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Illinois Compiled Statutes

Information maintained by the Legislative Reference Bureau
Updating the database of the Illinois Compiled Statutes (ILCS) is an ongoing process. Recent laws may not yet be included in the ILCS database, but they are found on this site as Public Acts soon after they become law. For information concerning the relationship between statutes and Public Acts, refer to the Guide.

Because the statute database is maintained primarily for legislative drafting purposes, statutory changes are sometimes included in the statute database before they take effect. If the source note at the end of a Section of the statutes includes a Public Act that has not yet taken effect, the version of the law that is currently in effect may have already been removed from the database and you should refer to that Public Act to see the changes made to the current law.


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305 ILCS 5/Art. I

 
    (305 ILCS 5/Art. I heading)
ARTICLE I. PUBLIC PURPOSE - SHORT
TITLE - PRIOR STATUTE - CONSTRUCTION

305 ILCS 5/1-1

    (305 ILCS 5/1-1) (from Ch. 23, par. 1-1)
    Sec. 1-1. Public purpose-Aims in providing financial aid and services. The purpose of this Code is to assist in the alleviation and prevention of poverty and thereby to protect and promote the health and welfare of all the people of this State.
    To accomplish this purpose, this Code authorizes financial aid and social welfare services for persons in need thereof by reason of unemployment, illness, or other cause depriving them of the means of a livelihood compatible with health and well-being, and provides for the development, use and coordination of all resources in this State, governmental and private.
    The Illinois Department shall establish such standards of financial aid and services as will encourage and assist applicants and recipients to maintain a livelihood compatible with health and well being and to develop their self-reliance and realize their capacities for self-care, self-support, and responsible citizenship.
    The maintenance and strengthening of the family unit shall be a principal consideration in the administration of this Code. All public aid policies shall be formulated and administered to achieve this end.
(Source: P.A. 89-507, eff. 7-1-97.)

305 ILCS 5/1-2

    (305 ILCS 5/1-2) (from Ch. 23, par. 1-2)
    Sec. 1-2. Short title. This Act may be cited as the Illinois Public Aid Code.
(Source: P.A. 86-1475.)

305 ILCS 5/1-3

    (305 ILCS 5/1-3) (from Ch. 23, par. 1-3)
    Sec. 1-3. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/1-4

    (305 ILCS 5/1-4) (from Ch. 23, par. 1-4)
    Sec. 1-4. Reference to article.
    Whenever reference is made in this Code to an Article or Articles, the reference applies to an Article or Articles of this Code, unless the context otherwise requires.
(Source: Laws 1967, p. 122.)

305 ILCS 5/1-5

    (305 ILCS 5/1-5) (from Ch. 23, par. 1-5)
    Sec. 1-5. Construction.
    The provisions of this Code shall be liberally construed to effect its objects and purposes.
(Source: Laws 1967, p. 122.)

305 ILCS 5/1-6

    (305 ILCS 5/1-6) (from Ch. 23, par. 1-6)
    Sec. 1-6. Notwithstanding any provisions of this Code to the contrary, a person, if eligible, shall be required to file for unemployment compensation benefits as a condition for qualifying for public assistance benefits under programs of aid to the aged, blind, or disabled, aid to families with dependent children, and aid to families with dependent children-- unemployed, which are administered by the Illinois Department, or general assistance programs administered by some other public agency.
(Source: P.A. 89-507, eff. 7-1-97.)

305 ILCS 5/1-7

    (305 ILCS 5/1-7) (from Ch. 23, par. 1-7)
    Sec. 1-7. (a) For purposes of determining eligibility for assistance under this Code, the Illinois Department, County Departments, and local governmental units shall exclude from consideration restitution payments, including all income and resources derived therefrom, made to persons of Japanese or Aleutian ancestry pursuant to the federal Civil Liberties Act of 1988 and the Aleutian and Pribilof Island Restitution Act, P.L. 100-383.
    (b) For purposes of any program or form of assistance where a person's income or assets are considered in determining eligibility or level of assistance, whether under this Code or another authority, neither the State of Illinois nor any entity or person administering a program wholly or partially financed by the State of Illinois or any of its political subdivisions shall include restitution payments, including all income and resources derived therefrom, made pursuant to the federal Civil Liberties Act of 1988 and the Aleutian and Pribilof Island Restitution Act, P.L. 100-383, in the calculation of income or assets for determining eligibility or level of assistance.
    (c) For purposes of determining eligibility for or the amount of assistance under this Code, except for the determination of eligibility for payments or programs under the TANF employment, education, and training programs and the Food Stamp Employment and Training Program, the Illinois Department, County Departments, and local governmental units shall exclude from consideration any financial assistance received under any student aid program administered by an agency of this State or the federal government, by a person who is enrolled as a full-time or part-time student of any public or private university, college, or community college in this State.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/1-8

    (305 ILCS 5/1-8)
    Sec. 1-8. Fugitives ineligible.
    (a) The following persons are not eligible for aid under this Code, or federal food stamps or federal food stamp benefits:
        (1) A person who has fled from the jurisdiction of
    
any court of record of this or any other state or of the United States to avoid prosecution for a felony or to avoid giving testimony in any criminal proceeding involving the alleged commission of a felony.
        (2) A person who has fled to avoid imprisonment in a
    
correctional facility of this or any other state or the United States for having committed a felony.
        (3) A person who has escaped from a correctional
    
facility of this or any other state or the United States if the person was incarcerated for having committed a felony.
        (4) A person who is violating a condition of
    
probation or parole imposed under federal or State law.
    In this Section, "felony" means a violation of a penal statute of this or any other state or the United States for which a sentence to death or to a term of imprisonment in a penitentiary for one year or more is provided.
    To implement this Section, the Illinois Department may exchange necessary information with an appropriate law enforcement agency of this or any other state, a political subdivision of this or any other state, or the United States.
    (b) (Blank).
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/1-8.5

    (305 ILCS 5/1-8.5)
    Sec. 1-8.5. Eligibility for medical assistance during periods of incarceration or detention.
    (a) To the extent permitted by federal law and notwithstanding any other provision of this Code, the Department of Healthcare and Family Services shall not cancel a person's eligibility for medical assistance solely because that person has become an inmate of a public institution, including, but not limited to, a county jail, juvenile detention center, or State correctional facility. The person may remain enrolled for medical assistance as long as all other eligibility criteria are met.
    (b) The Department may adopt rules to permit a person to apply for medical assistance while he or she is an inmate of a public institution as described in subsection (a). The rules may limit applications to persons who would be likely to qualify for medical assistance if they resided in the community. Any such person who is not already enrolled for medical assistance may apply for medical assistance prior to the date of scheduled release or discharge from a penal institution or county jail or similar status.
    (c) Except as provided under Section 17 of the County Jail Act, the Department shall not be responsible to provide medical assistance under this Code for any medical care, services, or supplies provided to a person while he or she is an inmate of a public institution as described in subsection (a). The responsibility for providing medical care shall remain as otherwise provided by law with the Department of Corrections, county, or other arresting authority. The Department may seek federal financial participation, to the extent that it is available and with the cooperation of the Department of Juvenile Justice, the Department of Corrections, or the relevant county, for the costs of those services.
    (d) To the extent permitted under State and federal law, the Department shall develop procedures to expedite required periodic reviews of continued eligibility for persons described in subsection (a).
    (e) Counties, the Department of Juvenile Justice, the Department of Human Services, and the Department of Corrections shall cooperate with the Department in administering this Section. That cooperation shall include managing eligibility processing and sharing information sufficient to inform the Department, in a manner established by the Department, that a person enrolled in the medical assistance program has been detained or incarcerated.
    (f) The Department shall resume responsibility for providing medical assistance upon release of the person to the community as long as all of the following apply:
        (1) The person is enrolled for medical assistance at
    
the time of release.
        (2) Neither a county, the Department of Juvenile
    
Justice, the Department of Corrections, nor any other criminal justice authority continues to bear responsibility for the person's medical care.
        (3) The county, the Department of Juvenile Justice,
    
or the Department of Corrections provides timely notice of the date of release in a manner established by the Department.
    (g) This Section applies on and after December 31, 2011.
(Source: P.A. 98-139, eff. 1-1-14.)

305 ILCS 5/1-9

    (305 ILCS 5/1-9)
    Sec. 1-9. Misrepresentation of residence. A person who has been convicted in federal or State court of having made a fraudulent statement or representation with respect to residence in order to receive assistance simultaneously from 2 or more states shall be ineligible for cash assistance under this Code for 10 years beginning on the date of conviction.
(Source: P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/1-10

    (305 ILCS 5/1-10)
    Sec. 1-10. Drug convictions.
    (a) Persons convicted of an offense under the Illinois Controlled Substances Act, the Cannabis Control Act, or the Methamphetamine Control and Community Protection Act which is a Class X felony, or a Class 1 felony, or comparable federal criminal law which has as an element the possession, use, or distribution of a controlled substance, as defined in Section 102(6) of the federal Controlled Substances Act (21 U.S.C. 802(c)), shall not be eligible for cash assistance provided under this Code.
    (b) Persons convicted of any other felony under the Illinois Controlled Substances Act, the Cannabis Control Act, or the Methamphetamine Control and Community Protection Act which is not a Class X or Class 1 felony, or comparable federal criminal law which has as an element the possession, use, or distribution of a controlled substance, as defined in Section 102(6) of the federal Controlled Substances Act (21 U.S.C. 802(c)), shall not be eligible for cash assistance provided under this Code for 2 years from the date of conviction. This prohibition shall not apply if the person is in a drug treatment program, aftercare program, or similar program as defined by rule.
    (c) Persons shall not be determined ineligible for food stamps provided under this Code based upon a conviction of any felony or comparable federal or State criminal law which has an element the possession, use or distribution of a controlled substance, as defined in Section 102(6) of the federal Controlled Substances Act (21 U.S.C. 802(c)).
(Source: P.A. 98-756, eff. 7-16-14.)

305 ILCS 5/1-11

    (305 ILCS 5/1-11)
    Sec. 1-11. Citizenship. To the extent not otherwise provided in this Code or federal law, all clients who receive cash or medical assistance under Article III, IV, V, or VI of this Code must meet the citizenship requirements as established in this Section. To be eligible for assistance an individual, who is otherwise eligible, must be either a United States citizen or included in one of the following categories of non-citizens:
        (1) United States veterans honorably discharged and
    
persons on active military duty, and the spouse and unmarried dependent children of these persons;
        (2) Refugees under Section 207 of the Immigration and
    
Nationality Act;
        (3) Asylees under Section 208 of the Immigration and
    
Nationality Act;
        (4) Persons for whom deportation has been withheld
    
under Section 243(h) of the Immigration and Nationality Act;
        (5) Persons granted conditional entry under Section
    
203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980;
        (6) Persons lawfully admitted for permanent residence
    
under the Immigration and Nationality Act;
        (7) Parolees, for at least one year, under Section
    
212(d)(5) of the Immigration and Nationality Act;
        (8) Nationals of Cuba or Haiti admitted on or after
    
April 21, 1980;
        (9) Amerasians from Vietnam, and their close family
    
members, admitted through the Orderly Departure Program beginning on March 20, 1988;
        (10) Persons identified by the federal Office of
    
Refugee Resettlement (ORR) as victims of trafficking;
        (11) Persons legally residing in the United States
    
who were members of a Hmong or Highland Laotian tribe when the tribe helped United States personnel by taking part in a military or rescue operation during the Vietnam era (between August 5, 1965 and May 7, 1975); this also includes the person's spouse, a widow or widower who has not remarried, and unmarried dependent children;
        (12) American Indians born in Canada under Section
    
289 of the Immigration and Nationality Act and members of an Indian tribe as defined in Section 4e of the Indian Self-Determination and Education Assistance Act; and
        (13) Persons who are a spouse, widow, or child of a
    
U.S. citizen or a spouse or child of a legal permanent resident (LPR) who have been battered or subjected to extreme cruelty by the U.S. citizen or LPR or a member of that relative's family who lived with them, who no longer live with the abuser or plan to live separately within one month of receipt of assistance and whose need for assistance is due, at least in part, to the abuse.
    Those persons who are in the categories set forth in subdivisions 6 and 7 of this Section, who enter the United States on or after August 22, 1996, shall not be eligible for 5 years beginning on the date the person entered the United States.
    The Illinois Department may, by rule, cover prenatal care or emergency medical care for non-citizens who are not otherwise eligible under this Section. Local governmental units which do not receive State funds may impose their own citizenship requirements and are authorized to provide any benefits and impose any citizenship requirements as are allowed under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193).
(Source: P.A. 93-342, eff. 7-24-03.)

