ILCS 5/3-10.2 rep.)
(305 ILCS 5/3-10.3 rep.)
(305 ILCS 5/3-10.4 rep.)
(305 ILCS 5/3-10.5 rep.)
(305 ILCS 5/3-10.6 rep.)
(305 ILCS 5/3-10.7 rep.)
(305 ILCS 5/3-10.8 rep.)
(305 ILCS 5/3-10.9 rep.)
(305 ILCS 5/3-10.10 rep.)
(305 ILCS 5/5-13.5 rep.)
Section 40-10. The Illinois Public Aid Code is amended by

repealing Sections 3-10, 3-10.1, 3-10.2, 3-10.3, 3-10.4,
3-10.5, 3-10.6, 3-10.7, 3-10.8, 3-10.9, and 3-10.10, and
5-13.5.
ARTICLE 45.
Section 45-5. The Illinois Public Aid Code is amended by
changing Section 5-5.07 as follows:
(305 ILCS 5/5-5.07)
Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem
rate. The Department of Children and Family Services shall pay
the DCFS per diem rate for inpatient psychiatric stay at a
free-standing psychiatric hospital or a hospital with a
pediatric or adolescent inpatient psychiatric unit effective
the 11th day when a child is in the hospital beyond medical
necessity, and the parent or caregiver has denied the child
access to the home and has refused or failed to make provisions
for another living arrangement for the child or the child's
discharge is being delayed due to a pending inquiry or
investigation by the Department of Children and Family
Services. If any portion of a hospital stay is reimbursed
under this Section, the hospital stay shall not be eligible
for payment under the provisions of Section 14-13 of this
Code. This Section is inoperative on and after July 1, 2021.
Notwithstanding the provision of Public Act 101-209 stating

that this Section is inoperative on and after July 1, 2020,
this Section is operative from July 1, 2020 through July 1,
2023.
(Source: Reenacted by P.A. 101-15, eff. 6-14-19; reenacted by
P.A. 101-209, eff. 8-5-19; P.A. 101-655, eff. 3-12-21;
102-201, eff. 7-30-21; 102-558, eff. 8-20-21.)
ARTICLE 50.
Section 50-5. The Illinois Public Aid Code is amended by
changing Section 5-4.2 and by adding Section 5-30d 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) On and after July 1, 2018, the Department shall
increase the base rate of reimbursement for both base charges
and mileage charges for ground ambulance service providers for

medical transportation services provided by means of a ground
ambulance to a level not lower than 112% of the base rate in
effect as of June 30, 2018.
(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20;
102-364, eff. 1-1-22; 102-650, eff. 8-27-21; revised 11-8-21.)
(305 ILCS 5/5-30d new)
Sec. 5-30d. Increased funding for transportation services.
Beginning no later than January 1, 2023 and subject to federal
approval, the amount allocated to fund rates for medi-car,
service car, and attendant services provided to adults and
children under the medical assistance program shall be
increased by an approximate amount of $24,000,000.
ARTICLE 55.
Section 55-5. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.23 as follows:
(5 ILCS 100/5-45.23 new)
Sec. 5-45.23. Emergency rulemaking; medical services to
noncitizens. To provide for the expeditious and timely
implementation of changes made by this amendatory Act of the
102nd General Assembly to Section 12-4.35 of the Illinois
Public Aid Code, emergency rules implementing the changes made
by this amendatory Act of the 102nd General Assembly to

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. 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 102nd General Assembly.
Section 55-10. 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
this amendatory Act of the 102nd General Assembly 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).
(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; revised 7-15-21.)
ARTICLE 999.