SB0741 EnrolledLRB098 04975 KTG 35005 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4
Article 1

 
5    Section 1-5. The Illinois Public Aid Code is amended by
6adding Article V-F as follows:
 
7    (305 ILCS 5/Art. V-F heading new)
8
ARTICLE V-F. MEDICARE-MEDICAID ALIGNMENT
9
INITIATIVE (MMAI) NURSING HOME
10
RESIDENTS' MANAGED CARE RIGHTS LAW

 
11    (305 ILCS 5/5F-1 new)
12    Sec. 5F-1. Short title. This Article may be referred to as
13the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home
14Residents' Managed Care Rights Law.
 
15    (305 ILCS 5/5F-5 new)
16    Sec. 5F-5. Findings. The General Assembly finds that
17elderly Illinoisans residing in a nursing home have the right
18to:
19        (1) quality health care regardless of the payer;
20        (2) receive medically necessary care prescribed by

 

 

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1    their doctors;
2        (3) a simple appeal process when care is denied; and
3        (4) make decisions about their care and where they
4    receive it.
 
5    (305 ILCS 5/5F-10 new)
6    Sec. 5F-10. Scope. This Article applies to policies and
7contracts amended, delivered, issued, or renewed on or after
8the effective date of this amendatory Act of the 98th General
9Assembly for the nursing home component of the
10Medicare-Medicaid Alignment Initiative. This Article does not
11diminish a managed care organization's duties and
12responsibilities under other federal or State laws or rules
13adopted under those laws and the 3-way Medicare-Medicaid
14Alignment Initiative contract.
 
15    (305 ILCS 5/5F-15 new)
16    Sec. 5F-15. Definitions. As used in this Article:
17    "Appeal" means any of the procedures that deal with the
18review of adverse organization determinations on the health
19care services the enrollee believes he or she is entitled to
20receive, including delay in providing, arranging for, or
21approving the health care services, such that a delay would
22adversely affect the health of the enrollee or on any amounts
23the enrollee must pay for a service, as defined under 42 CFR
24422.566(b). These procedures include reconsiderations by the

 

 

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1managed care organization and, if necessary, an independent
2review entity as provided by the Health Carrier External Review
3Act, hearings before administrative law judges, review by the
4Medicare Appeals Council, and judicial review.
5    "Demonstration Project" means the nursing home component
6of the Medicare-Medicaid Alignment Initiative Demonstration
7Project.
8    "Department" means the Department of Healthcare and Family
9Services.
10    "Enrollee" means an individual who resides in a nursing
11home or is qualified to be admitted to a nursing home and is
12enrolled with a managed care organization participating in the
13Demonstration Project.
14    "Health care services" means the diagnosis, treatment, and
15prevention of disease and includes medication, primary care,
16nursing or medical care, mental health treatment, psychiatric
17rehabilitation, memory loss services, physical, occupational,
18and speech rehabilitation, enhanced care, medical supplies and
19equipment and the repair of such equipment, and assistance with
20activities of daily living.
21    "Managed care organization" or "MCO" means an entity that
22meets the definition of health maintenance organization as
23defined in the Health Maintenance Organization Act, is
24licensed, regulated and in good standing with the Department of
25Insurance, and is authorized to participate in the nursing home
26component of the Medicare-Medicaid Alignment Initiative

 

 

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1Demonstration Project by a 3-way contract with the Department
2of Healthcare and Family Services and the Centers for Medicare
3and Medicaid Services.
4    "Medical professional" means a physician, physician
5assistant, or nurse practitioner.
6    "Medically necessary" means health care services that a
7medical professional, exercising prudent clinical judgment,
8would provide to a patient for the purpose of preventing,
9evaluating, diagnosing, or treating an illness, injury, or
10disease or its symptoms, and that are: (i) in accordance with
11the generally accepted standards of medical practice; (ii)
12clinically appropriate, in terms of type, frequency, extent,
13site, and duration, and considered effective for the patient's
14illness, injury, or disease; and (iii) not primarily for the
15convenience of the patient, a medical professional, other
16health care provider, caregiver, family member, or other
17interested party.
18    "Nursing home" means a facility licensed under the Nursing
19Home Care Act.
20    "Nurse practitioner" means an individual properly licensed
21as a nurse practitioner under the Nurse Practice Act.
22    "Physician" means an individual licensed to practice in all
23branches of medicine under the Medical Practice Act of 1987.
24    "Physician assistant" means an individual properly
25licensed under the Physician Assistant Practice Act of 1987.
26    "Resident" means an enrollee who is receiving personal or

 

 

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1medical care, including, but not limited to, mental health
2treatment, psychiatric rehabilitation, physical
3rehabilitation, and assistance with activities of daily
4living, from a nursing home.
5    "RAI Manual" means the most recent Resident Assessment
6Instrument Manual, published by the Centers for Medicare and
7Medicaid Services.
8    "Resident's representative" means a person designated in
9writing by a resident to be the resident's representative or
10the resident's guardian, as described by the Nursing Home Care
11Act.
12    "SNFist" means a medical professional specializing in the
13care of individuals residing in nursing homes employed by or
14under contract with a MCO.
15    "Transition period" means a period of time immediately
16following enrollment into the Demonstration Project or an
17enrollee's movement from one managed care organization to
18another managed care organization or one care setting to
19another care setting.
 
20    (305 ILCS 5/5F-20 new)
21    Sec. 5F-20. Network adequacy.
22    (a) Every managed care organization shall allow every
23nursing home in its service area an opportunity to be a network
24contracted facility at the plan's standard terms, conditions,
25and rates. Either party may opt to limit the contract to

 

 

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1existing residents only.
2    (b) With the exception of subsection (c) of this Section, a
3managed care organization shall only terminate or refuse to
4renew a contract with a nursing home if the nursing home fails
5to meet quality standards if the following conditions are met:
6        (1) the quality standards are made known to the nursing
7    home;
8        (2) the quality standards can be objectively measured
9    through data;
10        (3) the nursing home is measured on at least a year's
11    worth of performance;
12        (4) a nursing home that the MCO has determined did not
13    meet a quality standard has the opportunity to contest that
14    determination by challenging the accuracy or the
15    measurement of the data through an arbitration process
16    agreed to by contract; and
17        (5) the Department may attempt to mediate a dispute
18    prior to arbitration.
19    (c) A managed care organization may terminate or refuse to
20renew a contract with a nursing home for a material breach of
21the contract, including, but not limited to, failure to grant
22reasonable and timely access to the MCO's care coordinators,
23SNFists and other providers, termination from the Medicare or
24Medicaid program, or revocation of license.
 
25    (305 ILCS 5/5F-25 new)

 

 

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1    Sec. 5F-25. Care coordination. Care coordination provided
2to all enrollees in the Demonstration Project shall conform to
3the following requirements:
4        (1) care coordination services shall be
5    enrollee-driven and person-centered;
6        (2) all enrollees in the Demonstration Project shall
7    have the right to receive health care services in the care
8    setting of their choice, except as permitted by Part 4 of
9    Article III of the Nursing Home Care Act with respect to
10    involuntary transfers and discharges; and
11        (3) decisions shall be based on the enrollee's best
12    interests.
 
13    (305 ILCS 5/5F-30 new)
14    Sec. 5F-30. Continuity of care. When a nursing home
15resident first transitions to a managed care organization from
16the fee-for-service system or from another managed care
17organization, the managed care organization shall honor the
18existing care plan and any necessary changes to that care plan
19until the MCO has completed a comprehensive assessment and new
20care plan, to the extent such services are covered benefits
21under the contract, which shall be consistent with the
22requirements of the RAI Manual.
23    When an enrollee of a managed care organization is moving
24from a community setting to a nursing home, and the MCO is
25properly notified of the proposed admission by a network

 

 

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1nursing home, and the managed care organization fails to
2participate in developing a care plan within the time frames
3required by nursing home regulations, the MCO must honor a care
4plan developed by the nursing home until the MCO has completed
5a comprehensive assessment and a new care plan to the extent
6such services are covered benefits under the contract,
7consistent with the requirements of the RAI Manual.
8    A nursing home shall have the ability to refuse admission
9of an enrollee for whom care is required that the nursing home
10determines is outside the scope of its license and healthcare
11capabilities.
 
12    (305 ILCS 5/5F-32 new)
13    Sec. 5F-32. Non-emergency prior approval and appeal.
14    (a) MCOs must have a method of receiving prior approval
15requests 24 hours a day, 7 days a week, 365 days a year for
16nursing home residents. If a response is not provided within 24
17hours of the request and the nursing home is required by
18regulation to provide a service because a physician ordered it,
19the MCO must pay for the service if it is a covered service
20under the MCO's contract in the Demonstration Project, provided
21that the request is consistent with the policies and procedures
22of the MCO.
23    In a non-emergency situation, notwithstanding any
24provisions in State law to the contrary, in the event a
25resident's physician orders a service, treatment, or test that

 

 

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1is not approved by the MCO, the physician and the provider may
2utilize an expedited appeal to the MCO.
3    If an enrollee or provider requests an expedited appeal
4pursuant to 42 CFR 438.410, the MCO shall notify the enrollee
5or provider within 24 hours after the submission of the appeal
6of all information from the enrollee or provider that the MCO
7requires to evaluate the appeal. The MCO shall render a
8decision on an expedited appeal within 24 hours after receipt
9of the required information.
10    (b) While the appeal is pending or if the ordered service,
11treatment, or test is denied after appeal, the Department of
12Public Health may not cite the nursing home for failure to
13provide the ordered service, treatment, or test. The nursing
14home shall not be liable or responsible for an injury in any
15regulatory proceeding for the following:
16        (1) failure to follow the appealed or denied order; or
17        (2) injury to the extent it was caused by the delay or
18    failure to perform the appealed or denied service,
19    treatment, or test.
20Provided however, a nursing home shall continue to monitor,
21document, and ensure the patient's safety. Nothing in this
22subsection (b) is intended to otherwise change the nursing
23home's existing obligations under State and federal law to
24appropriately care for its residents.
 
25    (305 ILCS 5/5F-35 new)

 

 

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1    Sec. 5F-35. Reimbursement. The Department shall provide
2each managed care organization with the quarterly
3facility-specific RUG-IV nursing component per diem along with
4any add-ons for enhanced care services, support component per
5diem, and capital component per diem effective for each nursing
6home under contract with the managed care organization.
 
7    (305 ILCS 5/5F-40 new)
8    Sec. 5F-40. Contractual requirements.
9    (a) Every contract shall contain a clause for termination
10consistent with the Managed Care Reform and Patient Rights Act
11providing nursing homes the ability to terminate the contract.
12    (b) All changes to the contract by the MCO shall be
13preceded by 30 days' written notice sent to the nursing home.
 
14    (305 ILCS 5/5F-45 new)
15    Sec. 5F-45. Prohibition. No managed care organization or
16contract shall contain any provision, policy, or procedure that
17limits, restricts, or waives any rights set forth in this
18Article or is expressly prohibited by this Article. Any such
19policy or procedure is void and unenforceable.
 
20    Section 1-10. The Health Maintenance Organization Act is
21amended by changing Section 1-2 as follows:
 
22    (215 ILCS 125/1-2)  (from Ch. 111 1/2, par. 1402)

 

 

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1    Sec. 1-2. Definitions. As used in this Act, unless the
2context otherwise requires, the following terms shall have the
3meanings ascribed to them:
4    (1) "Advertisement" means any printed or published
5material, audiovisual material and descriptive literature of
6the health care plan used in direct mail, newspapers,
7magazines, radio scripts, television scripts, billboards and
8similar displays; and any descriptive literature or sales aids
9of all kinds disseminated by a representative of the health
10care plan for presentation to the public including, but not
11limited to, circulars, leaflets, booklets, depictions,
12illustrations, form letters and prepared sales presentations.
13    (2) "Director" means the Director of Insurance.
14    (3) "Basic health care services" means emergency care, and
15inpatient hospital and physician care, outpatient medical
16services, mental health services and care for alcohol and drug
17abuse, including any reasonable deductibles and co-payments,
18all of which are subject to the limitations described in
19Section 4-20 of this Act and as determined by the Director
20pursuant to rule.
21    (4) "Enrollee" means an individual who has been enrolled in
22a health care plan.
23    (5) "Evidence of coverage" means any certificate,
24agreement, or contract issued to an enrollee setting out the
25coverage to which he is entitled in exchange for a per capita
26prepaid sum.

 

 

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1    (6) "Group contract" means a contract for health care
2services which by its terms limits eligibility to members of a
3specified group.
4    (7) "Health care plan" means any arrangement whereby any
5organization undertakes to provide or arrange for and pay for
6or reimburse the cost of basic health care services, excluding
7any reasonable deductibles and copayments, from providers
8selected by the Health Maintenance Organization and such
9arrangement consists of arranging for or the provision of such
10health care services, as distinguished from mere
11indemnification against the cost of such services, except as
12otherwise authorized by Section 2-3 of this Act, on a per
13capita prepaid basis, through insurance or otherwise. A "health
14care plan" also includes any arrangement whereby an
15organization undertakes to provide or arrange for or pay for or
16reimburse the cost of any health care service for persons who
17are enrolled under Article V of the Illinois Public Aid Code or
18under the Children's Health Insurance Program Act through
19providers selected by the organization and the arrangement
20consists of making provision for the delivery of health care
21services, as distinguished from mere indemnification. A
22"health care plan" also includes any arrangement pursuant to
23Section 4-17. Nothing in this definition, however, affects the
24total medical services available to persons eligible for
25medical assistance under the Illinois Public Aid Code.
26    (8) "Health care services" means any services included in

 

 

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1the furnishing to any individual of medical or dental care, or
2the hospitalization or incident to the furnishing of such care
3or hospitalization as well as the furnishing to any person of
4any and all other services for the purpose of preventing,
5alleviating, curing or healing human illness or injury.
6    (9) "Health Maintenance Organization" means any
7organization formed under the laws of this or another state to
8provide or arrange for one or more health care plans under a
9system which causes any part of the risk of health care
10delivery to be borne by the organization or its providers.
11    (10) "Net worth" means admitted assets, as defined in
12Section 1-3 of this Act, minus liabilities.
13    (11) "Organization" means any insurance company, a
14nonprofit corporation authorized under the Dental Service Plan
15Act or the Voluntary Health Services Plans Act, or a
16corporation organized under the laws of this or another state
17for the purpose of operating one or more health care plans and
18doing no business other than that of a Health Maintenance
19Organization or an insurance company. "Organization" shall
20also mean the University of Illinois Hospital as defined in the
21University of Illinois Hospital Act or a unit of local
22government health system operating within a county with a
23population of 3,000,000 or more.
24    (12) "Provider" means any physician, hospital facility,
25facility licensed under the Nursing Home Care Act, or other
26person which is licensed or otherwise authorized to furnish

 

 

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1health care services and also includes any other entity that
2arranges for the delivery or furnishing of health care service.
3    (13) "Producer" means a person directly or indirectly
4associated with a health care plan who engages in solicitation
5or enrollment.
6    (14) "Per capita prepaid" means a basis of prepayment by
7which a fixed amount of money is prepaid per individual or any
8other enrollment unit to the Health Maintenance Organization or
9for health care services which are provided during a definite
10time period regardless of the frequency or extent of the
11services rendered by the Health Maintenance Organization,
12except for copayments and deductibles and except as provided in
13subsection (f) of Section 5-3 of this Act.
14    (15) "Subscriber" means a person who has entered into a
15contractual relationship with the Health Maintenance
16Organization for the provision of or arrangement of at least
17basic health care services to the beneficiaries of such
18contract.
19(Source: P.A. 97-1148, eff. 1-24-13.)
 
20    Section 1-15. The Managed Care Reform and Patient Rights
21Act is amended by changing Section 10 as follows:
 
22    (215 ILCS 134/10)
23    Sec. 10. Definitions:
24    "Adverse determination" means a determination by a health

 

 

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1care plan under Section 45 or by a utilization review program
2under Section 85 that a health care service is not medically
3necessary.
4    "Clinical peer" means a health care professional who is in
5the same profession and the same or similar specialty as the
6health care provider who typically manages the medical
7condition, procedures, or treatment under review.
8    "Department" means the Department of Insurance.
9    "Emergency medical condition" means a medical condition
10manifesting itself by acute symptoms of sufficient severity
11(including, but not limited to, severe pain) such that a
12prudent layperson, who possesses an average knowledge of health
13and medicine, could reasonably expect the absence of immediate
14medical attention to result in:
15        (1) placing the health of the individual (or, with
16    respect to a pregnant woman, the health of the woman or her
17    unborn child) in serious jeopardy;
18        (2) serious impairment to bodily functions; or
19        (3) serious dysfunction of any bodily organ or part.
20    "Emergency medical screening examination" means a medical
21screening examination and evaluation by a physician licensed to
22practice medicine in all its branches, or to the extent
23permitted by applicable laws, by other appropriately licensed
24personnel under the supervision of or in collaboration with a
25physician licensed to practice medicine in all its branches to
26determine whether the need for emergency services exists.

 

 

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1    "Emergency services" means, with respect to an enrollee of
2a health care plan, transportation services, including but not
3limited to ambulance services, and covered inpatient and
4outpatient hospital services furnished by a provider qualified
5to furnish those services that are needed to evaluate or
6stabilize an emergency medical condition. "Emergency services"
7does not refer to post-stabilization medical services.
8    "Enrollee" means any person and his or her dependents
9enrolled in or covered by a health care plan.
10    "Health care plan" means a plan, including, but not limited
11to, a health maintenance organization, a managed care community
12network as defined in the Illinois Public Aid Code, or an
13accountable care entity as defined in the Illinois Public Aid
14Code that receives capitated payments to cover medical services
15from the Department of Healthcare and Family Services, that
16establishes, operates, or maintains a network of health care
17providers that has entered into an agreement with the plan to
18provide health care services to enrollees to whom the plan has
19the ultimate obligation to arrange for the provision of or
20payment for services through organizational arrangements for
21ongoing quality assurance, utilization review programs, or
22dispute resolution. Nothing in this definition shall be
23construed to mean that an independent practice association or a
24physician hospital organization that subcontracts with a
25health care plan is, for purposes of that subcontract, a health
26care plan.

 

 

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1    For purposes of this definition, "health care plan" shall
2not include the following:
3        (1) indemnity health insurance policies including
4    those using a contracted provider network;
5        (2) health care plans that offer only dental or only
6    vision coverage;
7        (3) preferred provider administrators, as defined in
8    Section 370g(g) of the Illinois Insurance Code;
9        (4) employee or employer self-insured health benefit
10    plans under the federal Employee Retirement Income
11    Security Act of 1974;
12        (5) health care provided pursuant to the Workers'
13    Compensation Act or the Workers' Occupational Diseases
14    Act; and
15        (6) not-for-profit voluntary health services plans
16    with health maintenance organization authority in
17    existence as of January 1, 1999 that are affiliated with a
18    union and that only extend coverage to union members and
19    their dependents.
20    "Health care professional" means a physician, a registered
21professional nurse, or other individual appropriately licensed
22or registered to provide health care services.
23    "Health care provider" means any physician, hospital
24facility, facility licensed under the Nursing Home Care Act, or
25other person that is licensed or otherwise authorized to
26deliver health care services. Nothing in this Act shall be

 

 

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1construed to define Independent Practice Associations or
2Physician-Hospital Organizations as health care providers.
3    "Health care services" means any services included in the
4furnishing to any individual of medical care, or the
5hospitalization incident to the furnishing of such care, as
6well as the furnishing to any person of any and all other
7services for the purpose of preventing, alleviating, curing, or
8healing human illness or injury including home health and
9pharmaceutical services and products.
10    "Medical director" means a physician licensed in any state
11to practice medicine in all its branches appointed by a health
12care plan.
13    "Person" means a corporation, association, partnership,
14limited liability company, sole proprietorship, or any other
15legal entity.
16    "Physician" means a person licensed under the Medical
17Practice Act of 1987.
18    "Post-stabilization medical services" means health care
19services provided to an enrollee that are furnished in a
20licensed hospital by a provider that is qualified to furnish
21such services, and determined to be medically necessary and
22directly related to the emergency medical condition following
23stabilization.
24    "Stabilization" means, with respect to an emergency
25medical condition, to provide such medical treatment of the
26condition as may be necessary to assure, within reasonable

 

 

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1medical probability, that no material deterioration of the
2condition is likely to result.
3    "Utilization review" means the evaluation of the medical
4necessity, appropriateness, and efficiency of the use of health
5care services, procedures, and facilities.
6    "Utilization review program" means a program established
7by a person to perform utilization review.
8(Source: P.A. 91-617, eff. 1-1-00.)
 
9
Article 5

 
10    Section 5-5. The Illinois Health Facilities Planning Act is
11amended by changing Sections 3 and 12 as follows:
 
12    (20 ILCS 3960/3)  (from Ch. 111 1/2, par. 1153)
13    (Section scheduled to be repealed on December 31, 2019)
14    Sec. 3. Definitions. As used in this Act:
15    "Health care facilities" means and includes the following
16facilities, organizations, and related persons:
17        1. An ambulatory surgical treatment center required to
18    be licensed pursuant to the Ambulatory Surgical Treatment
19    Center Act;
20        2. An institution, place, building, or agency required
21    to be licensed pursuant to the Hospital Licensing Act;
22        3. Skilled and intermediate long term care facilities
23    licensed under the Nursing Home Care Act;

 

 

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1        3.5. Skilled and intermediate care facilities licensed
2    under the ID/DD Community Care Act;
3        3.7. Facilities licensed under the Specialized Mental
4    Health Rehabilitation Act of 2013;
5        4. Hospitals, nursing homes, ambulatory surgical
6    treatment centers, or kidney disease treatment centers
7    maintained by the State or any department or agency
8    thereof;
9        5. Kidney disease treatment centers, including a
10    free-standing hemodialysis unit required to be licensed
11    under the End Stage Renal Disease Facility Act;
12        6. An institution, place, building, or room used for
13    the performance of outpatient surgical procedures that is
14    leased, owned, or operated by or on behalf of an
15    out-of-state facility;
16        7. An institution, place, building, or room used for
17    provision of a health care category of service, including,
18    but not limited to, cardiac catheterization and open heart
19    surgery; and
20        8. An institution, place, building, or room used for
21    provision of major medical equipment used in the direct
22    clinical diagnosis or treatment of patients, and whose
23    project cost is in excess of the capital expenditure
24    minimum.
25    This Act shall not apply to the construction of any new
26facility or the renovation of any existing facility located on

 

 

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1any campus facility as defined in Section 5-5.8b of the
2Illinois Public Aid Code, provided that the campus facility
3encompasses 30 or more contiguous acres and that the new or
4renovated facility is intended for use by a licensed
5residential facility.
6    No federally owned facility shall be subject to the
7provisions of this Act, nor facilities used solely for healing
8by prayer or spiritual means.
9    No facility licensed under the Supportive Residences
10Licensing Act or the Assisted Living and Shared Housing Act
11shall be subject to the provisions of this Act.
12    No facility established and operating under the
13Alternative Health Care Delivery Act as a children's respite
14care center alternative health care model demonstration
15program or as an Alzheimer's Disease Management Center
16alternative health care model demonstration program shall be
17subject to the provisions of this Act.
18    A facility designated as a supportive living facility that
19is in good standing with the program established under Section
205-5.01a of the Illinois Public Aid Code shall not be subject to
21the provisions of this Act.
22    This Act does not apply to facilities granted waivers under
23Section 3-102.2 of the Nursing Home Care Act. However, if a
24demonstration project under that Act applies for a certificate
25of need to convert to a nursing facility, it shall meet the
26licensure and certificate of need requirements in effect as of

 

 

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1the date of application.
2    This Act does not apply to a dialysis facility that
3provides only dialysis training, support, and related services
4to individuals with end stage renal disease who have elected to
5receive home dialysis. This Act does not apply to a dialysis
6unit located in a licensed nursing home that offers or provides
7dialysis-related services to residents with end stage renal
8disease who have elected to receive home dialysis within the
9nursing home. The Board, however, may require these dialysis
10facilities and licensed nursing homes to report statistical
11information on a quarterly basis to the Board to be used by the
12Board to conduct analyses on the need for proposed kidney
13disease treatment centers.
14    This Act shall not apply to the closure of an entity or a
15portion of an entity licensed under the Nursing Home Care Act,
16the Specialized Mental Health Rehabilitation Act of 2013, or
17the ID/DD Community Care Act, with the exceptions of facilities
18operated by a county or Illinois Veterans Homes, that elects to
19convert, in whole or in part, to an assisted living or shared
20housing establishment licensed under the Assisted Living and
21Shared Housing Act and with the exception of a facility
22licensed under the Specialized Mental Health Rehabilitation
23Act of 2013 in connection with a proposal to close a facility
24and re-establish the facility in another location.
25    This Act does not apply to any change of ownership of a
26healthcare facility that is licensed under the Nursing Home

 

 

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1Care Act, the Specialized Mental Health Rehabilitation Act of
22013, or the ID/DD Community Care Act, with the exceptions of
3facilities operated by a county or Illinois Veterans Homes.
4Changes of ownership of facilities licensed under the Nursing
5Home Care Act must meet the requirements set forth in Sections
63-101 through 3-119 of the Nursing Home Care Act.
7    With the exception of those health care facilities
8specifically included in this Section, nothing in this Act
9shall be intended to include facilities operated as a part of
10the practice of a physician or other licensed health care
11professional, whether practicing in his individual capacity or
12within the legal structure of any partnership, medical or
13professional corporation, or unincorporated medical or
14professional group. Further, this Act shall not apply to
15physicians or other licensed health care professional's
16practices where such practices are carried out in a portion of
17a health care facility under contract with such health care
18facility by a physician or by other licensed health care
19professionals, whether practicing in his individual capacity
20or within the legal structure of any partnership, medical or
21professional corporation, or unincorporated medical or
22professional groups, unless the entity constructs, modifies,
23or establishes a health care facility as specifically defined
24in this Section. This Act shall apply to construction or
25modification and to establishment by such health care facility
26of such contracted portion which is subject to facility

 

 

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1licensing requirements, irrespective of the party responsible
2for such action or attendant financial obligation.
3    No permit or exemption is required for a facility licensed
4under the ID/DD Community Care Act prior to the reduction of
5the number of beds at a facility. If there is a total reduction
6of beds at a facility licensed under the ID/DD Community Care
7Act, this is a discontinuation or closure of the facility.
8However, if a facility licensed under the ID/DD Community Care
9Act reduces the number of beds or discontinues the facility,
10that facility must notify the Board as provided in Section 14.1
11of this Act.
12    "Person" means any one or more natural persons, legal
13entities, governmental bodies other than federal, or any
14combination thereof.
15    "Consumer" means any person other than a person (a) whose
16major occupation currently involves or whose official capacity
17within the last 12 months has involved the providing,
18administering or financing of any type of health care facility,
19(b) who is engaged in health research or the teaching of
20health, (c) who has a material financial interest in any
21activity which involves the providing, administering or
22financing of any type of health care facility, or (d) who is or
23ever has been a member of the immediate family of the person
24defined by (a), (b), or (c).
25    "State Board" or "Board" means the Health Facilities and
26Services Review Board.

 

 

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1    "Construction or modification" means the establishment,
2erection, building, alteration, reconstruction, modernization,
3improvement, extension, discontinuation, change of ownership,
4of or by a health care facility, or the purchase or acquisition
5by or through a health care facility of equipment or service
6for diagnostic or therapeutic purposes or for facility
7administration or operation, or any capital expenditure made by
8or on behalf of a health care facility which exceeds the
9capital expenditure minimum; however, any capital expenditure
10made by or on behalf of a health care facility for (i) the
11construction or modification of a facility licensed under the
12Assisted Living and Shared Housing Act or (ii) a conversion
13project undertaken in accordance with Section 30 of the Older
14Adult Services Act shall be excluded from any obligations under
15this Act.
16    "Establish" means the construction of a health care
17facility or the replacement of an existing facility on another
18site or the initiation of a category of service.
19    "Major medical equipment" means medical equipment which is
20used for the provision of medical and other health services and
21which costs in excess of the capital expenditure minimum,
22except that such term does not include medical equipment
23acquired by or on behalf of a clinical laboratory to provide
24clinical laboratory services if the clinical laboratory is
25independent of a physician's office and a hospital and it has
26been determined under Title XVIII of the Social Security Act to

 

 

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1meet the requirements of paragraphs (10) and (11) of Section
21861(s) of such Act. In determining whether medical equipment
3has a value in excess of the capital expenditure minimum, the
4value of studies, surveys, designs, plans, working drawings,
5specifications, and other activities essential to the
6acquisition of such equipment shall be included.
7    "Capital Expenditure" means an expenditure: (A) made by or
8on behalf of a health care facility (as such a facility is
9defined in this Act); and (B) which under generally accepted
10accounting principles is not properly chargeable as an expense
11of operation and maintenance, or is made to obtain by lease or
12comparable arrangement any facility or part thereof or any
13equipment for a facility or part; and which exceeds the capital
14expenditure minimum.
15    For the purpose of this paragraph, the cost of any studies,
16surveys, designs, plans, working drawings, specifications, and
17other activities essential to the acquisition, improvement,
18expansion, or replacement of any plant or equipment with
19respect to which an expenditure is made shall be included in
20determining if such expenditure exceeds the capital
21expenditures minimum. Unless otherwise interdependent, or
22submitted as one project by the applicant, components of
23construction or modification undertaken by means of a single
24construction contract or financed through the issuance of a
25single debt instrument shall not be grouped together as one
26project. Donations of equipment or facilities to a health care

 

 

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1facility which if acquired directly by such facility would be
2subject to review under this Act shall be considered capital
3expenditures, and a transfer of equipment or facilities for
4less than fair market value shall be considered a capital
5expenditure for purposes of this Act if a transfer of the
6equipment or facilities at fair market value would be subject
7to review.
8    "Capital expenditure minimum" means $11,500,000 for
9projects by hospital applicants, $6,500,000 for applicants for
10projects related to skilled and intermediate care long-term
11care facilities licensed under the Nursing Home Care Act, and
12$3,000,000 for projects by all other applicants, which shall be
13annually adjusted to reflect the increase in construction costs
14due to inflation, for major medical equipment and for all other
15capital expenditures.
16    "Non-clinical service area" means an area (i) for the
17benefit of the patients, visitors, staff, or employees of a
18health care facility and (ii) not directly related to the
19diagnosis, treatment, or rehabilitation of persons receiving
20services from the health care facility. "Non-clinical service
21areas" include, but are not limited to, chapels; gift shops;
22news stands; computer systems; tunnels, walkways, and
23elevators; telephone systems; projects to comply with life
24safety codes; educational facilities; student housing;
25patient, employee, staff, and visitor dining areas;
26administration and volunteer offices; modernization of

 

 

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1structural components (such as roof replacement and masonry
2work); boiler repair or replacement; vehicle maintenance and
3storage facilities; parking facilities; mechanical systems for
4heating, ventilation, and air conditioning; loading docks; and
5repair or replacement of carpeting, tile, wall coverings,
6window coverings or treatments, or furniture. Solely for the
7purpose of this definition, "non-clinical service area" does
8not include health and fitness centers.
9    "Areawide" means a major area of the State delineated on a
10geographic, demographic, and functional basis for health
11planning and for health service and having within it one or
12more local areas for health planning and health service. The
13term "region", as contrasted with the term "subregion", and the
14word "area" may be used synonymously with the term "areawide".
15    "Local" means a subarea of a delineated major area that on
16a geographic, demographic, and functional basis may be
17considered to be part of such major area. The term "subregion"
18may be used synonymously with the term "local".
19    "Physician" means a person licensed to practice in
20accordance with the Medical Practice Act of 1987, as amended.
21    "Licensed health care professional" means a person
22licensed to practice a health profession under pertinent
23licensing statutes of the State of Illinois.
24    "Director" means the Director of the Illinois Department of
25Public Health.
26    "Agency" means the Illinois Department of Public Health.