305 ILCS 5/Art. II

 
    (305 ILCS 5/Art. II heading)
ARTICLE II. DEFINITIONS

305 ILCS 5/2-1

    (305 ILCS 5/2-1) (from Ch. 23, par. 2-1)
    Sec. 2-1. Definitions.
    The terms defined in this Article shall have the meanings ascribed to them, except when the context otherwise requires.
(Source: Laws 1967, p. 122.)

305 ILCS 5/2-2

    (305 ILCS 5/2-2) (from Ch. 23, par. 2-2)
    Sec. 2-2. "Public aid".
    Financial aid and all rehabilitative and other services provided under this Code for basic maintenance support; medical, surgical, dental, pharmaceutical, optometric, or nursing services, or other remedial care recognized under State law; rehabilitative services; education, training or retraining for employment or self-support work; funeral and burial expenses; and such other care and services as are determined to be necessary in each case.
(Source: Laws 1967, p. 122.)

305 ILCS 5/2-3

    (305 ILCS 5/2-3) (from Ch. 23, par. 2-3)
    Sec. 2-3. "Money payment" or "grant". A payment made direct to the recipient, his legal representative, or other substitute payee by warrant, check, direct deposit transmittal or other instrument for basic maintenance support or other purpose.
(Source: P.A. 82-391.)

305 ILCS 5/2-4

    (305 ILCS 5/2-4) (from Ch. 23, par. 2-4)
    Sec. 2-4. "Grantee" or "payee".
    The person to whom a money payment is made.
(Source: Laws 1967, p. 122.)

305 ILCS 5/2-5

    (305 ILCS 5/2-5) (from Ch. 23, par. 2-5)
    Sec. 2-5. "Vendor payment".
    A payment made directly to the person, firm, corporation, association, agency, institution or other legal entity supplying goods or services to a recipient.
(Source: Laws 1967, p. 122.)

305 ILCS 5/2-6

    (305 ILCS 5/2-6) (from Ch. 23, par. 2-6)
    Sec. 2-6. "Financial aid". A money or vendor payment to or in behalf of a recipient for basic maintenance support or medical assistance provided under Articles III, IV, V, and VI.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/2-7

    (305 ILCS 5/2-7) (from Ch. 23, par. 2-7)
    Sec. 2-7. "Social services": assistance, other than financial aid, provided under Article IX.
(Source: P.A. 82-440.)

305 ILCS 5/2-8

    (305 ILCS 5/2-8) (from Ch. 23, par. 2-8)
    Sec. 2-8. "Applicant": A person who has applied for financial aid under any of the provisions of this Code.
(Source: Laws 1967, p. 122.)

305 ILCS 5/2-9

    (305 ILCS 5/2-9) (from Ch. 23, par. 2-9)
    Sec. 2-9. "Recipient": A person who is receiving financial aid under any of the provisions of this Code.
(Source: Laws 1967, p. 122.)

305 ILCS 5/2-10

    (305 ILCS 5/2-10) (from Ch. 23, par. 2-10)
    Sec. 2-10. "Residence": The establishment of a permanent home within this State.
    A person is deemed to have established his permanent home within this State if he has acquired by purchase, rental, or other arrangement housing facilities which he uses as his home; has located his household equipment, furnishings and personal belongings therein; and is or has been employed, is seeking employment, or is engaged in other self-support activity, in the community in which he lives or within a distance reasonably proximate thereto, within or without the State, which is accessible to his home by public or private transportation facilities and to which he regularly commutes, or, if he cannot engage in employment or other self-support activity, is maintained in such home by relatives responsible for his support or by other sources or means of maintenance and support. A person shall not be required to occupy a permanent dwelling or have a fixed home or mailing address in order to establish a permanent home within this State. However, a recipient who moves from this State for the purpose of obtaining employment or other means of support or care shall retain his residence eligibility for a period of 12 months, provided he has not acquired residence eligibility for public aid under the laws of any State to which he has moved.
    The residence of a married woman shall be that of her husband unless they are living separate and apart, in which case she may acquire a separate residence.
    Minor children shall have the residence of their father if they reside with him; if they reside with their mother they shall have her residence.
    A minor, neither of whose parents has acquired a residence, may acquire a residence as if he or she were a person of full age.
    Every minor upon marriage may acquire a residence as if he or she were a person of full age.
    Applicants for or recipients of public aid shall meet such durational requirements as to residence as may be specified in the Article governing the category under which they are applying for or receiving aid.
    Temporary absence from the State, absence while in the service of the State or Nation, or entry into a hospital or other medical care institution outside the State for medical treatment, shall not affect a person's residence.
    A recipient of aid under Article III, IV or VI who, for any reason, has remained outside the State for a continuous period of more than 12 months shall prima facie be presumed to have lost his residence and shall receive no further aid unless and until he submits evidence sufficient to prove he has retained his residence. If the evidence proves that the absence was without intention to change his residence, the recipient shall be deemed to have maintained his residence eligibility and the grant of aid shall be continued or resumed.
(Source: P.A. 85-1231.)

305 ILCS 5/2-11

    (305 ILCS 5/2-11) (from Ch. 23, par. 2-11)
    Sec. 2-11. "Family Unit": Husband and wife and a child or children under age 21. Spouses and parents of children under age 21 constitute "legally responsible relatives" or "responsible relatives" wherever those terms may be used in this Code in respect to their support obligation enforceable by court action or an administrative order of the Illinois Department, as provided in Article X, or enforceable through other State or Federal laws.
    The support obligation of other persons defined as "legally responsible relatives" in this Section prior to October 6, 1969 for aid extended to their dependents prior to that date shall remain unimpaired.
(Source: P.A. 79-474.)

305 ILCS 5/2-12

    (305 ILCS 5/2-12) (from Ch. 23, par. 2-12)
    Sec. 2-12. "Illinois Department"; "Department". In this Code, "Illinois Department" or "Department", when a particular entity is not specified, means the following:
    (1) In the case of a function performed before July 1, 1997 (the effective date of the Department of Human Services Act), the term means the Department of Public Aid.
    (2) In the case of a function to be performed on or after July 1, 1997 under Article III, IV, VI, IX, or IXA, the term means the Department of Human Services as successor to the Illinois Department of Public Aid.
    (3) In the case of a function to be performed on or after July 1, 1997 under Article V, V-A, V-B, V-C, V-D, V-E, X, XIV, or XV, the term means the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid).
    (4) In the case of a function to be performed on or after July 1, 1997 under Article I, II, VIIIA, XI, XII, or XIII, the term means the Department of Human Services (acting as successor to the Illinois Department of Public Aid) or the Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) or both, according to whether that function, in the specific context, has been allocated to the Department of Human Services or the Department of Healthcare and Family Services (formerly Department of Public Aid) or both of those departments.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/2-12.5

    (305 ILCS 5/2-12.5)
    Sec. 2-12.5. "Director of the Illinois Department"; "Director of the Department"; "Director". In this Code, "Director of the Illinois Department", "Director of the Department", or "Director", when a particular official is not specified, means the following:
    (1) In the case of a function performed before July 1, 1997 (the effective date of the Department of Human Services Act), the term means the Director of Public Aid.
    (2) In the case of a function to be performed on or after July 1, 1997 under Article III, IV, VI, IX, or IXA, the term means the Secretary of Human Services.
    (3) In the case of a function to be performed on or after July 1, 1997 under Article V, V-A, V-B, V-C, V-D, V-E, X, XIV, or XV, the term means the Director of Healthcare and Family Services (formerly Director of Public Aid).
    (4) In the case of a function to be performed on or after July 1, 1997 under Article I, II, VIIIA, XI, XII, or XIII, the term means the Secretary of Human Services or the Director of Healthcare and Family Services (formerly Director of Public Aid) or both, according to whether that function, in the specific context, has been allocated to the Department of Human Services or the Department of Healthcare and Family Services (formerly Department of Public Aid) or both of those departments.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/2-13

    (305 ILCS 5/2-13) (from Ch. 23, par. 2-13)
    Sec. 2-13. "County department". The Department of Human Services local office or offices in each county in this State.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/2-14

    (305 ILCS 5/2-14) (from Ch. 23, par. 2-14)
    Sec. 2-14. "Local governmental unit". Every county, city, village, incorporated town or township charged with the duty of providing public aid under Article VI; and County Veterans Assistance Commissions providing general assistance to indigent war veterans and their families under Section 12-21.13 of Article XII.
    However, should any Section of this Code impose the obligation of providing medical assistance to persons who are non-residents of the State of Illinois upon a local governmental unit, the term "local governmental unit" shall not include townships. In such case the obligation for providing medical assistance to non-residents which would otherwise be the duty of a township shall become the obligation of the Department of Healthcare and Family Services.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/2-15

    (305 ILCS 5/2-15) (from Ch. 23, par. 2-15)
    Sec. 2-15. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/2-16

    (305 ILCS 5/2-16) (from Ch. 23, par. 2-16)
    Sec. 2-16. "Service provider": A person or corporation who furnishes medical, educational, psychiatric, vocational or rehabilitative services to a recipient under this Code, but excluding an employee of the Illinois Department or a County Department.
(Source: P.A. 82-555.)

305 ILCS 5/2-17

    (305 ILCS 5/2-17) (from Ch. 23, par. 2-17)
    Sec. 2-17. "Unable to purchase care and maintenance": For the purposes of this Code and Division 5-21 of the Counties Code, a person receiving Medical Assistance under this Code shall not be deemed "unable to purchase care and maintenance".
(Source: P.A. 86-1475.)

305 ILCS 5/2-18

    (305 ILCS 5/2-18)
    Sec. 2-18. Domestic or sexual violence. "Domestic or sexual violence" means domestic violence, sexual assault, or stalking. Domestic or sexual violence may occur through electronic communication.
    "Domestic violence" means "abuse" as defined in Section 103 of the Illinois Domestic Violence Act of 1986 by a "family or household member" as defined in Section 103 of the Illinois Domestic Violence Act of 1986.
    "Sexual assault" means any conduct proscribed by Sections 11-1.20, 11-1.30, 11-1.40, 11-1.50, 11-1.60, 12-13, 12-14, 12-14.1, 12-15, and 12-16 of the Criminal Code of 1961 or the Criminal Code of 2012.
    "Stalking" means any conduct proscribed by Sections 12-7.3, 12-7.4, and 12-7.5 of the Criminal Code of 1961 or the Criminal Code of 2012.
    "Electronic communication" includes communications via telephone, mobile phone, computer, e-mail, video recorder, fax machine, telex, or pager, or any other "electronic communication" as defined in Section 12-7.5 of the Criminal Code of 2012.
(Source: P.A. 96-866, eff. 7-1-10; 97-1150, eff. 1-25-13.)