 

 

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1    "Alternative health care model" means a facility or program
2authorized under the Alternative Health Care Delivery Act.
3    "Out-of-state facility" means a person that is both (i)
4licensed as a hospital or as an ambulatory surgery center under
5the laws of another state or that qualifies as a hospital or an
6ambulatory surgery center under regulations adopted pursuant
7to the Social Security Act and (ii) not licensed under the
8Ambulatory Surgical Treatment Center Act, the Hospital
9Licensing Act, or the Nursing Home Care Act. Affiliates of
10out-of-state facilities shall be considered out-of-state
11facilities. Affiliates of Illinois licensed health care
12facilities 100% owned by an Illinois licensed health care
13facility, its parent, or Illinois physicians licensed to
14practice medicine in all its branches shall not be considered
15out-of-state facilities. Nothing in this definition shall be
16construed to include an office or any part of an office of a
17physician licensed to practice medicine in all its branches in
18Illinois that is not required to be licensed under the
19Ambulatory Surgical Treatment Center Act.
20    "Change of ownership of a health care facility" means a
21change in the person who has ownership or control of a health
22care facility's physical plant and capital assets. A change in
23ownership is indicated by the following transactions: sale,
24transfer, acquisition, lease, change of sponsorship, or other
25means of transferring control.
26    "Related person" means any person that: (i) is at least 50%

 

 

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1owned, directly or indirectly, by either the health care
2facility or a person owning, directly or indirectly, at least
350% of the health care facility; or (ii) owns, directly or
4indirectly, at least 50% of the health care facility.
5    "Charity care" means care provided by a health care
6facility for which the provider does not expect to receive
7payment from the patient or a third-party payer.
8    "Freestanding emergency center" means a facility subject
9to licensure under Section 32.5 of the Emergency Medical
10Services (EMS) Systems Act.
11    "Category of service" means a grouping by generic class of
12various types or levels of support functions, equipment, care,
13or treatment provided to patients or residents, including, but
14not limited to, classes such as medical-surgical, pediatrics,
15or cardiac catheterization. A category of service may include
16subcategories or levels of care that identify a particular
17degree or type of care within the category of service. Nothing
18in this definition shall be construed to include the practice
19of a physician or other licensed health care professional while
20functioning in an office providing for the care, diagnosis, or
21treatment of patients. A category of service that is subject to
22the Board's jurisdiction must be designated in rules adopted by
23the Board.
24(Source: P.A. 97-38, eff. 6-28-11; 97-277, eff. 1-1-12; 97-813,
25eff. 7-13-12; 97-980, eff. 8-17-12; 98-414, eff. 1-1-14.)
 

 

 

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1    (20 ILCS 3960/12)  (from Ch. 111 1/2, par. 1162)
2    (Section scheduled to be repealed on December 31, 2019)
3    Sec. 12. Powers and duties of State Board. For purposes of
4this Act, the State Board shall exercise the following powers
5and duties:
6    (1) Prescribe rules, regulations, standards, criteria,
7procedures or reviews which may vary according to the purpose
8for which a particular review is being conducted or the type of
9project reviewed and which are required to carry out the
10provisions and purposes of this Act. Policies and procedures of
11the State Board shall take into consideration the priorities
12and needs of medically underserved areas and other health care
13services identified through the comprehensive health planning
14process, giving special consideration to the impact of projects
15on access to safety net services.
16    (2) Adopt procedures for public notice and hearing on all
17proposed rules, regulations, standards, criteria, and plans
18required to carry out the provisions of this Act.
19    (3) (Blank).
20    (4) Develop criteria and standards for health care
21facilities planning, conduct statewide inventories of health
22care facilities, maintain an updated inventory on the Board's
23web site reflecting the most recent bed and service changes and
24updated need determinations when new census data become
25available or new need formulae are adopted, and develop health
26care facility plans which shall be utilized in the review of

 

 

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1applications for permit under this Act. Such health facility
2plans shall be coordinated by the Board with pertinent State
3Plans. Inventories pursuant to this Section of skilled or
4intermediate care facilities licensed under the Nursing Home
5Care Act, skilled or intermediate care facilities licensed
6under the ID/DD Community Care Act, facilities licensed under
7the Specialized Mental Health Rehabilitation Act, or nursing
8homes licensed under the Hospital Licensing Act shall be
9conducted on an annual basis no later than July 1 of each year
10and shall include among the information requested a list of all
11services provided by a facility to its residents and to the
12community at large and differentiate between active and
13inactive beds.
14    In developing health care facility plans, the State Board
15shall consider, but shall not be limited to, the following:
16        (a) The size, composition and growth of the population
17    of the area to be served;
18        (b) The number of existing and planned facilities
19    offering similar programs;
20        (c) The extent of utilization of existing facilities;
21        (d) The availability of facilities which may serve as
22    alternatives or substitutes;
23        (e) The availability of personnel necessary to the
24    operation of the facility;
25        (f) Multi-institutional planning and the establishment
26    of multi-institutional systems where feasible;

 

 

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1        (g) The financial and economic feasibility of proposed
2    construction or modification; and
3        (h) In the case of health care facilities established
4    by a religious body or denomination, the needs of the
5    members of such religious body or denomination may be
6    considered to be public need.
7    The health care facility plans which are developed and
8adopted in accordance with this Section shall form the basis
9for the plan of the State to deal most effectively with
10statewide health needs in regard to health care facilities.
11    (5) Coordinate with the Center for Comprehensive Health
12Planning and other state agencies having responsibilities
13affecting health care facilities, including those of licensure
14and cost reporting. Beginning no later than January 1, 2013,
15the Department of Public Health shall produce a written annual
16report to the Governor and the General Assembly regarding the
17development of the Center for Comprehensive Health Planning.
18The Chairman of the State Board and the State Board
19Administrator shall also receive a copy of the annual report.
20    (6) Solicit, accept, hold and administer on behalf of the
21State any grants or bequests of money, securities or property
22for use by the State Board or Center for Comprehensive Health
23Planning in the administration of this Act; and enter into
24contracts consistent with the appropriations for purposes
25enumerated in this Act.
26    (7) The State Board shall prescribe procedures for review,

 

 

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1standards, and criteria which shall be utilized to make
2periodic reviews and determinations of the appropriateness of
3any existing health services being rendered by health care
4facilities subject to the Act. The State Board shall consider
5recommendations of the Board in making its determinations.
6    (8) Prescribe, in consultation with the Center for
7Comprehensive Health Planning, rules, regulations, standards,
8and criteria for the conduct of an expeditious review of
9applications for permits for projects of construction or
10modification of a health care facility, which projects are
11classified as emergency, substantive, or non-substantive in
12nature.
13    Six months after June 30, 2009 (the effective date of
14Public Act 96-31), substantive projects shall include no more
15than the following:
16        (a) Projects to construct (1) a new or replacement
17    facility located on a new site or (2) a replacement
18    facility located on the same site as the original facility
19    and the cost of the replacement facility exceeds the
20    capital expenditure minimum, which shall be reviewed by the
21    Board within 120 days;
22        (b) Projects proposing a (1) new service within an
23    existing healthcare facility or (2) discontinuation of a
24    service within an existing healthcare facility, which
25    shall be reviewed by the Board within 60 days; or
26        (c) Projects proposing a change in the bed capacity of

 

 

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1    a health care facility by an increase in the total number
2    of beds or by a redistribution of beds among various
3    categories of service or by a relocation of beds from one
4    physical facility or site to another by more than 20 beds
5    or more than 10% of total bed capacity, as defined by the
6    State Board, whichever is less, over a 2-year period.
7    The Chairman may approve applications for exemption that
8meet the criteria set forth in rules or refer them to the full
9Board. The Chairman may approve any unopposed application that
10meets all of the review criteria or refer them to the full
11Board.
12    Such rules shall not abridge the right of the Center for
13Comprehensive Health Planning to make recommendations on the
14classification and approval of projects, nor shall such rules
15prevent the conduct of a public hearing upon the timely request
16of an interested party. Such reviews shall not exceed 60 days
17from the date the application is declared to be complete.
18    (9) Prescribe rules, regulations, standards, and criteria
19pertaining to the granting of permits for construction and
20modifications which are emergent in nature and must be
21undertaken immediately to prevent or correct structural
22deficiencies or hazardous conditions that may harm or injure
23persons using the facility, as defined in the rules and
24regulations of the State Board. This procedure is exempt from
25public hearing requirements of this Act.
26    (10) Prescribe rules, regulations, standards and criteria

 

 

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1for the conduct of an expeditious review, not exceeding 60
2days, of applications for permits for projects to construct or
3modify health care facilities which are needed for the care and
4treatment of persons who have acquired immunodeficiency
5syndrome (AIDS) or related conditions.
6    (11) Issue written decisions upon request of the applicant
7or an adversely affected party to the Board. Requests for a
8written decision shall be made within 15 days after the Board
9meeting in which a final decision has been made. A "final
10decision" for purposes of this Act is the decision to approve
11or deny an application, or take other actions permitted under
12this Act, at the time and date of the meeting that such action
13is scheduled by the Board. The staff of the Board shall prepare
14a written copy of the final decision and the Board shall
15approve a final copy for inclusion in the formal record. The
16Board shall consider, for approval, the written draft of the
17final decision no later than the next scheduled Board meeting.
18The written decision shall identify the applicable criteria and
19factors listed in this Act and the Board's regulations that
20were taken into consideration by the Board when coming to a
21final decision. If the Board denies or fails to approve an
22application for permit or exemption, the Board shall include in
23the final decision a detailed explanation as to why the
24application was denied and identify what specific criteria or
25standards the applicant did not fulfill.
26    (12) Require at least one of its members to participate in

 

 

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1any public hearing, after the appointment of a majority of the
2members to the Board.
3    (13) Provide a mechanism for the public to comment on, and
4request changes to, draft rules and standards.
5    (14) Implement public information campaigns to regularly
6inform the general public about the opportunity for public
7hearings and public hearing procedures.
8    (15) Establish a separate set of rules and guidelines for
9long-term care that recognizes that nursing homes are a
10different business line and service model from other regulated
11facilities. An open and transparent process shall be developed
12that considers the following: how skilled nursing fits in the
13continuum of care with other care providers, modernization of
14nursing homes, establishment of more private rooms,
15development of alternative services, and current trends in
16long-term care services. The Chairman of the Board shall
17appoint a permanent Health Services Review Board Long-term Care
18Facility Advisory Subcommittee that shall develop and
19recommend to the Board the rules to be established by the Board
20under this paragraph (15). The Subcommittee shall also provide
21continuous review and commentary on policies and procedures
22relative to long-term care and the review of related projects.
23In consultation with other experts from the health field of
24long-term care, the Board and the Subcommittee shall study new
25approaches to the current bed need formula and Health Service
26Area boundaries to encourage flexibility and innovation in

 

 

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1design models reflective of the changing long-term care
2marketplace and consumer preferences. The Subcommittee shall
3evaluate, and make recommendations to the State Board
4regarding, the buying, selling, and exchange of beds between
5long-term care facilities within a specified geographic area or
6drive time. The Board shall file the proposed related
7administrative rules for the separate rules and guidelines for
8long-term care required by this paragraph (15) by no later than
9September 30, 2011. The Subcommittee shall be provided a
10reasonable and timely opportunity to review and comment on any
11review, revision, or updating of the criteria, standards,
12procedures, and rules used to evaluate project applications as
13provided under Section 12.3 of this Act.
14    (16) Establish a separate set of rules and guidelines for
15facilities licensed under the Specialized Mental Health
16Rehabilitation Act of 2013. An application for the
17re-establishment of a facility in connection with the
18relocation of the facility shall not be granted unless the
19applicant has a contractual relationship with at least one
20hospital to provide emergency and inpatient mental health
21services required by facility consumers, and at least one
22community mental health agency to provide oversight and
23assistance to facility consumers while living in the facility,
24and appropriate services, including case management, to assist
25them to prepare for discharge and reside stably in the
26community thereafter. No new facilities licensed under the

 

 

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1Specialized Mental Health Rehabilitation Act of 2013 shall be
2established after the effective date of this amendatory Act of
3the 98th General Assembly except in connection with the
4relocation of an existing facility to a new location. An
5application for a new location shall not be approved unless
6there are adequate community services accessible to the
7consumers within a reasonable distance, or by use of public
8transportation, so as to facilitate the goal of achieving
9maximum individual self-care and independence. At no time shall
10the total number of authorized beds under this Act in
11facilities licensed under the Specialized Mental Health
12Rehabilitation Act of 2013 exceed the number of authorized beds
13on the effective date of this amendatory Act of the 98th
14General Assembly.
15(Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813,
16eff. 7-13-12; 97-1045, eff. 8-21-13; 97-1115, eff. 8-27-12;
1798-414, eff. 1-1-14; 98-463, eff. 8-16-13.)
 
18    Section 5-10. The Illinois Public Aid Code is amended by
19changing Sections 5-5.12 and 5-30 and by adding Section 5-30.1
20as follows:
 
21    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
22    Sec. 5-5.12. Pharmacy payments.
23    (a) Every request submitted by a pharmacy for reimbursement
24under this Article for prescription drugs provided to a

 

 

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1recipient of aid under this Article shall include the name of
2the prescriber or an acceptable identification number as
3established by the Department.
4    (b) Pharmacies providing prescription drugs under this
5Article shall be reimbursed at a rate which shall include a
6professional dispensing fee as determined by the Illinois
7Department, plus the current acquisition cost of the
8prescription drug dispensed. The Illinois Department shall
9update its information on the acquisition costs of all
10prescription drugs no less frequently than every 30 days.
11However, the Illinois Department may set the rate of
12reimbursement for the acquisition cost, by rule, at a
13percentage of the current average wholesale acquisition cost.
14    (c) (Blank).
15    (d) The Department shall review utilization of narcotic
16medications in the medical assistance program and impose
17utilization controls that protect against abuse.
18    (e) When making determinations as to which drugs shall be
19on a prior approval list, the Department shall include as part
20of the analysis for this determination, the degree to which a
21drug may affect individuals in different ways based on factors
22including the gender of the person taking the medication.
23    (f) The Department shall cooperate with the Department of
24Public Health and the Department of Human Services Division of
25Mental Health in identifying psychotropic medications that,
26when given in a particular form, manner, duration, or frequency

 

 

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1(including "as needed") in a dosage, or in conjunction with
2other psychotropic medications to a nursing home resident or to
3a resident of a facility licensed under the ID/DD Community
4Care Act, may constitute a chemical restraint or an
5"unnecessary drug" as defined by the Nursing Home Care Act or
6Titles XVIII and XIX of the Social Security Act and the
7implementing rules and regulations. The Department shall
8require prior approval for any such medication prescribed for a
9nursing home resident or to a resident of a facility licensed
10under the ID/DD Community Care Act, that appears to be a
11chemical restraint or an unnecessary drug. The Department shall
12consult with the Department of Human Services Division of
13Mental Health in developing a protocol and criteria for
14deciding whether to grant such prior approval.
15    (g) The Department may by rule provide for reimbursement of
16the dispensing of a 90-day supply of a generic or brand name,
17non-narcotic maintenance medication in circumstances where it
18is cost effective.
19    (g-5) On and after July 1, 2012, the Department may require
20the dispensing of drugs to nursing home residents be in a 7-day
21supply or other amount less than a 31-day supply. The
22Department shall pay only one dispensing fee per 31-day supply.
23    (h) Effective July 1, 2011, the Department shall
24discontinue coverage of select over-the-counter drugs,
25including analgesics and cough and cold and allergy
26medications.

 

 

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1    (h-5) On and after July 1, 2012, the Department shall
2impose utilization controls, including, but not limited to,
3prior approval on specialty drugs, oncolytic drugs, drugs for
4the treatment of HIV or AIDS, immunosuppressant drugs, and
5biological products in order to maximize savings on these
6drugs. The Department may adjust payment methodologies for
7non-pharmacy billed drugs in order to incentivize the selection
8of lower-cost drugs. For drugs for the treatment of AIDS, the
9Department shall take into consideration the potential for
10non-adherence by certain populations, and shall develop
11protocols with organizations or providers primarily serving
12those with HIV/AIDS, as long as such measures intend to
13maintain cost neutrality with other utilization management
14controls such as prior approval. For hemophilia, the Department
15shall develop a program of utilization review and control which
16may include, in the discretion of the Department, prior
17approvals. The Department may impose special standards on
18providers that dispense blood factors which shall include, in
19the discretion of the Department, staff training and education;
20patient outreach and education; case management; in-home
21patient assessments; assay management; maintenance of stock;
22emergency dispensing timeframes; data collection and
23reporting; dispensing of supplies related to blood factor
24infusions; cold chain management and packaging practices; care
25coordination; product recalls; and emergency clinical
26consultation. The Department may require patients to receive a

 

 

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1comprehensive examination annually at an appropriate provider
2in order to be eligible to continue to receive blood factor.
3    (i) On and after July 1, 2012, the Department shall reduce
4any rate of reimbursement for services or other payments or
5alter any methodologies authorized by this Code to reduce any
6rate of reimbursement for services or other payments in
7accordance with Section 5-5e.
8    (j) On and after July 1, 2012, the Department shall impose
9limitations on prescription drugs such that the Department
10shall not provide reimbursement for more than 4 prescriptions,
11including 3 brand name prescriptions, for distinct drugs in a
1230-day period, unless prior approval is received for all
13prescriptions in excess of the 4-prescription limit. Drugs in
14the following therapeutic classes shall not be subject to prior
15approval as a result of the 4-prescription limit:
16immunosuppressant drugs, oncolytic drugs, and anti-retroviral
17drugs, and, on or after July 1, 2014, antipsychotic drugs. On
18or after July 1, 2014, the Department may exempt children with
19complex medical needs enrolled in a care coordination entity
20contracted with the Department to solely coordinate care for
21such children, if the Department determines that the entity has
22a comprehensive drug reconciliation program.
23    (k) No medication therapy management program implemented
24by the Department shall be contrary to the provisions of the
25Pharmacy Practice Act.
26    (l) Any provider enrolled with the Department that bills

 

 

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1the Department for outpatient drugs and is eligible to enroll
2in the federal Drug Pricing Program under Section 340B of the
3federal Public Health Services Act shall enroll in that
4program. No entity participating in the federal Drug Pricing
5Program under Section 340B of the federal Public Health
6Services Act may exclude Medicaid from their participation in
7that program, although the Department may exclude entities
8defined in Section 1905(l)(2)(B) of the Social Security Act
9from this requirement.
10(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333,
11eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12;
1297-813, eff. 7-13-12; 98-463, eff. 8-16-13.)
 
13    (305 ILCS 5/5-30)
14    Sec. 5-30. Care coordination.
15    (a) At least 50% of recipients eligible for comprehensive
16medical benefits in all medical assistance programs or other
17health benefit programs administered by the Department,
18including the Children's Health Insurance Program Act and the
19Covering ALL KIDS Health Insurance Act, shall be enrolled in a
20care coordination program by no later than January 1, 2015. For
21purposes of this Section, "coordinated care" or "care
22coordination" means delivery systems where recipients will
23receive their care from providers who participate under
24contract in integrated delivery systems that are responsible
25for providing or arranging the majority of care, including

 

 

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1primary care physician services, referrals from primary care
2physicians, diagnostic and treatment services, behavioral
3health services, in-patient and outpatient hospital services,
4dental services, and rehabilitation and long-term care
5services. The Department shall designate or contract for such
6integrated delivery systems (i) to ensure enrollees have a
7choice of systems and of primary care providers within such
8systems; (ii) to ensure that enrollees receive quality care in
9a culturally and linguistically appropriate manner; and (iii)
10to ensure that coordinated care programs meet the diverse needs
11of enrollees with developmental, mental health, physical, and
12age-related disabilities.
13    (b) Payment for such coordinated care shall be based on
14arrangements where the State pays for performance related to
15health care outcomes, the use of evidence-based practices, the
16use of primary care delivered through comprehensive medical
17homes, the use of electronic medical records, and the
18appropriate exchange of health information electronically made
19either on a capitated basis in which a fixed monthly premium
20per recipient is paid and full financial risk is assumed for
21the delivery of services, or through other risk-based payment
22arrangements.
23    (c) To qualify for compliance with this Section, the 50%
24goal shall be achieved by enrolling medical assistance
25enrollees from each medical assistance enrollment category,
26including parents, children, seniors, and people with

 

 

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1disabilities to the extent that current State Medicaid payment
2laws would not limit federal matching funds for recipients in
3care coordination programs. In addition, services must be more
4comprehensively defined and more risk shall be assumed than in
5the Department's primary care case management program as of the
6effective date of this amendatory Act of the 96th General
7Assembly.
8    (d) The Department shall report to the General Assembly in
9a separate part of its annual medical assistance program
10report, beginning April, 2012 until April, 2016, on the
11progress and implementation of the care coordination program
12initiatives established by the provisions of this amendatory
13Act of the 96th General Assembly. The Department shall include
14in its April 2011 report a full analysis of federal laws or
15regulations regarding upper payment limitations to providers
16and the necessary revisions or adjustments in rate
17methodologies and payments to providers under this Code that
18would be necessary to implement coordinated care with full
19financial risk by a party other than the Department.
20    (e) Integrated Care Program for individuals with chronic
21mental health conditions.
22        (1) The Integrated Care Program shall encompass
23    services administered to recipients of medical assistance
24    under this Article to prevent exacerbations and
25    complications using cost-effective, evidence-based
26    practice guidelines and mental health management

 

 

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1    strategies.
2        (2) The Department may utilize and expand upon existing
3    contractual arrangements with integrated care plans under
4    the Integrated Care Program for providing the coordinated
5    care provisions of this Section.
6        (3) Payment for such coordinated care shall be based on
7    arrangements where the State pays for performance related
8    to mental health outcomes on a capitated basis in which a
9    fixed monthly premium per recipient is paid and full
10    financial risk is assumed for the delivery of services, or
11    through other risk-based payment arrangements such as
12    provider-based care coordination.
13        (4) The Department shall examine whether chronic
14    mental health management programs and services for
15    recipients with specific chronic mental health conditions
16    do any or all of the following:
17            (A) Improve the patient's overall mental health in
18        a more expeditious and cost-effective manner.
19            (B) Lower costs in other aspects of the medical
20        assistance program, such as hospital admissions,
21        emergency room visits, or more frequent and
22        inappropriate psychotropic drug use.
23        (5) The Department shall work with the facilities and
24    any integrated care plan participating in the program to
25    identify and correct barriers to the successful
26    implementation of this subsection (e) prior to and during

 

 

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1    the implementation to best facilitate the goals and
2    objectives of this subsection (e).
3    (f) A hospital that is located in a county of the State in
4which the Department mandates some or all of the beneficiaries
5of the Medical Assistance Program residing in the county to
6enroll in a Care Coordination Program, as set forth in Section
75-30 of this Code, shall not be eligible for any non-claims
8based payments not mandated by Article V-A of this Code for
9which it would otherwise be qualified to receive, unless the
10hospital is a Coordinated Care Participating Hospital no later
11than 60 days after the effective date of this amendatory Act of
12the 97th General Assembly or 60 days after the first mandatory
13enrollment of a beneficiary in a Coordinated Care program. For
14purposes of this subsection, "Coordinated Care Participating
15Hospital" means a hospital that meets one of the following
16criteria:
17        (1) The hospital has entered into a contract to provide
18    hospital services with one or more MCOs to enrollees of the
19    care coordination program.
20        (2) The hospital has not been offered a contract by a
21    care coordination plan that the Department has determined
22    to be a good faith offer and that pays at least as much as
23    the Department would pay, on a fee-for-service basis, not
24    including disproportionate share hospital adjustment
25    payments or any other supplemental adjustment or add-on
26    payment to the base fee-for-service rate, except to the

 

 

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1    extent such adjustments or add-on payments are
2    incorporated into the development of the applicable MCO
3    capitated rates.
4    As used in this subsection (f), "MCO" means any entity
5which contracts with the Department to provide services where
6payment for medical services is made on a capitated basis.
7    (g) No later than August 1, 2013, the Department shall
8issue a purchase of care solicitation for Accountable Care
9Entities (ACE) to serve any children and parents or caretaker
10relatives of children eligible for medical assistance under
11this Article. An ACE may be a single corporate structure or a
12network of providers organized through contractual
13relationships with a single corporate entity. The solicitation
14shall require that:
15        (1) An ACE operating in Cook County be capable of
16    serving at least 40,000 eligible individuals in that
17    county; an ACE operating in Lake, Kane, DuPage, or Will
18    Counties be capable of serving at least 20,000 eligible
19    individuals in those counties and an ACE operating in other
20    regions of the State be capable of serving at least 10,000
21    eligible individuals in the region in which it operates.
22    During initial periods of mandatory enrollment, the
23    Department shall require its enrollment services
24    contractor to use a default assignment algorithm that
25    ensures if possible an ACE reaches the minimum enrollment
26    levels set forth in this paragraph.

 

 

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1        (2) An ACE must include at a minimum the following
2    types of providers: primary care, specialty care,
3    hospitals, and behavioral healthcare.
4        (3) An ACE shall have a governance structure that
5    includes the major components of the health care delivery
6    system, including one representative from each of the
7    groups listed in paragraph (2).
8        (4) An ACE must be an integrated delivery system,
9    including a network able to provide the full range of
10    services needed by Medicaid beneficiaries and system
11    capacity to securely pass clinical information across
12    participating entities and to aggregate and analyze that
13    data in order to coordinate care.
14        (5) An ACE must be capable of providing both care
15    coordination and complex case management, as necessary, to
16    beneficiaries. To be responsive to the solicitation, a
17    potential ACE must outline its care coordination and
18    complex case management model and plan to reduce the cost
19    of care.
20        (6) In the first 18 months of operation, unless the ACE
21    selects a shorter period, an ACE shall be paid care
22    coordination fees on a per member per month basis that are
23    projected to be cost neutral to the State during the term
24    of their payment and, subject to federal approval, be
25    eligible to share in additional savings generated by their
26    care coordination.

 

 

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1        (7) In months 19 through 36 of operation, unless the
2    ACE selects a shorter period, an ACE shall be paid on a
3    pre-paid capitation basis for all medical assistance
4    covered services, under contract terms similar to Managed
5    Care Organizations (MCO), with the Department sharing the
6    risk through either stop-loss insurance for extremely high
7    cost individuals or corridors of shared risk based on the
8    overall cost of the total enrollment in the ACE. The ACE
9    shall be responsible for claims processing, encounter data
10    submission, utilization control, and quality assurance.
11        (8) In the fourth and subsequent years of operation, an
12    ACE shall convert to a Managed Care Community Network
13    (MCCN), as defined in this Article, or Health Maintenance
14    Organization pursuant to the Illinois Insurance Code,
15    accepting full-risk capitation payments.
16    The Department shall allow potential ACE entities 5 months
17from the date of the posting of the solicitation to submit
18proposals. After the solicitation is released, in addition to
19the MCO rate development data available on the Department's
20website, subject to federal and State confidentiality and
21privacy laws and regulations, the Department shall provide 2
22years of de-identified summary service data on the targeted
23population, split between children and adults, showing the
24historical type and volume of services received and the cost of
25those services to those potential bidders that sign a data use
26agreement. The Department may add up to 2 non-state government

 

 

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1employees with expertise in creating integrated delivery
2systems to its review team for the purchase of care
3solicitation described in this subsection. Any such
4individuals must sign a no-conflict disclosure and
5confidentiality agreement and agree to act in accordance with
6all applicable State laws.
7    During the first 2 years of an ACE's operation, the
8Department shall provide claims data to the ACE on its
9enrollees on a periodic basis no less frequently than monthly.
10    Nothing in this subsection shall be construed to limit the
11Department's mandate to enroll 50% of its beneficiaries into
12care coordination systems by January 1, 2015, using all
13available care coordination delivery systems, including Care
14Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
15to affect the current CCEs, MCCNs, and MCOs selected to serve
16seniors and persons with disabilities prior to that date.
17    Nothing in this subsection precludes the Department from
18considering future proposals for new ACEs or expansion of
19existing ACEs at the discretion of the Department.
20    (h) Department contracts with MCOs and other entities
21reimbursed by risk based capitation shall have a minimum
22medical loss ratio of 85%, shall require the MCO or other
23entity to pay claims within 30 days of receiving a bill that
24contains all the essential information needed to adjudicate the
25bill, and shall require the entity to pay a penalty that is at
26least equal to the penalty imposed under the Illinois Insurance

 

 

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1Code for any claims not paid within this time period shall
2require the entity to establish an appeals and grievances
3process for consumers and providers, and shall require the
4entity to provide a quality assurance and utilization review
5program. Entities contracted with the Department to coordinate
6healthcare regardless of risk shall be measured utilizing the
7same quality metrics. The quality metrics may be population
8specific. Any contracted entity serving at least 5,000 seniors
9or people with disabilities or 15,000 individuals in other
10populations covered by the Medical Assistance Program that has
11been receiving full-risk capitation for a year shall be
12accredited by a national accreditation organization authorized
13by the Department within 2 years after the date it is eligible
14to become accredited. The requirements of this subsection shall
15apply to contracts with MCOs entered into or renewed or
16extended after June 1, 2013.
17    (h-5) The Department shall monitor and enforce compliance
18by MCOs with agreements they have entered into with providers
19on issues that include, but are not limited to, timeliness of
20payment, payment rates, and processes for obtaining prior
21approval. The Department may impose sanctions on MCOs for
22violating provisions of those agreements that include, but are
23not limited to, financial penalties, suspension of enrollment
24of new enrollees, and termination of the MCO's contract with
25the Department. As used in this subsection (h-5), "MCO" has the
26meaning ascribed to that term in Section 5-30.1 of this Code.