305 ILCS 5/Art. III

 
    (305 ILCS 5/Art. III heading)
ARTICLE III. AID TO THE AGED, BLIND
OR DISABLED

305 ILCS 5/3-1

    (305 ILCS 5/3-1) (from Ch. 23, par. 3-1)
    Sec. 3-1. Eligibility Requirements. Financial aid in meeting basic maintenance requirements for a livelihood compatible with health and well-being shall be given under this Article to or in behalf of aged, blind, or disabled persons who meet the eligibility conditions of Sections 3-1.1 through 3-1.7. Financial aid under this Article shall be available only for persons who are receiving Supplemental Security Income (SSI) or who have been found ineligible for SSI (i) on the basis of income or (ii) due to expiration of the period of eligibility for refugees and asylees pursuant to 8 U.S.C. 1612(a)(2).
    "Aged person" means a person who has attained age 65, as demonstrated by such evidence of age as the Illinois Department may by rule prescribe.
    "Blind person" means a person who has no vision or whose vision with corrective glasses is so defective as to prevent the performance of ordinary duties or tasks for which eyesight is essential. The Illinois Department shall define blindness in terms of ophthalmic measurements or ocular conditions. For purposes of this Act, an Illinois Person with a Disability Identification Card issued pursuant to the Illinois Identification Card Act, indicating that the person thereon named has a Type 3 disability shall be evidence that such person is a blind person within the meaning of this Section; however, such a card shall not qualify such person for aid as a blind person under this Act, and eligibility for aid as a blind person shall be determined as provided in this Act.
    "Disabled person" means a person age 18 or over who has a physical or mental impairment, disease, or loss which is of a permanent nature and which substantially impairs his ability to perform labor or services or to engage in useful occupations for which he is qualified, as determined by rule and regulation of the Illinois Department. For purposes of this Act, an Illinois Person with a Disability Identification Card issued pursuant to the Illinois Identification Card Act, indicating that the person thereon named has a Type 1 or 2, Class 2 disability shall be evidence that such person is a disabled person under this Section; however, such a card shall not qualify such person for aid as a disabled person under this Act, and eligibility for aid as a disabled person shall be determined as provided in this Act. If federal law or regulation permit or require the inclusion of blind or disabled persons whose blindness or disability is not of the degree specified in the foregoing definitions, or permit or require the inclusion of disabled persons under age 18 or aged persons under age 65, the Illinois Department, upon written approval of the Governor, may provide by rule that all aged, blind or disabled persons toward whose aid federal funds are available be eligible for assistance under this Article as is given to those who meet the foregoing definitions of blind person and disabled person or aged person.
(Source: P.A. 96-22, eff. 6-30-09; 97-1064, eff. 1-1-13.)

305 ILCS 5/3-1a

    (305 ILCS 5/3-1a) (from Ch. 23, par. 3-1a)
    Sec. 3-1a. Interim Assistance.
    (a) (Blank).
    (b) The Illinois Department may establish, by rule, an advocacy program to help clients pursue Supplemental Security Income applications and, if the client is found ineligible for Supplemental Security Income initially, to help the client pursue the Supplemental Security Income reconsideration and appeal process. This program may be limited to specific geographic areas.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/3-1.2

    (305 ILCS 5/3-1.2) (from Ch. 23, par. 3-1.2)
    Sec. 3-1.2. Need. Income available to the person, when added to contributions in money, substance, or services from other sources, including contributions from legally responsible relatives, must be insufficient to equal the grant amount established by Department regulation for such person.
    In determining earned income to be taken into account, consideration shall be given to any expenses reasonably attributable to the earning of such income. If federal law or regulations permit or require exemption of earned or other income and resources, the Illinois Department shall provide by rule and regulation that the amount of income to be disregarded be increased (1) to the maximum extent so required and (2) to the maximum extent permitted by federal law or regulation in effect as of the date this amendatory Act becomes law. The Illinois Department may also provide by rule and regulation that the amount of resources to be disregarded be increased to the maximum extent so permitted or required. Subject to federal approval, resources (for example, land, buildings, equipment, supplies, or tools), including farmland property and personal property used in the income-producing operations related to the farmland (for example, equipment and supplies, motor vehicles, or tools), necessary for self-support, up to $6,000 of the person's equity in the income-producing property, provided that the property produces a net annual income of at least 6% of the excluded equity value of the property, are exempt. Equity value in excess of $6,000 shall not be excluded. If the activity produces income that is less than 6% of the exempt equity due to reasons beyond the person's control (for example, the person's illness or crop failure) and there is a reasonable expectation that the property will again produce income equal to or greater than 6% of the equity value (for example, a medical prognosis that the person is expected to respond to treatment or that drought-resistant corn will be planted), the equity value in the property up to $6,000 is exempt. If the person owns more than one piece of property and each produces income, each piece of property shall be looked at to determine whether the 6% rule is met, and then the amounts of the person's equity in all of those properties shall be totaled to determine whether the total equity is $6,000 or less. The total equity value of all properties that is exempt shall be limited to $6,000.
    In determining the resources of an individual or any dependents, the Department shall exclude from consideration the value of funeral and burial spaces, funeral and burial insurance the proceeds of which can only be used to pay the funeral and burial expenses of the insured and funds specifically set aside for the funeral and burial arrangements of the individual or his or her dependents, including prepaid funeral and burial plans, to the same extent that such items are excluded from consideration under the federal Supplemental Security Income program (SSI).
    Prepaid funeral or burial contracts are exempt to the following extent:
        (1) Funds in a revocable prepaid funeral or
    
burial contract are exempt up to $1,500, except that any portion of a contract that clearly represents the purchase of burial space, as that term is defined for purposes of the Supplemental Security Income program, is exempt regardless of value.
        (2) Funds in an irrevocable prepaid funeral or
    
burial contract are exempt up to $5,874, except that any portion of a contract that clearly represents the purchase of burial space, as that term is defined for purposes of the Supplemental Security Income program, is exempt regardless of value. This amount shall be adjusted annually for any increase in the Consumer Price Index. The amount exempted shall be limited to the price of the funeral goods and services to be provided upon death. The contract must provide a complete description of the funeral goods and services to be provided and the price thereof. Any amount in the contract not so specified shall be treated as a transfer of assets for less than fair market value.
        (3) A prepaid, guaranteed-price funeral or
    
burial contract, funded by an irrevocable assignment of a person's life insurance policy to a trust, is exempt. The amount exempted shall be limited to the amount of the insurance benefit designated for the cost of the funeral goods and services to be provided upon the person's death. The contract must provide a complete description of the funeral goods and services to be provided and the price thereof. Any amount in the contract not so specified shall be treated as a transfer of assets for less than fair market value. The trust must include a statement that, upon the death of the person, the State will receive all amounts remaining in the trust, including any remaining payable proceeds under the insurance policy up to an amount equal to the total medical assistance paid on behalf of the person. The trust is responsible for ensuring that the provider of funeral services under the contract receives the proceeds of the policy when it provides the funeral goods and services specified under the contract. The irrevocable assignment of ownership of the insurance policy must be acknowledged by the insurance company.
    Notwithstanding any other provision of this Code to the contrary, an irrevocable trust containing the resources of a person who is determined to have a disability shall be considered exempt from consideration. A pooled trust must be established and managed by a non-profit association that pools funds but maintains a separate account for each beneficiary. The trust may be established by the person, a parent, grandparent, legal guardian, or court. It must be established for the sole benefit of the person and language contained in the trust shall stipulate that any amount remaining in the trust (up to the amount expended by the Department on medical assistance) that is not retained by the trust for reasonable administrative costs related to wrapping up the affairs of the subaccount shall be paid to the Department upon the death of the person. After a person reaches age 65, any funding by or on behalf of the person to the trust shall be treated as a transfer of assets for less than fair market value unless the person is a ward of a county public guardian or the State Guardian pursuant to Section 13-5 of the Probate Act of 1975 or Section 30 of the Guardianship and Advocacy Act and lives in the community, or the person is a ward of a county public guardian or the State Guardian pursuant to Section 13-5 of the Probate Act of 1975 or Section 30 of the Guardianship and Advocacy Act and a court has found that any expenditures from the trust will maintain or enhance the person's quality of life. If the trust contains proceeds from a personal injury settlement, any Department charge must be satisfied in order for the transfer to the trust to be treated as a transfer for fair market value.
    The homestead shall be exempt from consideration except to the extent that it meets the income and shelter needs of the person. "Homestead" means the dwelling house and contiguous real estate owned and occupied by the person, regardless of its value. Subject to federal approval, a person shall not be eligible for long-term care services, however, if the person's equity interest in his or her homestead exceeds the minimum home equity as allowed and increased annually under federal law. Subject to federal approval, on and after the effective date of this amendatory Act of the 97th General Assembly, homestead property transferred to a trust shall no longer be considered homestead property.
    Occasional or irregular gifts in cash, goods or services from persons who are not legally responsible relatives which are of nominal value or which do not have significant effect in meeting essential requirements shall be disregarded. The eligibility of any applicant for or recipient of public aid under this Article is not affected by the payment of any grant under the "Senior Citizens and Disabled Persons Property Tax Relief Act" or any distributions or items of income described under subparagraph (X) of paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax Act.
    The Illinois Department may, after appropriate investigation, establish and implement a consolidated standard to determine need and eligibility for and amount of benefits under this Article or a uniform cash supplement to the federal Supplemental Security Income program for all or any part of the then current recipients under this Article; provided, however, that the establishment or implementation of such a standard or supplement shall not result in reductions in benefits under this Article for the then current recipients of such benefits.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)

305 ILCS 5/3-1.3

    (305 ILCS 5/3-1.3) (from Ch. 23, par. 3-1.3)
    Sec. 3-1.3. Property transfers. To the extent required under federal law, a person shall not make or have made a voluntary or involuntary assignment or transfer of any legal or equitable interests in real or personal property, whether vested, contingent or inchoate, for less than fair market value.
(Source: P.A. 88-554, eff. 7-26-94.)

305 ILCS 5/3-1.4

    (305 ILCS 5/3-1.4) (from Ch. 23, par. 3-1.4)
    Sec. 3-1.4. Residents of public institutions. Residents of municipal, county, state or national institutions for persons with mental illness or persons with a developmental disability or for the tuberculous, or residents of a home or other institution maintained by such governmental bodies when not in need of institutional care because of sickness, convalescence, infirmity, or chronic illness, and inmates of penal or correctional institutions maintained by such governmental bodies, may qualify for aid under this Article only after they have ceased to be residents or inmates, but they may apply in advance of their discharge. Applications received from residents scheduled for discharge from such institutions shall be processed by the Department in an expeditious manner. For persons whose applications are approved, the date of eligibility shall be the date of release from the institution.
    A person shall not be deemed a resident of a State institution for persons with mental illness or persons with a developmental disability within the meaning of this Section if he or she has been conditionally discharged by the Department of Mental Health and Developmental Disabilities or the Department of Human Services (acting as successor to the Department of Mental Health and Developmental Disabilities) and is no longer residing in the institution.
    Recipients of benefits under this Article who become residents of such institutions shall be permitted a period of up to 30 days in such institutions without suspension or termination of eligibility; if residency in an institution extends beyond 30 days the eligibility for all benefits except Aid to Families with Dependent Children shall be suspended. Benefits shall be restored, effective on the date of discharge or release, for persons who are residents of institutions. Within a reasonable time after the discharge of a person who was a resident of an institution, the Department shall redetermine the eligibility of such person.
    The Department shall provide for procedures to expedite the determination of disability of persons scheduled to be discharged from facilities operated by the Department.
    If federal law or regulations governing grants under this Article permit the inclusion of persons who are residents of institutions designated in this Section beyond the period authorized herein, the Illinois Department, upon a determination that the appropriations for public aid are sufficient for such purpose, and upon approval of the Governor, may provide by general and uniform rule for the waiver of the provisions of this Section which would otherwise disqualify such person for aid under this Article.
(Source: P.A. 88-380; 89-507, eff. 7-1-97.)

305 ILCS 5/3-1.5

    (305 ILCS 5/3-1.5) (from Ch. 23, par. 3-1.5)
    Sec. 3-1.5. Residents of private institutions.
    Persons who are residents of or who are being maintained by a private institution may qualify only if they have not purchased care and maintenance in the institution by cash or by transfer of property, or having purchased care and maintenance, only after the amount of the cash or property has been wholly consumed for care and maintenance.
(Source: Laws 1967, p. 122.)