 

 

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1(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
 
2    (305 ILCS 5/5-30.1 new)
3    Sec. 5-30.1. Managed care protections.
4    (a) As used in this Section:
5    "Managed care organization" or "MCO" means any entity which
6contracts with the Department to provide services where payment
7for medical services is made on a capitated basis.
8    "Emergency services" include:
9        (1) emergency services, as defined by Section 10 of the
10    Managed Care Reform and Patient Rights Act;
11        (2) emergency medical screening examinations, as
12    defined by Section 10 of the Managed Care Reform and
13    Patient Rights Act;
14        (3) post-stabilization medical services, as defined by
15    Section 10 of the Managed Care Reform and Patient Rights
16    Act; and
17        (4) emergency medical conditions, as defined by
18    Section 10 of the Managed Care Reform and Patient Rights
19    Act.
20    (b) As provided by Section 5-16.12, managed care
21organizations are subject to the provisions of the Managed Care
22Reform and Patient Rights Act.
23    (c) An MCO shall pay any provider of emergency services
24that does not have in effect a contract with the contracted
25Medicaid MCO. The default rate of reimbursement shall be the

 

 

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1rate paid under Illinois Medicaid fee-for-service program
2methodology, including all policy adjusters, including but not
3limited to Medicaid High Volume Adjustments, Medicaid
4Percentage Adjustments, Outpatient High Volume Adjustments,
5and all outlier add-on adjustments to the extent such
6adjustments are incorporated in the development of the
7applicable MCO capitated rates.
8    (d) An MCO shall pay for all post-stabilization services as
9a covered service in any of the following situations:
10        (1) the MCO authorized such services;
11        (2) such services were administered to maintain the
12    enrollee's stabilized condition within one hour after a
13    request to the MCO for authorization of further
14    post-stabilization services;
15        (3) the MCO did not respond to a request to authorize
16    such services within one hour;
17        (4) the MCO could not be contacted; or
18        (5) the MCO and the treating provider, if the treating
19    provider is a non-affiliated provider, could not reach an
20    agreement concerning the enrollee's care and an affiliated
21    provider was unavailable for a consultation, in which case
22    the MCO must pay for such services rendered by the treating
23    non-affiliated provider until an affiliated provider was
24    reached and either concurred with the treating
25    non-affiliated provider's plan of care or assumed
26    responsibility for the enrollee's care. Such payment shall

 

 

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1    be made at the default rate of reimbursement paid under
2    Illinois Medicaid fee-for-service program methodology,
3    including all policy adjusters, including but not limited
4    to Medicaid High Volume Adjustments, Medicaid Percentage
5    Adjustments, Outpatient High Volume Adjustments and all
6    outlier add-on adjustments to the extent that such
7    adjustments are incorporated in the development of the
8    applicable MCO capitated rates.
9    (e) The following requirements apply to MCOs in determining
10payment for all emergency services:
11        (1) MCOs shall not impose any requirements for prior
12    approval of emergency services.
13        (2) The MCO shall cover emergency services provided to
14    enrollees who are temporarily away from their residence and
15    outside the contracting area to the extent that the
16    enrollees would be entitled to the emergency services if
17    they still were within the contracting area.
18        (3) The MCO shall have no obligation to cover medical
19    services provided on an emergency basis that are not
20    covered services under the contract.
21        (4) The MCO shall not condition coverage for emergency
22    services on the treating provider notifying the MCO of the
23    enrollee's screening and treatment within 10 days after
24    presentation for emergency services.
25        (5) The determination of the attending emergency
26    physician, or the provider actually treating the enrollee,

 

 

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1    of whether an enrollee is sufficiently stabilized for
2    discharge or transfer to another facility, shall be binding
3    on the MCO. The MCO shall cover emergency services for all
4    enrollees whether the emergency services are provided by an
5    affiliated or non-affiliated provider.
6        (6) The MCO's financial responsibility for
7    post-stabilization care services it has not pre-approved
8    ends when:
9            (A) a plan physician with privileges at the
10        treating hospital assumes responsibility for the
11        enrollee's care;
12            (B) a plan physician assumes responsibility for
13        the enrollee's care through transfer;
14            (C) a contracting entity representative and the
15        treating physician reach an agreement concerning the
16        enrollee's care; or
17            (D) the enrollee is discharged.
18    (f) Network adequacy.
19        (1) The Department shall:
20            (A) ensure that an adequate provider network is in
21        place, taking into consideration health professional
22        shortage areas and medically underserved areas;
23            (B) publicly release an explanation of its process
24        for analyzing network adequacy;
25            (C) periodically ensure that an MCO continues to
26        have an adequate network in place; and

 

 

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1            (D) require MCOs to maintain an updated and public
2        list of network providers.
3    (g) Timely payment of claims.
4        (1) The MCO shall pay a claim within 30 days of
5    receiving a claim that contains all the essential
6    information needed to adjudicate the claim.
7        (2) The MCO shall notify the billing party of its
8    inability to adjudicate a claim within 30 days of receiving
9    that claim.
10        (3) The MCO shall pay a penalty that is at least equal
11    to the penalty imposed under the Illinois Insurance Code
12    for any claims not timely paid.
13        (4) The Department may establish a process for MCOs to
14    expedite payments to providers based on criteria
15    established by the Department.
16    (h) The Department shall not expand mandatory MCO
17enrollment into new counties beyond those counties already
18designated by the Department as of June 1, 2014 for the
19individuals whose eligibility for medical assistance is not the
20seniors or people with disabilities population until the
21Department provides an opportunity for accountable care
22entities and MCOs to participate in such newly designated
23counties.
24    (i) The requirements of this Section apply to contracts
25with accountable care entities and MCOs entered into, amended,
26or renewed after the effective date of this amendatory Act of

 

 

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1the 98th General Assembly.
 
2
Article 10

 
3    Section 10-5. The Specialized Mental Health Rehabilitation
4Act of 2013 is amended by changing Sections 1-101.5, 1-101.6,
51-102, 4-108, and 5-101 and by adding Section 4-108.5 as
6follows:
 
7    (210 ILCS 49/1-101.5)
8    Sec. 1-101.5. Prior law.
9    (a) This Act provides for licensure of long term care
10facilities that are federally designated as institutions for
11the mentally diseased on the effective date of this Act and
12specialize in providing services to individuals with a serious
13mental illness. On and after the effective date of this Act,
14these facilities shall be governed by this Act instead of the
15Nursing Home Care Act.
16    (b) All consent decrees that apply to facilities federally
17designated as institutions for the mentally diseased shall
18continue to apply to facilities licensed under this Act.
19    (c) A facility licensed under this Act may voluntarily
20close, and the facility may reopen in an underserved region of
21the State, if the facility receives a certificate of need from
22the Health Facilities and Services Review Board. At no time
23shall the total number of licensed beds under this Act exceed

 

 

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1the total number of licensed beds existing on July 22, 2013
2(the effective date of Public Act 98-104).
3(Source: P.A. 98-104, eff. 7-22-13.)
 
4    (210 ILCS 49/1-101.6)
5    Sec. 1-101.6. Mental health system planning. The General
6Assembly finds the services contained in this Act are necessary
7for the effective delivery of mental health services for the
8citizens of the State of Illinois. The General Assembly also
9finds that the mental health system in the State requires
10further review to develop additional needed services. To ensure
11the adequacy of community-based services and to offer choice to
12all individuals with serious mental illness who choose to live
13in the community, and for whom the community is the appropriate
14setting, but are at risk of institutional care, the Governor
15shall convene a working group to develop the process and
16procedure for identifying needed services in the different
17geographic regions of the State. The Governor shall include the
18Division of Mental Health of the Department of Human Services,
19the Department of Healthcare and Family Services, the
20Department of Public Health, community mental health
21providers, statewide associations of mental health providers,
22mental health advocacy groups, and any other entity as deemed
23appropriate for participation in the working group. The
24Department of Human Services shall provide staff and support to
25this working group.

 

 

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1    Before September 1, 2014, the State shall develop and
2implement a service authorization system available 24 hours a
3day, 7 days a week for approval of services in the following 3
4levels of care under this Act: crisis stabilization; recovery
5and rehabilitation supports; and transitional living units.
6(Source: P.A. 98-104, eff. 7-22-13.)
 
7    (210 ILCS 49/1-102)
8    Sec. 1-102. Definitions. For the purposes of this Act,
9unless the context otherwise requires:
10    "Abuse" means any physical or mental injury or sexual
11assault inflicted on a consumer other than by accidental means
12in a facility.
13    "Accreditation" means any of the following:
14        (1) the Joint Commission;
15        (2) the Commission on Accreditation of Rehabilitation
16    Facilities;
17        (3) the Healthcare Facilities Accreditation Program;
18    or
19        (4) any other national standards of care as approved by
20    the Department.
21    "Applicant" means any person making application for a
22license or a provisional license under this Act.
23    "Consumer" means a person, 18 years of age or older,
24admitted to a mental health rehabilitation facility for
25evaluation, observation, diagnosis, treatment, stabilization,

 

 

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1recovery, and rehabilitation.
2    "Consumer" does not mean any of the following:
3        (i) an individual requiring a locked setting;
4        (ii) an individual requiring psychiatric
5    hospitalization because of an acute psychiatric crisis;
6        (iii) an individual under 18 years of age;
7        (iv) an individual who is actively suicidal or violent
8    toward others;
9        (v) an individual who has been found unfit to stand
10    trial;
11        (vi) an individual who has been found not guilty by
12    reason of insanity based on committing a violent act, such
13    as sexual assault, assault with a deadly weapon, arson, or
14    murder;
15        (vii) an individual subject to temporary detention and
16    examination under Section 3-607 of the Mental Health and
17    Developmental Disabilities Code;
18        (viii) an individual deemed clinically appropriate for
19    inpatient admission in a State psychiatric hospital; and
20        (ix) an individual transferred by the Department of
21    Corrections pursuant to Section 3-8-5 of the Unified Code
22    of Corrections.
23    "Consumer record" means a record that organizes all
24information on the care, treatment, and rehabilitation
25services rendered to a consumer in a specialized mental health
26rehabilitation facility.

 

 

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1    "Controlled drugs" means those drugs covered under the
2federal Comprehensive Drug Abuse Prevention Control Act of
31970, as amended, or the Illinois Controlled Substances Act.
4    "Department" means the Department of Public Health.
5    "Discharge" means the full release of any consumer from a
6facility.
7    "Drug administration" means the act in which a single dose
8of a prescribed drug or biological is given to a consumer. The
9complete act of administration entails removing an individual
10dose from a container, verifying the dose with the prescriber's
11orders, giving the individual dose to the consumer, and
12promptly recording the time and dose given.
13    "Drug dispensing" means the act entailing the following of
14a prescription order for a drug or biological and proper
15selection, measuring, packaging, labeling, and issuance of the
16drug or biological to a consumer.
17    "Emergency" means a situation, physical condition, or one
18or more practices, methods, or operations which present
19imminent danger of death or serious physical or mental harm to
20consumers of a facility.
21    "Facility" means a specialized mental health
22rehabilitation facility that provides at least one of the
23following services: (1) triage center; (2) crisis
24stabilization; (3) recovery and rehabilitation supports; or
25(4) transitional living units for 3 or more persons. The
26facility shall provide a 24-hour program that provides

 

 

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1intensive support and recovery services designed to assist
2persons, 18 years or older, with mental disorders to develop
3the skills to become self-sufficient and capable of increasing
4levels of independent functioning. It includes facilities that
5meet the following criteria:
6        (1) 100% of the consumer population of the facility has
7    a diagnosis of serious mental illness;
8        (2) no more than 15% of the consumer population of the
9    facility is 65 years of age or older;
10        (3) none of the consumers are non-ambulatory;
11        (4) none of the consumers have a primary diagnosis of
12    moderate, severe, or profound intellectual disability; and
13        (5) the facility must have been licensed under the
14    Specialized Mental Health Rehabilitation Act or the
15    Nursing Home Care Act immediately preceding the effective
16    date of this Act and qualifies as a institute for mental
17    disease under the federal definition of the term.
18    "Facility" does not include the following:
19        (1) a home, institution, or place operated by the
20    federal government or agency thereof, or by the State of
21    Illinois;
22        (2) a hospital, sanitarium, or other institution whose
23    principal activity or business is the diagnosis, care, and
24    treatment of human illness through the maintenance and
25    operation as organized facilities therefor which is
26    required to be licensed under the Hospital Licensing Act;

 

 

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1        (3) a facility for child care as defined in the Child
2    Care Act of 1969;
3        (4) a community living facility as defined in the
4    Community Living Facilities Licensing Act;
5        (5) a nursing home or sanatorium operated solely by and
6    for persons who rely exclusively upon treatment by
7    spiritual means through prayer, in accordance with the
8    creed or tenets of any well-recognized church or religious
9    denomination; however, such nursing home or sanatorium
10    shall comply with all local laws and rules relating to
11    sanitation and safety;
12        (6) a facility licensed by the Department of Human
13    Services as a community-integrated living arrangement as
14    defined in the Community-Integrated Living Arrangements
15    Licensure and Certification Act;
16        (7) a supportive residence licensed under the
17    Supportive Residences Licensing Act;
18        (8) a supportive living facility in good standing with
19    the program established under Section 5-5.01a of the
20    Illinois Public Aid Code, except only for purposes of the
21    employment of persons in accordance with Section 3-206.01
22    of the Nursing Home Care Act;
23        (9) an assisted living or shared housing establishment
24    licensed under the Assisted Living and Shared Housing Act,
25    except only for purposes of the employment of persons in
26    accordance with Section 3-206.01 of the Nursing Home Care

 

 

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1    Act;
2        (10) an Alzheimer's disease management center
3    alternative health care model licensed under the
4    Alternative Health Care Delivery Act;
5        (11) a home, institution, or other place operated by or
6    under the authority of the Illinois Department of Veterans'
7    Affairs;
8        (12) a facility licensed under the ID/DD Community Care
9    Act; or
10        (13) a facility licensed under the Nursing Home Care
11    Act after the effective date of this Act.
12    "Executive director" means a person who is charged with the
13general administration and supervision of a facility licensed
14under this Act.
15    "Guardian" means a person appointed as a guardian of the
16person or guardian of the estate, or both, of a consumer under
17the Probate Act of 1975.
18    "Identified offender" means a person who meets any of the
19following criteria:
20        (1) Has been convicted of, found guilty of, adjudicated
21    delinquent for, found not guilty by reason of insanity for,
22    or found unfit to stand trial for, any felony offense
23    listed in Section 25 of the Health Care Worker Background
24    Check Act, except for the following:
25            (i) a felony offense described in Section 10-5 of
26        the Nurse Practice Act;

 

 

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1            (ii) a felony offense described in Section 4, 5, 6,
2        8, or 17.02 of the Illinois Credit Card and Debit Card
3        Act;
4            (iii) a felony offense described in Section 5, 5.1,
5        5.2, 7, or 9 of the Cannabis Control Act;
6            (iv) a felony offense described in Section 401,
7        401.1, 404, 405, 405.1, 407, or 407.1 of the Illinois
8        Controlled Substances Act; and
9            (v) a felony offense described in the
10        Methamphetamine Control and Community Protection Act.
11        (2) Has been convicted of, adjudicated delinquent for,
12    found not guilty by reason of insanity for, or found unfit
13    to stand trial for, any sex offense as defined in
14    subsection (c) of Section 10 of the Sex Offender Management
15    Board Act.
16    "Transitional living units" are residential units within a
17facility that have the purpose of assisting the consumer in
18developing and reinforcing the necessary skills to live
19independently outside of the facility. The duration of stay in
20such a setting shall not exceed 120 days for each consumer.
21Nothing in this definition shall be construed to be a
22prerequisite for transitioning out of a facility.
23    "Licensee" means the person, persons, firm, partnership,
24association, organization, company, corporation, or business
25trust to which a license has been issued.
26    "Misappropriation of a consumer's property" means the

 

 

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1deliberate misplacement, exploitation, or wrongful temporary
2or permanent use of a consumer's belongings or money without
3the consent of a consumer or his or her guardian.
4    "Neglect" means a facility's failure to provide, or willful
5withholding of, adequate medical care, mental health
6treatment, psychiatric rehabilitation, personal care, or
7assistance that is necessary to avoid physical harm and mental
8anguish of a consumer.
9    "Personal care" means assistance with meals, dressing,
10movement, bathing, or other personal needs, maintenance, or
11general supervision and oversight of the physical and mental
12well-being of an individual who is incapable of maintaining a
13private, independent residence or who is incapable of managing
14his or her person, whether or not a guardian has been appointed
15for such individual. "Personal care" shall not be construed to
16confine or otherwise constrain a facility's pursuit to develop
17the skills and abilities of a consumer to become
18self-sufficient and capable of increasing levels of
19independent functioning.
20    "Recovery and rehabilitation supports" means a program
21that facilitates a consumer's longer-term symptom management
22and stabilization while preparing the consumer for
23transitional living units by improving living skills and
24community socialization. The duration of stay in such a setting
25shall be established by the Department by rule.
26    "Restraint" means:

 

 

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1        (i) a physical restraint that is any manual method or
2    physical or mechanical device, material, or equipment
3    attached or adjacent to a consumer's body that the consumer
4    cannot remove easily and restricts freedom of movement or
5    normal access to one's body; devices used for positioning,
6    including, but not limited to, bed rails, gait belts, and
7    cushions, shall not be considered to be restraints for
8    purposes of this Section; or
9        (ii) a chemical restraint that is any drug used for
10    discipline or convenience and not required to treat medical
11    symptoms; the Department shall, by rule, designate certain
12    devices as restraints, including at least all those devices
13    that have been determined to be restraints by the United
14    States Department of Health and Human Services in
15    interpretive guidelines issued for the purposes of
16    administering Titles XVIII and XIX of the federal Social
17    Security Act. For the purposes of this Act, restraint shall
18    be administered only after utilizing a coercive free
19    environment and culture.
20    "Self-administration of medication" means consumers shall
21be responsible for the control, management, and use of their
22own medication.
23    "Crisis stabilization" means a secure and separate unit
24that provides short-term behavioral, emotional, or psychiatric
25crisis stabilization as an alternative to hospitalization or
26re-hospitalization for consumers from residential or community

 

 

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1placement. The duration of stay in such a setting shall not
2exceed 21 days for each consumer.
3    "Therapeutic separation" means the removal of a consumer
4from the milieu to a room or area which is designed to aid in
5the emotional or psychiatric stabilization of that consumer.
6    "Triage center" means a non-residential 23-hour center
7that serves as an alternative to emergency room care,
8hospitalization, or re-hospitalization for consumers in need
9of short-term crisis stabilization. Consumers may access a
10triage center from a number of referral sources, including
11family, emergency rooms, hospitals, community behavioral
12health providers, federally qualified health providers, or
13schools, including colleges or universities. A triage center
14may be located in a building separate from the licensed
15location of a facility, but shall not be more than 1,000 feet
16from the licensed location of the facility and must meet all of
17the facility standards applicable to the licensed location. If
18the triage center does operate in a separate building, safety
19personnel shall be provided, on site, 24 hours per day and the
20triage center shall meet all other staffing requirements
21without counting any staff employed in the main facility
22building.
23(Source: P.A. 98-104, eff. 7-22-13.)
 
24    (210 ILCS 49/4-108)
25    Sec. 4-108. Surveys and inspections. The Department shall

 

 

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1conduct surveys of licensed facilities and their certified
2programs and services. The Department shall review the records
3or premises, or both, as it deems appropriate for the purpose
4of determining compliance with this Act and the rules
5promulgated under this Act. The Department shall have access to
6and may reproduce or photocopy any books, records, and other
7documents maintained by the facility to the extent necessary to
8carry out this Act and the rules promulgated under this Act.
9The Department shall not divulge or disclose the contents of a
10record under this Section as otherwise prohibited by this Act.
11Any holder of a license or applicant for a license shall be
12deemed to have given consent to any authorized officer,
13employee, or agent of the Department to enter and inspect the
14facility in accordance with this Article. Refusal to permit
15such entry or inspection shall constitute grounds for denial,
16suspension, or revocation of a license under this Act.
17        (1) The Department shall conduct surveys to determine
18    compliance and may conduct surveys to investigate
19    complaints.
20        (2) Determination of compliance with the service
21    requirements shall be based on a survey centered on
22    individuals that sample services being provided.
23        (3) Determination of compliance with the general
24    administrative requirements shall be based on a review of
25    facility records and observation of individuals and staff.
26        (4) The Department shall conduct surveys of licensed

 

 

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1    facilities and their certified programs and services to
2    determine the extent to which these facilities provide high
3    quality interventions, especially evidence-based
4    practices, appropriate to the assessed clinical needs of
5    individuals in the various levels of care.
6(Source: P.A. 98-104, eff. 7-22-13.)
 
7    (210 ILCS 49/4-108.5 new)
8    Sec. 4-108.5. Provisional licensure period; surveys.
9During the provisional licensure period, the Department shall
10conduct surveys to determine compliance with timetables and
11benchmarks with a facility's provisional licensure application
12plan of operation. Timetables and benchmarks shall be
13established in rule and shall include, but not be limited to,
14the following: (1) training of new and existing staff; (2)
15establishment of a data collection and reporting program for
16the facility's Quality Assessment and Performance Improvement
17Program; and (3) compliance with building environment
18standards beyond compliance with Chapter 33 of the National
19Fire Protection Association (NFPA) 101 Life Safety Code.
20    During the provisional licensure period, the Department
21shall conduct State licensure surveys as well as a conformance
22standard review to determine compliance with timetables and
23benchmarks associated with the accreditation process.
24Timetables and benchmarks shall be met in accordance with the
25preferred accrediting organization conformance standards and

 

 

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1recommendations and shall include, but not be limited to,
2conducting a comprehensive facility self-evaluation in
3accordance with an established national accreditation program.
4The facility shall submit all data reporting and outcomes
5required by accrediting organization to the Department of
6Public Health for review to determine progress towards
7accreditation. Accreditation status shall supplement but not
8replace the State's licensure surveys of facilities licensed
9under this Act and their certified programs and services to
10determine the extent to which these facilities provide high
11quality interventions, especially evidence-based practices,
12appropriate to the assessed clinical needs of individuals in
13the 4 certified levels of care.
14    Except for incidents involving the potential for harm,
15serious harm, death, or substantial facility failure to address
16a serious systemic issue within 60 days, findings of the
17facility's root cause analysis of problems and the facility's
18Quality Assessment and Performance Improvement program in
19accordance with item (22) of Section 4-104 shall not be used as
20a basis for non-compliance.
21    The Department shall have the authority to hire licensed
22practitioners of the healing arts and qualified mental health
23professionals to consult with and participate in survey and
24inspection activities.
 
25    (210 ILCS 49/5-101)

 

 

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1    Sec. 5-101. Managed care entity, coordinated care entity,
2and accountable care entity payments. For facilities licensed
3by the Department of Public Health under this Act, the payment
4for services provided shall be determined by negotiation with
5managed care entities, coordinated care entities, or
6accountable care entities. However, for 3 years after the
7effective date of this Act, in no event shall the reimbursement
8rate paid to facilities licensed under this Act be less than
9the rate in effect on June 30, 2013 less $7.07 times the number
10of occupied bed days, as that term is defined in Article V-B of
11the Illinois Public Aid Code, for each facility previously
12licensed under the Nursing Home Care Act on June 30, 2013; or
13the rate in effect on June 30, 2013 for each facility licensed
14under the Specialized Mental Health Rehabilitation Act on June
1530, 2013. Any adjustment in the support component or the
16capital component for facilities licensed by the Department of
17Public Health under the Nursing Home Care Act shall apply
18equally to facilities licensed by the Department of Public
19Health under this Act for the duration of the provisional
20licensure period as defined in Section 4-105 of this Act.
21    The Department of Healthcare and Family Services shall
22publish a reimbursement rate for triage, crisis stabilization,
23and transitional living services by December 1, 2014.
24(Source: P.A. 98-104, eff. 7-22-13.)
 
25
Article 15

 

 

 

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1    Section 15-5. The Illinois Public Aid Code is amended by
2changing Sections 5A-8 and 5A-12.2 as follows:
 
3    (305 ILCS 5/5A-8)  (from Ch. 23, par. 5A-8)
4    Sec. 5A-8. Hospital Provider Fund.
5    (a) There is created in the State Treasury the Hospital
6Provider Fund. Interest earned by the Fund shall be credited to
7the Fund. The Fund shall not be used to replace any moneys
8appropriated to the Medicaid program by the General Assembly.
9    (b) The Fund is created for the purpose of receiving moneys
10in accordance with Section 5A-6 and disbursing moneys only for
11the following purposes, notwithstanding any other provision of
12law:
13        (1) For making payments to hospitals as required under
14    this Code, under the Children's Health Insurance Program
15    Act, under the Covering ALL KIDS Health Insurance Act, and
16    under the Long Term Acute Care Hospital Quality Improvement
17    Transfer Program Act.
18        (2) For the reimbursement of moneys collected by the
19    Illinois Department from hospitals or hospital providers
20    through error or mistake in performing the activities
21    authorized under this Code.
22        (3) For payment of administrative expenses incurred by
23    the Illinois Department or its agent in performing
24    activities under this Code, under the Children's Health

 

 

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1    Insurance Program Act, under the Covering ALL KIDS Health
2    Insurance Act, and under the Long Term Acute Care Hospital
3    Quality Improvement Transfer Program Act.
4        (4) For payments of any amounts which are reimbursable
5    to the federal government for payments from this Fund which
6    are required to be paid by State warrant.
7        (5) For making transfers, as those transfers are
8    authorized in the proceedings authorizing debt under the
9    Short Term Borrowing Act, but transfers made under this
10    paragraph (5) shall not exceed the principal amount of debt
11    issued in anticipation of the receipt by the State of
12    moneys to be deposited into the Fund.
13        (6) For making transfers to any other fund in the State
14    treasury, but transfers made under this paragraph (6) shall
15    not exceed the amount transferred previously from that
16    other fund into the Hospital Provider Fund plus any
17    interest that would have been earned by that fund on the
18    monies that had been transferred.
19        (6.5) For making transfers to the Healthcare Provider
20    Relief Fund, except that transfers made under this
21    paragraph (6.5) shall not exceed $60,000,000 in the
22    aggregate.
23        (7) For making transfers not exceeding the following
24    amounts, related to in State fiscal years 2013 through 2018
25    and 2014, to the following designated funds:
26            Health and Human Services Medicaid Trust

 

 

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1                Fund..............................$20,000,000
2            Long-Term Care Provider Fund..........$30,000,000
3            General Revenue Fund.................$80,000,000.
4    Transfers under this paragraph shall be made within 7 days
5    after the payments have been received pursuant to the
6    schedule of payments provided in subsection (a) of Section
7    5A-4.
8        (7.1) (Blank). For making transfers not exceeding the
9    following amounts, in State fiscal year 2015, to the
10    following designated funds:
11            Health and Human Services Medicaid Trust
12                 Fund..............................$10,000,000
13            Long-Term Care Provider Fund..........$15,000,000
14            General Revenue Fund.................$40,000,000.
15    Transfers under this paragraph shall be made within 7 days
16    after the payments have been received pursuant to the
17    schedule of payments provided in subsection (a) of Section
18    5A-4.
19        (7.5) (Blank).
20        (7.8) (Blank).
21        (7.9) (Blank).
22        (7.10) For State fiscal year years 2013 and 2014, for
23    making transfers of the moneys resulting from the
24    assessment under subsection (b-5) of Section 5A-2 and
25    received from hospital providers under Section 5A-4 and
26    transferred into the Hospital Provider Fund under Section

 

 

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1    5A-6 to the designated funds not exceeding the following
2    amounts in that State fiscal year:
3            Health Care Provider Relief Fund.....$100,000,000
4        $50,000,000
5        Transfers under this paragraph shall be made within 7
6    days after the payments have been received pursuant to the
7    schedule of payments provided in subsection (a) of Section
8    5A-4.
9        The additional amount of transfers in this paragraph
10    (7.10), authorized by this amendatory Act of the 98th
11    General Assembly, shall be made within 10 State business
12    days after the effective date of this amendatory Act of the
13    98th General Assembly. That authority shall remain in
14    effect even if this amendatory Act of the 98th General
15    Assembly does not become law until State fiscal year 2015.
16        (7.10a) For State fiscal years 2015 through 2018, for
17    making transfers of the moneys resulting from the
18    assessment under subsection (b-5) of Section 5A-2 and
19    received from hospital providers under Section 5A-4 and
20    transferred into the Hospital Provider Fund under Section
21    5A-6 to the designated funds not exceeding the following
22    amounts related to each State fiscal year:
23            Health Care Provider Relief
24        Fund .....................................$50,000,000
25        Transfers under this paragraph shall be made within 7
26    days after the payments have been received pursuant to the

 

 

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1    schedule of payments provided in subsection (a) of Section
2    5A-4.
3        (7.11) (Blank). For State fiscal year 2015, for making
4    transfers of the moneys resulting from the assessment under
5    subsection (b-5) of Section 5A-2 and received from hospital
6    providers under Section 5A-4 and transferred into the
7    Hospital Provider Fund under Section 5A-6 to the designated
8    funds not exceeding the following amounts in that State
9    fiscal year:
10            Health Care Provider Relief Fund......$25,000,000
11        Transfers under this paragraph shall be made within 7
12    days after the payments have been received pursuant to the
13    schedule of payments provided in subsection (a) of Section
14    5A-4.
15        (7.12) For State fiscal year 2013, for increasing by
16    21/365ths the transfer of the moneys resulting from the
17    assessment under subsection (b-5) of Section 5A-2 and
18    received from hospital providers under Section 5A-4 for the
19    portion of State fiscal year 2012 beginning June 10, 2012
20    through June 30, 2012 and transferred into the Hospital
21    Provider Fund under Section 5A-6 to the designated funds
22    not exceeding the following amounts in that State fiscal
23    year:
24            Health Care Provider Relief Fund......$2,870,000
25        Since the federal Centers for Medicare and Medicaid
26    Services approval of the assessment authorized under

 

 

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1    subsection (b-5) of Section 5A-2, received from hospital
2    providers under Section 5A-4 and the payment methodologies
3    to hospitals required under Section 5A-12.4 was not
4    received by the Department until State fiscal year 2014 and
5    since the Department made retroactive payments during
6    State fiscal year 2014 related to the referenced period of
7    June 2012, the transfer authority granted in this paragraph
8    (7.12) is extended through the date that is 10 State
9    business days after the effective date of this amendatory
10    Act of the 98th General Assembly.
11        (8) For making refunds to hospital providers pursuant
12    to Section 5A-10.
13        (9) For making payment to capitated managed care
14    organizations as described in subsections (s) and (t) of
15    Section 5A-12.2 of this Code.
16    Disbursements from the Fund, other than transfers
17authorized under paragraphs (5) and (6) of this subsection,
18shall be by warrants drawn by the State Comptroller upon
19receipt of vouchers duly executed and certified by the Illinois
20Department.
21    (c) The Fund shall consist of the following:
22        (1) All moneys collected or received by the Illinois
23    Department from the hospital provider assessment imposed
24    by this Article.
25        (2) All federal matching funds received by the Illinois
26    Department as a result of expenditures made by the Illinois

 

 

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1    Department that are attributable to moneys deposited in the
2    Fund.
3        (3) Any interest or penalty levied in conjunction with
4    the administration of this Article.
5        (3.5) As applicable, proceeds from surety bond
6    payments payable to the Department as referenced in
7    subsection (s) of Section 5A-12.2 of this Code.
8        (4) Moneys transferred from another fund in the State
9    treasury.
10        (5) All other moneys received for the Fund from any
11    other source, including interest earned thereon.
12    (d) (Blank).
13(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12;
1498-104, eff. 7-22-13; 98-463, eff. 8-16-13; revised 10-21-13.)
 
15    (305 ILCS 5/5A-12.2)
16    (Section scheduled to be repealed on January 1, 2015)
17    Sec. 5A-12.2. Hospital access payments on or after July 1,
182008.
19    (a) To preserve and improve access to hospital services,
20for hospital services rendered on or after July 1, 2008, the
21Illinois Department shall, except for hospitals described in
22subsection (b) of Section 5A-3, make payments to hospitals as
23set forth in this Section. These payments shall be paid in 12
24equal installments on or before the seventh State business day
25of each month, except that no payment shall be due within 100

 

 

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1days after the later of the date of notification of federal
2approval of the payment methodologies required under this
3Section or any waiver required under 42 CFR 433.68, at which
4time the sum of amounts required under this Section prior to
5the date of notification is due and payable. Payments under
6this Section are not due and payable, however, until (i) the
7methodologies described in this Section are approved by the
8federal government in an appropriate State Plan amendment and
9(ii) the assessment imposed under this Article is determined to
10be a permissible tax under Title XIX of the Social Security
11Act.
12    (a-5) The Illinois Department may, when practicable,
13accelerate the schedule upon which payments authorized under
14this Section are made.
15    (b) Across-the-board inpatient adjustment.
16        (1) In addition to rates paid for inpatient hospital
17    services, the Department shall pay to each Illinois general
18    acute care hospital an amount equal to 40% of the total
19    base inpatient payments paid to the hospital for services
20    provided in State fiscal year 2005.
21        (2) In addition to rates paid for inpatient hospital
22    services, the Department shall pay to each freestanding
23    Illinois specialty care hospital as defined in 89 Ill. Adm.
24    Code 149.50(c)(1), (2), or (4) an amount equal to 60% of
25    the total base inpatient payments paid to the hospital for
26    services provided in State fiscal year 2005.

 

 

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1        (3) In addition to rates paid for inpatient hospital
2    services, the Department shall pay to each freestanding
3    Illinois rehabilitation or psychiatric hospital an amount
4    equal to $1,000 per Medicaid inpatient day multiplied by
5    the increase in the hospital's Medicaid inpatient
6    utilization ratio (determined using the positive
7    percentage change from the rate year 2005 Medicaid
8    inpatient utilization ratio to the rate year 2007 Medicaid
9    inpatient utilization ratio, as calculated by the
10    Department for the disproportionate share determination).
11        (4) In addition to rates paid for inpatient hospital
12    services, the Department shall pay to each Illinois
13    children's hospital an amount equal to 20% of the total
14    base inpatient payments paid to the hospital for services
15    provided in State fiscal year 2005 and an additional amount
16    equal to 20% of the base inpatient payments paid to the
17    hospital for psychiatric services provided in State fiscal
18    year 2005.
19        (5) In addition to rates paid for inpatient hospital
20    services, the Department shall pay to each Illinois
21    hospital eligible for a pediatric inpatient adjustment
22    payment under 89 Ill. Adm. Code 148.298, as in effect for
23    State fiscal year 2007, a supplemental pediatric inpatient
24    adjustment payment equal to:
25            (i) For freestanding children's hospitals as
26        defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5

 

 

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1        multiplied by the hospital's pediatric inpatient
2        adjustment payment required under 89 Ill. Adm. Code
3        148.298, as in effect for State fiscal year 2008.
4            (ii) For hospitals other than freestanding
5        children's hospitals as defined in 89 Ill. Adm. Code
6        149.50(c)(3)(B), 1.0 multiplied by the hospital's
7        pediatric inpatient adjustment payment required under
8        89 Ill. Adm. Code 148.298, as in effect for State
9        fiscal year 2008.
10    (c) Outpatient adjustment.
11        (1) In addition to the rates paid for outpatient
12    hospital services, the Department shall pay each Illinois
13    hospital an amount equal to 2.2 multiplied by the
14    hospital's ambulatory procedure listing payments for
15    categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code
16    148.140(b), for State fiscal year 2005.
17        (2) In addition to the rates paid for outpatient
18    hospital services, the Department shall pay each Illinois
19    freestanding psychiatric hospital an amount equal to 3.25
20    multiplied by the hospital's ambulatory procedure listing
21    payments for category 5b, as defined in 89 Ill. Adm. Code
22    148.140(b)(1)(E), for State fiscal year 2005.
23    (d) Medicaid high volume adjustment. In addition to rates
24paid for inpatient hospital services, the Department shall pay
25to each Illinois general acute care hospital that provided more
26than 20,500 Medicaid inpatient days of care in State fiscal

 

 

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1year 2005 amounts as follows:
2        (1) For hospitals with a case mix index equal to or
3    greater than the 85th percentile of hospital case mix
4    indices, $350 for each Medicaid inpatient day of care
5    provided during that period; and
6        (2) For hospitals with a case mix index less than the
7    85th percentile of hospital case mix indices, $100 for each
8    Medicaid inpatient day of care provided during that period.
9    (e) Capital adjustment. In addition to rates paid for
10inpatient hospital services, the Department shall pay an
11additional payment to each Illinois general acute care hospital
12that has a Medicaid inpatient utilization rate of at least 10%
13(as calculated by the Department for the rate year 2007
14disproportionate share determination) amounts as follows:
15        (1) For each Illinois general acute care hospital that
16    has a Medicaid inpatient utilization rate of at least 10%
17    and less than 36.94% and whose capital cost is less than
18    the 60th percentile of the capital costs of all Illinois
19    hospitals, the amount of such payment shall equal the
20    hospital's Medicaid inpatient days multiplied by the
21    difference between the capital costs at the 60th percentile
22    of the capital costs of all Illinois hospitals and the
23    hospital's capital costs.
24        (2) For each Illinois general acute care hospital that
25    has a Medicaid inpatient utilization rate of at least
26    36.94% and whose capital cost is less than the 75th

 

 

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1    percentile of the capital costs of all Illinois hospitals,
2    the amount of such payment shall equal the hospital's
3    Medicaid inpatient days multiplied by the difference
4    between the capital costs at the 75th percentile of the
5    capital costs of all Illinois hospitals and the hospital's
6    capital costs.
7    (f) Obstetrical care adjustment.
8        (1) In addition to rates paid for inpatient hospital
9    services, the Department shall pay $1,500 for each Medicaid
10    obstetrical day of care provided in State fiscal year 2005
11    by each Illinois rural hospital that had a Medicaid
12    obstetrical percentage (Medicaid obstetrical days divided
13    by Medicaid inpatient days) greater than 15% for State
14    fiscal year 2005.
15        (2) In addition to rates paid for inpatient hospital
16    services, the Department shall pay $1,350 for each Medicaid
17    obstetrical day of care provided in State fiscal year 2005
18    by each Illinois general acute care hospital that was
19    designated a level III perinatal center as of December 31,
20    2006, and that had a case mix index equal to or greater
21    than the 45th percentile of the case mix indices for all
22    level III perinatal centers.
23        (3) In addition to rates paid for inpatient hospital
24    services, the Department shall pay $900 for each Medicaid
25    obstetrical day of care provided in State fiscal year 2005
26    by each Illinois general acute care hospital that was

 

 

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1    designated a level II or II+ perinatal center as of
2    December 31, 2006, and that had a case mix index equal to
3    or greater than the 35th percentile of the case mix indices
4    for all level II and II+ perinatal centers.
5    (g) Trauma adjustment.
6        (1) In addition to rates paid for inpatient hospital
7    services, the Department shall pay each Illinois general
8    acute care hospital designated as a trauma center as of
9    July 1, 2007, a payment equal to 3.75 multiplied by the
10    hospital's State fiscal year 2005 Medicaid capital
11    payments.
12        (2) In addition to rates paid for inpatient hospital
13    services, the Department shall pay $400 for each Medicaid
14    acute inpatient day of care provided in State fiscal year
15    2005 by each Illinois general acute care hospital that was
16    designated a level II trauma center, as defined in 89 Ill.
17    Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1,
18    2007.
19        (3) In addition to rates paid for inpatient hospital
20    services, the Department shall pay $235 for each Illinois
21    Medicaid acute inpatient day of care provided in State
22    fiscal year 2005 by each level I pediatric trauma center
23    located outside of Illinois that had more than 8,000
24    Illinois Medicaid inpatient days in State fiscal year 2005.
25    (h) Supplemental tertiary care adjustment. In addition to
26rates paid for inpatient services, the Department shall pay to

 

 

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1each Illinois hospital eligible for tertiary care adjustment
2payments under 89 Ill. Adm. Code 148.296, as in effect for
3State fiscal year 2007, a supplemental tertiary care adjustment
4payment equal to the tertiary care adjustment payment required
5under 89 Ill. Adm. Code 148.296, as in effect for State fiscal
6year 2007.
7    (i) Crossover adjustment. In addition to rates paid for
8inpatient services, the Department shall pay each Illinois
9general acute care hospital that had a ratio of crossover days
10to total inpatient days for medical assistance programs
11administered by the Department (utilizing information from
122005 paid claims) greater than 50%, and a case mix index
13greater than the 65th percentile of case mix indices for all
14Illinois hospitals, a rate of $1,125 for each Medicaid
15inpatient day including crossover days.
16    (j) Magnet hospital adjustment. In addition to rates paid
17for inpatient hospital services, the Department shall pay to
18each Illinois general acute care hospital and each Illinois
19freestanding children's hospital that, as of February 1, 2008,
20was recognized as a Magnet hospital by the American Nurses
21Credentialing Center and that had a case mix index greater than
22the 75th percentile of case mix indices for all Illinois
23hospitals amounts as follows:
24        (1) For hospitals located in a county whose eligibility
25    growth factor is greater than the mean, $450 multiplied by
26    the eligibility growth factor for the county in which the

 

 

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1    hospital is located for each Medicaid inpatient day of care
2    provided by the hospital during State fiscal year 2005.
3        (2) For hospitals located in a county whose eligibility
4    growth factor is less than or equal to the mean, $225
5    multiplied by the eligibility growth factor for the county
6    in which the hospital is located for each Medicaid
7    inpatient day of care provided by the hospital during State
8    fiscal year 2005.
9    For purposes of this subsection, "eligibility growth
10factor" means the percentage by which the number of Medicaid
11recipients in the county increased from State fiscal year 1998
12to State fiscal year 2005.
13    (k) For purposes of this Section, a hospital that is
14enrolled to provide Medicaid services during State fiscal year
152005 shall have its utilization and associated reimbursements
16annualized prior to the payment calculations being performed
17under this Section.
18    (l) For purposes of this Section, the terms "Medicaid
19days", "ambulatory procedure listing services", and
20"ambulatory procedure listing payments" do not include any
21days, charges, or services for which Medicare or a managed care
22organization reimbursed on a capitated basis was liable for
23payment, except where explicitly stated otherwise in this
24Section.
25    (m) For purposes of this Section, in determining the
26percentile ranking of an Illinois hospital's case mix index or

 

 

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1capital costs, hospitals described in subsection (b) of Section
25A-3 shall be excluded from the ranking.
3    (n) Definitions. Unless the context requires otherwise or
4unless provided otherwise in this Section, the terms used in
5this Section for qualifying criteria and payment calculations
6shall have the same meanings as those terms have been given in
7the Illinois Department's administrative rules as in effect on
8March 1, 2008. Other terms shall be defined by the Illinois
9Department by rule.
10    As used in this Section, unless the context requires
11otherwise:
12    "Base inpatient payments" means, for a given hospital, the
13sum of base payments for inpatient services made on a per diem
14or per admission (DRG) basis, excluding those portions of per
15admission payments that are classified as capital payments.
16Disproportionate share hospital adjustment payments, Medicaid
17Percentage Adjustments, Medicaid High Volume Adjustments, and
18outlier payments, as defined by rule by the Department as of
19January 1, 2008, are not base payments.
20    "Capital costs" means, for a given hospital, the total
21capital costs determined using the most recent 2005 Medicare
22cost report as contained in the Healthcare Cost Report
23Information System file, for the quarter ending on December 31,
242006, divided by the total inpatient days from the same cost
25report to calculate a capital cost per day. The resulting
26capital cost per day is inflated to the midpoint of State

 

 

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1fiscal year 2009 utilizing the national hospital market price
2proxies (DRI) hospital cost index. If a hospital's 2005
3Medicare cost report is not contained in the Healthcare Cost
4Report Information System, the Department may obtain the data
5necessary to compute the hospital's capital costs from any
6source available, including, but not limited to, records
7maintained by the hospital provider, which may be inspected at
8all times during business hours of the day by the Illinois
9Department or its duly authorized agents and employees.
10    "Case mix index" means, for a given hospital, the sum of
11the DRG relative weighting factors in effect on January 1,
122005, for all general acute care admissions for State fiscal
13year 2005, excluding Medicare crossover admissions and
14transplant admissions reimbursed under 89 Ill. Adm. Code
15148.82, divided by the total number of general acute care
16admissions for State fiscal year 2005, excluding Medicare
17crossover admissions and transplant admissions reimbursed
18under 89 Ill. Adm. Code 148.82.
19    "Medicaid inpatient day" means, for a given hospital, the
20sum of days of inpatient hospital days provided to recipients
21of medical assistance under Title XIX of the federal Social
22Security Act, excluding days for individuals eligible for
23Medicare under Title XVIII of that Act (Medicaid/Medicare
24crossover days), as tabulated from the Department's paid claims
25data for admissions occurring during State fiscal year 2005
26that was adjudicated by the Department through March 23, 2007.

 

 

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1    "Medicaid obstetrical day" means, for a given hospital, the
2sum of days of inpatient hospital days grouped by the
3Department to DRGs of 370 through 375 provided to recipients of
4medical assistance under Title XIX of the federal Social
5Security Act, excluding days for individuals eligible for
6Medicare under Title XVIII of that Act (Medicaid/Medicare
7crossover days), as tabulated from the Department's paid claims
8data for admissions occurring during State fiscal year 2005
9that was adjudicated by the Department through March 23, 2007.
10    "Outpatient ambulatory procedure listing payments" means,
11for a given hospital, the sum of payments for ambulatory
12procedure listing services, as described in 89 Ill. Adm. Code
13148.140(b), provided to recipients of medical assistance under
14Title XIX of the federal Social Security Act, excluding
15payments for individuals eligible for Medicare under Title
16XVIII of the Act (Medicaid/Medicare crossover days), as
17tabulated from the Department's paid claims data for services
18occurring in State fiscal year 2005 that were adjudicated by
19the Department through March 23, 2007.
20    (o) The Department may adjust payments made under this
21Section 5A-12.2 to comply with federal law or regulations
22regarding hospital-specific payment limitations on
23government-owned or government-operated hospitals.
24    (p) Notwithstanding any of the other provisions of this
25Section, the Department is authorized to adopt rules that
26change the hospital access improvement payments specified in

 

 

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1this Section, but only to the extent necessary to conform to
2any federally approved amendment to the Title XIX State plan.
3Any such rules shall be adopted by the Department as authorized
4by Section 5-50 of the Illinois Administrative Procedure Act.
5Notwithstanding any other provision of law, any changes
6implemented as a result of this subsection (p) shall be given
7retroactive effect so that they shall be deemed to have taken
8effect as of the effective date of this Section.
9    (q) (Blank).
10    (r) On and after July 1, 2012, the Department shall reduce
11any rate of reimbursement for services or other payments or
12alter any methodologies authorized by this Code to reduce any
13rate of reimbursement for services or other payments in
14accordance with Section 5-5e.
15    (s) On or after July 1, 2014, but no later than October 1,
162014, and no less than annually thereafter, the Department may
17increase capitation payments to capitated managed care
18organizations (MCOs) to equal the aggregate reduction of
19payments made in this Section and in Section 5A-12.4 by a
20uniform percentage on a regional basis to preserve access to
21hospital services for recipients under the Illinois Medical
22Assistance Program. The aggregate amount of all increased
23capitation payments to all MCOs for a fiscal year shall be the
24amount needed to avoid reduction in payments authorized under
25Section 5A-15. Payments to MCOs under this Section shall be
26consistent with actuarial certification and shall be published

 

 

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1by the Department each year. Each MCO shall only expend the
2increased capitation payments it receives under this Section to
3support the availability of hospital services and to ensure
4access to hospital services, with such expenditures being made
5within 15 calendar days from when the MCO receives the
6increased capitation payment. The Department shall make
7available, on a monthly basis, a report of the capitation
8payments that are made to each MCO pursuant to this subsection,
9including the number of enrollees for which such payment is
10made, the per enrollee amount of the payment, and any
11adjustments that have been made. Payments made under this
12subsection shall be guaranteed by a surety bond obtained by the
13MCO in an amount established by the Department to approximate
14one month's liability of payments authorized under this
15subsection. The Department may advance the payments guaranteed
16by the surety bond. Payments to MCOs that would be paid
17consistent with actuarial certification and enrollment in the
18absence of the increased capitation payments under this Section
19shall not be reduced as a consequence of payments made under
20this subsection.
21    As used in this subsection, "MCO" means an entity which
22contracts with the Department to provide services where payment
23for medical services is made on a capitated basis.
24    (t) On or after July 1, 2014, the Department may increase
25capitation payments to capitated managed care organizations
26(MCOs) to equal the aggregate reduction of payments made in

 

 

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1Section 5A-12.5 to preserve access to hospital services for
2recipients under the Illinois Medical Assistance Program.
3Payments to MCOs under this Section shall be consistent with
4actuarial certification and shall be published by the
5Department each year. Each MCO shall only expend the increased
6capitation payments it receives under this Section to support
7the availability of hospital services and to ensure access to
8hospital services, with such expenditures being made within 15
9calendar days from when the MCO receives the increased
10capitation payment. The Department may advance the payments to
11hospitals under this subsection, in the event the MCO fails to
12make such payments. The Department shall make available, on a
13monthly basis, a report of the capitation payments that are
14made to each MCO pursuant to this subsection, including the
15number of enrollees for which such payment is made, the per
16enrollee amount of the payment, and any adjustments that have
17been made. Payments to MCOs that would be paid consistent with
18actuarial certification and enrollment in the absence of the
19increased capitation payments under this subsection shall not
20be reduced as a consequence of payments made under this
21subsection.
22    As used in this subsection, "MCO" means an entity which
23contracts with the Department to provide services where payment
24for medical services is made on a capitated basis.
25(Source: P.A. 96-821, eff. 11-20-09; 97-689, eff. 6-14-12.)
 

 

 

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1
Article 20

 
2    Section 20-5. The Illinois Administrative Procedure Act is
3amended by changing Section 5-45 as follows:
 
4    (5 ILCS 100/5-45)  (from Ch. 127, par. 1005-45)
5    Sec. 5-45. Emergency rulemaking.
6    (a) "Emergency" means the existence of any situation that
7any agency finds reasonably constitutes a threat to the public
8interest, safety, or welfare.
9    (b) If any agency finds that an emergency exists that
10requires adoption of a rule upon fewer days than is required by
11Section 5-40 and states in writing its reasons for that
12finding, the agency may adopt an emergency rule without prior
13notice or hearing upon filing a notice of emergency rulemaking
14with the Secretary of State under Section 5-70. The notice
15shall include the text of the emergency rule and shall be
16published in the Illinois Register. Consent orders or other
17court orders adopting settlements negotiated by an agency may
18be adopted under this Section. Subject to applicable
19constitutional or statutory provisions, an emergency rule
20becomes effective immediately upon filing under Section 5-65 or
21at a stated date less than 10 days thereafter. The agency's
22finding and a statement of the specific reasons for the finding
23shall be filed with the rule. The agency shall take reasonable
24and appropriate measures to make emergency rules known to the

 

 

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1persons who may be affected by them.
2    (c) An emergency rule may be effective for a period of not
3longer than 150 days, but the agency's authority to adopt an
4identical rule under Section 5-40 is not precluded. No
5emergency rule may be adopted more than once in any 24 month
6period, except that this limitation on the number of emergency
7rules that may be adopted in a 24 month period does not apply
8to (i) emergency rules that make additions to and deletions
9from the Drug Manual under Section 5-5.16 of the Illinois
10Public Aid Code or the generic drug formulary under Section
113.14 of the Illinois Food, Drug and Cosmetic Act, (ii)
12emergency rules adopted by the Pollution Control Board before
13July 1, 1997 to implement portions of the Livestock Management
14Facilities Act, (iii) emergency rules adopted by the Illinois
15Department of Public Health under subsections (a) through (i)
16of Section 2 of the Department of Public Health Act when
17necessary to protect the public's health, (iv) emergency rules
18adopted pursuant to subsection (n) of this Section, (v)
19emergency rules adopted pursuant to subsection (o) of this
20Section, or (vi) emergency rules adopted pursuant to subsection
21(c-5) of this Section. Two or more emergency rules having
22substantially the same purpose and effect shall be deemed to be
23a single rule for purposes of this Section.
24    (c-5) To facilitate the maintenance of the program of group
25health benefits provided to annuitants, survivors, and retired
26employees under the State Employees Group Insurance Act of

 

 

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11971, rules to alter the contributions to be paid by the State,
2annuitants, survivors, retired employees, or any combination
3of those entities, for that program of group health benefits,
4shall be adopted as emergency rules. The adoption of those
5rules shall be considered an emergency and necessary for the
6public interest, safety, and welfare.
7    (d) In order to provide for the expeditious and timely
8implementation of the State's fiscal year 1999 budget,
9emergency rules to implement any provision of Public Act 90-587
10or 90-588 or any other budget initiative for fiscal year 1999
11may be adopted in accordance with this Section by the agency
12charged with administering that provision or initiative,
13except that the 24-month limitation on the adoption of
14emergency rules and the provisions of Sections 5-115 and 5-125
15do not apply to rules adopted under this subsection (d). The
16adoption of emergency rules authorized by this subsection (d)
17shall be deemed to be necessary for the public interest,
18safety, and welfare.
19    (e) In order to provide for the expeditious and timely
20implementation of the State's fiscal year 2000 budget,
21emergency rules to implement any provision of this amendatory
22Act of the 91st General Assembly or any other budget initiative
23for fiscal year 2000 may be adopted in accordance with this
24Section by the agency charged with administering that provision
25or initiative, except that the 24-month limitation on the
26adoption of emergency rules and the provisions of Sections

 

 

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15-115 and 5-125 do not apply to rules adopted under this
2subsection (e). The adoption of emergency rules authorized by
3this subsection (e) shall be deemed to be necessary for the
4public interest, safety, and welfare.
5    (f) In order to provide for the expeditious and timely
6implementation of the State's fiscal year 2001 budget,
7emergency rules to implement any provision of this amendatory
8Act of the 91st General Assembly or any other budget initiative
9for fiscal year 2001 may be adopted in accordance with this
10Section by the agency charged with administering that provision
11or initiative, except that the 24-month limitation on the
12adoption of emergency rules and the provisions of Sections
135-115 and 5-125 do not apply to rules adopted under this
14subsection (f). The adoption of emergency rules authorized by
15this subsection (f) shall be deemed to be necessary for the
16public interest, safety, and welfare.
17    (g) In order to provide for the expeditious and timely
18implementation of the State's fiscal year 2002 budget,
19emergency rules to implement any provision of this amendatory
20Act of the 92nd General Assembly or any other budget initiative
21for fiscal year 2002 may be adopted in accordance with this
22Section by the agency charged with administering that provision
23or initiative, except that the 24-month limitation on the
24adoption of emergency rules and the provisions of Sections
255-115 and 5-125 do not apply to rules adopted under this
26subsection (g). The adoption of emergency rules authorized by

 

 

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1this subsection (g) shall be deemed to be necessary for the
2public interest, safety, and welfare.
3    (h) In order to provide for the expeditious and timely
4implementation of the State's fiscal year 2003 budget,
5emergency rules to implement any provision of this amendatory
6Act of the 92nd General Assembly or any other budget initiative
7for fiscal year 2003 may be adopted in accordance with this
8Section by the agency charged with administering that provision
9or initiative, except that the 24-month limitation on the
10adoption of emergency rules and the provisions of Sections
115-115 and 5-125 do not apply to rules adopted under this
12subsection (h). The adoption of emergency rules authorized by
13this subsection (h) shall be deemed to be necessary for the
14public interest, safety, and welfare.
15    (i) In order to provide for the expeditious and timely
16implementation of the State's fiscal year 2004 budget,
17emergency rules to implement any provision of this amendatory
18Act of the 93rd General Assembly or any other budget initiative
19for fiscal year 2004 may be adopted in accordance with this
20Section by the agency charged with administering that provision
21or initiative, except that the 24-month limitation on the
22adoption of emergency rules and the provisions of Sections
235-115 and 5-125 do not apply to rules adopted under this
24subsection (i). The adoption of emergency rules authorized by
25this subsection (i) shall be deemed to be necessary for the
26public interest, safety, and welfare.

 

 

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1    (j) In order to provide for the expeditious and timely
2implementation of the provisions of the State's fiscal year
32005 budget as provided under the Fiscal Year 2005 Budget
4Implementation (Human Services) Act, emergency rules to
5implement any provision of the Fiscal Year 2005 Budget
6Implementation (Human Services) Act may be adopted in
7accordance with this Section by the agency charged with
8administering that provision, except that the 24-month
9limitation on the adoption of emergency rules and the
10provisions of Sections 5-115 and 5-125 do not apply to rules
11adopted under this subsection (j). The Department of Public Aid
12may also adopt rules under this subsection (j) necessary to
13administer the Illinois Public Aid Code and the Children's
14Health Insurance Program Act. The adoption of emergency rules
15authorized by this subsection (j) shall be deemed to be
16necessary for the public interest, safety, and welfare.
17    (k) In order to provide for the expeditious and timely
18implementation of the provisions of the State's fiscal year
192006 budget, emergency rules to implement any provision of this
20amendatory Act of the 94th General Assembly or any other budget
21initiative for fiscal year 2006 may be adopted in accordance
22with this Section by the agency charged with administering that
23provision or initiative, except that the 24-month limitation on
24the adoption of emergency rules and the provisions of Sections
255-115 and 5-125 do not apply to rules adopted under this
26subsection (k). The Department of Healthcare and Family

 

 

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1Services may also adopt rules under this subsection (k)
2necessary to administer the Illinois Public Aid Code, the
3Senior Citizens and Disabled Persons Property Tax Relief Act,
4the Senior Citizens and Disabled Persons Prescription Drug
5Discount Program Act (now the Illinois Prescription Drug
6Discount Program Act), and the Children's Health Insurance
7Program Act. The adoption of emergency rules authorized by this
8subsection (k) shall be deemed to be necessary for the public
9interest, safety, and welfare.
10    (l) In order to provide for the expeditious and timely
11implementation of the provisions of the State's fiscal year
122007 budget, the Department of Healthcare and Family Services
13may adopt emergency rules during fiscal year 2007, including
14rules effective July 1, 2007, in accordance with this
15subsection to the extent necessary to administer the
16Department's responsibilities with respect to amendments to
17the State plans and Illinois waivers approved by the federal
18Centers for Medicare and Medicaid Services necessitated by the
19requirements of Title XIX and Title XXI of the federal Social
20Security Act. The adoption of emergency rules authorized by
21this subsection (l) shall be deemed to be necessary for the
22public interest, safety, and welfare.
23    (m) In order to provide for the expeditious and timely
24implementation of the provisions of the State's fiscal year
252008 budget, the Department of Healthcare and Family Services
26may adopt emergency rules during fiscal year 2008, including

 

 

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1rules effective July 1, 2008, in accordance with this
2subsection to the extent necessary to administer the
3Department's responsibilities with respect to amendments to
4the State plans and Illinois waivers approved by the federal
5Centers for Medicare and Medicaid Services necessitated by the
6requirements of Title XIX and Title XXI of the federal Social
7Security Act. The adoption of emergency rules authorized by
8this subsection (m) shall be deemed to be necessary for the
9public interest, safety, and welfare.
10    (n) In order to provide for the expeditious and timely
11implementation of the provisions of the State's fiscal year
122010 budget, emergency rules to implement any provision of this
13amendatory Act of the 96th General Assembly or any other budget
14initiative authorized by the 96th General Assembly for fiscal
15year 2010 may be adopted in accordance with this Section by the
16agency charged with administering that provision or
17initiative. The adoption of emergency rules authorized by this
18subsection (n) shall be deemed to be necessary for the public
19interest, safety, and welfare. The rulemaking authority
20granted in this subsection (n) shall apply only to rules
21promulgated during Fiscal Year 2010.
22    (o) In order to provide for the expeditious and timely
23implementation of the provisions of the State's fiscal year
242011 budget, emergency rules to implement any provision of this
25amendatory Act of the 96th General Assembly or any other budget
26initiative authorized by the 96th General Assembly for fiscal

 

 

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1year 2011 may be adopted in accordance with this Section by the
2agency charged with administering that provision or
3initiative. The adoption of emergency rules authorized by this
4subsection (o) is deemed to be necessary for the public
5interest, safety, and welfare. The rulemaking authority
6granted in this subsection (o) applies only to rules
7promulgated on or after the effective date of this amendatory
8Act of the 96th General Assembly through June 30, 2011.
9    (p) In order to provide for the expeditious and timely
10implementation of the provisions of Public Act 97-689,
11emergency rules to implement any provision of Public Act 97-689
12may be adopted in accordance with this subsection (p) by the
13agency charged with administering that provision or
14initiative. The 150-day limitation of the effective period of
15emergency rules does not apply to rules adopted under this
16subsection (p), and the effective period may continue through
17June 30, 2013. The 24-month limitation on the adoption of
18emergency rules does not apply to rules adopted under this
19subsection (p). The adoption of emergency rules authorized by
20this subsection (p) is deemed to be necessary for the public
21interest, safety, and welfare.
22    (q) In order to provide for the expeditious and timely
23implementation of the provisions of Articles 7, 8, 9, 11, and
2412 of this amendatory Act of the 98th General Assembly,
25emergency rules to implement any provision of Articles 7, 8, 9,
2611, and 12 of this amendatory Act of the 98th General Assembly

 

 

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1may be adopted in accordance with this subsection (q) by the
2agency charged with administering that provision or
3initiative. The 24-month limitation on the adoption of
4emergency rules does not apply to rules adopted under this
5subsection (q). The adoption of emergency rules authorized by
6this subsection (q) is deemed to be necessary for the public
7interest, safety, and welfare.
8    (r) In order to provide for the expeditious and timely
9implementation of the provisions of this amendatory Act of the
1098th General Assembly, emergency rules to implement this
11amendatory Act of the 98th General Assembly may be adopted in
12accordance with this subsection (r) by the Department of
13Healthcare and Family Services. The 24-month limitation on the
14adoption of emergency rules does not apply to rules adopted
15under this subsection (r). The adoption of emergency rules
16authorized by this subsection (r) is deemed to be necessary for
17the public interest, safety, and welfare.
18(Source: P.A. 97-689, eff. 6-14-12; 97-695, eff. 7-1-12;
1998-104, eff. 7-22-13; 98-463, eff. 8-16-13.)
 
20    Section 20-10. The Children's Health Insurance Program Act
21is amended by changing Section 7 as follows:
 
22    (215 ILCS 106/7)
23    Sec. 7. Eligibility verification. Notwithstanding any
24other provision of this Act, with respect to applications for

 

 

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1benefits provided under the Program, eligibility shall be
2determined in a manner that ensures program integrity and that
3complies with federal law and regulations while minimizing
4unnecessary barriers to enrollment. To this end, as soon as
5practicable, and unless the Department receives written denial
6from the federal government, this Section shall be implemented:
7    (a) The Department of Healthcare and Family Services or its
8designees shall:
9        (1) By no later than July 1, 2011, require verification
10    of, at a minimum, one month's income from all sources
11    required for determining the eligibility of applicants to
12    the Program. Such verification shall take the form of pay
13    stubs, business or income and expense records for
14    self-employed persons, letters from employers, and any
15    other valid documentation of income including data
16    obtained electronically by the Department or its designees
17    from other sources as described in subsection (b) of this
18    Section.
19        (2) By no later than October 1, 2011, require
20    verification of, at a minimum, one month's income from all
21    sources required for determining the continued eligibility
22    of recipients at their annual review of eligibility under
23    the Program. Such verification shall take the form of pay
24    stubs, business or income and expense records for
25    self-employed persons, letters from employers, and any
26    other valid documentation of income including data

 

 

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1    obtained electronically by the Department or its designees
2    from other sources as described in subsection (b) of this
3    Section. The Department shall send a notice to the
4    recipient at least 60 days prior to the end of the period
5    of eligibility that informs them of the requirements for
6    continued eligibility. If a recipient does not fulfill the
7    requirements for continued eligibility by the deadline
8    established in the notice, a notice of cancellation shall
9    be issued to the recipient and coverage shall end on the
10    last day of the eligibility period. A recipient's
11    eligibility may be reinstated without requiring a new
12    application if the recipient fulfills the requirements for
13    continued eligibility prior to the end of the third month
14    following the last date of coverage (or longer period if
15    required by federal regulations). Nothing in this Section
16    shall prevent an individual whose coverage has been
17    cancelled from reapplying for health benefits at any time.
18        (3) By no later than July 1, 2011, require verification
19    of Illinois residency.
20    (b) The Department shall establish or continue cooperative
21arrangements with the Social Security Administration, the
22Illinois Secretary of State, the Department of Human Services,
23the Department of Revenue, the Department of Employment
24Security, and any other appropriate entity to gain electronic
25access, to the extent allowed by law, to information available
26to those entities that may be appropriate for electronically

 

 

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1verifying any factor of eligibility for benefits under the
2Program. Data relevant to eligibility shall be provided for no
3other purpose than to verify the eligibility of new applicants
4or current recipients of health benefits under the Program.
5Data will be requested or provided for any new applicant or
6current recipient only insofar as that individual's
7circumstances are relevant to that individual's or another
8individual's eligibility.
9    (c) Within 90 days of the effective date of this amendatory
10Act of the 96th General Assembly, the Department of Healthcare
11and Family Services shall send notice to current recipients
12informing them of the changes regarding their eligibility
13verification.
14(Source: P.A. 96-1501, eff. 1-25-11.)
 