305 ILCS 5/3-1.6

    (305 ILCS 5/3-1.6) (from Ch. 23, par. 3-1.6)
    Sec. 3-1.6. (Repealed).
(Source: P.A. 77-1802. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/3-1.7

    (305 ILCS 5/3-1.7) (from Ch. 23, par. 3-1.7)
    Sec. 3-1.7. Multiple convictions for violations of this Code. Any person found guilty of a second violation of Article VIIIA shall be ineligible for financial aid under this Article, as provided in Section 8A-8.
(Source: P.A. 82-440.)

305 ILCS 5/3-2

    (305 ILCS 5/3-2) (from Ch. 23, par. 3-2)
    Sec. 3-2. Conditions for basic maintenance grants to persons receiving institutional care.
    A resident of a public or private home or institution maintained for the care of persons who are sick, convalescent, infirm or chronically ill, may, if otherwise qualified, be granted financial aid for basic maintenance, subject to the rules and regulations of the Illinois Department, if the facilities of the home or institution are in conformity with standards prescribed by the Department of Public Health for safeguarding the health, safety, and comfort of the residents thereof, and provide such services as may be prescribed by the Illinois Department for enhancing their rehabilitation or increasing their capacity for self-care.
(Source: Laws 1967, p. 122.)

305 ILCS 5/3-2.5

    (305 ILCS 5/3-2.5)
    Sec. 3-2.5. (Repealed).
(Source: P.A. 93-774, eff. 7-21-04. Repealed by P.A. 95-322, eff. 1-1-08.)

305 ILCS 5/3-2.6

    (305 ILCS 5/3-2.6)
    Sec. 3-2.6. Sheltered care rates. The Department of Human Services shall increase the sheltered care rates in effect on June 30, 2008, by 10%.
(Source: P.A. 95-780, eff. 8-5-08.)

305 ILCS 5/3-3

    (305 ILCS 5/3-3) (from Ch. 23, par. 3-3)
    Sec. 3-3. Examination as to blindness. For all purposes, the Illinois Department may accept determinations as to blindness performed under the auspices of the Federal Social Security Administration and properly certified to the Department.
(Source: P.A. 89-21, eff. 7-1-95.)

305 ILCS 5/3-4

    (305 ILCS 5/3-4) (from Ch. 23, par. 3-4)
    Sec. 3-4. Examination as to disability. For all purposes, the Illinois Department may accept determinations as to disability performed under the auspices of the Federal Social Security Administration and properly certified to the Department.
(Source: P.A. 89-21, eff. 7-1-95.)

305 ILCS 5/3-5

    (305 ILCS 5/3-5) (from Ch. 23, par. 3-5)
    Sec. 3-5. Amount of aid. The amount and nature of financial aid granted to or in behalf of aged, blind, or disabled persons shall be determined in accordance with the standards, grant amounts, rules and regulations of the Illinois Department. Due regard shall be given to the requirements and conditions existing in each case, and to the amount of property owned and the income, money contributions, and other support, and resources received or obtainable by the person, from whatever source. However, the amount and nature of any financial aid is not affected by the payment of any grant under the "Senior Citizens and Disabled Persons Property Tax Relief Act" or any distributions or items of income described under subparagraph (X) of paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax Act. The aid shall be sufficient, when added to all other income, money contributions and support, to provide the person with a grant in the amount established by Department regulation for such a person, based upon standards providing a livelihood compatible with health and well-being. Financial aid under this Article granted to persons who have been found ineligible for Supplemental Security Income (SSI) due to expiration of the period of eligibility for refugees and asylees pursuant to 8 U.S.C. 1612(a)(2) shall equal 90% of the current maximum SSI payment amount per month.
(Source: P.A. 97-689, eff. 6-14-12; 98-674, eff. 6-30-14.)

305 ILCS 5/3-5a

    (305 ILCS 5/3-5a) (from Ch. 23, par. 3-5a)
    Sec. 3-5a. Protective payments to substitute payee. If the person, by reason of his physical or mental condition, is unable to manage funds, or if, for any reason, he persistently mismanages the grant to the detriment of his best interests, the County Department, in accordance with the rules and regulations of the Illinois Department, may make a protective payment by designating a person who is interested in or concerned with the person's welfare to receive the grant in his behalf.
    The substitute payee shall serve without compensation and assume the obligation of seeing that the grant is expended for the recipient's benefit. He may spend the grant for the recipient, or supervise the recipient in its use, depending upon the circumstances in the case, and shall make such monthly reports to the County Department as the County Department and the Illinois Department may require.
    The County Department shall terminate the protective payment when it has made a determination that the grant will be used for the recipient's welfare.
    A substitute payee may be removed, in accordance with the rules and regulations of the Illinois Department, for unsatisfactory service. Such removal may be effected without hearing. The decision shall not be appealable to the Illinois Department nor shall it be reviewable in the courts.
    The County Department shall conduct such periodic reviews as may be required by the Illinois Department to determine whether there is a continuing need for a protective payment. If it appears that the need for such payment is likely to continue beyond a reasonable period, the County Department shall take action for appointment by the circuit court of a guardian or legal representative for the purpose of receiving and managing the public aid grant.
    The person shall be advised, in advance of a determination to make a protective payment, that he may appeal the decision to the Illinois Department under the provisions of Section 11-8 of Article XI.
(Source: Laws 1967, p. 2324.)

305 ILCS 5/3-6

    (305 ILCS 5/3-6) (from Ch. 23, par. 3-6)
    Sec. 3-6. Entitlement to medical assistance.
    Persons qualified for financial aid for basic maintenance shall be entitled to receive, under Article V, all necessary medical assistance.
(Source: Laws 1967, p. 122.)

305 ILCS 5/3-7

    (305 ILCS 5/3-7) (from Ch. 23, par. 3-7)
    Sec. 3-7. Entitlement to Social Services. Persons qualified for financial aid for basic maintenance shall be entitled to receive, under Article IX, such rehabilitative, training or other social services as are appropriate.
(Source: P.A. 82-440.)

305 ILCS 5/3-8

    (305 ILCS 5/3-8) (from Ch. 23, par. 3-8)
    Sec. 3-8. Funeral and burial. If the estate of a deceased recipient is insufficient to pay for funeral and burial expenses, and if no other resources, including assistance from legally responsible relatives, are available for such purposes, there shall be paid, in accordance with the standards, rules and regulations of the Illinois Department, such reasonable amounts as may be necessary to meet costs of the funeral, burial space, and cemetery charges, or to reimburse any person not financially responsible for the deceased who has voluntarily made expenditures for such costs.
(Source: P.A. 90-372, eff. 7-1-98.)

305 ILCS 5/3-9

    (305 ILCS 5/3-9) (from Ch. 23, par. 3-9)
    Sec. 3-9. Claim against the estate of a deceased recipient. On the death of a person who has been a recipient, the total amount paid under this Article shall be filed and allowed as a claim against that person's estate or as a claim against the estate of that person's surviving spouse. No claim of the State, however, shall be enforced against any real estate while it is occupied as a homestead by the recipient's surviving spouse, or a relative of the recipient as defined by the rules and regulations of the Illinois Department, if no claims by other creditors have been filed against the estate, or, if such claims have been filed, they remain dormant for failure of prosecution or failure of the claimant to compel administration of the estate for the purpose of payment. "Homestead", as used in this Section, means the dwelling house and contiguous real estate occupied by a surviving spouse, or defined relative of the recipient, regardless of the value of the property.
    The transfer of money, personal property or other personal assets, or any interest therein, by a present or former recipient into a joint tenancy account in a bank or other institution or depository shall be prima facie evidence of an intent to defeat the claim against his estate. The transfer may be voided in an appropriate legal action, or the Illinois Department may consider the recipient's interest in the joint tenancy account as an asset of his estate for the purpose of the claim provided by this Section.
    The Illinois Department may, by rule, defer or waive the enforcement of its claim hereunder if the deceased recipient is survived by a dependent spouse and minor child or children, or if rehabilitative training for employment or other means of self-support for the surviving spouse or children is feasible and the deferment or waiver of the claim would facilitate achievement of self-support status and prevent or reduce the likelihood of return to dependency upon public aid.
    The estate claim herein provided is in addition to the lien claim established in Section 3-10.
(Source: P.A. 88-85.)

305 ILCS 5/3-10

    (305 ILCS 5/3-10) (from Ch. 23, par. 3-10)
    Sec. 3-10. Lien on real property interests. Subject to the provisions of Sections 3-10.1 to 3-10.10, inclusive, the State shall have a lien upon all legal and equitable interests of recipients in real property, whether vested or contingent, including legal and equitable rights and interests of the recipient to coal, gas, oil, iron and other underground mineral resources, for basic maintenance grants paid under this Article, and for payments made to preserve the lien as provided in Section 3-10.5. The lien shall attach to such interests owned or subsequently acquired by persons who were recipients on or after the effective date of this Code, and in respect to which interests a notice of lien has been recorded or filed as provided in Sections 3-10.2 and 3-10.3.
    Liens recorded or filed under the provision of Article VIII-A of the 1949 Code for which the period of enforceability has not expired shall not be affected by the enactment of this Code.
(Source: P.A. 88-85.)

305 ILCS 5/3-10.1

    (305 ILCS 5/3-10.1) (from Ch. 23, par. 3-10.1)
    Sec. 3-10.1. Execution of notice of lien. The County Department of the county in which the recipient resides shall execute a notice of lien which shall contain the name and address of the recipient, a legal description of the property, the fact that a lien is being claimed for aid paid under this Article, and such other information as the Illinois Department may by rule prescribe.
    The notice shall designate the County Superintendent of Public Aid in his official capacity, and his successors in office, as the holder of the lien and shall be executed by the County Superintendent, in his official capacity, and shall be acknowledged substantially in the following form:
    "State of Illinois, County of (name of county): I (give name of the officer and his official title) certify that (name and official title of superintendent of public aid) personally known to me to be the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person and acknowledged that he signed the instrument as required of him by law, for the uses therein set forth."
    "Dated (insert date).
    ...............................
    Signature of officer (Seal)."
(Source: P.A. 91-357, eff. 7-29-99.)

305 ILCS 5/3-10.2

    (305 ILCS 5/3-10.2) (from Ch. 23, par. 3-10.2)
    Sec. 3-10.2. Recording or filing of notice of lien. Upon the recording or filing of the notice of lien with the recorder or Registrar of Titles of the county or counties in which the real estate is situated, the State shall have a lien thereon under the provisions of the 1949 Code, if applicable, for aid to the aged, blind or disabled, and a lien for similar aid paid on and after the effective date of this Code, and for payments made under Section 3-10.5 to preserve the lien. The lien shall be prior to any lien thereafter recorded or filed and shall be notice to a subsequent purchaser, assignor or encumbrancer of the existence and nature of such lien.
    The lien shall be inferior to the lien of general taxes, special assessment and special taxes heretofore or hereafter levied by any political subdivision or municipal corporation of the State.
    In case title to land to be affected by the notice of lien is registered under "An Act concerning land titles", approved May 1, 1897, as amended, the notice shall be filed in the office of the registrar of titles of the county within which the property is situated and shall be entered upon the register of titles as a memorial or charge upon each folium of the register of titles affected by such notice; but the State shall not have a preference over the rights of any bona fide purchaser, mortgagee, judgment creditor, or other lien holders registered prior to the registration of such notice.
    In the administration of the estate of a deceased recipient the lien shall also be inferior to funeral expenses not in excess of $500 and burial expenses to the extent allowable under this Code, attorney's fees allowed by the court in relation to such administration, and other expenses of administration.
    The lien shall be enforceable for a period of 5 years from the date of recordation or filing of the notice of lien. The lien may be extended for additional 5 year periods upon the filing or recordation of a new notice of lien prior to the expiration of the current period of enforceability.
(Source: P.A. 83-358.)

305 ILCS 5/3-10.3

    (305 ILCS 5/3-10.3) (from Ch. 23, par. 3-10.3)
    Sec. 3-10.3. Recorder's duties. The recorder in counties in which he is required to keep a tract index shall record and index the notice of lien and any certificate of release issued pursuant to Section 3-10.6 in the manner provided by law for the recording and indexing of other instruments. In all other counties the recorder of deeds shall procure a file labeled "Aid to the Aged, Blind or Disabled Real Estate Lien Notices" and an index book labeled "Aid to the Aged, Blind or Disabled Real Estate Lien Index".
    When a notice of lien is presented for filing he shall file it in numerical order and enter it alphabetically in respect to each person to whom the lien applies in the index. The entry shall show the name and address of the recipient, the serial number of the notice and date and hour of filing. When a certificate of release of lien issued by the County Department is presented for filing in the office of recorder or registrar of titles where the notice of lien was filed, the recorder, in the case of nonregistered property shall permanently attach the certificate of release to the notice of lien and shall enter the certificate of release and the date in the index on the line where the notice of lien is entered. In the case of registered property, the registrar of titles shall file and enter upon each folium of the register of titles affected thereby a memorial of the certificate of release, which memorial, when so entered, shall act as a release pro tanto of any memorial of such notice of lien previously filed and registered.
(Source: P.A. 83-358.)

305 ILCS 5/3-10.4

    (305 ILCS 5/3-10.4) (from Ch. 23, par. 3-10.4)
    Sec. 3-10.4. Court costs waived. The Illinois Department and County Departments shall not be required to furnish bond or make a deposit for or pay any costs or fees of any court or officer thereof in any legal proceeding involving the lien.
(Source: P.A. 83-889.)

305 ILCS 5/3-10.5

    (305 ILCS 5/3-10.5) (from Ch. 23, par. 3-10.5)
    Sec. 3-10.5. Payment to preserve lien.
    To protect the lien of the State for reimbursement of aid paid under this Article, the Illinois Department may, from funds which are available for that purpose, pay or provide for the payment of necessary or essential repairs, purchase tax certificates, pay balances due on land contracts, or pay or cause to be satisfied any prior liens on the property to which the lien hereunder applies.
(Source: Laws 1967, p. 122.)

305 ILCS 5/3-10.6

    (305 ILCS 5/3-10.6) (from Ch. 23, par. 3-10.6)
    Sec. 3-10.6. Release of lien.
    The County Department, under the rules and regulations of the Illinois Department, shall issue a certificate of release of lien upon payment by the recipient, his spouse, heirs at law, next of kin, or personal representatives, of the total amount of aid to which the lien applies, or upon submission of a bond with surety or sureties satisfactory to the Illinois Department, conditioned upon payment of such amount. A certificate of release may also be issued upon payment of the value of the property to which the lien applies; in such case, the release shall reserve the Illinois Department's claim for the balance against subsequently discovered assets of the recipient.
    The Illinois Department may also by rule provide for release of the lien in the case of recipients who have dependent spouses and minor children or for whom rehabilitative training for employment or other means of self-support is feasible where release of the lien would facilitate achievement of self-support status and prevent or reduce the likelihood of return to dependency.
(Source: Laws 1967, p. 122.)

305 ILCS 5/3-10.7

    (305 ILCS 5/3-10.7) (from Ch. 23, par. 3-10.7)
    Sec. 3-10.7. Foreclosure of lien. Upon the death of the recipient, or prior thereto in cases of fraud if the Illinois Department deems such action necessary to preserve the security of the lien, the Illinois Department, acting in behalf of the State, may foreclose the lien in a judicial proceeding to the same extent and in the same manner as in the enforcement of other liens. The process, practice and procedure for such foreclosure shall be the same as provided in the Civil Practice Law, as amended.
    If the amount bid for the property at the sale is less than the amount of the lien, or if there are no bidders, the Illinois Department may purchase the property for the use of the People of the State of Illinois. Property so acquired may be sold to the highest bidder, after advertisement in the State official newspaper, the sale to be not less than 10 days after the advertisement. Upon a sale, the deed shall be executed by the Illinois Department for the use of the People of the State of Illinois, and shall be signed by the Director.
    Except in cases of fraud, the Illinois Department shall defer foreclosure proceedings on property occupied as a homestead by the recipient, his surviving spouse, or a relative of the recipient as defined by the rules and regulations of the Illinois Department.
(Source: P.A. 89-507, eff. 7-1-97.)

305 ILCS 5/3-10.8

    (305 ILCS 5/3-10.8) (from Ch. 23, par. 3-10.8)
    Sec. 3-10.8. Joint tenancy interest.) A joint tenancy interest in real property shall be subject to the lien created by Section 3-10. The filing and approval of an application for aid under this Article on or after the effective date of this Code shall constitute a severance of the joint tenancy, effective on the date of the filing or recording of the notice of lien.
    The severance shall be solely for the purpose of enforcing the lien. For all other purposes, the joint tenancy shall remain in effect and be unimpaired.
    The lien shall be enforceable only to the extent of the interest of the recipient. A fractional part of the property, to be determined by dividing the total value of the property by the number of joint tenants, shall be presumed to have belonged absolutely to the recipient.
    A release of lien executed under Section 3-10.6 and filed, registered or recorded as provided in Sections 3-10.2 and 3-10.3, or the expiration of the 5 year period of limitation or any renewal period where no judicial proceedings are pending for the enforcement of the lien, shall nullify the severance of the joint tenancy. Judicial proceedings for the enforcement of the lien against registered land or any judgment predicated on such proceedings shall not affect such registered land unless the provisions of "An Act concerning land titles", approved May 1, 1897, as amended, are complied with. In either case the acceptance of aid thereafter shall, upon the recording or filing of a notice of lien under Sections 3-10.2 and 3-10.3, again result in the severance of the joint tenancy of the recipient. The repeal of the 1949 Code shall not affect the validity of a lien or severance of a joint tenancy interest established prior to the effective date of this Code.
(Source: P.A. 79-1365.)

305 ILCS 5/3-10.9

    (305 ILCS 5/3-10.9) (from Ch. 23, par. 3-10.9)
    Sec. 3-10.9. Redemption. Except as to any sale had by virtue of a judgment of foreclosure in accordance with Article XV of the Code of Civil Procedure, whenever real estate has been or is sold at judicial or judgment sale and the lien thereon in favor of the Illinois Department is junior or inferior to the lien so enforced or foreclosed by or through that sale, the right to redeem in any manner under or by virtue of such lien from such sale or from the lien so foreclosed or enforced shall terminate at the end of 12 months from the date upon which there is filed for record in the office of the Recorder for the County in which the lands so sold are situated, if such lands are unregistered, or in the office of the Registrar of Titles for such County, if such lands are registered, a certified copy of the original or duplicate recorded or registered certificate of such sale, such certified copy being endorsed by the Director showing service of a copy of such certificate upon him or her, and upon such service such officer shall make such endorsement. Such service may be by United States registered or certified mail.
(Source: P.A. 89-507, eff. 7-1-97.)

305 ILCS 5/3-10.10

    (305 ILCS 5/3-10.10) (from Ch. 23, par. 3-10.10)
    Sec. 3-10.10. Sale of property of deceased recipient-Order for amount of lien-Preservation of lien. Whenever the court having jurisdiction of the estate of a decedent determines that it is necessary or desirable for the proper administration of the estate to sell real property upon which the State has a lien imposed by this Article, the Court shall enter an order for the total amount of which the State has a lien, as determined by evidence submitted to it by the Illinois Department through the appropriate County Department or Departments.
    The superiority of such lien shall not be affected thereby and shall be satisfied from the proceeds of sale in the same manner as specified in Section 3-10.7 for foreclosure of the lien. The Illinois Department shall have the same power of purchase and subsequent sale as set forth in the second paragraph of Section 3-10.7. The lien may be released by the County Department in accordance with the provisions of Section 3-10.6.
(Source: Laws 1967, p. 122.)

305 ILCS 5/3-11

    (305 ILCS 5/3-11) (from Ch. 23, par. 3-11)
    Sec. 3-11. Fraudulent transfer of real property. A transfer of any legal or equitable interest in real property, whether vested, contingent, or inchoate, by a person who is or has been a recipient, including any such transfers prior to application which would have initially disqualified the person as provided in Section 3-1.3, shall, under any of the following conditions, be deemed prima facie fraudulent as to the Illinois Department.
    (1.) Where the deed or assignment has not been recorded or registered by the grantee, trustee, or assignee
    (2.) When the deed or assignment, even though recorded or registered, fails to state the consideration
    (3.) When the consideration for the deed or assignment, even though recorded or registered, is not paid
    (4.) When the consideration for the deed or assignment, even though recorded or registered, does not approximate the fair, cash market value.
    The Attorney General, upon request of the Illinois Department, shall file suit to rescind any such transfer or assignment of real property. Any aid furnished under this Article shall be recoverable in any such proceeding from such person or from his estate.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/3-12

    (305 ILCS 5/3-12) (from Ch. 23, par. 3-12)
    Sec. 3-12. (Repealed).
(Source: Repealed by P.A. 88-412.)

305 ILCS 5/3-13

    (305 ILCS 5/3-13) (from Ch. 23, par. 3-13)
    Sec. 3-13. Federal program - Declaration of responsibilities: It is the position of this State that the Federal Government should meet its obligation to provide financial aid to those aged, blind or disabled persons eligible under Article III hereof so as to assure those persons a standard of living compatible with health and well-being, including any supplementary aid program provided to meet special or emergency needs, and it is the position of this State that the Federal Government should meet its obligation to provide continuing supplemental nutritional aid for such persons through the Federal Food Stamp Program or through full reimbursement for expenditures made in lieu of such Food Stamp Program.
    (a) The Illinois Department may, from federal reimbursements received under this Section, make disbursements to any attorney, or advocate working under the supervision of an attorney, who represents a recipient of assistance under Article VI of this Code in a program administered by the Illinois Department, in an appeal of any claim for federal Supplemental Security Income benefits before an administrative law judge which is decided in favor of such recipient. The amount of such disbursement shall be equal to 25% of the maximum federal Supplemental Security Income grant payable to an individual for a period of one year. No such disbursement shall be made unless a petition and a copy of the favorable decision is submitted by such attorney or advocate to the Illinois Department within 60 days of the date of such decision. The disbursement shall be made within 30 days after the petition is received. The Illinois Department shall promulgate rules and regulations necessary to implement this subsection.
    (b) The Illinois Department shall institute a State program to fully supplement the federal Supplemental Security Income grants of all persons in the aged, blind, or disabled categories who meet the eligibility and need requirements of this Code. The amount or amounts of such supplementary payments shall be established by the Director of the Illinois Department in a manner consistent with the other provisions of this Article III.
    (c) The Illinois Department, the Comptroller and the Treasurer, are authorized to disburse to the Federal Government amounts appropriated to the Illinois Department for use in furnishing aid to persons eligible under Article III of this Code, to receive reimbursements from the Federal Government therefor, and to establish administrative procedures necessary for the accomplishment of such a payment system.
(Source: P.A. 93-632, eff. 2-1-04.)

305 ILCS 5/3-14

    (305 ILCS 5/3-14) (from Ch. 23, par. 3-14)
    Sec. 3-14.
    Authorization for Federal administration of supplement: The Illinois Department is authorized to enter into an agreement with the Secretary of Health, Education and Welfare for the Secretary to administer, as provided in Section 1616 of the Social Security Act, any or all portions of a State program to supplement grants.
(Source: P.A. 78-3rd S.S.-22.)