15    Section 20-15. The Covering ALL KIDS Health Insurance Act
16is amended by changing Sections 7 and 20 as follows:
 
17    (215 ILCS 170/7)
18    (Section scheduled to be repealed on July 1, 2016)
19    Sec. 7. Eligibility verification. Notwithstanding any
20other provision of this Act, with respect to applications for
21benefits provided under the Program, eligibility shall be
22determined in a manner that ensures program integrity and that
23complies with federal law and regulations while minimizing
24unnecessary barriers to enrollment. To this end, as soon as

 

 

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1practicable, and unless the Department receives written denial
2from the federal government, this Section shall be implemented:
3    (a) The Department of Healthcare and Family Services or its
4designees shall:
5        (1) By July 1, 2011, require verification of, at a
6    minimum, one month's income from all sources required for
7    determining the eligibility of applicants to the Program.
8    Such verification shall take the form of pay stubs,
9    business or income and expense records for self-employed
10    persons, letters from employers, and any other valid
11    documentation of income including data obtained
12    electronically by the Department or its designees from
13    other sources as described in subsection (b) of this
14    Section.
15        (2) By October 1, 2011, require verification of, at a
16    minimum, one month's income from all sources required for
17    determining the continued eligibility of recipients at
18    their annual review of eligibility under the Program. Such
19    verification shall take the form of pay stubs, business or
20    income and expense records for self-employed persons,
21    letters from employers, and any other valid documentation
22    of income including data obtained electronically by the
23    Department or its designees from other sources as described
24    in subsection (b) of this Section. The Department shall
25    send a notice to recipients at least 60 days prior to the
26    end of their period of eligibility that informs them of the

 

 

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1    requirements for continued eligibility. If a recipient
2    does not fulfill the requirements for continued
3    eligibility by the deadline established in the notice, a
4    notice of cancellation shall be issued to the recipient and
5    coverage shall end on the last day of the eligibility
6    period. A recipient's eligibility may be reinstated
7    without requiring a new application if the recipient
8    fulfills the requirements for continued eligibility prior
9    to the end of the third month following the last date of
10    coverage (or longer period if required by federal
11    regulations). Nothing in this Section shall prevent an
12    individual whose coverage has been cancelled from
13    reapplying for health benefits at any time.
14        (3) By July 1, 2011, require verification of Illinois
15    residency.
16    (b) The Department shall establish or continue cooperative
17arrangements with the Social Security Administration, the
18Illinois Secretary of State, the Department of Human Services,
19the Department of Revenue, the Department of Employment
20Security, and any other appropriate entity to gain electronic
21access, to the extent allowed by law, to information available
22to those entities that may be appropriate for electronically
23verifying any factor of eligibility for benefits under the
24Program. Data relevant to eligibility shall be provided for no
25other purpose than to verify the eligibility of new applicants
26or current recipients of health benefits under the Program.

 

 

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1Data will be requested or provided for any new applicant or
2current recipient only insofar as that individual's
3circumstances are relevant to that individual's or another
4individual's eligibility.
5    (c) Within 90 days of the effective date of this amendatory
6Act of the 96th General Assembly, the Department of Healthcare
7and Family Services shall send notice to current recipients
8informing them of the changes regarding their eligibility
9verification.
10(Source: P.A. 96-1501, eff. 1-25-11.)
 
11    (215 ILCS 170/20)
12    (Section scheduled to be repealed on July 1, 2016)
13    Sec. 20. Eligibility.
14    (a) To be eligible for the Program, a person must be a
15child:
16        (1) who is a resident of the State of Illinois;
17        (2) who is ineligible for medical assistance under the
18    Illinois Public Aid Code or benefits under the Children's
19    Health Insurance Program Act;
20        (3) who either (i) effective July 1, 2014, who has in
21    accordance with 42 CFR 457.805 (78 FR 42313, July 15, 2013)
22    or any other federal requirement necessary to obtain
23    federal financial participation for expenditures made
24    under this Act, has been without health insurance coverage
25    for 90 days; 12 months, (ii) whose parent has lost

 

 

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1    employment that made available affordable dependent health
2    insurance coverage, until such time as affordable
3    employer-sponsored dependent health insurance coverage is
4    again available for the child as set forth by the
5    Department in rules, (iii) (ii) who is a newborn whose
6    responsible relative does not have available affordable
7    private or employer-sponsored health insurance; or (iii) ,
8    or (iv) who, within one year of applying for coverage under
9    this Act, lost medical benefits under the Illinois Public
10    Aid Code or the Children's Health Insurance Program Act;
11    and
12        (3.5) whose household income, as determined, effective
13    October 1, 2013, by the Department, is at or below 300% of
14    the federal poverty level as determined in compliance with
15    42 U.S.C. 1397bb(b)(1)(B)(v) and applicable federal
16    regulations. This item (3.5) is effective July 1, 2011.
17    An entity that provides health insurance coverage (as
18defined in Section 2 of the Comprehensive Health Insurance Plan
19Act) to Illinois residents shall provide health insurance data
20match to the Department of Healthcare and Family Services as
21provided by and subject to Section 5.5 of the Illinois
22Insurance Code. The Department of Healthcare and Family
23Services may impose an administrative penalty as provided under
24Section 12-4.45 of the Illinois Public Aid Code on entities
25that have established a pattern of failure to provide the
26information required under this Section.

 

 

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1    The Department of Healthcare and Family Services, in
2collaboration with the Department of Insurance, shall adopt
3rules governing the exchange of information under this Section.
4The rules shall be consistent with all laws relating to the
5confidentiality or privacy of personal information or medical
6records, including provisions under the Federal Health
7Insurance Portability and Accountability Act (HIPAA).
8    (b) The Department shall monitor the availability and
9retention of employer-sponsored dependent health insurance
10coverage and shall modify the period described in subdivision
11(a)(3) if necessary to promote retention of private or
12employer-sponsored health insurance and timely access to
13healthcare services, but at no time shall the period described
14in subdivision (a)(3) be less than 6 months.
15    (c) The Department, at its discretion, may take into
16account the affordability of dependent health insurance when
17determining whether employer-sponsored dependent health
18insurance coverage is available upon reemployment of a child's
19parent as provided in subdivision (a)(3).
20    (d) A child who is determined to be eligible for the
21Program shall remain eligible for 12 months, provided that the
22child maintains his or her residence in this State, has not yet
23attained 19 years of age, and is not excluded under subsection
24(e).
25    (e) A child is not eligible for coverage under the Program
26if:

 

 

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1        (1) the premium required under Section 40 has not been
2    timely paid; if the required premiums are not paid, the
3    liability of the Program shall be limited to benefits
4    incurred under the Program for the time period for which
5    premiums have been paid; re-enrollment shall be completed
6    before the next covered medical visit, and the first
7    month's required premium shall be paid in advance of the
8    next covered medical visit; or
9        (2) the child is an inmate of a public institution or
10    an institution for mental diseases.
11    (f) The Department may adopt rules, including, but not
12limited to: rules regarding annual renewals of eligibility for
13the Program in conformance with Section 7 of this Act; rules
14providing for re-enrollment, grace periods, notice
15requirements, and hearing procedures under subdivision (e)(1)
16of this Section; and rules regarding what constitutes
17availability and affordability of private or
18employer-sponsored health insurance, with consideration of
19such factors as the percentage of income needed to purchase
20children or family health insurance, the availability of
21employer subsidies, and other relevant factors.
22    (g) Each child enrolled in the Program as of July 1, 2011
23whose family income, as established by the Department, exceeds
24300% of the federal poverty level may remain enrolled in the
25Program for 12 additional months commencing July 1, 2011.
26Continued enrollment pursuant to this subsection shall be

 

 

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1available only if the child continues to meet all eligibility
2criteria established under the Program as of the effective date
3of this amendatory Act of the 96th General Assembly without a
4break in coverage. Nothing contained in this subsection shall
5prevent a child from qualifying for any other health benefits
6program operated by the Department.
7(Source: P.A. 98-130, eff. 8-2-13.)
 
8    Section 20-20. The Illinois Public Aid Code is amended by
9changing Sections 5-2.1a and 11-5.1 as follows:
 
10    (305 ILCS 5/5-2.1a)
11    Sec. 5-2.1a. Treatment of trust amounts. To the extent
12required by federal law, the Department of Healthcare and
13Family Services Illinois Department shall provide by rule for
14the consideration of trusts and similar legal instruments or
15devices established by a person in the Illinois Department's
16determination of the person's eligibility for and the amount of
17assistance provided under this Article. This Section shall be
18enforced by the Department of Human Services, acting as
19successor to the Department of Public Aid under the Department
20of Human Services Act.
21(Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
 
22    (305 ILCS 5/11-5.1)
23    Sec. 11-5.1. Eligibility verification. Notwithstanding any

 

 

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1other provision of this Code, with respect to applications for
2medical assistance provided under Article V of this Code,
3eligibility shall be determined in a manner that ensures
4program integrity and complies with federal laws and
5regulations while minimizing unnecessary barriers to
6enrollment. To this end, as soon as practicable, and unless the
7Department receives written denial from the federal
8government, this Section shall be implemented:
9    (a) The Department of Healthcare and Family Services or its
10designees shall:
11        (1) By no later than July 1, 2011, require verification
12    of, at a minimum, one month's income from all sources
13    required for determining the eligibility of applicants for
14    medical assistance under this Code. Such verification
15    shall take the form of pay stubs, business or income and
16    expense records for self-employed persons, letters from
17    employers, and any other valid documentation of income
18    including data obtained electronically by the Department
19    or its designees from other sources as described in
20    subsection (b) of this Section.
21        (2) By no later than October 1, 2011, require
22    verification of, at a minimum, one month's income from all
23    sources required for determining the continued eligibility
24    of recipients at their annual review of eligibility for
25    medical assistance under this Code. Such verification
26    shall take the form of pay stubs, business or income and

 

 

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1    expense records for self-employed persons, letters from
2    employers, and any other valid documentation of income
3    including data obtained electronically by the Department
4    or its designees from other sources as described in
5    subsection (b) of this Section. The Department shall send a
6    notice to recipients at least 60 days prior to the end of
7    their period of eligibility that informs them of the
8    requirements for continued eligibility. If a recipient
9    does not fulfill the requirements for continued
10    eligibility by the deadline established in the notice a
11    notice of cancellation shall be issued to the recipient and
12    coverage shall end on the last day of the eligibility
13    period. A recipient's eligibility may be reinstated
14    without requiring a new application if the recipient
15    fulfills the requirements for continued eligibility prior
16    to the end of the third month following the last date of
17    coverage (or longer period if required by federal
18    regulations). Nothing in this Section shall prevent an
19    individual whose coverage has been cancelled from
20    reapplying for health benefits at any time.
21        (3) By no later than July 1, 2011, require verification
22    of Illinois residency.
23    (b) The Department shall establish or continue cooperative
24arrangements with the Social Security Administration, the
25Illinois Secretary of State, the Department of Human Services,
26the Department of Revenue, the Department of Employment

 

 

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1Security, and any other appropriate entity to gain electronic
2access, to the extent allowed by law, to information available
3to those entities that may be appropriate for electronically
4verifying any factor of eligibility for benefits under the
5Program. Data relevant to eligibility shall be provided for no
6other purpose than to verify the eligibility of new applicants
7or current recipients of health benefits under the Program.
8Data shall be requested or provided for any new applicant or
9current recipient only insofar as that individual's
10circumstances are relevant to that individual's or another
11individual's eligibility.
12    (c) Within 90 days of the effective date of this amendatory
13Act of the 96th General Assembly, the Department of Healthcare
14and Family Services shall send notice to current recipients
15informing them of the changes regarding their eligibility
16verification.
17(Source: P.A. 96-1501, eff. 1-25-11.)
 
18
Article 25

 
19    Section 25-5. The State Finance Act is amended by changing
20Section 6z-30 as follows:
 
21    (30 ILCS 105/6z-30)
22    Sec. 6z-30. University of Illinois Hospital Services Fund.
23    (a) The University of Illinois Hospital Services Fund is

 

 

SB0741 Enrolled- 119 -LRB098 04975 KTG 35005 b

1created as a special fund in the State Treasury. The following
2moneys shall be deposited into the Fund:
3        (1) As soon as possible after the beginning of fiscal
4    year 2010, and in no event later than July 30, the State
5    Comptroller and the State Treasurer shall automatically
6    transfer $30,000,000 from the General Revenue Fund to the
7    University of Illinois Hospital Services Fund.
8        (1.5) Starting in fiscal year 2011, as soon as possible
9    after the beginning of each fiscal year, and in no event
10    later than July 30, the State Comptroller and the State
11    Treasurer shall automatically transfer $45,000,000 from
12    the General Revenue Fund to the University of Illinois
13    Hospital Services Fund; except that, in fiscal year 2012
14    only, the State Comptroller and the State Treasurer shall
15    transfer $90,000,000 from the General Revenue Fund to the
16    University of Illinois Hospital Services Fund under this
17    paragraph, and, in fiscal year 2013 only, the State
18    Comptroller and the State Treasurer shall transfer no
19    amounts from the General Revenue Fund to the University of
20    Illinois Hospital Services Fund under this paragraph.
21        (2) All intergovernmental transfer payments to the
22    Department of Healthcare and Family Services by the
23    University of Illinois made pursuant to an
24    intergovernmental agreement under subsection (b) or (c) of
25    Section 5A-3 of the Illinois Public Aid Code.
26        (3) All federal matching funds received by the

 

 

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1    Department of Healthcare and Family Services (formerly
2    Illinois Department of Public Aid) as a result of
3    expenditures made by the Department that are attributable
4    to moneys that were deposited in the Fund.
5        (4) All other moneys received for the Fund from any
6    other source, including interest earned thereon.
7    (b) Moneys in the fund may be used by the Department of
8Healthcare and Family Services, subject to appropriation and to
9an interagency agreement between that Department and the Board
10of Trustees of the University of Illinois, to reimburse the
11University of Illinois Hospital for hospital and pharmacy
12services, to reimburse practitioners who are employed by the
13University of Illinois, to reimburse other health care
14facilities and health plans operated by the University of
15Illinois, and to pass through to the University of Illinois
16federal financial participation earned by the State as a result
17of expenditures made by the University of Illinois.
18    (c) (Blank).
19(Source: P.A. 96-45, eff. 7-15-09; 96-959, eff. 7-1-10; 97-732,
20eff. 6-30-12.)
 
21    Section 25-10. The Illinois Public Aid Code is amended by
22changing Section 12-9 as follows:
 
23    (305 ILCS 5/12-9)  (from Ch. 23, par. 12-9)
24    Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The

 

 

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1Public Aid Recoveries Trust Fund shall consist of (1)
2recoveries by the Department of Healthcare and Family Services
3(formerly Illinois Department of Public Aid) authorized by this
4Code in respect to applicants or recipients under Articles III,
5IV, V, and VI, including recoveries made by the Department of
6Healthcare and Family Services (formerly Illinois Department
7of Public Aid) from the estates of deceased recipients, (2)
8recoveries made by the Department of Healthcare and Family
9Services (formerly Illinois Department of Public Aid) in
10respect to applicants and recipients under the Children's
11Health Insurance Program Act, and the Covering ALL KIDS Health
12Insurance Act, (2.5) recoveries made by the Department of
13Healthcare and Family Services in connection with the
14imposition of an administrative penalty as provided under
15Section 12-4.45, (3) federal funds received on behalf of and
16earned by State universities and local governmental entities
17for services provided to applicants or recipients covered under
18this Code, the Children's Health Insurance Program Act, and the
19Covering ALL KIDS Health Insurance Act, (3.5) federal financial
20participation revenue related to eligible disbursements made
21by the Department of Healthcare and Family Services from
22appropriations required by this Section, and (4) all other
23moneys received to the Fund, including interest thereon. The
24Fund shall be held as a special fund in the State Treasury.
25    Disbursements from this Fund shall be only (1) for the
26reimbursement of claims collected by the Department of

 

 

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1Healthcare and Family Services (formerly Illinois Department
2of Public Aid) through error or mistake, (2) for payment to
3persons or agencies designated as payees or co-payees on any
4instrument, whether or not negotiable, delivered to the
5Department of Healthcare and Family Services (formerly
6Illinois Department of Public Aid) as a recovery under this
7Section, such payment to be in proportion to the respective
8interests of the payees in the amount so collected, (3) for
9payments to the Department of Human Services for collections
10made by the Department of Healthcare and Family Services
11(formerly Illinois Department of Public Aid) on behalf of the
12Department of Human Services under this Code, the Children's
13Health Insurance Program Act, and the Covering ALL KIDS Health
14Insurance Act, (4) for payment of administrative expenses
15incurred in performing the activities authorized under this
16Code, the Children's Health Insurance Program Act, and the
17Covering ALL KIDS Health Insurance Act, (5) for payment of fees
18to persons or agencies in the performance of activities
19pursuant to the collection of monies owed the State that are
20collected under this Code, the Children's Health Insurance
21Program Act, and the Covering ALL KIDS Health Insurance Act,
22(6) for payments of any amounts which are reimbursable to the
23federal government which are required to be paid by State
24warrant by either the State or federal government, and (7) for
25payments to State universities and local governmental entities
26of federal funds for services provided to applicants or

 

 

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1recipients covered under this Code, the Children's Health
2Insurance Program Act, and the Covering ALL KIDS Health
3Insurance Act. Disbursements from this Fund for purposes of
4items (4) and (5) of this paragraph shall be subject to
5appropriations from the Fund to the Department of Healthcare
6and Family Services (formerly Illinois Department of Public
7Aid).
8    The balance in this Fund on the first day of each calendar
9quarter, after payment therefrom of any amounts reimbursable to
10the federal government, and minus the amount reasonably
11anticipated to be needed to make the disbursements during that
12quarter authorized by this Section during the current and
13following 3 calendar months, shall be certified by the Director
14of Healthcare and Family Services and transferred by the State
15Comptroller to the Drug Rebate Fund or the Healthcare Provider
16Relief Fund in the State Treasury, as appropriate, on at least
17an annual basis by June 30th of each fiscal year within 30 days
18of the first day of each calendar quarter. The Director of
19Healthcare and Family Services may certify and the State
20Comptroller shall transfer to the Drug Rebate Fund or the
21Healthcare Provider Relief Fund amounts on a more frequent
22basis.
23    On July 1, 1999, the State Comptroller shall transfer the
24sum of $5,000,000 from the Public Aid Recoveries Trust Fund
25(formerly the Public Assistance Recoveries Trust Fund) into the
26DHS Recoveries Trust Fund.

 

 

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1(Source: P.A. 97-647, eff. 1-1-12; 97-689, eff. 6-14-12;
298-130, eff. 8-2-13.)
 
3
Article 30

 
4    Section 30-5. The Illinois Public Aid Code is amended by
5adding Section 5A-12.5 as follows:
 
6    (305 ILCS 5/5A-12.5 new)
7    Sec. 5A-12.5. Affordable Care Act adults; hospital access
8payments. The Department shall, subject to federal approval,
9mirror the Medical Assistance hospital reimbursement
10methodology, including hospital access payments as defined in
11Section 5A-12.2 of this Article and hospital access improvement
12payments as defined in Section 5A-12.4 of this Article, in
13compliance with the equivalent rate provisions of the
14Affordable Care Act.
15    As used in this Section, "Affordable Care Act" is the
16collective term for the Patient Protection and Affordable Care
17Act (Pub. L. 111-148) and the Health Care and Education
18Reconciliation Act of 2010 (Pub. L. 111-152).
 
19
Article 35

 
20    Section 35-5. The Hospital Licensing Act is amended by
21changing Section 6.09 as follows:
 

 

 

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1    (210 ILCS 85/6.09)  (from Ch. 111 1/2, par. 147.09)
2    Sec. 6.09. (a) In order to facilitate the orderly
3transition of aged and disabled patients from hospitals to
4post-hospital care, whenever a patient who qualifies for the
5federal Medicare program is hospitalized, the patient shall be
6notified of discharge at least 24 hours prior to discharge from
7the hospital. With regard to pending discharges to a skilled
8nursing facility, the hospital must notify the case
9coordination unit, as defined in 89 Ill. Adm. Code 240.260, at
10least 24 hours prior to discharge. When the assessment is
11completed in the hospital, the case coordination unit shall
12provide the discharge planner with a copy of the prescreening
13information and accompanying materials, which the discharge
14planner shall transmit when the patient is discharged to a
15skilled nursing facility. If or, if home health services are
16ordered, the hospital must inform its designated case
17coordination unit, as defined in 89 Ill. Adm. Code 240.260, of
18the pending discharge and must provide the patient with the
19case coordination unit's telephone number and other contact
20information.
21    (b) Every hospital shall develop procedures for a physician
22with medical staff privileges at the hospital or any
23appropriate medical staff member to provide the discharge
24notice prescribed in subsection (a) of this Section. The
25procedures must include prohibitions against discharging or

 

 

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1referring a patient to any of the following if unlicensed,
2uncertified, or unregistered: (i) a board and care facility, as
3defined in the Board and Care Home Act; (ii) an assisted living
4and shared housing establishment, as defined in the Assisted
5Living and Shared Housing Act; (iii) a facility licensed under
6the Nursing Home Care Act, the Specialized Mental Health
7Rehabilitation Act of 2013, or the ID/DD Community Care Act;
8(iv) a supportive living facility, as defined in Section
95-5.01a of the Illinois Public Aid Code; or (v) a free-standing
10hospice facility licensed under the Hospice Program Licensing
11Act if licensure, certification, or registration is required.
12The Department of Public Health shall annually provide
13hospitals with a list of licensed, certified, or registered
14board and care facilities, assisted living and shared housing
15establishments, nursing homes, supportive living facilities,
16facilities licensed under the ID/DD Community Care Act or the
17Specialized Mental Health Rehabilitation Act of 2013, and
18hospice facilities. Reliance upon this list by a hospital shall
19satisfy compliance with this requirement. The procedure may
20also include a waiver for any case in which a discharge notice
21is not feasible due to a short length of stay in the hospital
22by the patient, or for any case in which the patient
23voluntarily desires to leave the hospital before the expiration
24of the 24 hour period.
25    (c) At least 24 hours prior to discharge from the hospital,
26the patient shall receive written information on the patient's

 

 

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1right to appeal the discharge pursuant to the federal Medicare
2program, including the steps to follow to appeal the discharge
3and the appropriate telephone number to call in case the
4patient intends to appeal the discharge.
5    (d) Before transfer of a patient to a long term care
6facility licensed under the Nursing Home Care Act where elderly
7persons reside, a hospital shall as soon as practicable
8initiate a name-based criminal history background check by
9electronic submission to the Department of State Police for all
10persons between the ages of 18 and 70 years; provided, however,
11that a hospital shall be required to initiate such a background
12check only with respect to patients who:
13        (1) are transferring to a long term care facility for
14    the first time;
15        (2) have been in the hospital more than 5 days;
16        (3) are reasonably expected to remain at the long term
17    care facility for more than 30 days;
18        (4) have a known history of serious mental illness or
19    substance abuse; and
20        (5) are independently ambulatory or mobile for more
21    than a temporary period of time.
22    A hospital may also request a criminal history background
23check for a patient who does not meet any of the criteria set
24forth in items (1) through (5).
25    A hospital shall notify a long term care facility if the
26hospital has initiated a criminal history background check on a

 

 

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1patient being discharged to that facility. In all circumstances
2in which the hospital is required by this subsection to
3initiate the criminal history background check, the transfer to
4the long term care facility may proceed regardless of the
5availability of criminal history results. Upon receipt of the
6results, the hospital shall promptly forward the results to the
7appropriate long term care facility. If the results of the
8background check are inconclusive, the hospital shall have no
9additional duty or obligation to seek additional information
10from, or about, the patient.
11(Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813,
12eff. 7-13-12; 98-104, eff. 7-22-13.)
 
13    Section 35-10. The Illinois Public Aid Code is amended by
14changing Section 11-5.4 as follows:
 
15    (305 ILCS 5/11-5.4)
16    Sec. 11-5.4. Expedited long-term care eligibility
17determination and enrollment.
18    (a) An expedited long-term care eligibility determination
19and enrollment system shall be established to reduce long-term
20care determinations to 90 days or fewer by July 1, 2014 and
21streamline the long-term care enrollment process.
22Establishment of the system shall be a joint venture of the
23Department of Human Services and Healthcare and Family Services
24and the Department on Aging. The Governor shall name a lead

 

 

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1agency no later than 30 days after the effective date of this
2amendatory Act of the 98th General Assembly to assume
3responsibility for the full implementation of the
4establishment and maintenance of the system. Project outcomes
5shall include an enhanced eligibility determination tracking
6system accessible to providers and a centralized application
7review and eligibility determination with all applicants
8reviewed within 90 days of receipt by the State of a complete
9application. If the Department of Healthcare and Family
10Services' Office of the Inspector General determines that there
11is a likelihood that a non-allowable transfer of assets has
12occurred, and the facility in which the applicant resides is
13notified, an extension of up to 90 days shall be permissible.
14On or before December 31, 2015, a streamlined application and
15enrollment process shall be put in place based on the following
16principles:
17        (1) Minimize the burden on applicants by collecting
18    only the data necessary to determine eligibility for
19    medical services, long-term care services, and spousal
20    impoverishment offset.
21        (2) Integrate online data sources to simplify the
22    application process by reducing the amount of information
23    needed to be entered and to expedite eligibility
24    verification.
25        (3) Provide online prompts to alert the applicant that
26    information is missing or not complete.

 

 

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1    (b) The Department shall, on or before July 1, 2014, assess
2the feasibility of incorporating all information needed to
3determine eligibility for long-term care services, including
4asset transfer and spousal impoverishment financials, into the
5State's integrated eligibility system identifying all
6resources needed and reasonable timeframes for achieving the
7specified integration.
8    (c) The lead agency shall file interim reports with the
9Chairs and Minority Spokespersons of the House and Senate Human
10Services Committees no later than September 1, 2013 and on
11February 1, 2014. The Department of Healthcare and Family
12Services shall include in the annual Medicaid report for State
13Fiscal Year 2014 and every fiscal year thereafter information
14concerning implementation of the provisions of this Section.
15    (d) No later than August 1, 2014, the Auditor General shall
16report to the General Assembly concerning the extent to which
17the timeframes specified in this Section have been met and the
18extent to which State staffing levels are adequate to meet the
19requirements of this Section.
20    (e) The Department of Healthcare and Family Services, the
21Department of Human Services, and the Department on Aging shall
22take the following steps to achieve federally established
23timeframes for eligibility determinations for Medicaid and
24long-term care benefits and shall work toward the federal goal
25of real time determinations:
26        (1) The Departments shall review, in collaboration

 

 

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1    with representatives of affected providers, all forms and
2    procedures currently in use, federal guidelines either
3    suggested or mandated, and staff deployment by September
4    30, 2014 to identify additional measures that can improve
5    long-term care eligibility processing and make adjustments
6    where possible.
7        (2) No later than June 30, 2014, the Department of
8    Healthcare and Family Services shall issue vouchers for
9    advance payments not to exceed $50,000,000 to nursing
10    facilities with significant outstanding Medicaid liability
11    associated with services provided to residents with
12    Medicaid applications pending and residents facing the
13    greatest delays. Each facility with an advance payment
14    shall state in writing whether its own recoupment schedule
15    will be in 3 or 6 equal monthly installments, as long as
16    all advances are recouped by June 30, 2015.
17        (3) The Department of Healthcare and Family Services'
18    Office of Inspector General and the Department of Human
19    Services shall immediately forgo resource review and
20    review of transfers during the relevant look-back period
21    for applications that were submitted prior to September 1,
22    2013. An applicant who applied prior to September 1, 2013,
23    who was denied for failure to cooperate in providing
24    required information, and whose application was
25    incorrectly reviewed under the wrong look-back period
26    rules may request review and correction of the denial based

 

 

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1    on this subsection. If found eligible upon review, such
2    applicants shall be retroactively enrolled.
3        (4) As soon as practicable, the Department of
4    Healthcare and Family Services shall implement policies
5    and promulgate rules to simplify financial eligibility
6    verification in the following instances: (A) for
7    applicants or recipients who are receiving Supplemental
8    Security Income payments or who had been receiving such
9    payments at the time they were admitted to a nursing
10    facility and (B) for applicants or recipients with verified
11    income at or below 100% of the federal poverty level when
12    the declared value of their countable resources is no
13    greater than the allowable amounts pursuant to Section 5-2
14    of this Code for classes of eligible persons for whom a
15    resource limit applies. Such simplified verification
16    policies shall apply to community cases as well as
17    long-term care cases.
18        (5) As soon as practicable, but not later than July 1,
19    2014, the Department of Healthcare and Family Services and
20    the Department of Human Services shall jointly begin a
21    special enrollment project by using simplified eligibility
22    verification policies and by redeploying caseworkers
23    trained to handle long-term care cases to prioritize those
24    cases, until the backlog is eliminated and processing time
25    is within 90 days. This project shall apply to applications
26    for long-term care received by the State on or before May

 

 

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1    15, 2014.
2        (6) As soon as practicable, but not later than
3    September 1, 2014, the Department on Aging shall make
4    available to long-term care facilities and community
5    providers upon request, through an electronic method, the
6    information contained within the Interagency Certification
7    of Screening Results completed by the pre-screener, in a
8    form and manner acceptable to the Department of Human
9    Services.
10        (7) Effective 30 days after the completion of 3
11    regionally based trainings, nursing facilities shall
12    submit all applications for medical assistance online via
13    the Application for Benefits Eligibility (ABE) website.
14    This requirement shall extend to scanning and uploading
15    with the online application any required additional forms
16    such as the Long Term Care Facility Notification and the
17    Additional Financial Information for Long Term Care
18    Applicants as well as scanned copies of any supporting
19    documentation. Long-term care facility admission documents
20    must be submitted as required in Section 5-5 of this Code.
21    No local Department of Human Services office shall refuse
22    to accept an electronically filed application.
23        (8) Notwithstanding any other provision of this Code,
24    the Department of Human Services and the Department of
25    Healthcare and Family Services' Office of the Inspector
26    General shall, upon request, allow an applicant additional

 

 

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1    time to submit information and documents needed as part of
2    a review of available resources or resources transferred
3    during the look-back period. The initial extension shall
4    not exceed 30 days. A second extension of 30 days may be
5    granted upon request. Any request for information issued by
6    the State to an applicant shall include the following: an
7    explanation of the information required and the date by
8    which the information must be submitted; a statement that
9    failure to respond in a timely manner can result in denial
10    of the application; a statement that the applicant or the
11    facility in the name of the applicant may seek an
12    extension; and the name and contact information of a
13    caseworker in case of questions. Any such request for
14    information shall also be sent to the facility. In deciding
15    whether to grant an extension, the Department of Human
16    Services or the Department of Healthcare and Family
17    Services' Office of the Inspector General shall take into
18    account what is in the best interest of the applicant. The
19    time limits for processing an application shall be tolled
20    during the period of any extension granted under this
21    subsection.
22        (9) The Department of Human Services and the Department
23    of Healthcare and Family Services must jointly compile data
24    on pending applications and post a monthly report on each
25    Department's website for the purposes of monitoring
26    long-term care eligibility processing. The report must

 

 

SB0741 Enrolled- 135 -LRB098 04975 KTG 35005 b

1    specify the number of applications pending long-term care
2    eligibility determination and admission in the following
3    categories:
4            (A) Length of time application is pending - 0 to 90
5        days, 91 days to 180 days, 181 days to 12 months, over
6        12 months to 18 months, over 18 months to 24 months,
7        and over 24 months.
8            (B) Percentage of applications pending in the
9        Department of Human Services' Family Community
10        Resource Centers, in the Department of Human Services'
11        long-term care hubs, with the Department of Healthcare
12        and Family Services' Office of Inspector General, and
13        those applications which are being tolled due to
14        requests for extension of time for additional
15        information.
16            (C) Status of pending applications.
17(Source: P.A. 98-104, eff. 7-22-13.)
 
18
Article 40

 
19    Section 40-5. The Illinois Public Aid Code is amended by
20changing Sections 5A-2, 5A-5, 5A-10, and 5A-14 as follows:
 
21    (305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
22    (Section scheduled to be repealed on January 1, 2015)
23    Sec. 5A-2. Assessment.

 

 

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1    (a) Subject to Sections 5A-3 and 5A-10, for State fiscal
2years 2009 through 2018 2014, and from July 1, 2014 through
3December 31, 2014, an annual assessment on inpatient services
4is imposed on each hospital provider in an amount equal to
5$218.38 multiplied by the difference of the hospital's occupied
6bed days less the hospital's Medicare bed days, provided,
7however, that the amount of $218.38 shall be increased by a
8uniform percentage to generate an amount equal to 75% of the
9State share of the payments authorized under Section 12-5, with
10such increase only taking effect upon the date that a State
11share for such payments is required under federal law.
12    For State fiscal years 2009 through 2014, and after, a
13hospital's occupied bed days and Medicare bed days shall be
14determined using the most recent data available from each
15hospital's 2005 Medicare cost report as contained in the
16Healthcare Cost Report Information System file, for the quarter
17ending on December 31, 2006, without regard to any subsequent
18adjustments or changes to such data. If a hospital's 2005
19Medicare cost report is not contained in the Healthcare Cost
20Report Information System, then the Illinois Department may
21obtain the hospital provider's occupied bed days and Medicare
22bed days from any source available, including, but not limited
23to, records maintained by the hospital provider, which may be
24inspected at all times during business hours of the day by the
25Illinois Department or its duly authorized agents and
26employees.