305 ILCS 5/3-15

    (305 ILCS 5/3-15) (from Ch. 23, par. 3-15)
    Sec. 3-15. (Repealed).
(Source: P.A. 78-3rd S.S.-22. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/Art. IV

 
    (305 ILCS 5/Art. IV heading)
ARTICLE IV. TEMPORARY ASSISTANCE FOR NEEDY FAMILIES

305 ILCS 5/4-0.5

    (305 ILCS 5/4-0.5)
    Sec. 4-0.5. Aid to Families with Dependent Children Program inoperative after June 30, 1997. The Aid to Families with Dependent Children (AFDC) Program shall be inoperative after June 30, 1997. Under the federal Temporary Assistance for Needy Children Program the Illinois Department shall develop an alternative program of mutual responsibility between the Illinois Department and the client to allow the family to become self-sufficient or employed as quickly as possible through (i) the provision of transitional assistance to families in the form of emergency one-time payments to prevent job loss, temporary assistance while searching for or being trained for work, or paternity establishment and child support enforcement or (ii) the provision for continued work.
(Source: P.A. 89-6, eff. 3-6-95; 90-17, eff. 7-1-97.)

305 ILCS 5/4-0.6

    (305 ILCS 5/4-0.6)
    Sec. 4-0.6. Reference to AFDC considered a reference to TANF. On and after the effective date of this amendatory Act of 1997, any reference to Aid to Families with Dependent Children or AFDC shall be considered to be a reference to Temporary Assistance for Needy Families or TANF.
(Source: P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-1

    (305 ILCS 5/4-1) (from Ch. 23, par. 4-1)
    Sec. 4-1. Eligibility requirements. Financial aid in meeting basic maintenance requirements for a livelihood compatible with health and well-being shall be given under this Article to or in behalf of families with dependent children who meet the eligibility conditions of Sections 4-1.1 through 4-1.12. It shall be the policy of the Illinois Department to provide aid under this Article to all qualified persons who seek assistance and to conduct outreach efforts to educate the public about the program. The Department shall provide timely, accurate, and fair service to all applicants for assistance. Persons who meet the eligibility criteria authorized under this Article shall be treated equally, provided that nothing in this Article shall be construed to create an entitlement to a particular grant or service level or to aid in amounts not authorized under this Code, nor construed to limit the authority of the General Assembly to change the eligibility requirements or provisions respecting assistance amounts. The General Assembly recognizes that the need for aid will fluctuate with the economic situation in Illinois and that at times the number of people receiving aid under this Article will increase.
    The Illinois Department shall advise every applicant for and recipient of aid under this Article of (i) the requirement that all recipients move toward self-sufficiency and (ii) the value and benefits of employment. As a condition of eligibility for that aid, every person who applies for aid under this Article on or after the effective date of this amendatory Act of 1995 shall prepare and submit, as part of the application or subsequent redetermination, a personal plan for achieving employment and self-sufficiency. The plan shall incorporate the individualized assessment and employability plan set out in subsections (d), (f), and (g) of Section 9A-8. The plan may be amended as the recipient's needs change. The assessment process to develop the plan shall include questions that screen for domestic violence issues and steps needed to address these issues may be part of the plan. If the individual indicates that he or she is a victim of domestic violence, he or she may also be referred to an available domestic violence program. Failure of the client to follow through on the personal plan for employment and self-sufficiency may be a basis for sanction under Section 4-21.
(Source: P.A. 96-866, eff. 7-1-10; 97-813, eff. 7-13-12.)

305 ILCS 5/4-1.1

    (305 ILCS 5/4-1.1) (from Ch. 23, par. 4-1.1)
    Sec. 4-1.1. Child age eligibility.
    (a) Every assistance unit must include a child, except as provided in subsections (b) and (c). The child or children must have already been born and be under age 18, or, if age 18, must be a full-time student in a secondary school or the equivalent level of vocational or technical training.
    (b) Grants shall be provided for assistance units consisting exclusively of a pregnant woman with no dependent child, and may include her husband if living with her, if the pregnancy has been determined by medical diagnosis.
    (c) Grants may be provided for assistance units consisting of only adults if all the children living with those adults are disabled and receive Supplemental Security Income.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-1.2

    (305 ILCS 5/4-1.2) (from Ch. 23, par. 4-1.2)
    Sec. 4-1.2. Living Arrangements - Parents - Relatives - Foster Care.
    (a) The child or children must (1) be living with his or their father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle or aunt, or other relative approved by the Illinois Department, in a place of residence maintained by one or more of such relatives as his or their own home, or (2) have been (a) removed from the home of the parents or other relatives by judicial order under the Juvenile Court Act or the Juvenile Court Act of 1987, as amended, (b) placed under the guardianship of the Department of Children and Family Services, and (c) under such guardianship, placed in a foster family home, group home or child care institution licensed pursuant to the "Child Care Act of 1969", approved May 15, 1969, as amended, or approved by that Department as meeting standards established for licensing under that Act, or (3) have been relinquished in accordance with the Abandoned Newborn Infant Protection Act. A child so placed in foster care who was not receiving aid under this Article in or for the month in which the court proceedings leading to that placement were initiated may qualify only if he lived in the home of his parents or other relatives at the time the proceedings were initiated, or within 6 months prior to the month of initiation, and would have received aid in and for that month if application had been made therefor.
    (b) The Illinois Department may, by rule, establish those persons who are living together who must be included in the same assistance unit in order to receive cash assistance under this Article and the income and assets of those persons in an assistance unit which must be considered in determining eligibility.
    (c) The conditions of qualification herein specified shall not prejudice aid granted under this Code for foster care prior to the effective date of this 1969 Amendatory Act.
(Source: P.A. 92-408, eff. 8-17-01; 92-432, eff. 8-17-01.)

305 ILCS 5/4-1.2a

    (305 ILCS 5/4-1.2a) (from Ch. 23, par. 4-1.2a)
    Sec. 4-1.2a. Residents of public institutions. Residents of municipal, county, state or national institutions for persons with mental illness or persons with a developmental disability or for the tuberculous, or residents of a home or other institution maintained by such governmental bodies when not in need of institutional care because of sickness, convalescence, infirmity, or chronic illness, and inmates of penal or correctional institutions maintained by such governmental bodies, may qualify for aid under this Article only after they have ceased to be residents or inmates.
    A person shall not be deemed a resident of a State institution for persons with mental illness or persons with a developmental disability within the meaning of this Section if he or she has been conditionally discharged by the Department of Mental Health and Developmental Disabilities or the Department of Human Services (acting as successor to the Department of Mental Health and Developmental Disabilities) and is no longer residing in the institution.
    Recipients of benefits under this Article who become residents of such institutions shall be permitted a period of up to 30 days in such institutions without suspension or termination of eligibility. Benefits for which such person is eligible shall be restored, effective on the date of discharge or release, for persons who are residents of institutions. Within a reasonable time after the discharge of a person who was a resident of an institution, the Department shall redetermine the eligibility of such person.
    The Department shall provide for procedures to expedite the determination of incapacity or ability to engage in employment of persons scheduled to be discharged from facilities operated by the Department.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-1.2b

    (305 ILCS 5/4-1.2b) (from Ch. 23, par. 4-1.2b)
    Sec. 4-1.2b. (Repealed).
(Source: P.A. 87-1056. Repealed by P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-1.2c

    (305 ILCS 5/4-1.2c)
    Sec. 4-1.2c. Residence of child who is pregnant or a parent.
    (a) Notwithstanding any other provision of this Code, no aid shall be paid under this Article on behalf of a person under age 18 who has never married and who has a child or is pregnant, unless that person resides with a parent, legal guardian, or other adult relative or in a foster home, maternity home, or other adult-supervised living arrangement.
    (b) The Illinois Department may make an exception to the requirement of subsection (a) in any of the following circumstances:
        (1) The person has no living parent or legal
    
guardian, or the parent's or legal guardian's whereabouts are unknown.
        (2) The Illinois Department determines that the
    
physical health or safety of the person or the person's child would be jeopardized.
        (3) The person has lived apart from the parent or
    
legal guardian for a period of at least one year before the child's birth or before applying for aid under this Article.
    (c) (Blank).
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-1.3

    (305 ILCS 5/4-1.3) (from Ch. 23, par. 4-1.3)
    Sec. 4-1.3. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-1.4

    (305 ILCS 5/4-1.4) (from Ch. 23, par. 4-1.4)
    Sec. 4-1.4. (Repealed.)
(Source: Laws 1967, p. 122. Repealed by P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-1.5a

    (305 ILCS 5/4-1.5a) (from Ch. 23, par. 4-1.5a)
    Sec. 4-1.5a. Multiple convictions for violations of this Code. To the extent permitted under federal law, any person found guilty of a second violation of Article VIIIA or under any law of the United States or of any State which is substantially similar to Sections 8A-2 through 8A-5 shall be ineligible for financial aid under this Article, as provided in Section 8A-8.
(Source: P.A. 85-286.)

305 ILCS 5/4-1.6

    (305 ILCS 5/4-1.6) (from Ch. 23, par. 4-1.6)
    Sec. 4-1.6. Need. Income available to the family as defined by the Illinois Department by rule, or to the child in the case of a child removed from his or her home, when added to contributions in money, substance or services from other sources, including income available from parents absent from the home or from a stepparent, contributions made for the benefit of the parent or other persons necessary to provide care and supervision to the child, and contributions from legally responsible relatives, must be equal to or less than the grant amount established by Department regulation for such a person. For purposes of eligibility for aid under this Article, the Department shall (a) disregard all earned income between the grant amount and 50% of the Federal Poverty Level and (b) disregard the value of all assets held by the family.
    In considering income to be taken into account, consideration shall be given to any expenses reasonably attributable to the earning of such income. Three-fourths of the earned income of a household eligible for aid under this Article shall be disregarded when determining the level of assistance for which a household is eligible. The Illinois Department may also permit all or any portion of earned or other income to be set aside for the future identifiable needs of a child. The Illinois Department may provide by rule and regulation for the exemptions thus permitted or required. The eligibility of any applicant for or recipient of public aid under this Article is not affected by the payment of any grant under the "Senior Citizens and Disabled Persons Property Tax Relief Act" or any distributions or items of income described under subparagraph (X) of paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax Act.
    The Illinois Department may, by rule, set forth criteria under which an assistance unit is ineligible for cash assistance under this Article for a specified number of months due to the receipt of a lump sum payment.
(Source: P.A. 97-689, eff. 6-14-12; 98-114, eff. 7-29-13.)

305 ILCS 5/4-1.6a

    (305 ILCS 5/4-1.6a)
    Sec. 4-1.6a. (Repealed).
(Source: P.A. 88-205. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-1.6b

    (305 ILCS 5/4-1.6b)
    Sec. 4-1.6b. Date for providing aid; employability assessment.
    (a) The Department shall provide financial aid no more than 45 days after the date of application.
    (b) During the first 45 days after the date of application, the applicant shall undergo a thorough employability assessment, in accordance with subsection (d) of Section 9A-8 of this Code, and shall prepare a personal plan for achieving employment and self-sufficiency in accordance with Section 4-1 of this Code. The requirement to engage in work-related activity may commence 30 days after the date of application.
    (c) Financial aid under this Article shall be authorized effective 30 days after the date of application, provided that the applicant is eligible on that date.
(Source: P.A. 96-866, eff. 7-1-10; 97-683, eff. 7-1-12.)

305 ILCS 5/4-1.7

    (305 ILCS 5/4-1.7) (from Ch. 23, par. 4-1.7)
    Sec. 4-1.7. Enforcement of Parental Child Support Obligation. If the parent or parents of the child are failing to meet or are delinquent in their legal obligation to support the child, the parent or other person having custody of the child or the Department of Healthcare and Family Services may request the law enforcement officer authorized or directed by law to so act to file action for the enforcement of such remedies as the law provides for the fulfillment of the child support obligation.
    If a parent has a judicial remedy against the other parent to compel child support, or if, as the result of an action initiated by or in behalf of one parent against the other, a child support order has been entered in respect to which there is noncompliance or delinquency, or where the order so entered may be changed upon petition to the court to provide additional support, the parent or other person having custody of the child or the Department of Healthcare and Family Services may request the appropriate law enforcement officer to seek enforcement of the remedy, or of the support order, or a change therein to provide additional support. If the law enforcement officer is not authorized by law to so act in these instances, the parent, or if so authorized by law the other person having custody of the child, or the Department of Healthcare and Family Services may initiate an action to enforce these remedies.
    A parent or other person having custody of the child must comply with the requirements of Title IV of the federal Social Security Act, and the regulations duly promulgated thereunder, and any rules promulgated by the Illinois Department regarding enforcement of the child support obligation. The Department of Healthcare and Family Services and the Department of Human Services may provide by rule for the grant or continuation of aid to the person for a temporary period if he or she accepts counseling or other services designed to increase his or her motivation to seek enforcement of the child support obligation.
    In addition to any other definition of failure or refusal to comply with the requirements of Title IV of the federal Social Security Act, or Illinois Department rule, in the case of failure to attend court hearings, the parent or other person can show cooperation by attending a court hearing or, if a court hearing cannot be scheduled within 14 days following the court hearing that was missed, by signing a statement that the parent or other person is now willing to cooperate in the child support enforcement process and will appear at any later scheduled court date. The parent or other person can show cooperation by signing such a statement only once. If failure to attend the court hearing or other failure to cooperate results in the case being dismissed, such a statement may be signed after 2 months.
    No denial or termination of medical assistance pursuant to this Section shall commence during pregnancy of the parent or other person having custody of the child or for 30 days after the termination of such pregnancy. The termination of medical assistance may commence thereafter if the Department of Healthcare and Family Services determines that the failure or refusal to comply with this Section persists. Postponement of denial or termination of medical assistance during pregnancy under this paragraph shall be effective only to the extent it does not conflict with federal law or regulation.
    Any evidence a parent or other person having custody of the child gives in order to comply with the requirements of this Section shall not render him or her liable to prosecution under Section 11-35 or 11-40 of the Criminal Code of 2012.
    When so requested, the Department of Healthcare and Family Services and the Department of Human Services shall provide such services and assistance as the law enforcement officer may require in connection with the filing of any action hereunder.
    The Department of Healthcare and Family Services and the Department of Human Services, as an expense of administration, may also provide applicants for and recipients of aid with such services and assistance, including assumption of the reasonable costs of prosecuting any action or proceeding, as may be necessary to enable them to enforce the child support liability required hereunder.
    Nothing in this Section shall be construed as a requirement that an applicant or recipient file an action for dissolution of marriage against his or her spouse.
(Source: P.A. 96-1551, eff. 7-1-11; 97-1150, eff. 1-25-13.)

305 ILCS 5/4-1.8

    (305 ILCS 5/4-1.8) (from Ch. 23, par. 4-1.8)
    Sec. 4-1.8. Registration for and Acceptance of Employment. Individuals who are unemployed, or employed for less than the full working time for the occupation in which they are engaged, and dependent members of the family age 16 or over who are not in regular attendance in school as defined in Section 4-1.1, must comply with and are subject to all the requirements of Article IXA.
(Source: P.A. 86-1184; 86-1381.)

305 ILCS 5/4-1.9

    (305 ILCS 5/4-1.9) (from Ch. 23, par. 4-1.9)
    Sec. 4-1.9. Participation in Educational and Vocational Training Programs.
    (a) A parent or parents and a child age 16 or over not in regular attendance in school, as defined in Section 4-1.1 as that Section existed on August 26, 1969 (the effective date of Public Act 76-1047), for whom education and training is suitable, must participate in the educational and vocational training programs provided pursuant to Article IXA.
    (b) A parent who is less than 20 years of age and who has not received a high school diploma or high school equivalency certificate is required to be enrolled in school or in an educational program that is expected to result in the receipt of a high school diploma or high school equivalency certificate, except 18 and 19 year old parents may be assigned to work activities or training if it is determined based on an individualized assessment that secondary school is inappropriate.
(Source: P.A. 89-6, eff. 3-6-95; 90-17, eff. 7-1-97.)

305 ILCS 5/4-1.10

    (305 ILCS 5/4-1.10) (from Ch. 23, par. 4-1.10)
    Sec. 4-1.10. Acceptance of Assignment to Job Search, Training and Work Programs. An individual for whom the job search, training and work programs established under Article IXA are applicable must accept assignment to such programs. The Illinois Department and the local governmental unit shall determine, pursuant to rules and regulations, sanctions for persons failing to comply with the requirements under this Section. However, no participant shall be sanctioned for failure to satisfy job search requirements before a full assessment of the participant's job readiness and employability, except that for those persons subject to the job search program operated under this Section an assessment as defined by rule at the time of intake will meet the assessment requirement. No participant shall be sanctioned for failure to satisfy the minimum number of employer contacts if the participant made a good faith effort.
(Source: P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-1.11

    (305 ILCS 5/4-1.11) (from Ch. 23, par. 4-1.11)
    Sec. 4-1.11. (Repealed).
(Source: P.A. 88-554, eff. 7-26-94. Repealed by P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-1.12

    (305 ILCS 5/4-1.12)
    Sec. 4-1.12. Five year limitation.
    No assistance unit shall be eligible for a cash grant under this Article if it includes an adult who has received cash assistance as an adult for 60 months, whether or not consecutive, after the effective date of this amendatory Act of 1997. The Illinois Department may exempt individual assistance units from the 60-month limitation or determine circumstances under which a month or months would not count towards the 60-month limitation even though the assistance unit did receive cash assistance under this Article.
(Source: P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-2

    (305 ILCS 5/4-2) (from Ch. 23, par. 4-2)
    Sec. 4-2. Amount of aid.
    (a) The amount and nature of financial aid shall be determined in accordance with the grant amounts, rules and regulations of the Illinois Department. Due regard shall be given to the self-sufficiency requirements of the family and to the income, money contributions and other support and resources available, from whatever source. However, the amount and nature of any financial aid is not affected by the payment of any grant under the "Senior Citizens and Disabled Persons Property Tax Relief Act" or any distributions or items of income described under subparagraph (X) of paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax Act. The aid shall be sufficient, when added to all other income, money contributions and support to provide the family with a grant in the amount established by Department regulation.
    Subject to appropriation, beginning on July 1, 2008, the Department of Human Services shall increase TANF grant amounts in effect on June 30, 2008 by 15%. The Department is authorized to administer this increase but may not otherwise adopt any rule to implement this increase.
    (b) The Illinois Department may conduct special projects, which may be known as Grant Diversion Projects, under which recipients of financial aid under this Article are placed in jobs and their grants are diverted to the employer who in turn makes payments to the recipients in the form of salary or other employment benefits. The Illinois Department shall by rule specify the terms and conditions of such Grant Diversion Projects. Such projects shall take into consideration and be coordinated with the programs administered under the Illinois Emergency Employment Development Act.
    (c) The amount and nature of the financial aid for a child requiring care outside his own home shall be determined in accordance with the rules and regulations of the Illinois Department, with due regard to the needs and requirements of the child in the foster home or institution in which he has been placed.
    (d) If the Department establishes grants for family units consisting exclusively of a pregnant woman with no dependent child or including her husband if living with her, the grant amount for such a unit shall be equal to the grant amount for an assistance unit consisting of one adult, or 2 persons if the husband is included. Other than as herein described, an unborn child shall not be counted in determining the size of an assistance unit or for calculating grants.
    Payments for basic maintenance requirements of a child or children and the relative with whom the child or children are living shall be prescribed, by rule, by the Illinois Department.
    Grants under this Article shall not be supplemented by General Assistance provided under Article VI.
    (e) Grants shall be paid to the parent or other person with whom the child or children are living, except for such amount as is paid in behalf of the child or his parent or other relative to other persons or agencies pursuant to this Code or the rules and regulations of the Illinois Department.
    (f) Subject to subsection (f-5), an assistance unit, receiving financial aid under this Article or temporarily ineligible to receive aid under this Article under a penalty imposed by the Illinois Department for failure to comply with the eligibility requirements or that voluntarily requests termination of financial assistance under this Article and becomes subsequently eligible for assistance within 9 months, shall not receive any increase in the amount of aid solely on account of the birth of a child; except that an increase is not prohibited when the birth is (i) of a child of a pregnant woman who became eligible for aid under this Article during the pregnancy, or (ii) of a child born within 10 months after the date of implementation of this subsection, or (iii) of a child conceived after a family became ineligible for assistance due to income or marriage and at least 3 months of ineligibility expired before any reapplication for assistance. This subsection does not, however, prevent a unit from receiving a general increase in the amount of aid that is provided to all recipients of aid under this Article.
    The Illinois Department is authorized to transfer funds, and shall use any budgetary savings attributable to not increasing the grants due to the births of additional children, to supplement existing funding for employment and training services for recipients of aid under this Article IV. The Illinois Department shall target, to the extent the supplemental funding allows, employment and training services to the families who do not receive a grant increase after the birth of a child. In addition, the Illinois Department shall provide, to the extent the supplemental funding allows, such families with up to 24 months of transitional child care pursuant to Illinois Department rules. All remaining supplemental funds shall be used for employment and training services or transitional child care support.
    In making the transfers authorized by this subsection, the Illinois Department shall first determine, pursuant to regulations adopted by the Illinois Department for this purpose, the amount of savings attributable to not increasing the grants due to the births of additional children. Transfers may be made from General Revenue Fund appropriations for distributive purposes authorized by Article IV of this Code only to General Revenue Fund appropriations for employability development services including operating and administrative costs and related distributive purposes under Article IXA of this Code. The Director, with the approval of the Governor, shall certify the amount and affected line item appropriations to the State Comptroller.
    Nothing in this subsection shall be construed to prohibit the Illinois Department from using funds under this Article IV to provide assistance in the form of vouchers that may be used to pay for goods and services deemed by the Illinois Department, by rule, as suitable for the care of the child such as diapers, clothing, school supplies, and cribs.
    (f-5) Subsection (f) shall not apply to affect the monthly assistance amount of any family as a result of the birth of a child on or after January 1, 2004. As resources permit after January 1, 2004, the Department may cease applying subsection (f) to limit assistance to families receiving assistance under this Article on January 1, 2004, with respect to children born prior to that date. In any event, subsection (f) shall be completely inoperative on and after July 1, 2007.
    (g) (Blank).
    (h) Notwithstanding any other provision of this Code, the Illinois Department is authorized to reduce payment levels used to determine cash grants under this Article after December 31 of any fiscal year if the Illinois Department determines that the caseload upon which the appropriations for the current fiscal year are based have increased by more than 5% and the appropriation is not sufficient to ensure that cash benefits under this Article do not exceed the amounts appropriated for those cash benefits. Reductions in payment levels may be accomplished by emergency rule under Section 5-45 of the Illinois Administrative Procedure Act, except that the limitation on the number of emergency rules that may be adopted in a 24-month period shall not apply and the provisions of Sections 5-115 and 5-125 of the Illinois Administrative Procedure Act shall not apply. Increases in payment levels shall be accomplished only in accordance with Section 5-40 of the Illinois Administrative Procedure Act. Before any rule to increase payment levels promulgated under this Section shall become effective, a joint resolution approving the rule must be adopted by a roll call vote by a majority of the members elected to each chamber of the General Assembly.
(Source: P.A. 96-1000, eff. 7-2-10; 97-689, eff. 6-14-12.)

305 ILCS 5/4-3

    (305 ILCS 5/4-3) (from Ch. 23, par. 4-3)
    Sec. 4-3. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-3a

    (305 ILCS 5/4-3a) (from Ch. 23, par. 4-3a)
    Sec. 4-3a. No otherwise qualified handicapped child receiving special education and related services under Article 14 of The School Code shall solely by reason of his or her handicap be excluded from the participation in or be denied the benefits of or be subjected to discrimination under any program or activity provided by the Department.
(Source: P.A. 80-1403.)