 

 

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1    (b) (Blank).
2    (b-5) Subject to Sections 5A-3 and 5A-10, for the portion
3of State fiscal year 2012, beginning June 10, 2012 through June
430, 2012, and for State fiscal years 2013 through 2018 2014,
5and July 1, 2014 through December 31, 2014, an annual
6assessment on outpatient services is imposed on each hospital
7provider in an amount equal to .008766 multiplied by the
8hospital's outpatient gross revenue, provided, however, that
9the amount of .008766 shall be increased by a uniform
10percentage to generate an amount equal to 25% of the State
11share of the payments authorized under Section 12-5, with such
12increase only taking effect upon the date that a State share
13for such payments is required under federal law. For the period
14beginning June 10, 2012 through June 30, 2012, the annual
15assessment on outpatient services shall be prorated by
16multiplying the assessment amount by a fraction, the numerator
17of which is 21 days and the denominator of which is 365 days.
18    For the portion of State fiscal year 2012, beginning June
1910, 2012 through June 30, 2012, and State fiscal years 2013
20through 2018 2014, and July 1, 2014 through December 31, 2014,
21a hospital's outpatient gross revenue shall be determined using
22the most recent data available from each hospital's 2009
23Medicare cost report as contained in the Healthcare Cost Report
24Information System file, for the quarter ending on June 30,
252011, without regard to any subsequent adjustments or changes
26to such data. If a hospital's 2009 Medicare cost report is not

 

 

SB0741 Enrolled- 138 -LRB098 04975 KTG 35005 b

1contained in the Healthcare Cost Report Information System,
2then the Department may obtain the hospital provider's
3outpatient gross revenue from any source available, including,
4but not limited to, records maintained by the hospital
5provider, which may be inspected at all times during business
6hours of the day by the Department or its duly authorized
7agents and employees.
8    (c) (Blank).
9    (d) Notwithstanding any of the other provisions of this
10Section, the Department is authorized to adopt rules to reduce
11the rate of any annual assessment imposed under this Section,
12as authorized by Section 5-46.2 of the Illinois Administrative
13Procedure Act.
14    (e) Notwithstanding any other provision of this Section,
15any plan providing for an assessment on a hospital provider as
16a permissible tax under Title XIX of the federal Social
17Security Act and Medicaid-eligible payments to hospital
18providers from the revenues derived from that assessment shall
19be reviewed by the Illinois Department of Healthcare and Family
20Services, as the Single State Medicaid Agency required by
21federal law, to determine whether those assessments and
22hospital provider payments meet federal Medicaid standards. If
23the Department determines that the elements of the plan may
24meet federal Medicaid standards and a related State Medicaid
25Plan Amendment is prepared in a manner and form suitable for
26submission, that State Plan Amendment shall be submitted in a

 

 

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1timely manner for review by the Centers for Medicare and
2Medicaid Services of the United States Department of Health and
3Human Services and subject to approval by the Centers for
4Medicare and Medicaid Services of the United States Department
5of Health and Human Services. No such plan shall become
6effective without approval by the Illinois General Assembly by
7the enactment into law of related legislation. Notwithstanding
8any other provision of this Section, the Department is
9authorized to adopt rules to reduce the rate of any annual
10assessment imposed under this Section. Any such rules may be
11adopted by the Department under Section 5-50 of the Illinois
12Administrative Procedure Act.
13(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12;
1498-104, eff. 7-22-13.)
 
15    (305 ILCS 5/5A-5)  (from Ch. 23, par. 5A-5)
16    Sec. 5A-5. Notice; penalty; maintenance of records.
17    (a) The Illinois Department shall send a notice of
18assessment to every hospital provider subject to assessment
19under this Article. The notice of assessment shall notify the
20hospital of its assessment and shall be sent after receipt by
21the Department of notification from the Centers for Medicare
22and Medicaid Services of the U.S. Department of Health and
23Human Services that the payment methodologies required under
24this Article and, if necessary, the waiver granted under 42 CFR
25433.68 have been approved. The notice shall be on a form

 

 

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1prepared by the Illinois Department and shall state the
2following:
3        (1) The name of the hospital provider.
4        (2) The address of the hospital provider's principal
5    place of business from which the provider engages in the
6    occupation of hospital provider in this State, and the name
7    and address of each hospital operated, conducted, or
8    maintained by the provider in this State.
9        (3) The occupied bed days, occupied bed days less
10    Medicare days, adjusted gross hospital revenue, or
11    outpatient gross revenue of the hospital provider
12    (whichever is applicable), the amount of assessment
13    imposed under Section 5A-2 for the State fiscal year for
14    which the notice is sent, and the amount of each
15    installment to be paid during the State fiscal year.
16        (4) (Blank).
17        (5) Other reasonable information as determined by the
18    Illinois Department.
19    (b) If a hospital provider conducts, operates, or maintains
20more than one hospital licensed by the Illinois Department of
21Public Health, the provider shall pay the assessment for each
22hospital separately.
23    (c) Notwithstanding any other provision in this Article, in
24the case of a person who ceases to conduct, operate, or
25maintain a hospital in respect of which the person is subject
26to assessment under this Article as a hospital provider, the

 

 

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1assessment for the State fiscal year in which the cessation
2occurs shall be adjusted by multiplying the assessment computed
3under Section 5A-2 by a fraction, the numerator of which is the
4number of days in the year during which the provider conducts,
5operates, or maintains the hospital and the denominator of
6which is 365. Immediately upon ceasing to conduct, operate, or
7maintain a hospital, the person shall pay the assessment for
8the year as so adjusted (to the extent not previously paid).
9    (d) Notwithstanding any other provision in this Article, a
10provider who commences conducting, operating, or maintaining a
11hospital, upon notice by the Illinois Department, shall pay the
12assessment computed under Section 5A-2 and subsection (e) in
13installments on the due dates stated in the notice and on the
14regular installment due dates for the State fiscal year
15occurring after the due dates of the initial notice.
16    (e) Notwithstanding any other provision in this Article,
17for State fiscal years 2009 through 2018 2014, in the case of a
18hospital provider that did not conduct, operate, or maintain a
19hospital in 2005, the assessment for that State fiscal year
20shall be computed on the basis of hypothetical occupied bed
21days for the full calendar year as determined by the Illinois
22Department. Notwithstanding any other provision in this
23Article, for the portion of State fiscal year 2012 beginning
24June 10, 2012 through June 30, 2012, and for State fiscal years
252013 through 2018 2014, and for July 1, 2014 through December
2631, 2014, in the case of a hospital provider that did not

 

 

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1conduct, operate, or maintain a hospital in 2009, the
2assessment under subsection (b-5) of Section 5A-2 for that
3State fiscal year shall be computed on the basis of
4hypothetical gross outpatient revenue for the full calendar
5year as determined by the Illinois Department.
6    (f) Every hospital provider subject to assessment under
7this Article shall keep sufficient records to permit the
8determination of adjusted gross hospital revenue for the
9hospital's fiscal year. All such records shall be kept in the
10English language and shall, at all times during regular
11business hours of the day, be subject to inspection by the
12Illinois Department or its duly authorized agents and
13employees.
14    (g) The Illinois Department may, by rule, provide a
15hospital provider a reasonable opportunity to request a
16clarification or correction of any clerical or computational
17errors contained in the calculation of its assessment, but such
18corrections shall not extend to updating the cost report
19information used to calculate the assessment.
20    (h) (Blank).
21(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12;
2298-104, eff. 7-22-13; 98-463, eff. 8-16-13; revised 10-21-13.)
 
23    (305 ILCS 5/5A-10)  (from Ch. 23, par. 5A-10)
24    Sec. 5A-10. Applicability.
25    (a) The assessment imposed by subsection (a) of Section

 

 

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15A-2 shall cease to be imposed and the Department's obligation
2to make payments shall immediately cease, and any moneys
3remaining in the Fund shall be refunded to hospital providers
4in proportion to the amounts paid by them, if:
5        (1) The payments to hospitals required under this
6    Article are not eligible for federal matching funds under
7    Title XIX or XXI of the Social Security Act;
8        (2) For State fiscal years 2009 through 2018 2014, and
9    July 1, 2014 through December 31, 2014, the Department of
10    Healthcare and Family Services adopts any administrative
11    rule change to reduce payment rates or alters any payment
12    methodology that reduces any payment rates made to
13    operating hospitals under the approved Title XIX or Title
14    XXI State plan in effect January 1, 2008 except for:
15            (A) any changes for hospitals described in
16        subsection (b) of Section 5A-3;
17            (B) any rates for payments made under this Article
18        V-A;
19            (C) any changes proposed in State plan amendment
20        transmittal numbers 08-01, 08-02, 08-04, 08-06, and
21        08-07;
22            (D) in relation to any admissions on or after
23        January 1, 2011, a modification in the methodology for
24        calculating outlier payments to hospitals for
25        exceptionally costly stays, for hospitals reimbursed
26        under the diagnosis-related grouping methodology in

 

 

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1        effect on July 1, 2011; provided that the Department
2        shall be limited to one such modification during the
3        36-month period after the effective date of this
4        amendatory Act of the 96th General Assembly; or
5            (E) any changes affecting hospitals authorized by
6        Public Act 97-689; or .
7            (F) any changes authorized by Section 14-12 of this
8        Code, or for any changes authorized under Section 5A-15
9        of this Code.
10    (b) The assessment imposed by Section 5A-2 shall not take
11effect or shall cease to be imposed, and the Department's
12obligation to make payments shall immediately cease, if the
13assessment is determined to be an impermissible tax under Title
14XIX of the Social Security Act. Moneys in the Hospital Provider
15Fund derived from assessments imposed prior thereto shall be
16disbursed in accordance with Section 5A-8 to the extent federal
17financial participation is not reduced due to the
18impermissibility of the assessments, and any remaining moneys
19shall be refunded to hospital providers in proportion to the
20amounts paid by them.
21    (c) The assessments imposed by subsection (b-5) of Section
225A-2 shall not take effect or shall cease to be imposed, the
23Department's obligation to make payments shall immediately
24cease, and any moneys remaining in the Fund shall be refunded
25to hospital providers in proportion to the amounts paid by
26them, if the payments to hospitals required under Section

 

 

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15A-12.4 are not eligible for federal matching funds under Title
2XIX of the Social Security Act.
3    (d) The assessments imposed by Section 5A-2 shall not take
4effect or shall cease to be imposed, the Department's
5obligation to make payments shall immediately cease, and any
6moneys remaining in the Fund shall be refunded to hospital
7providers in proportion to the amounts paid by them, if:
8        (1) for State fiscal years 2013 through 2018 2014, and
9    July 1, 2014 through December 31, 2014, the Department
10    reduces any payment rates to hospitals as in effect on May
11    1, 2012, or alters any payment methodology as in effect on
12    May 1, 2012, that has the effect of reducing payment rates
13    to hospitals, except for any changes affecting hospitals
14    authorized in Public Act 97-689 and any changes authorized
15    by Section 14-12 of this Code, and except for any changes
16    authorized under Section 5A-15; or
17        (2) for State fiscal years 2013 through 2018 2014, and
18    July 1, 2014 through December 31, 2014, the Department
19    reduces any supplemental payments made to hospitals below
20    the amounts paid for services provided in State fiscal year
21    2011 as implemented by administrative rules adopted and in
22    effect on or prior to June 30, 2011, except for any changes
23    affecting hospitals authorized in Public Act 97-689 and any
24    changes authorized by Section 14-12 of this Code, and
25    except for any changes authorized under Section 5A-15; or .
26        (3) for State fiscal years 2015 through 2018, the

 

 

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1    Department reduces the overall effective rate of
2    reimbursement to hospitals below the level authorized
3    under Section 14-12 of this Code, except for any changes
4    under Section 14-12 or Section 5A-15 of this Code.
5(Source: P.A. 97-72, eff. 7-1-11; 97-74, eff. 6-30-11; 97-688,
6eff. 6-14-12; 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)
 
7    (305 ILCS 5/5A-14)
8    Sec. 5A-14. Repeal of assessments and disbursements.
9    (a) Section 5A-2 is repealed on July 1, 2018 January 1,
102015.
11    (b) Section 5A-12 is repealed on July 1, 2005.
12    (c) Section 5A-12.1 is repealed on July 1, 2008.
13    (d) Section 5A-12.2 and Section 5A-12.4 are repealed on
14July 1, 2018 January 1, 2015.
15    (e) Section 5A-12.3 is repealed on July 1, 2011.
16(Source: P.A. 96-821, eff. 11-20-09; 96-1530, eff. 2-16-11;
1797-688, eff. 6-14-12; 97-689, eff. 6-14-12.)
 
18
Article 45

 
19    Section 45-5. The Illinois Public Aid Code is amended by
20changing Section 14-8 and by adding Section 14-12 as follows:
 
21    (305 ILCS 5/14-8)  (from Ch. 23, par. 14-8)
22    Sec. 14-8. Disbursements to Hospitals.

 

 

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1    (a) For inpatient hospital services rendered on and after
2September 1, 1991, the Illinois Department shall reimburse
3hospitals for inpatient services at an inpatient payment rate
4calculated for each hospital based upon the Medicare
5Prospective Payment System as set forth in Sections 1886(b),
6(d), (g), and (h) of the federal Social Security Act, and the
7regulations, policies, and procedures promulgated thereunder,
8except as modified by this Section. Payment rates for inpatient
9hospital services rendered on or after September 1, 1991 and on
10or before September 30, 1992 shall be calculated using the
11Medicare Prospective Payment rates in effect on September 1,
121991. Payment rates for inpatient hospital services rendered on
13or after October 1, 1992 and on or before March 31, 1994 shall
14be calculated using the Medicare Prospective Payment rates in
15effect on September 1, 1992. Payment rates for inpatient
16hospital services rendered on or after April 1, 1994 shall be
17calculated using the Medicare Prospective Payment rates
18(including the Medicare grouping methodology and weighting
19factors as adjusted pursuant to paragraph (1) of this
20subsection) in effect 90 days prior to the date of admission.
21For services rendered on or after July 1, 1995, the
22reimbursement methodology implemented under this subsection
23shall not include those costs referred to in Sections
241886(d)(5)(B) and 1886(h) of the Social Security Act. The
25additional payment amounts required under Section
261886(d)(5)(F) of the Social Security Act, for hospitals serving

 

 

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1a disproportionate share of low-income or indigent patients,
2are not required under this Section. For hospital inpatient
3services rendered on or after July 1, 1995 and on or before
4June 30, 2014, the Illinois Department shall reimburse
5hospitals using the relative weighting factors and the base
6payment rates calculated for each hospital that were in effect
7on June 30, 1995, less the portion of such rates attributed by
8the Illinois Department to the cost of medical education.
9        (1) The weighting factors established under Section
10    1886(d)(4) of the Social Security Act shall not be used in
11    the reimbursement system established under this Section.
12    Rather, the Illinois Department shall establish by rule
13    Medicaid weighting factors to be used in the reimbursement
14    system established under this Section.
15        (2) The Illinois Department shall define by rule those
16    hospitals or distinct parts of hospitals that shall be
17    exempt from the reimbursement system established under
18    this Section. In defining such hospitals, the Illinois
19    Department shall take into consideration those hospitals
20    exempt from the Medicare Prospective Payment System as of
21    September 1, 1991. For hospitals defined as exempt under
22    this subsection, the Illinois Department shall by rule
23    establish a reimbursement system for payment of inpatient
24    hospital services rendered on and after September 1, 1991.
25    For all hospitals that are children's hospitals as defined
26    in Section 5-5.02 of this Code, the reimbursement

 

 

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1    methodology shall, through June 30, 1992, net of all
2    applicable fees, at least equal each children's hospital
3    1990 ICARE payment rates, indexed to the current year by
4    application of the DRI hospital cost index from 1989 to the
5    year in which payments are made. Excepting county providers
6    as defined in Article XV of this Code, hospitals licensed
7    under the University of Illinois Hospital Act, and
8    facilities operated by the Department of Mental Health and
9    Developmental Disabilities (or its successor, the
10    Department of Human Services) for hospital inpatient
11    services rendered on or after July 1, 1995 and on or before
12    June 30, 2014, the Illinois Department shall reimburse
13    children's hospitals, as defined in 89 Illinois
14    Administrative Code Section 149.50(c)(3), at the rates in
15    effect on June 30, 1995, and shall reimburse all other
16    hospitals at the rates in effect on June 30, 1995, less the
17    portion of such rates attributed by the Illinois Department
18    to the cost of medical education. For inpatient hospital
19    services provided on or after August 1, 1998, the Illinois
20    Department may establish by rule a means of adjusting the
21    rates of children's hospitals, as defined in 89 Illinois
22    Administrative Code Section 149.50(c)(3), that did not
23    meet that definition on June 30, 1995, in order for the
24    inpatient hospital rates of such hospitals to take into
25    account the average inpatient hospital rates of those
26    children's hospitals that did meet the definition of

 

 

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1    children's hospitals on June 30, 1995.
2        (3) (Blank).
3        (4) Notwithstanding any other provision of this
4    Section, hospitals that on August 31, 1991, have a contract
5    with the Illinois Department under Section 3-4 of the
6    Illinois Health Finance Reform Act may elect to continue to
7    be reimbursed at rates stated in such contracts for general
8    and specialty care.
9        (5) In addition to any payments made under this
10    subsection (a), the Illinois Department shall make the
11    adjustment payments required by Section 5-5.02 of this
12    Code; provided, that in the case of any hospital reimbursed
13    under a per case methodology, the Illinois Department shall
14    add an amount equal to the product of the hospital's
15    average length of stay, less one day, multiplied by 20, for
16    inpatient hospital services rendered on or after September
17    1, 1991 and on or before September 30, 1992.
18    (b) (Blank).
19    (b-5) Excepting county providers as defined in Article XV
20of this Code, hospitals licensed under the University of
21Illinois Hospital Act, and facilities operated by the Illinois
22Department of Mental Health and Developmental Disabilities (or
23its successor, the Department of Human Services), for
24outpatient services rendered on or after July 1, 1995 and
25before July 1, 1998 the Illinois Department shall reimburse
26children's hospitals, as defined in the Illinois

 

 

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1Administrative Code Section 149.50(c)(3), at the rates in
2effect on June 30, 1995, less that portion of such rates
3attributed by the Illinois Department to the outpatient
4indigent volume adjustment and shall reimburse all other
5hospitals at the rates in effect on June 30, 1995, less the
6portions of such rates attributed by the Illinois Department to
7the cost of medical education and attributed by the Illinois
8Department to the outpatient indigent volume adjustment. For
9outpatient services provided on or after July 1, 1998 and on or
10before June 30, 2014, reimbursement rates shall be established
11by rule.
12    (c) In addition to any other payments under this Code, the
13Illinois Department shall develop a hospital disproportionate
14share reimbursement methodology that, effective July 1, 1991,
15through September 30, 1992, shall reimburse hospitals
16sufficiently to expend the fee monies described in subsection
17(b) of Section 14-3 of this Code and the federal matching funds
18received by the Illinois Department as a result of expenditures
19made by the Illinois Department as required by this subsection
20(c) and Section 14-2 that are attributable to fee monies
21deposited in the Fund, less amounts applied to adjustment
22payments under Section 5-5.02.
23    (d) Critical Care Access Payments.
24        (1) In addition to any other payments made under this
25    Code, the Illinois Department shall develop a
26    reimbursement methodology that shall reimburse Critical

 

 

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1    Care Access Hospitals for the specialized services that
2    qualify them as Critical Care Access Hospitals. No
3    adjustment payments shall be made under this subsection on
4    or after July 1, 1995.
5        (2) "Critical Care Access Hospitals" includes, but is
6    not limited to, hospitals that meet at least one of the
7    following criteria:
8            (A) Hospitals located outside of a metropolitan
9        statistical area that are designated as Level II
10        Perinatal Centers and that provide a disproportionate
11        share of perinatal services to recipients; or
12            (B) Hospitals that are designated as Level I Trauma
13        Centers (adult or pediatric) and certain Level II
14        Trauma Centers as determined by the Illinois
15        Department; or
16            (C) Hospitals located outside of a metropolitan
17        statistical area and that provide a disproportionate
18        share of obstetrical services to recipients.
19    (e) Inpatient high volume adjustment. For hospital
20inpatient services, effective with rate periods beginning on or
21after October 1, 1993, in addition to rates paid for inpatient
22services by the Illinois Department, the Illinois Department
23shall make adjustment payments for inpatient services
24furnished by Medicaid high volume hospitals. The Illinois
25Department shall establish by rule criteria for qualifying as a
26Medicaid high volume hospital and shall establish by rule a

 

 

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1reimbursement methodology for calculating these adjustment
2payments to Medicaid high volume hospitals. No adjustment
3payment shall be made under this subsection for services
4rendered on or after July 1, 1995.
5    (f) The Illinois Department shall modify its current rules
6governing adjustment payments for targeted access, critical
7care access, and uncompensated care to classify those
8adjustment payments as not being payments to disproportionate
9share hospitals under Title XIX of the federal Social Security
10Act. Rules adopted under this subsection shall not be effective
11with respect to services rendered on or after July 1, 1995. The
12Illinois Department has no obligation to adopt or implement any
13rules or make any payments under this subsection for services
14rendered on or after July 1, 1995.
15    (f-5) The State recognizes that adjustment payments to
16hospitals providing certain services or incurring certain
17costs may be necessary to assure that recipients of medical
18assistance have adequate access to necessary medical services.
19These adjustments include payments for teaching costs and
20uncompensated care, trauma center payments, rehabilitation
21hospital payments, perinatal center payments, obstetrical care
22payments, targeted access payments, Medicaid high volume
23payments, and outpatient indigent volume payments. On or before
24April 1, 1995, the Illinois Department shall issue
25recommendations regarding (i) reimbursement mechanisms or
26adjustment payments to reflect these costs and services,

 

 

SB0741 Enrolled- 154 -LRB098 04975 KTG 35005 b

1including methods by which the payments may be calculated and
2the method by which the payments may be financed, and (ii)
3reimbursement mechanisms or adjustment payments to reflect
4costs and services of federally qualified health centers with
5respect to recipients of medical assistance.
6    (g) If one or more hospitals file suit in any court
7challenging any part of this Article XIV, payments to hospitals
8under this Article XIV shall be made only to the extent that
9sufficient monies are available in the Fund and only to the
10extent that any monies in the Fund are not prohibited from
11disbursement under any order of the court.
12    (h) Payments under the disbursement methodology described
13in this Section are subject to approval by the federal
14government in an appropriate State plan amendment.
15    (i) The Illinois Department may by rule establish criteria
16for and develop methodologies for adjustment payments to
17hospitals participating under this Article.
18    (j) Hospital Residing Long Term Care Services. In addition
19to any other payments made under this Code, the Illinois
20Department may by rule establish criteria and develop
21methodologies for payments to hospitals for Hospital Residing
22Long Term Care Services.
23    (k) Critical Access Hospital outpatient payments. In
24addition to any other payments authorized under this Code, the
25Illinois Department shall reimburse critical access hospitals,
26as designated by the Illinois Department of Public Health in

 

 

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1accordance with 42 CFR 485, Subpart F, for outpatient services
2at an amount that is no less than the cost of providing such
3services, based on Medicare cost principles. Payments under
4this subsection shall be subject to appropriation.
5    (l) On and after July 1, 2012, the Department shall reduce
6any rate of reimbursement for services or other payments or
7alter any methodologies authorized by this Code to reduce any
8rate of reimbursement for services or other payments in
9accordance with Section 5-5e.
10(Source: P.A. 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)
 
11    (305 ILCS 5/14-12 new)
12    Sec. 14-12. Hospital rate reform payment system. The
13hospital payment system pursuant to Section 14-11 of this
14Article shall be as follows:
15    (a) Inpatient hospital services. Effective for discharges
16on and after July 1, 2014, reimbursement for inpatient general
17acute care services shall utilize the All Patient Refined
18Diagnosis Related Grouping (APR-DRG) software, version 30,
19distributed by 3MTM Health Information System.
20        (1) The Department shall establish Medicaid weighting
21    factors to be used in the reimbursement system established
22    under this subsection. Initial weighting factors shall be
23    the weighting factors as published by 3M Health Information
24    System, associated with Version 30.0 adjusted for the
25    Illinois experience.

 

 

SB0741 Enrolled- 156 -LRB098 04975 KTG 35005 b

1        (2) The Department shall establish a
2    statewide-standardized amount to be used in the inpatient
3    reimbursement system. The Department shall publish these
4    amounts on its website no later than 10 calendar days prior
5    to their effective date.
6        (3) In addition to the statewide-standardized amount,
7    the Department shall develop adjusters to adjust the rate
8    of reimbursement for critical Medicaid providers or
9    services for trauma, transplantation services, perinatal
10    care, and Graduate Medical Education (GME).
11        (4) The Department shall develop add-on payments to
12    account for exceptionally costly inpatient stays,
13    consistent with Medicare outlier principles. Outlier fixed
14    loss thresholds may be updated to control for excessive
15    growth in outlier payments no more frequently than on an
16    annual basis, but at least triennially. Upon updating the
17    fixed loss thresholds, the Department shall be required to
18    update base rates within 12 months.
19        (5) The Department shall define those hospitals or
20    distinct parts of hospitals that shall be exempt from the
21    APR-DRG reimbursement system established under this
22    Section. The Department shall publish these hospitals'
23    inpatient rates on its website no later than 10 calendar
24    days prior to their effective date.
25        (6) Beginning July 1, 2014 and ending on June 30, 2018,
26    in addition to the statewide-standardized amount, the

 

 

SB0741 Enrolled- 157 -LRB098 04975 KTG 35005 b

1    Department shall develop an adjustor to adjust the rate of
2    reimbursement for safety-net hospitals defined in Section
3    5-5e.1 of this Code excluding pediatric hospitals.
4        (7) Beginning July 1, 2014 and ending on June 30, 2018,
5    in addition to the statewide-standardized amount, the
6    Department shall develop an adjustor to adjust the rate of
7    reimbursement for Illinois freestanding inpatient
8    psychiatric hospitals that are not designated as
9    children's hospitals by the Department but are primarily
10    treating patients under the age of 21.
11    (b) Outpatient hospital services. Effective for dates of
12service on and after July 1, 2014, reimbursement for outpatient
13services shall utilize the Enhanced Ambulatory Procedure
14Grouping (E-APG) software, version 3.7 distributed by 3MTM
15Health Information System.
16        (1) The Department shall establish Medicaid weighting
17    factors to be used in the reimbursement system established
18    under this subsection. The initial weighting factors shall
19    be the weighting factors as published by 3M Health
20    Information System, associated with Version 3.7.
21        (2) The Department shall establish service specific
22    statewide-standardized amounts to be used in the
23    reimbursement system.
24            (A) The initial statewide standardized amounts,
25        with the labor portion adjusted by the Calendar Year
26        2013 Medicare Outpatient Prospective Payment System

 

 

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1        wage index with reclassifications, shall be published
2        by the Department on its website no later than 10
3        calendar days prior to their effective date.
4            (B) The Department shall establish adjustments to
5        the statewide-standardized amounts for each Critical
6        Access Hospital, as designated by the Department of
7        Public Health in accordance with 42 CFR 485, Subpart F.
8        The EAPG standardized amounts are determined
9        separately for each critical access hospital such that
10        simulated EAPG payments using outpatient base period
11        paid claim data plus payments under Section 5A-12.4 of
12        this Code net of the associated tax costs are equal to
13        the estimated costs of outpatient base period claims
14        data with a rate year cost inflation factor applied.
15        (3) In addition to the statewide-standardized amounts,
16    the Department shall develop adjusters to adjust the rate
17    of reimbursement for critical Medicaid hospital outpatient
18    providers or services, including outpatient high volume or
19    safety-net hospitals.
20    (c) In consultation with the hospital community, the
21Department is authorized to replace 89 Ill. Admin. Code 152.150
22as published in 38 Ill. Reg. 4980 through 4986 within 12 months
23of the effective date of this amendatory Act of the 98th
24General Assembly. If the Department does not replace these
25rules within 12 months of the effective date of this amendatory
26Act of the 98th General Assembly, the rules in effect for

 

 

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1152.150 as published in 38 Ill. Reg. 4980 through 4986 shall
2remain in effect until modified by rule by the Department.
3Nothing in this subsection shall be construed to mandate that
4the Department file a replacement rule.
5    (d) Transition period. There shall be a transition period
6to the reimbursement systems authorized under this Section that
7shall begin on the effective date of these systems and continue
8until June 30, 2018, unless extended by rule by the Department.
9To help provide an orderly and predictable transition to the
10new reimbursement systems and to preserve and enhance access to
11the hospital services during this transition, the Department
12shall allocate a transitional hospital access pool of at least
13$290,000,000 annually so that transitional hospital access
14payments are made to hospitals.
15        (1) After the transition period, the Department may
16    begin incorporating the transitional hospital access pool
17    into the base rate structure.
18        (2) After the transition period, if the Department
19    reduces payments from the transitional hospital access
20    pool, it shall increase base rates, develop new adjustors,
21    adjust current adjustors, develop new hospital access
22    payments based on updated information, or any combination
23    thereof by an amount equal to the decreases proposed in the
24    transitional hospital access pool payments, ensuring that
25    the entire transitional hospital access pool amount shall
26    continue to be used for hospital payments.

 

 

SB0741 Enrolled- 160 -LRB098 04975 KTG 35005 b

1    (e) Beginning 36 months after initial implementation, the
2Department shall update the reimbursement components in
3subsections (a) and (b), including standardized amounts and
4weighting factors, and at least triennially and no more
5frequently than annually thereafter. The Department shall
6publish these updates on its website no later than 30 calendar
7days prior to their effective date.
8    (f) Continuation of supplemental payments. Any
9supplemental payments authorized under Illinois Administrative
10Code 148 effective January 1, 2014 and that continue during the
11period of July 1, 2014 through December 31, 2014 shall remain
12in effect as long as the assessment imposed by Section 5A-2 is
13in effect.
14    (g) Notwithstanding subsections (a) through (f) of this
15Section, any updates to the system shall not result in any
16diminishment of the overall effective rates of reimbursement as
17of the implementation date of the new system (July 1, 2014).
18These updates shall not preclude variations in any individual
19component of the system or hospital rate variations. Nothing in
20this Section shall prohibit the Department from increasing the
21rates of reimbursement or developing payments to ensure access
22to hospital services. Nothing in this Section shall be
23construed to guarantee a minimum amount of spending in the
24aggregate or per hospital as spending may be impacted by
25factors including but not limited to the number of individuals
26in the medical assistance program and the severity of illness

 

 

SB0741 Enrolled- 161 -LRB098 04975 KTG 35005 b

1of the individuals.
2    (h) The Department shall have the authority to modify by
3rulemaking any changes to the rates or methodologies in this
4Section as required by the federal government to obtain federal
5financial participation for expenditures made under this
6Section.
7    (i) Except for subsections (g) and (h) of this Section, the
8Department shall, pursuant to subsection (c) of Section 5-40 of
9the Illinois Administrative Procedure Act, provide for
10presentation at the June 2014 hearing of the Joint Committee on
11Administrative Rules (JCAR) additional written notice to JCAR
12of the following rules in order to commence the second notice
13period for the following rules: rules published in the Illinois
14Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559
15(Medical Payment), 4628 (Specialized Health Care Delivery
16Systems), 4640 (Hospital Services), 4932 (Diagnostic Related
17Grouping (DRG) Prospective Payment System (PPS)), and 4977
18(Hospital Reimbursement Changes), and published in the
19Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
20(Specialized Health Care Delivery Systems) and 6505 (Hospital
21Services).
 
22
Article 50

 
23    Section 50-5. The Specialized Mental Health Rehabilitation
24Act of 2013 is amended by changing Sections 3-116 and 3-205 as

 

 

SB0741 Enrolled- 162 -LRB098 04975 KTG 35005 b

1follows:
 
2    (210 ILCS 49/3-116)
3    Sec. 3-116. Experimental research. No consumer shall be
4subjected to experimental research or treatment without first
5obtaining his or her informed, written consent. The conduct of
6any experimental research or treatment shall be authorized and
7monitored by an institutional review board appointed by the
8Director of the Department executive director. The membership,
9operating procedures and review criteria for the institutional
10review board shall be prescribed under rules and regulations of
11the Department and shall comply with the requirements for
12institutional review boards established by the federal Food and
13Drug Administration. No person who has received compensation in
14the prior 3 years from an entity that manufactures,
15distributes, or sells pharmaceuticals, biologics, or medical
16devices may serve on the institutional review board.
17    No facility shall permit experimental research or
18treatment to be conducted on a consumer, or give access to any
19person or person's records for a retrospective study about the
20safety or efficacy of any care or treatment, without the prior
21written approval of the institutional review board. No
22executive director, or person licensed by the State to provide
23medical care or treatment to any person, may assist or
24participate in any experimental research on or treatment of a
25consumer, including a retrospective study, that does not have

 

 

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1the prior written approval of the board. Such conduct shall be
2grounds for professional discipline by the Department of
3Financial and Professional Regulation.
4    The institutional review board may exempt from ongoing
5review research or treatment initiated on a consumer before the
6individual's admission to a facility and for which the board
7determines there is adequate ongoing oversight by another
8institutional review board. Nothing in this Section shall
9prevent a facility, any facility employee, or any other person
10from assisting or participating in any experimental research on
11or treatment of a consumer, if the research or treatment began
12before the person's admission to a facility, until the board
13has reviewed the research or treatment and decided to grant or
14deny approval or to exempt the research or treatment from
15ongoing review.
16(Source: P.A. 98-104, eff. 7-22-13.)
 
17    (210 ILCS 49/3-205)
18    Sec. 3-205. Disclosure of information to public. Standards
19for the disclosure of information to the public shall be
20established by rule. These information disclosure standards
21shall include, but are not limited to, the following: staffing
22and personnel levels, licensure and inspection information,
23national accreditation information, consumer charges cost and
24reimbursement information, and consumer complaint information.
25Rules for the public disclosure of information shall be in

 

 

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1accordance with the provisions for inspection and copying of
2public records in the Freedom of Information Act. The
3Department of Healthcare and Family Services shall make
4facility cost reports available on its website.
5(Source: P.A. 98-104, eff. 7-22-13.)
 
6
Article 55

 
7    Section 55-5. The State Finance Act is amended by adding
8Section 5.855 as follows:
 
9    (30 ILCS 105/5.855 new)
10    Sec. 5.855. The Supportive Living Facility Fund.
 
11    Section 55-10. The Specialized Mental Health
12Rehabilitation Act of 2013 is amended by adding Section 5-102
13as follows:
 
14    (210 ILCS 49/5-102 new)
15    Sec. 5-102. Transition payments. In addition to payments
16already required by law, the Department of Healthcare and
17Family Services shall make payments to facilities licensed
18under this Act in the amount of $29.43 per licensed bed, per
19day, for the period beginning June 1, 2014 and ending June 30,
202014.
 

 

 

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1    Section 55-15. The Illinois Public Aid Code is amended by
2changing Sections 5-5, 5-5.01a, 5-5.2, 5-5.4h, 5-5e, 5-5e.1,
35-5f, 5B-1, 5C-1, 5C-2, and 5C-7 and by adding Section 5C-10
4and Article V-G as follows:
 
5    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
6    Sec. 5-5. Medical services. The Illinois Department, by
7rule, shall determine the quantity and quality of and the rate
8of reimbursement for the medical assistance for which payment
9will be authorized, and the medical services to be provided,
10which may include all or part of the following: (1) inpatient
11hospital services; (2) outpatient hospital services; (3) other
12laboratory and X-ray services; (4) skilled nursing home
13services; (5) physicians' services whether furnished in the
14office, the patient's home, a hospital, a skilled nursing home,
15or elsewhere; (6) medical care, or any other type of remedial
16care furnished by licensed practitioners; (7) home health care
17services; (8) private duty nursing service; (9) clinic
18services; (10) dental services, including prevention and
19treatment of periodontal disease and dental caries disease for
20pregnant women, provided by an individual licensed to practice
21dentistry or dental surgery; for purposes of this item (10),
22"dental services" means diagnostic, preventive, or corrective
23procedures provided by or under the supervision of a dentist in
24the practice of his or her profession; (11) physical therapy
25and related services; (12) prescribed drugs, dentures, and

 

 

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1prosthetic devices; and eyeglasses prescribed by a physician
2skilled in the diseases of the eye, or by an optometrist,
3whichever the person may select; (13) other diagnostic,
4screening, preventive, and rehabilitative services, including
5to ensure that the individual's need for intervention or
6treatment of mental disorders or substance use disorders or
7co-occurring mental health and substance use disorders is
8determined using a uniform screening, assessment, and
9evaluation process inclusive of criteria, for children and
10adults; for purposes of this item (13), a uniform screening,
11assessment, and evaluation process refers to a process that
12includes an appropriate evaluation and, as warranted, a
13referral; "uniform" does not mean the use of a singular
14instrument, tool, or process that all must utilize; (14)
15transportation and such other expenses as may be necessary;
16(15) medical treatment of sexual assault survivors, as defined
17in Section 1a of the Sexual Assault Survivors Emergency
18Treatment Act, for injuries sustained as a result of the sexual
19assault, including examinations and laboratory tests to
20discover evidence which may be used in criminal proceedings
21arising from the sexual assault; (16) the diagnosis and
22treatment of sickle cell anemia; and (17) any other medical
23care, and any other type of remedial care recognized under the
24laws of this State, but not including abortions, or induced
25miscarriages or premature births, unless, in the opinion of a
26physician, such procedures are necessary for the preservation

 

 

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1of the life of the woman seeking such treatment, or except an
2induced premature birth intended to produce a live viable child
3and such procedure is necessary for the health of the mother or
4her unborn child. The Illinois Department, by rule, shall
5prohibit any physician from providing medical assistance to
6anyone eligible therefor under this Code where such physician
7has been found guilty of performing an abortion procedure in a
8wilful and wanton manner upon a woman who was not pregnant at
9the time such abortion procedure was performed. The term "any
10other type of remedial care" shall include nursing care and
11nursing home service for persons who rely on treatment by
12spiritual means alone through prayer for healing.
13    Notwithstanding any other provision of this Section, a
14comprehensive tobacco use cessation program that includes
15purchasing prescription drugs or prescription medical devices
16approved by the Food and Drug Administration shall be covered
17under the medical assistance program under this Article for
18persons who are otherwise eligible for assistance under this
19Article.
20    Notwithstanding any other provision of this Code, the
21Illinois Department may not require, as a condition of payment
22for any laboratory test authorized under this Article, that a
23physician's handwritten signature appear on the laboratory
24test order form. The Illinois Department may, however, impose
25other appropriate requirements regarding laboratory test order
26documentation.

 

 

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1    Upon receipt of federal approval of an amendment to the
2Illinois Title XIX State Plan for this purpose, the Department
3shall authorize the Chicago Public Schools (CPS) to procure a
4vendor or vendors to manufacture eyeglasses for individuals
5enrolled in a school within the CPS system. CPS shall ensure
6that its vendor or vendors are enrolled as providers in the
7medical assistance program and in any capitated Medicaid
8managed care entity (MCE) serving individuals enrolled in a
9school within the CPS system. Under any contract procured under
10this provision, the vendor or vendors must serve only
11individuals enrolled in a school within the CPS system. Claims
12for services provided by CPS's vendor or vendors to recipients
13of benefits in the medical assistance program under this Code,
14the Children's Health Insurance Program, or the Covering ALL
15KIDS Health Insurance Program shall be submitted to the
16Department or the MCE in which the individual is enrolled for
17payment and shall be reimbursed at the Department's or the
18MCE's established rates or rate methodologies for eyeglasses.
19    On and after July 1, 2012, the Department of Healthcare and
20Family Services may provide the following services to persons
21eligible for assistance under this Article who are
22participating in education, training or employment programs
23operated by the Department of Human Services as successor to
24the Department of Public Aid:
25        (1) dental services provided by or under the
26    supervision of a dentist; and

 

 

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1        (2) eyeglasses prescribed by a physician skilled in the
2    diseases of the eye, or by an optometrist, whichever the
3    person may select.
4    Notwithstanding any other provision of this Code and
5subject to federal approval, the Department may adopt rules to
6allow a dentist who is volunteering his or her service at no
7cost to render dental services through an enrolled
8not-for-profit health clinic without the dentist personally
9enrolling as a participating provider in the medical assistance
10program. A not-for-profit health clinic shall include a public
11health clinic or Federally Qualified Health Center or other
12enrolled provider, as determined by the Department, through
13which dental services covered under this Section are performed.
14The Department shall establish a process for payment of claims
15for reimbursement for covered dental services rendered under
16this provision.
17    The Illinois Department, by rule, may distinguish and
18classify the medical services to be provided only in accordance
19with the classes of persons designated in Section 5-2.
20    The Department of Healthcare and Family Services must
21provide coverage and reimbursement for amino acid-based
22elemental formulas, regardless of delivery method, for the
23diagnosis and treatment of (i) eosinophilic disorders and (ii)
24short bowel syndrome when the prescribing physician has issued
25a written order stating that the amino acid-based elemental
26formula is medically necessary.

 

 

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1    The Illinois Department shall authorize the provision of,
2and shall authorize payment for, screening by low-dose
3mammography for the presence of occult breast cancer for women
435 years of age or older who are eligible for medical
5assistance under this Article, as follows:
6        (A) A baseline mammogram for women 35 to 39 years of
7    age.
8        (B) An annual mammogram for women 40 years of age or
9    older.
10        (C) A mammogram at the age and intervals considered
11    medically necessary by the woman's health care provider for
12    women under 40 years of age and having a family history of
13    breast cancer, prior personal history of breast cancer,
14    positive genetic testing, or other risk factors.
15        (D) A comprehensive ultrasound screening of an entire
16    breast or breasts if a mammogram demonstrates
17    heterogeneous or dense breast tissue, when medically
18    necessary as determined by a physician licensed to practice
19    medicine in all of its branches.
20    All screenings shall include a physical breast exam,
21instruction on self-examination and information regarding the
22frequency of self-examination and its value as a preventative
23tool. For purposes of this Section, "low-dose mammography"
24means the x-ray examination of the breast using equipment
25dedicated specifically for mammography, including the x-ray
26tube, filter, compression device, and image receptor, with an

 

 

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1average radiation exposure delivery of less than one rad per
2breast for 2 views of an average size breast. The term also
3includes digital mammography.
4    On and after January 1, 2012, providers participating in a
5quality improvement program approved by the Department shall be
6reimbursed for screening and diagnostic mammography at the same
7rate as the Medicare program's rates, including the increased
8reimbursement for digital mammography.
9    The Department shall convene an expert panel including
10representatives of hospitals, free-standing mammography
11facilities, and doctors, including radiologists, to establish
12quality standards.
13    Subject to federal approval, the Department shall
14establish a rate methodology for mammography at federally
15qualified health centers and other encounter-rate clinics.
16These clinics or centers may also collaborate with other
17hospital-based mammography facilities.
18    The Department shall establish a methodology to remind
19women who are age-appropriate for screening mammography, but
20who have not received a mammogram within the previous 18
21months, of the importance and benefit of screening mammography.
22    The Department shall establish a performance goal for
23primary care providers with respect to their female patients
24over age 40 receiving an annual mammogram. This performance
25goal shall be used to provide additional reimbursement in the
26form of a quality performance bonus to primary care providers

 

 

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1who meet that goal.
2    The Department shall devise a means of case-managing or
3patient navigation for beneficiaries diagnosed with breast
4cancer. This program shall initially operate as a pilot program
5in areas of the State with the highest incidence of mortality
6related to breast cancer. At least one pilot program site shall
7be in the metropolitan Chicago area and at least one site shall
8be outside the metropolitan Chicago area. An evaluation of the
9pilot program shall be carried out measuring health outcomes
10and cost of care for those served by the pilot program compared
11to similarly situated patients who are not served by the pilot
12program.
13    Any medical or health care provider shall immediately
14recommend, to any pregnant woman who is being provided prenatal
15services and is suspected of drug abuse or is addicted as
16defined in the Alcoholism and Other Drug Abuse and Dependency
17Act, referral to a local substance abuse treatment provider
18licensed by the Department of Human Services or to a licensed
19hospital which provides substance abuse treatment services.
20The Department of Healthcare and Family Services shall assure
21coverage for the cost of treatment of the drug abuse or
22addiction for pregnant recipients in accordance with the
23Illinois Medicaid Program in conjunction with the Department of
24Human Services.
25    All medical providers providing medical assistance to
26pregnant women under this Code shall receive information from

 

 

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1the Department on the availability of services under the Drug
2Free Families with a Future or any comparable program providing
3case management services for addicted women, including
4information on appropriate referrals for other social services
5that may be needed by addicted women in addition to treatment
6for addiction.
7    The Illinois Department, in cooperation with the
8Departments of Human Services (as successor to the Department
9of Alcoholism and Substance Abuse) and Public Health, through a
10public awareness campaign, may provide information concerning
11treatment for alcoholism and drug abuse and addiction, prenatal
12health care, and other pertinent programs directed at reducing
13the number of drug-affected infants born to recipients of
14medical assistance.
15    Neither the Department of Healthcare and Family Services
16nor the Department of Human Services shall sanction the
17recipient solely on the basis of her substance abuse.
18    The Illinois Department shall establish such regulations
19governing the dispensing of health services under this Article
20as it shall deem appropriate. The Department should seek the
21advice of formal professional advisory committees appointed by
22the Director of the Illinois Department for the purpose of
23providing regular advice on policy and administrative matters,
24information dissemination and educational activities for
25medical and health care providers, and consistency in
26procedures to the Illinois Department.

 

 

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1    The Illinois Department may develop and contract with
2Partnerships of medical providers to arrange medical services
3for persons eligible under Section 5-2 of this Code.
4Implementation of this Section may be by demonstration projects
5in certain geographic areas. The Partnership shall be
6represented by a sponsor organization. The Department, by rule,
7shall develop qualifications for sponsors of Partnerships.
8Nothing in this Section shall be construed to require that the
9sponsor organization be a medical organization.
10    The sponsor must negotiate formal written contracts with
11medical providers for physician services, inpatient and
12outpatient hospital care, home health services, treatment for
13alcoholism and substance abuse, and other services determined
14necessary by the Illinois Department by rule for delivery by
15Partnerships. Physician services must include prenatal and
16obstetrical care. The Illinois Department shall reimburse
17medical services delivered by Partnership providers to clients
18in target areas according to provisions of this Article and the
19Illinois Health Finance Reform Act, except that:
20        (1) Physicians participating in a Partnership and
21    providing certain services, which shall be determined by
22    the Illinois Department, to persons in areas covered by the
23    Partnership may receive an additional surcharge for such
24    services.
25        (2) The Department may elect to consider and negotiate
26    financial incentives to encourage the development of

 

 

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1    Partnerships and the efficient delivery of medical care.
2        (3) Persons receiving medical services through
3    Partnerships may receive medical and case management
4    services above the level usually offered through the
5    medical assistance program.
6    Medical providers shall be required to meet certain
7qualifications to participate in Partnerships to ensure the
8delivery of high quality medical services. These
9qualifications shall be determined by rule of the Illinois
10Department and may be higher than qualifications for
11participation in the medical assistance program. Partnership
12sponsors may prescribe reasonable additional qualifications
13for participation by medical providers, only with the prior
14written approval of the Illinois Department.
15    Nothing in this Section shall limit the free choice of
16practitioners, hospitals, and other providers of medical
17services by clients. In order to ensure patient freedom of
18choice, the Illinois Department shall immediately promulgate
19all rules and take all other necessary actions so that provided
20services may be accessed from therapeutically certified
21optometrists to the full extent of the Illinois Optometric
22Practice Act of 1987 without discriminating between service
23providers.
24    The Department shall apply for a waiver from the United
25States Health Care Financing Administration to allow for the
26implementation of Partnerships under this Section.

 

 

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1    The Illinois Department shall require health care
2providers to maintain records that document the medical care
3and services provided to recipients of Medical Assistance under
4this Article. Such records must be retained for a period of not
5less than 6 years from the date of service or as provided by
6applicable State law, whichever period is longer, except that
7if an audit is initiated within the required retention period
8then the records must be retained until the audit is completed
9and every exception is resolved. The Illinois Department shall
10require health care providers to make available, when
11authorized by the patient, in writing, the medical records in a
12timely fashion to other health care providers who are treating
13or serving persons eligible for Medical Assistance under this
14Article. All dispensers of medical services shall be required
15to maintain and retain business and professional records
16sufficient to fully and accurately document the nature, scope,
17details and receipt of the health care provided to persons
18eligible for medical assistance under this Code, in accordance
19with regulations promulgated by the Illinois Department. The
20rules and regulations shall require that proof of the receipt
21of prescription drugs, dentures, prosthetic devices and
22eyeglasses by eligible persons under this Section accompany
23each claim for reimbursement submitted by the dispenser of such
24medical services. No such claims for reimbursement shall be
25approved for payment by the Illinois Department without such
26proof of receipt, unless the Illinois Department shall have put

 

 

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1into effect and shall be operating a system of post-payment
2audit and review which shall, on a sampling basis, be deemed
3adequate by the Illinois Department to assure that such drugs,
4dentures, prosthetic devices and eyeglasses for which payment
5is being made are actually being received by eligible
6recipients. Within 90 days after the effective date of this
7amendatory Act of 1984, the Illinois Department shall establish
8a current list of acquisition costs for all prosthetic devices
9and any other items recognized as medical equipment and
10supplies reimbursable under this Article and shall update such
11list on a quarterly basis, except that the acquisition costs of
12all prescription drugs shall be updated no less frequently than
13every 30 days as required by Section 5-5.12.
14    The rules and regulations of the Illinois Department shall
15require that a written statement including the required opinion
16of a physician shall accompany any claim for reimbursement for
17abortions, or induced miscarriages or premature births. This
18statement shall indicate what procedures were used in providing
19such medical services.
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after July 22, 2013, the
22effective date of Public Act 98-104 this amendatory Act of the
2398th General Assembly, establish procedures to permit skilled
24care facilities licensed under the Nursing Home Care Act to
25submit monthly billing claims for reimbursement purposes.
26Following development of these procedures, the Department

 

 

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1shall have an additional 365 days to test the viability of the
2new system and to ensure that any necessary operational or
3structural changes to its information technology platforms are
4implemented.
5    The Illinois Department shall require all dispensers of
6medical services, other than an individual practitioner or
7group of practitioners, desiring to participate in the Medical
8Assistance program established under this Article to disclose
9all financial, beneficial, ownership, equity, surety or other
10interests in any and all firms, corporations, partnerships,
11associations, business enterprises, joint ventures, agencies,
12institutions or other legal entities providing any form of
13health care services in this State under this Article.
14    The Illinois Department may require that all dispensers of
15medical services desiring to participate in the medical
16assistance program established under this Article disclose,
17under such terms and conditions as the Illinois Department may
18by rule establish, all inquiries from clients and attorneys
19regarding medical bills paid by the Illinois Department, which
20inquiries could indicate potential existence of claims or liens
21for the Illinois Department.
22    Enrollment of a vendor shall be subject to a provisional
23period and shall be conditional for one year. During the period
24of conditional enrollment, the Department may terminate the
25vendor's eligibility to participate in, or may disenroll the
26vendor from, the medical assistance program without cause.

 

 

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1Unless otherwise specified, such termination of eligibility or
2disenrollment is not subject to the Department's hearing
3process. However, a disenrolled vendor may reapply without
4penalty.
5    The Department has the discretion to limit the conditional
6enrollment period for vendors based upon category of risk of
7the vendor.
8    Prior to enrollment and during the conditional enrollment
9period in the medical assistance program, all vendors shall be
10subject to enhanced oversight, screening, and review based on
11the risk of fraud, waste, and abuse that is posed by the
12category of risk of the vendor. The Illinois Department shall
13establish the procedures for oversight, screening, and review,
14which may include, but need not be limited to: criminal and
15financial background checks; fingerprinting; license,
16certification, and authorization verifications; unscheduled or
17unannounced site visits; database checks; prepayment audit
18reviews; audits; payment caps; payment suspensions; and other
19screening as required by federal or State law.
20    The Department shall define or specify the following: (i)
21by provider notice, the "category of risk of the vendor" for
22each type of vendor, which shall take into account the level of
23screening applicable to a particular category of vendor under
24federal law and regulations; (ii) by rule or provider notice,
25the maximum length of the conditional enrollment period for
26each category of risk of the vendor; and (iii) by rule, the

 

 

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1hearing rights, if any, afforded to a vendor in each category
2of risk of the vendor that is terminated or disenrolled during
3the conditional enrollment period.
4    To be eligible for payment consideration, a vendor's
5payment claim or bill, either as an initial claim or as a
6resubmitted claim following prior rejection, must be received
7by the Illinois Department, or its fiscal intermediary, no
8later than 180 days after the latest date on the claim on which
9medical goods or services were provided, with the following
10exceptions:
11        (1) In the case of a provider whose enrollment is in
12    process by the Illinois Department, the 180-day period
13    shall not begin until the date on the written notice from
14    the Illinois Department that the provider enrollment is
15    complete.
16        (2) In the case of errors attributable to the Illinois
17    Department or any of its claims processing intermediaries
18    which result in an inability to receive, process, or
19    adjudicate a claim, the 180-day period shall not begin
20    until the provider has been notified of the error.
21        (3) In the case of a provider for whom the Illinois
22    Department initiates the monthly billing process.
23        (4) In the case of a provider operated by a unit of
24    local government with a population exceeding 3,000,000
25    when local government funds finance federal participation
26    for claims payments.

 

 

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1    For claims for services rendered during a period for which
2a recipient received retroactive eligibility, claims must be
3filed within 180 days after the Department determines the
4applicant is eligible. For claims for which the Illinois
5Department is not the primary payer, claims must be submitted
6to the Illinois Department within 180 days after the final
7adjudication by the primary payer.
8    In the case of long term care facilities, within 5 days of
9receipt by the facility of required prescreening information,
10data for new admissions shall be entered into the Medical
11Electronic Data Interchange (MEDI) or the Recipient
12Eligibility Verification (REV) System or successor system, and
13within 15 days of receipt by the facility of required
14prescreening information, admission documents shall be
15submitted within 30 days of an admission to the facility
16through MEDI or REV the Medical Electronic Data Interchange
17(MEDI) or the Recipient Eligibility Verification (REV) System,
18or shall be submitted directly to the Department of Human
19Services using required admission forms. Effective September
201, 2014, admission documents, including all prescreening
21information, must be submitted through MEDI or REV.
22Confirmation numbers assigned to an accepted transaction shall
23be retained by a facility to verify timely submittal. Once an
24admission transaction has been completed, all resubmitted
25claims following prior rejection are subject to receipt no
26later than 180 days after the admission transaction has been

 

 

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1completed.
2    Claims that are not submitted and received in compliance
3with the foregoing requirements shall not be eligible for
4payment under the medical assistance program, and the State
5shall have no liability for payment of those claims.
6    To the extent consistent with applicable information and
7privacy, security, and disclosure laws, State and federal
8agencies and departments shall provide the Illinois Department
9access to confidential and other information and data necessary
10to perform eligibility and payment verifications and other
11Illinois Department functions. This includes, but is not
12limited to: information pertaining to licensure;
13certification; earnings; immigration status; citizenship; wage
14reporting; unearned and earned income; pension income;
15employment; supplemental security income; social security
16numbers; National Provider Identifier (NPI) numbers; the
17National Practitioner Data Bank (NPDB); program and agency
18exclusions; taxpayer identification numbers; tax delinquency;
19corporate information; and death records.
20    The Illinois Department shall enter into agreements with
21State agencies and departments, and is authorized to enter into
22agreements with federal agencies and departments, under which
23such agencies and departments shall share data necessary for
24medical assistance program integrity functions and oversight.
25The Illinois Department shall develop, in cooperation with
26other State departments and agencies, and in compliance with

 

 

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1applicable federal laws and regulations, appropriate and
2effective methods to share such data. At a minimum, and to the
3extent necessary to provide data sharing, the Illinois
4Department shall enter into agreements with State agencies and
5departments, and is authorized to enter into agreements with
6federal agencies and departments, including but not limited to:
7the Secretary of State; the Department of Revenue; the
8Department of Public Health; the Department of Human Services;
9and the Department of Financial and Professional Regulation.
10    Beginning in fiscal year 2013, the Illinois Department
11shall set forth a request for information to identify the
12benefits of a pre-payment, post-adjudication, and post-edit
13claims system with the goals of streamlining claims processing
14and provider reimbursement, reducing the number of pending or
15rejected claims, and helping to ensure a more transparent
16adjudication process through the utilization of: (i) provider
17data verification and provider screening technology; and (ii)
18clinical code editing; and (iii) pre-pay, pre- or
19post-adjudicated predictive modeling with an integrated case
20management system with link analysis. Such a request for
21information shall not be considered as a request for proposal
22or as an obligation on the part of the Illinois Department to
23take any action or acquire any products or services.
24    The Illinois Department shall establish policies,
25procedures, standards and criteria by rule for the acquisition,
26repair and replacement of orthotic and prosthetic devices and

 

 

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1durable medical equipment. Such rules shall provide, but not be
2limited to, the following services: (1) immediate repair or
3replacement of such devices by recipients; and (2) rental,
4lease, purchase or lease-purchase of durable medical equipment
5in a cost-effective manner, taking into consideration the
6recipient's medical prognosis, the extent of the recipient's
7needs, and the requirements and costs for maintaining such
8equipment. Subject to prior approval, such rules shall enable a
9recipient to temporarily acquire and use alternative or
10substitute devices or equipment pending repairs or
11replacements of any device or equipment previously authorized
12for such recipient by the Department.
13    The Department shall execute, relative to the nursing home
14prescreening project, written inter-agency agreements with the
15Department of Human Services and the Department on Aging, to
16effect the following: (i) intake procedures and common
17eligibility criteria for those persons who are receiving
18non-institutional services; and (ii) the establishment and
19development of non-institutional services in areas of the State
20where they are not currently available or are undeveloped; and
21(iii) notwithstanding any other provision of law, subject to
22federal approval, on and after July 1, 2012, an increase in the
23determination of need (DON) scores from 29 to 37 for applicants
24for institutional and home and community-based long term care;
25if and only if federal approval is not granted, the Department
26may, in conjunction with other affected agencies, implement

 

 

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1utilization controls or changes in benefit packages to
2effectuate a similar savings amount for this population; and
3(iv) no later than July 1, 2013, minimum level of care
4eligibility criteria for institutional and home and
5community-based long term care; and (v) no later than October
61, 2013, establish procedures to permit long term care
7providers access to eligibility scores for individuals with an
8admission date who are seeking or receiving services from the
9long term care provider. In order to select the minimum level
10of care eligibility criteria, the Governor shall establish a
11workgroup that includes affected agency representatives and
12stakeholders representing the institutional and home and
13community-based long term care interests. This Section shall
14not restrict the Department from implementing lower level of
15care eligibility criteria for community-based services in
16circumstances where federal approval has been granted.
17    The Illinois Department shall develop and operate, in
18cooperation with other State Departments and agencies and in
19compliance with applicable federal laws and regulations,
20appropriate and effective systems of health care evaluation and
21programs for monitoring of utilization of health care services
22and facilities, as it affects persons eligible for medical
23assistance under this Code.
24    The Illinois Department shall report annually to the
25General Assembly, no later than the second Friday in April of
261979 and each year thereafter, in regard to:

 

 

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1        (a) actual statistics and trends in utilization of
2    medical services by public aid recipients;
3        (b) actual statistics and trends in the provision of
4    the various medical services by medical vendors;
5        (c) current rate structures and proposed changes in
6    those rate structures for the various medical vendors; and
7        (d) efforts at utilization review and control by the
8    Illinois Department.
9    The period covered by each report shall be the 3 years
10ending on the June 30 prior to the report. The report shall
11include suggested legislation for consideration by the General
12Assembly. The filing of one copy of the report with the
13Speaker, one copy with the Minority Leader and one copy with
14the Clerk of the House of Representatives, one copy with the
15President, one copy with the Minority Leader and one copy with
16the Secretary of the Senate, one copy with the Legislative
17Research Unit, and such additional copies with the State
18Government Report Distribution Center for the General Assembly
19as is required under paragraph (t) of Section 7 of the State
20Library Act shall be deemed sufficient to comply with this
21Section.
22    Rulemaking authority to implement Public Act 95-1045, if
23any, is conditioned on the rules being adopted in accordance
24with all provisions of the Illinois Administrative Procedure
25Act and all rules and procedures of the Joint Committee on
26Administrative Rules; any purported rule not so adopted, for

 

 

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1whatever reason, is unauthorized.
2    On and after July 1, 2012, the Department shall reduce any
3rate of reimbursement for services or other payments or alter
4any methodologies authorized by this Code to reduce any rate of
5reimbursement for services or other payments in accordance with
6Section 5-5e.
7    Because kidney transplantation can be an appropriate, cost
8effective alternative to renal dialysis when medically
9necessary and notwithstanding the provisions of Section 1-11 of
10this Code, beginning October 1, 2014, the Department shall
11cover kidney transplantation for noncitizens with end-stage
12renal disease who are not eligible for comprehensive medical
13benefits, who meet the residency requirements of Section 5-3 of
14this Code, and who would otherwise meet the financial
15requirements of the appropriate class of eligible persons under
16Section 5-2 of this Code. To qualify for coverage of kidney
17transplantation, such person must be receiving emergency renal
18dialysis services covered by the Department. Providers under
19this Section shall be prior approved and certified by the
20Department to perform kidney transplantation and the services
21under this Section shall be limited to services associated with
22kidney transplantation.
23(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
24eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
259-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
267-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; revised

 

 

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19-19-13.)
 
2    (305 ILCS 5/5-5.01a)
3    Sec. 5-5.01a. Supportive living facilities program. The
4Department shall establish and provide oversight for a program
5of supportive living facilities that seek to promote resident
6independence, dignity, respect, and well-being in the most
7cost-effective manner.
8    A supportive living facility is either a free-standing
9facility or a distinct physical and operational entity within a
10nursing facility. A supportive living facility integrates
11housing with health, personal care, and supportive services and
12is a designated setting that offers residents their own
13separate, private, and distinct living units.
14    Sites for the operation of the program shall be selected by
15the Department based upon criteria that may include the need
16for services in a geographic area, the availability of funding,
17and the site's ability to meet the standards.
18    Beginning July 1, 2014, subject to federal approval, the
19Medicaid rates for supportive living facilities shall be equal
20to the supportive living facility Medicaid rate effective on
21June 30, 2014 increased by 8.85%. Once the assessment imposed
22at Article V-G of this Code is determined to be a permissible
23tax under Title XIX of the Social Security Act, the Department
24shall increase the Medicaid rates for supportive living
25facilities effective on July 1, 2014 by 9.09%. The Department

 

 

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1shall apply this increase retroactively to coincide with the
2imposition of the assessment in Article V-G of this Code in
3accordance with the approval for federal financial
4participation by the Centers for Medicare and Medicaid
5Services.
6    The Department may adopt rules to implement this Section.
7Rules that establish or modify the services, standards, and
8conditions for participation in the program shall be adopted by
9the Department in consultation with the Department on Aging,
10the Department of Rehabilitation Services, and the Department
11of Mental Health and Developmental Disabilities (or their
12successor agencies).
13    Facilities or distinct parts of facilities which are
14selected as supportive living facilities and are in good
15standing with the Department's rules are exempt from the
16provisions of the Nursing Home Care Act and the Illinois Health
17Facilities Planning Act.
18(Source: P.A. 94-342, eff. 7-26-05.)
 
19    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
20    Sec. 5-5.2. Payment.
21    (a) All nursing facilities that are grouped pursuant to
22Section 5-5.1 of this Act shall receive the same rate of
23payment for similar services.
24    (b) It shall be a matter of State policy that the Illinois
25Department shall utilize a uniform billing cycle throughout the

 

 

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1State for the long-term care providers.
2    (c) Notwithstanding any other provisions of this Code, the
3methodologies for reimbursement of nursing services as
4provided under this Article shall no longer be applicable for
5bills payable for nursing services rendered on or after a new
6reimbursement system based on the Resource Utilization Groups
7(RUGs) has been fully operationalized, which shall take effect
8for services provided on or after January 1, 2014.
9    (d) The new nursing services reimbursement methodology
10utilizing RUG-IV 48 grouper model, which shall be referred to
11as the RUGs reimbursement system, taking effect January 1,
122014, shall be based on the following:
13        (1) The methodology shall be resident-driven,
14    facility-specific, and cost-based.
15        (2) Costs shall be annually rebased and case mix index
16    quarterly updated. The nursing services methodology will
17    be assigned to the Medicaid enrolled residents on record as
18    of 30 days prior to the beginning of the rate period in the
19    Department's Medicaid Management Information System (MMIS)
20    as present on the last day of the second quarter preceding
21    the rate period.
22        (3) Regional wage adjustors based on the Health Service
23    Areas (HSA) groupings and adjusters in effect on April 30,
24    2012 shall be included.
25        (4) Case mix index shall be assigned to each resident
26    class based on the Centers for Medicare and Medicaid

 

 

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1    Services staff time measurement study in effect on July 1,
2    2013, utilizing an index maximization approach.
3        (5) The pool of funds available for distribution by
4    case mix and the base facility rate shall be determined
5    using the formula contained in subsection (d-1).
6    (d-1) Calculation of base year Statewide RUG-IV nursing
7base per diem rate.
8        (1) Base rate spending pool shall be:
9            (A) The base year resident days which are
10        calculated by multiplying the number of Medicaid
11        residents in each nursing home as indicated in the MDS
12        data defined in paragraph (4) by 365.
13            (B) Each facility's nursing component per diem in
14        effect on July 1, 2012 shall be multiplied by
15        subsection (A).
16            (C) Thirteen million is added to the product of
17        subparagraph (A) and subparagraph (B) to adjust for the
18        exclusion of nursing homes defined in paragraph (5).
19        (2) For each nursing home with Medicaid residents as
20    indicated by the MDS data defined in paragraph (4),
21    weighted days adjusted for case mix and regional wage
22    adjustment shall be calculated. For each home this
23    calculation is the product of:
24            (A) Base year resident days as calculated in
25        subparagraph (A) of paragraph (1).
26            (B) The nursing home's regional wage adjustor

 

 

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1        based on the Health Service Areas (HSA) groupings and
2        adjustors in effect on April 30, 2012.
3            (C) Facility weighted case mix which is the number
4        of Medicaid residents as indicated by the MDS data
5        defined in paragraph (4) multiplied by the associated
6        case weight for the RUG-IV 48 grouper model using
7        standard RUG-IV procedures for index maximization.
8            (D) The sum of the products calculated for each
9        nursing home in subparagraphs (A) through (C) above
10        shall be the base year case mix, rate adjusted weighted
11        days.
12        (3) The Statewide RUG-IV nursing base per diem rate:
13            (A) on January 1, 2014 shall be the quotient of the
14        paragraph (1) divided by the sum calculated under
15        subparagraph (D) of paragraph (2); and .
16            (B) on and after July 1, 2014, shall be the amount
17        calculated under subparagraph (A) of this paragraph
18        (3) plus $1.76.
19        (4) Minimum Data Set (MDS) comprehensive assessments
20    for Medicaid residents on the last day of the quarter used
21    to establish the base rate.
22        (5) Nursing facilities designated as of July 1, 2012 by
23    the Department as "Institutions for Mental Disease" shall
24    be excluded from all calculations under this subsection.
25    The data from these facilities shall not be used in the
26    computations described in paragraphs (1) through (4) above

 

 

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1    to establish the base rate.
2    (e) Beginning July 1, 2014, the Department shall allocate
3funding in the amount up to $10,000,000 for per diem add-ons to
4the RUGS methodology for dates of service on and after July 1,
52014:
6        (1) $0.63 for each resident who scores in I4200
7    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
8        (2) $2.67 for each resident who scores either a "1" or
9    "2" in any items S1200A through S1200I and also scores in
10    RUG groups PA1, PA2, BA1, or BA2.
11Notwithstanding any other provision of this Code, the
12Department shall by rule develop a reimbursement methodology
13reflective of the intensity of care and services requirements
14of low need residents in the lowest RUG IV groupers and
15corresponding regulations. Only that portion of the RUGs
16Reimbursement System spending pool described in subsection
17(d-1) attributed to the groupers as of July 1, 2013 for which
18the methodology in this Section is developed may be diverted
19for this purpose. The Department shall submit the rules no
20later than January 1, 2014 for an implementation date no later
21than January 1, 2015.
22If the Department does not implement this reimbursement
23methodology by the required date, the nursing component per
24diem on January 1, 2015 for residents classified in RUG-IV
25groups PA1, PA2, BA1, and BA2 shall be the blended rate of the
26calculated RUG-IV nursing component per diem and the nursing

 

 

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1component per diem in effect on July 1, 2012. This blended rate
2shall be applied only to nursing homes whose resident
3population is greater than or equal to 70% of the total
4residents served and whose RUG-IV nursing component per diem
5rate is less than the nursing component per diem in effect on
6July 1, 2012. This blended rate shall be in effect until the
7reimbursement methodology is implemented or until July 1, 2019,
8whichever is sooner.
9    (e-1) (Blank). Notwithstanding any other provision of this
10Article, rates established pursuant to this subsection shall
11not apply to any and all nursing facilities designated by the
12Department as "Institutions for Mental Disease" and shall be
13excluded from the RUGs Reimbursement System applicable to
14facilities not designated as "Institutions for the Mentally
15Diseased" by the Department.
16    (e-2) For dates of services beginning January 1, 2014, the
17RUG-IV nursing component per diem for a nursing home shall be
18the product of the statewide RUG-IV nursing base per diem rate,
19the facility average case mix index, and the regional wage
20adjustor. Transition rates for services provided between
21January 1, 2014 and December 31, 2014 shall be as follows:
22        (1) The transition RUG-IV per diem nursing rate for
23    nursing homes whose rate calculated in this subsection
24    (e-2) is greater than the nursing component rate in effect
25    July 1, 2012 shall be paid the sum of:
26            (A) The nursing component rate in effect July 1,

 

 

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1        2012; plus
2            (B) The difference of the RUG-IV nursing component
3        per diem calculated for the current quarter minus the
4        nursing component rate in effect July 1, 2012
5        multiplied by 0.88.
6        (2) The transition RUG-IV per diem nursing rate for
7    nursing homes whose rate calculated in this subsection
8    (e-2) is less than the nursing component rate in effect
9    July 1, 2012 shall be paid the sum of:
10            (A) The nursing component rate in effect July 1,
11        2012; plus
12            (B) The difference of the RUG-IV nursing component
13        per diem calculated for the current quarter minus the
14        nursing component rate in effect July 1, 2012
15        multiplied by 0.13.
16    (f) Notwithstanding any other provision of this Code, on
17and after July 1, 2012, reimbursement rates associated with the
18nursing or support components of the current nursing facility
19rate methodology shall not increase beyond the level effective
20May 1, 2011 until a new reimbursement system based on the RUGs
21IV 48 grouper model has been fully operationalized.
22    (g) Notwithstanding any other provision of this Code, on
23and after July 1, 2012, for facilities not designated by the
24Department of Healthcare and Family Services as "Institutions
25for Mental Disease", rates effective May 1, 2011 shall be
26adjusted as follows:

 

 

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1        (1) Individual nursing rates for residents classified
2    in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter
3    ending March 31, 2012 shall be reduced by 10%;
4        (2) Individual nursing rates for residents classified
5    in all other RUG IV groups shall be reduced by 1.0%;
6        (3) Facility rates for the capital and support
7    components shall be reduced by 1.7%.
8    (h) Notwithstanding any other provision of this Code, on
9and after July 1, 2012, nursing facilities designated by the
10Department of Healthcare and Family Services as "Institutions
11for Mental Disease" and "Institutions for Mental Disease" that
12are facilities licensed under the Specialized Mental Health
13Rehabilitation Act of 2013 shall have the nursing,
14socio-developmental, capital, and support components of their
15reimbursement rate effective May 1, 2011 reduced in total by
162.7%.
17    (i) On and after July 1, 2014, the reimbursement rates for
18the support component of the nursing facility rate for
19facilities licensed under the Nursing Home Care Act as skilled
20or intermediate care facilities shall be the rate in effect on
21June 30, 2014 increased by 8.17%.
22(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section
236-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff.
247-22-13; revised 9-19-13.)
 
25    (305 ILCS 5/5-5.4h)

 

 

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1    Sec. 5-5.4h. Medicaid reimbursement for long-term care
2facilities for persons under 22 years of age pediatric skilled
3nursing facilities.
4    (a) Facilities licensed as long-term care facilities for
5persons under 22 years of age uniquely licensed as pediatric
6skilled nursing facilities that serve severely and chronically
7ill pediatric patients shall have a specific reimbursement
8system designed to recognize the characteristics and needs of
9the patients they serve.
10    (b) For dates of services starting July 1, 2013 and until a
11new reimbursement system is designed, long-term care
12facilities for persons under 22 years of age pediatric skilled
13nursing facilities that meet the following criteria:
14        (1) serve exceptional care patients; and
15        (2) have 30% or more of their patients receiving
16    ventilator care;
17shall receive Medicaid reimbursement on a 30-day expedited
18schedule.
19    (c) Subject to federal approval of changes to the Title XIX
20State Plan, for dates of services starting July 1, 2014 and
21until a new reimbursement system is designed, long-term care
22facilities for persons under 22 years of age which meet the
23criteria in subsection (b) of this Section shall receive a per
24diem rate for clinically complex residents of $304. Clinically
25complex residents on a ventilator shall receive a per diem rate
26of $669.

 

 

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1    (d) To qualify for the per diem rate of $669 for clinically
2complex residents on a ventilator pursuant to subsection (c),
3facilities shall have a policy documenting their method of
4routine assessment of a resident's weaning potential with
5interventions implemented noted in the resident's record.
6    (e) For the purposes of this Section, a resident is
7considered clinically complex if the resident requires at least
8one of the following medical services:
9        (1) Tracheostomy care with dependence on mechanical
10    ventilation for a minimum of 6 hours each day.
11        (2) Tracheostomy care requiring suctioning at least
12    every 6 hours, room air mist or oxygen as needed, and
13    dependence on one of the treatment procedures listed under
14    paragraph (4) excluding the procedure listed in
15    subparagraph (A) of paragraph (4).
16        (3) Total parenteral nutrition or other intravenous
17    nutritional support and one of the treatment procedures
18    listed under paragraph (4).
19        (4) The following treatment procedures apply to the
20    conditions in paragraphs (2) and (3) of this subsection:
21            (A) Intermittent suctioning at least every 8 hours
22        and room air mist or oxygen as needed.
23            (B) Continuous intravenous therapy including
24        administration of therapeutic agents necessary for
25        hydration or of intravenous pharmaceuticals; or
26        intravenous pharmaceutical administration of more than

 

 

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1        one agent via a peripheral or central line, without
2        continuous infusion.
3            (C) Peritoneal dialysis treatments requiring at
4        least 4 exchanges every 24 hours.
5            (D) Tube feeding via nasogastric or gastrostomy
6        tube.
7            (E) Other medical technologies required
8        continuously, which in the opinion of the attending
9        physician require the services of a professional
10        nurse.
11(Source: P.A. 98-104, eff. 7-22-13.)
 
12    (305 ILCS 5/5-5e)
13    Sec. 5-5e. Adjusted rates of reimbursement.
14    (a) Rates or payments for services in effect on June 30,
152012 shall be adjusted and services shall be affected as
16required by any other provision of this amendatory Act of the
1797th General Assembly. In addition, the Department shall do the
18following:
19        (1) Delink the per diem rate paid for supportive living
20    facility services from the per diem rate paid for nursing
21    facility services, effective for services provided on or
22    after May 1, 2011.
23        (2) Cease payment for bed reserves in nursing
24    facilities and specialized mental health rehabilitation
25    facilities.

 

 

SB0741 Enrolled- 200 -LRB098 04975 KTG 35005 b

1        (2.5) Cease payment for bed reserves for purposes of
2    inpatient hospitalizations to intermediate care facilities
3    for persons with development disabilities, except in the
4    instance of residents who are under 21 years of age.
5        (3) Cease payment of the $10 per day add-on payment to
6    nursing facilities for certain residents with
7    developmental disabilities.
8    (b) After the application of subsection (a),
9notwithstanding any other provision of this Code to the
10contrary and to the extent permitted by federal law, on and
11after July 1, 2012, the rates of reimbursement for services and
12other payments provided under this Code shall further be
13reduced as follows:
14        (1) Rates or payments for physician services, dental
15    services, or community health center services reimbursed
16    through an encounter rate, and services provided under the
17    Medicaid Rehabilitation Option of the Illinois Title XIX
18    State Plan shall not be further reduced.
19        (2) Rates or payments, or the portion thereof, paid to
20    a provider that is operated by a unit of local government
21    or State University that provides the non-federal share of
22    such services shall not be further reduced.
23        (3) Rates or payments for hospital services delivered
24    by a hospital defined as a Safety-Net Hospital under
25    Section 5-5e.1 of this Code shall not be further reduced.
26        (4) Rates or payments for hospital services delivered

 

 

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1    by a Critical Access Hospital, which is an Illinois
2    hospital designated as a critical care hospital by the
3    Department of Public Health in accordance with 42 CFR 485,
4    Subpart F, shall not be further reduced.
5        (5) Rates or payments for Nursing Facility Services
6    shall only be further adjusted pursuant to Section 5-5.2 of
7    this Code.
8        (6) Rates or payments for services delivered by long
9    term care facilities licensed under the ID/DD Community
10    Care Act and developmental training services shall not be
11    further reduced.
12        (7) Rates or payments for services provided under
13    capitation rates shall be adjusted taking into
14    consideration the rates reduction and covered services
15    required by this amendatory Act of the 97th General
16    Assembly.
17        (8) For hospitals not previously described in this
18    subsection, the rates or payments for hospital services
19    shall be further reduced by 3.5%, except for payments
20    authorized under Section 5A-12.4 of this Code.
21        (9) For all other rates or payments for services
22    delivered by providers not specifically referenced in
23    paragraphs (1) through (8), rates or payments shall be
24    further reduced by 2.7%.
25    (c) Any assessment imposed by this Code shall continue and
26nothing in this Section shall be construed to cause it to

 

 

SB0741 Enrolled- 202 -LRB098 04975 KTG 35005 b

1cease.
2    (d) Notwithstanding any other provision of this Code to the
3contrary, subject to federal approval under Title XIX of the
4Social Security Act, for dates of service on and after July 1,
52014, rates or payments for services provided for the purpose
6of transitioning children from a hospital to home placement or
7other appropriate setting by a children's community-based
8health care center authorized under the Alternative Health Care
9Delivery Act shall be $683 per day.
10    (e) Notwithstanding any other provision of this Code to the
11contrary, subject to federal approval under Title XIX of the
12Social Security Act, for dates of service on and after July 1,
132014, rates or payments for home health visits shall be $72.
14    (f) Notwithstanding any other provision of this Code to the
15contrary, subject to federal approval under Title XIX of the
16Social Security Act, for dates of service on and after July 1,
172014, rates or payments for the certified nursing assistant
18component of the home health agency rate shall be $20.
19(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
 
20    (305 ILCS 5/5-5e.1)
21    Sec. 5-5e.1. Safety-Net Hospitals.
22    (a) A Safety-Net Hospital is an Illinois hospital that:
23        (1) is licensed by the Department of Public Health as a
24    general acute care or pediatric hospital; and
25        (2) is a disproportionate share hospital, as described

 

 

SB0741 Enrolled- 203 -LRB098 04975 KTG 35005 b

1    in Section 1923 of the federal Social Security Act, as
2    determined by the Department; and
3        (3) meets one of the following:
4            (A) has a MIUR of at least 40% and a charity
5        percent of at least 4%; or
6            (B) has a MIUR of at least 50%.
7    (b) Definitions. As used in this Section:
8        (1) "Charity percent" means the ratio of (i) the
9    hospital's charity charges for services provided to
10    individuals without health insurance or another source of
11    third party coverage to (ii) the Illinois total hospital
12    charges, each as reported on the hospital's OBRA form.
13        (2) "MIUR" means Medicaid Inpatient Utilization Rate
14    and is defined as a fraction, the numerator of which is the
15    number of a hospital's inpatient days provided in the
16    hospital's fiscal year ending 3 years prior to the rate
17    year, to patients who, for such days, were eligible for
18    Medicaid under Title XIX of the federal Social Security
19    Act, 42 USC 1396a et seq., excluding those persons eligible
20    for medical assistance pursuant to 42 U.S.C.
21    1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
22    Section 5-2 of this Article, and the denominator of which
23    is the total number of the hospital's inpatient days in
24    that same period, excluding those persons eligible for
25    medical assistance pursuant to 42 U.S.C.
26    1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of

 

 

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1    Section 5-2 of this Article.
2        (3) "OBRA form" means form HFS-3834, OBRA '93 data
3    collection form, for the rate year.
4        (4) "Rate year" means the 12-month period beginning on
5    October 1.
6    (c) Beginning July 1, 2012 and ending on June 30, 2018, For
7the 27-month period beginning July 1, 2012, a hospital that
8would have qualified for the rate year beginning October 1,
92011, shall be a Safety-Net Hospital.
10    (d) No later than August 15 preceding the rate year, each
11hospital shall submit the OBRA form to the Department. Prior to
12October 1, the Department shall notify each hospital whether it
13has qualified as a Safety-Net Hospital.
14    (e) The Department may promulgate rules in order to
15implement this Section.
16    (f) Nothing in this Section shall be construed as limiting
17the ability of the Department to include the Safety-Net
18Hospitals in the hospital rate reform mandated by Section 14-11
19of this Code and implemented under Section 14-12 of this Code
20and by administrative rulemaking.
21(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
 
22    (305 ILCS 5/5-5f)
23    Sec. 5-5f. Elimination and limitations of medical
24assistance services. Notwithstanding any other provision of
25this Code to the contrary, on and after July 1, 2012:

 

 

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1    (a) The following services shall no longer be a covered
2service available under this Code: group psychotherapy for
3residents of any facility licensed under the Nursing Home Care
4Act or the Specialized Mental Health Rehabilitation Act of
52013; and adult chiropractic services.
6    (b) The Department shall place the following limitations on
7services: (i) the Department shall limit adult eyeglasses to
8one pair every 2 years; (ii) the Department shall set an annual
9limit of a maximum of 20 visits for each of the following
10services: adult speech, hearing, and language therapy
11services, adult occupational therapy services, and physical
12therapy services; on or after October 1, 2014, the annual
13maximum limit of 20 visits shall expire but the Department
14shall require prior approval for all individuals for speech,
15hearing, and language therapy services, occupational therapy
16services, and physical therapy services; (iii) the Department
17shall limit adult podiatry services to individuals with
18diabetes; on or after October 1, 2014, podiatry services shall
19not be limited to individuals with diabetes; (iv) the
20Department shall pay for caesarean sections at the normal
21vaginal delivery rate unless a caesarean section was medically
22necessary; (v) the Department shall limit adult dental services
23to emergencies; beginning July 1, 2013, the Department shall
24ensure that the following conditions are recognized as
25emergencies: (A) dental services necessary for an individual in
26order for the individual to be cleared for a medical procedure,

 

 

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1such as a transplant; (B) extractions and dentures necessary
2for a diabetic to receive proper nutrition; (C) extractions and
3dentures necessary as a result of cancer treatment; and (D)
4dental services necessary for the health of a pregnant woman
5prior to delivery of her baby; on or after July 1, 2014, adult
6dental services shall no longer be limited to emergencies, and
7dental services necessary for the health of a pregnant woman
8prior to delivery of her baby shall continue to be covered; and
9(vi) effective July 1, 2012, the Department shall place
10limitations and require concurrent review on every inpatient
11detoxification stay to prevent repeat admissions to any
12hospital for detoxification within 60 days of a previous
13inpatient detoxification stay. The Department shall convene a
14workgroup of hospitals, substance abuse providers, care
15coordination entities, managed care plans, and other
16stakeholders to develop recommendations for quality standards,
17diversion to other settings, and admission criteria for
18patients who need inpatient detoxification, which shall be
19published on the Department's website no later than September
201, 2013.
21    (c) The Department shall require prior approval of the
22following services: wheelchair repairs costing more than $400,
23coronary artery bypass graft, and bariatric surgery consistent
24with Medicare standards concerning patient responsibility.
25Wheelchair repair prior approval requests shall be adjudicated
26within one business day of receipt of complete supporting

 

 

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1documentation. Providers may not break wheelchair repairs into
2separate claims for purposes of staying under the $400
3threshold for requiring prior approval. The wholesale price of
4manual and power wheelchairs, durable medical equipment and
5supplies, and complex rehabilitation technology products and
6services shall be defined as actual acquisition cost including
7all discounts.
8    (d) The Department shall establish benchmarks for
9hospitals to measure and align payments to reduce potentially
10preventable hospital readmissions, inpatient complications,
11and unnecessary emergency room visits. In doing so, the
12Department shall consider items, including, but not limited to,
13historic and current acuity of care and historic and current
14trends in readmission. The Department shall publish
15provider-specific historical readmission data and anticipated
16potentially preventable targets 60 days prior to the start of
17the program. In the instance of readmissions, the Department
18shall adopt policies and rates of reimbursement for services
19and other payments provided under this Code to ensure that, by
20June 30, 2013, expenditures to hospitals are reduced by, at a
21minimum, $40,000,000.
22    (e) The Department shall establish utilization controls
23for the hospice program such that it shall not pay for other
24care services when an individual is in hospice.
25    (f) For home health services, the Department shall require
26Medicare certification of providers participating in the

 

 

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1program and implement the Medicare face-to-face encounter
2rule. The Department shall require providers to implement
3auditable electronic service verification based on global
4positioning systems or other cost-effective technology.
5    (g) For the Home Services Program operated by the
6Department of Human Services and the Community Care Program
7operated by the Department on Aging, the Department of Human
8Services, in cooperation with the Department on Aging, shall
9implement an electronic service verification based on global
10positioning systems or other cost-effective technology.
11    (h) Effective with inpatient hospital admissions on or
12after July 1, 2012, the Department shall reduce the payment for
13a claim that indicates the occurrence of a provider-preventable
14condition during the admission as specified by the Department
15in rules. The Department shall not pay for services related to
16an other provider-preventable condition.
17    As used in this subsection (h):
18    "Provider-preventable condition" means a health care
19acquired condition as defined under the federal Medicaid
20regulation found at 42 CFR 447.26 or an other
21provider-preventable condition.
22    "Other provider-preventable condition" means a wrong
23surgical or other invasive procedure performed on a patient, a
24surgical or other invasive procedure performed on the wrong
25body part, or a surgical procedure or other invasive procedure
26performed on the wrong patient.

 

 

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1    (i) The Department shall implement cost savings
2initiatives for advanced imaging services, cardiac imaging
3services, pain management services, and back surgery. Such
4initiatives shall be designed to achieve annual costs savings.
5    (j) The Department shall ensure that beneficiaries with a
6diagnosis of epilepsy or seizure disorder in Department records
7will not require prior approval for anticonvulsants.
8(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section
96-240, eff. 7-22-13; 98-104, Article 9, Section 9-5, eff.
107-22-13; revised 9-19-13.)
 
11    (305 ILCS 5/5B-1)  (from Ch. 23, par. 5B-1)
12    Sec. 5B-1. Definitions. As used in this Article, unless the
13context requires otherwise:
14    "Fund" means the Long-Term Care Provider Fund.
15    "Long-term care facility" means (i) a nursing facility,
16whether public or private and whether organized for profit or
17not-for-profit, that is subject to licensure by the Illinois
18Department of Public Health under the Nursing Home Care Act or
19the ID/DD Community Care Act, including a county nursing home
20directed and maintained under Section 5-1005 of the Counties
21Code, and (ii) a part of a hospital in which skilled or
22intermediate long-term care services within the meaning of
23Title XVIII or XIX of the Social Security Act are provided;
24except that the term "long-term care facility" does not include
25a facility operated by a State agency or operated solely as an

 

 

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1intermediate care facility for the mentally retarded within the
2meaning of Title XIX of the Social Security Act.
3    "Long-term care provider" means (i) a person licensed by
4the Department of Public Health to operate and maintain a
5skilled nursing or intermediate long-term care facility or (ii)
6a hospital provider that provides skilled or intermediate
7long-term care services within the meaning of Title XVIII or
8XIX of the Social Security Act. For purposes of this paragraph,
9"person" means any political subdivision of the State,
10municipal corporation, individual, firm, partnership,
11corporation, company, limited liability company, association,
12joint stock association, or trust, or a receiver, executor,
13trustee, guardian, or other representative appointed by order
14of any court. "Hospital provider" means a person licensed by
15the Department of Public Health to conduct, operate, or
16maintain a hospital.
17    "Occupied bed days" shall be computed separately for each
18long-term care facility operated or maintained by a long-term
19care provider, and means the sum for all beds of the number of
20days during the month on which each bed was occupied by a
21resident, other than a resident for whom Medicare Part A is the
22primary payer. For a resident whose care is covered by the
23Medicare Medicaid Alignment initiative demonstration, Medicare
24Part A is considered the primary payer.
25(Source: P.A. 96-339, eff. 7-1-10; 96-1530, eff. 2-16-11;
2697-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813, eff.

 

 

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17-13-12.)
 
2    (305 ILCS 5/5C-1)  (from Ch. 23, par. 5C-1)
3    Sec. 5C-1. Definitions. As used in this Article, unless the
4context requires otherwise:
5    "Fund" means the Care Provider Fund for Persons with a
6Developmental Disability.
7    "Developmentally disabled care facility" means an
8intermediate care facility for the intellectually disabled
9within the meaning of Title XIX of the Social Security Act,
10whether public or private and whether organized for profit or
11not-for-profit, but shall not include any facility operated by
12the State.
13    "Developmentally disabled care provider" means a person
14conducting, operating, or maintaining a developmentally
15disabled care facility. For this purpose, "person" means any
16political subdivision of the State, municipal corporation,
17individual, firm, partnership, corporation, company, limited
18liability company, association, joint stock association, or
19trust, or a receiver, executor, trustee, guardian or other
20representative appointed by order of any court.
21    "Adjusted gross developmentally disabled care revenue"
22shall be computed separately for each developmentally disabled
23care facility conducted, operated, or maintained by a
24developmentally disabled care provider, and means the
25developmentally disabled care provider's total revenue for

 

 

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1inpatient residential services less contractual allowances and
2discounts on patients' accounts, but does not include
3non-patient revenue from sources such as contributions,
4donations or bequests, investments, day training services,
5television and telephone service, and rental of facility space.
6    "Long-term care facility for persons under 22 years of age
7serving clinically complex residents" means a facility
8licensed by the Department of Public Health as a long-term care
9facility for persons under 22 meeting the qualifications of
10Section 5-5.4h of this Code.
11(Source: P.A. 97-227, eff. 1-1-12; 98-463, eff. 8-16-13.)
 
12    (305 ILCS 5/5C-2)  (from Ch. 23, par. 5C-2)
13    Sec. 5C-2. Assessment; no local authorization to tax.
14    (a) For the privilege of engaging in the occupation of
15developmentally disabled care provider, an assessment is
16imposed upon each developmentally disabled care provider in an
17amount equal to 6%, or the maximum allowed under federal
18regulation, whichever is less, of its adjusted gross
19developmentally disabled care revenue for the prior State
20fiscal year. Notwithstanding any provision of any other Act to
21the contrary, this assessment shall be construed as a tax, but
22may not be added to the charges of an individual's nursing home
23care that is paid for in whole, or in part, by a federal,
24State, or combined federal-state medical care program, except
25those individuals receiving Medicare Part B benefits solely.

 

 

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1    (b) Nothing in this amendatory Act of 1995 shall be
2construed to authorize any home rule unit or other unit of
3local government to license for revenue or impose a tax or
4assessment upon a developmentally disabled care provider or the
5occupation of developmentally disabled care provider, or a tax
6or assessment measured by the income or earnings of a
7developmentally disabled care provider.
8    (c) Effective July 1, 2013, for the privilege of engaging
9in the occupation of long-term care facility for persons under
1022 years of age serving clinically complex residents provider,
11an assessment is imposed upon each long-term care facility for
12persons under 22 years of age serving clinically complex
13residents provider in the same amount and upon the same
14conditions and requirements as imposed in Article V-B of this
15Code and a license fee is imposed in the same amount and upon
16the same conditions and requirements as imposed in Article V-E
17of this Code. Notwithstanding any provision of any other Act to
18the contrary, the assessment and license fee imposed by this
19subsection (c) shall be construed as a tax, but may not be
20added to the charges of an individual's nursing home care that
21is paid for in whole, or in part, by a federal, State, or
22combined federal-State medical care program, except for those
23individuals receiving Medicare Part B benefits solely.
24(Source: P.A. 95-707, eff. 1-11-08.)
 
25    (305 ILCS 5/5C-7)  (from Ch. 23, par. 5C-7)

 

 

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1    Sec. 5C-7. Care Provider Fund for Persons with a
2Developmental Disability.
3    (a) There is created in the State Treasury the Care
4Provider Fund for Persons with a Developmental Disability.
5Interest earned by the Fund shall be credited to the Fund. The
6Fund shall not be used to replace any moneys appropriated to
7the Medicaid program by the General Assembly.
8    (b) The Fund is created for the purpose of receiving and
9disbursing assessment moneys in accordance with this Article.
10Disbursements from the Fund shall be made only as follows:
11        (1) For payments to intermediate care facilities for
12    the developmentally disabled under Title XIX of the Social
13    Security Act and Article V of this Code.
14        (2) For the reimbursement of moneys collected by the
15    Illinois Department through error or mistake, and to make
16    required payments under Section 5-4.28(a)(1) of this Code
17    if there are no moneys available for such payments in the
18    Medicaid Developmentally Disabled Provider Participation
19    Fee Trust Fund.
20        (3) For payment of administrative expenses incurred by
21    the Department of Human Services or its agent or the
22    Illinois Department or its agent in performing the
23    activities authorized by this Article.
24        (4) For payments of any amounts which are reimbursable
25    to the federal government for payments from this Fund which
26    are required to be paid by State warrant.

 

 

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1        (5) For making transfers to the General Obligation Bond
2    Retirement and Interest Fund as those transfers are
3    authorized in the proceedings authorizing debt under the
4    Short Term Borrowing Act, but transfers made under this
5    paragraph (5) shall not exceed the principal amount of debt
6    issued in anticipation of the receipt by the State of
7    moneys to be deposited into the Fund.
8        (6) For making refunds as required under Section 5C-10
9    of this Article.
10    Disbursements from the Fund, other than transfers to the
11General Obligation Bond Retirement and Interest Fund, shall be
12by warrants drawn by the State Comptroller upon receipt of
13vouchers duly executed and certified by the Illinois
14Department.
15    (c) The Fund shall consist of the following:
16        (1) All moneys collected or received by the Illinois
17    Department from the developmentally disabled care provider
18    assessment imposed by this Article.
19        (2) All federal matching funds received by the Illinois
20    Department as a result of expenditures made by the Illinois
21    Department that are attributable to moneys deposited in the
22    Fund.
23        (3) Any interest or penalty levied in conjunction with
24    the administration of this Article.
25        (4) Any balance in the Medicaid Developmentally
26    Disabled Care Provider Participation Fee Trust Fund in the

 

 

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SB0741 Enrolled