305 ILCS 5/4-4

    (305 ILCS 5/4-4) (from Ch. 23, par. 4-4)
    Sec. 4-4. Entitlement to medical assistance.
    Children and adults qualified for aid shall be entitled to receive, under Article V, all necessary medical assistance.
(Source: Laws 1967, p. 122.)

305 ILCS 5/4-4.1

    (305 ILCS 5/4-4.1)
    Sec. 4-4.1. Immunizations.
    (a) The Department of Healthcare and Family Services (formerly Illinois Department of Public Aid) shall develop and implement and that Department and the Department of Human Services shall jointly continue by rule a program to ensure that children under 5 years of age living in assistance units that receive benefits under this Code are immunized. The Illinois Department of Public Aid shall report to the Governor and the General Assembly on the progress of the program on April 1, 1994 and 1995.
    (b) Nothing in this Section shall be construed to require immunization of any child in contravention of the stated objections of a parent, guardian, or relative with custody of a child that the administration of immunizing agents conflicts with his or her religious tenets and practices.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/4-5

    (305 ILCS 5/4-5) (from Ch. 23, par. 4-5)
    Sec. 4-5. (Repealed).
(Source: Laws 1967, p. 122. Repealed by P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-6

    (305 ILCS 5/4-6) (from Ch. 23, par. 4-6)
    Sec. 4-6. (Repealed).
(Source: P.A. 85-195. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-7

    (305 ILCS 5/4-7) (from Ch. 23, par. 4-7)
    Sec. 4-7. Home Visits, Interviews or Communications. Each family receiving aid shall be interviewed in person or communicated with in investigations of applications for aid and at least once in each subsequent 12 month period to ascertain continuing need for such aid and to provide the child and his parents or relatives with such service and guidance as will strengthen family life and aid them in utilizing to the maximum their capacities for self-care, self-support, and responsible citizenship. However, the Department shall determine those assistance units where the possibility for public assistance fraud or abuse is greatest, or where there is the possibility of frequent changes in need or circumstances, or where any child in the home may be an abused or neglected child as determined by the Department of Children and Family Services under the Abused and Neglected Child Reporting Act, as now or hereafter amended, and shall by rule provide for more frequent interviews of or communications with those assistance units and for the implementation of necessary remedies under Sections 4-8 and 4-9 for those assistance units. Written reports of such interviews or communications and any related remedies shall become a part of the record in every case.
(Source: P.A. 85-1209.)

305 ILCS 5/4-8

    (305 ILCS 5/4-8) (from Ch. 23, par. 4-8)
    Sec. 4-8. Mismanagement of assistance grant.
    (a) If the County Department has reason to believe that the money payment for basic maintenance is not being used, or may not be used, in the best interests of the child and the family and that there is present or potential damage to the standards of health and well-being that the grant is intended to assure, the County Department shall provide the parent or other relative with the counseling and guidance services with respect to the use of the grant and the management of other funds available to the family as may be required to assure use of the grant in the best interests of the child and family. The Illinois Department shall by rule prescribe criteria which shall constitute evidence of grant mismanagement. The criteria shall include but not be limited to the following:
        (1) A determination that a child in the assistance
    
unit is not receiving proper and necessary support or other care for which assistance is being provided under this Code.
        (2) A record establishing that the parent or relative
    
has been found guilty of public assistance fraud under Article VIIIA.
        (3) A determination by an appropriate person, entity,
    
or agency that the parent or other relative requires treatment for alcohol or substance abuse, mental health services, or other special care or treatment.
    The Department shall at least consider non-payment of rent for two consecutive months as evidence of grant mismanagement by a parent or relative of a recipient who is responsible for making rental payments for the housing or shelter of the child or family, unless the Department determines that the non-payment is necessary for the protection of the health and well-being of the recipient. The County Department shall advise the parent or other relative grantee that continued mismanagement will result in the application of one of the sanctions specified in this Section.
    The Illinois Department shall consider irregular school attendance by children of school age grades 1 through 8, as evidence of lack of proper and necessary support or care. The Department may extend this consideration to children in grades higher than 8.
    The Illinois Department shall develop preventive programs in collaboration with school and social service networks to encourage school attendance of children receiving assistance under Article IV. To the extent that Illinois Department and community resources are available, the programs shall serve families whose children in grades 1 through 8 are not attending school regularly, as defined by the school. The Department may extend these programs to families whose children are in grades higher than 8. The programs shall include referrals from the school to a social service network, assessment and development of a service plan by one or more network representatives, and the Illinois Department's encouragement of the family to follow through with the service plan. Families that fail to follow the service plan as determined by the service provider, shall be subject to the protective payment provisions of this Section and Section 4-9 of this Code.
    Families for whom a protective payment plan has been in effect for at least 3 months and whose school children continue to regularly miss school shall be subject to sanction under Section 4-21. The sanction shall continue until the children demonstrate satisfactory attendance, as defined by the school. To the extent necessary to implement this Section, the Illinois Department shall seek appropriate waivers of federal requirements from the U.S. Department of Health and Human Services.
    (b) In areas of the State where clinically appropriate substance abuse treatment capacity is available, if the local office has reason to believe that a caretaker relative is experiencing substance abuse, the local office shall refer the caretaker relative to a licensed treatment provider for assessment. If the assessment indicates that the caretaker relative is experiencing substance abuse, the local office shall require the caretaker relative to comply with all treatment recommended by the assessment. If the caretaker relative refuses without good cause, as determined by rules of the Illinois Department, to submit to the assessment or treatment, the caretaker relative shall be ineligible for assistance, and the local office shall take one or more of the following actions:
        (i) If there is another family member or friend who
    
is ensuring that the family's needs are being met, that person, if willing, shall be assigned as protective payee.
        (ii) If there is no family member or close friend to
    
serve as protective payee, the local office shall provide for a protective payment to a substitute payee as provided in Section 4-9. The Department also shall determine whether a referral to the Department of Children and Family Services is warranted and, if appropriate, shall make the referral.
        (iii) The Department shall contact the individual who
    
is thought to be experiencing substance abuse and explain why the protective payee has been assigned and refer the individual to treatment.
    (c) This subsection (c) applies to cases other than those described in subsection (b). If the efforts to correct the mismanagement of the grant have failed, the County Department, in accordance with the rules and regulations of the Illinois Department, shall initiate one or more of the following actions:
        1. Provide for a protective payment to a substitute
    
payee, as provided in Section 4-9. This action may be initiated for any assistance unit containing a child determined to be neglected by the Department of Children and Family Services under the Abused and Neglected Child Reporting Act, and in any case involving a record of public assistance fraud.
        2. Provide for issuance of all or part of the grant
    
in the form of disbursing orders. This action may be initiated in any case involving a record of public assistance fraud, or upon the request of a substitute payee designated under Section 4-9.
        3. File a petition under the Juvenile Court Act of
    
1987 for an Order of Protection under Section 2-25, 2-26, 3-26, 3-27, 4-23, 4-24, 5-730, or 5-735 of that Act.
        4. Institute a proceeding under the Juvenile Court
    
Act of 1987 for the appointment of a guardian or legal representative for the purpose of receiving and managing the public aid grant.
        5. If the mismanagement of the grant, together with
    
other factors, has rendered the home unsuitable for the best welfare of the child, file a neglect petition under the Juvenile Court Act of 1987, requesting the removal of the child or children.
(Source: P.A. 91-357, eff. 7-29-99; 92-111, eff. 1-1-02.)

305 ILCS 5/4-9

    (305 ILCS 5/4-9) (from Ch. 23, par. 4-9)
    Sec. 4-9. Protective payment to substitute payee. If the parent or other grantee relative persistently mismanages the grant to the detriment of the child and the family but there is reason to believe that, with specialized counseling and guidance services, the parent or relative may develop ability to manage the funds properly, the County Department, in accordance with the rules and regulations of the Illinois Department, may designate a person who is interested in or concerned with the welfare of the child and its family to receive the aid payment on behalf of the family. The County Department may designate private welfare or social service agencies to serve as substitute payees in appropriate cases.
    The substitute payee shall serve without compensation and assume the obligation of seeing that the aid payment is expended for the benefit of the child and the family. He may spend the grant for the family, or supervise the parent or other relative in the use of the grant, depending upon the circumstances in each case, and shall make monthly reports to the County Department as the County Department and the Illinois Department may require.
    The County Department shall terminate the protective payment when it is no longer necessary to assure that the grant is being used for the welfare of the child and family, or when the parent or other relative is no longer receiving and no longer requires treatment for alcohol or substance abuse, mental health services, or other special care or treatment.
    A substitute payee may be removed, in accordance with the rules and regulations of the Illinois Department, for unsatisfactory service. The removal may be effected without hearing. The decision shall not be appealable to the Illinois Department nor shall it be reviewable in the courts.
    The County Department shall conduct periodic reviews as may be required by the Illinois Department to determine whether there is a continuing need for a protective payment. If it appears that the need for the payment is likely to continue beyond a reasonable period, the County Department shall take one of the other actions set out in Section 4-8.
    The parent or other relative shall be advised, in advance of a determination to make a protective payment, that he may appeal the decision to the Illinois Department under the provisions of Section 11-8 of Article XI.
(Source: P.A. 87-528; 87-895.)

305 ILCS 5/4-10

    (305 ILCS 5/4-10) (from Ch. 23, par. 4-10)
    Sec. 4-10. Funeral and burial. If the estate of a deceased recipient is insufficient to pay for funeral and burial expenses, and if no other resources, including assistance from legally responsible relatives, are available for such purposes, there shall be paid, in accordance with the standards, rules and regulations of the Illinois Department, such reasonable amounts as may be necessary to meet costs of the funeral, burial space, and cemetery charges or to reimburse any person not financially responsible for the deceased who has voluntarily made expenditures for such costs.
(Source: P.A. 90-372, eff. 7-1-98.)

305 ILCS 5/4-11

    (305 ILCS 5/4-11) (from Ch. 23, par. 4-11)
    Sec. 4-11. Charge of child.
    Public officials, agents, or representatives, in carrying out any of the provisions of this Article, shall not take charge of any child over the objection of either of the child's parents, or of the persons standing in loco parentis to the child, except pursuant to court order.
(Source: Laws 1967, p. 122.)

305 ILCS 5/4-12

    (305 ILCS 5/4-12) (from Ch. 23, par. 4-12)
    Sec. 4-12. Crisis assistance. Where a family has been (1) rendered homeless or threatened with homelessness by fire, flood, other natural disaster, eviction or court order to vacate the premises for reasons other than nonpayment of rent, or where a family has become homeless because they have left their residence due to domestic or sexual violence; (1.5) deprived of the household's income as a result of domestic or sexual violence; (2) deprived of essential items of furniture or essential clothing by fire or flood or other natural disaster; (3) deprived of food as a result of actions other than loss or theft of cash and where the deprivation cannot be promptly alleviated through the federal food stamp program; (4) as a result of a documented theft or documented loss of cash, deprived of food or essential clothing or deprived of shelter or immediately threatened with deprivation of shelter as evidenced by a court order requiring immediate eviction due to nonpayment of rent; or (5) rendered the victim of such other hardships as the Illinois Department shall by rule define, the Illinois Department may provide assistance to alleviate such needs. The Illinois Department shall verify need and determine eligibility for crisis assistance for families already receiving grants from the Illinois Department within 5 working days following application for such assistance and shall determine eligibility for all other families and afford such assistance for families found eligible within such time limits as the Illinois Department shall by rule provide. The Illinois Department may, by rule, limit crisis assistance to an eligible family to once in any 12 consecutive months. This limitation may be made for some or all items of crisis assistance.
    The Illinois Department by regulation shall specify the criteria for determining eligibility and the amount and nature of assistance to be provided. Where deprivation of shelter exists or is threatened, the Illinois Department may provide reasonable moving expenses, short term rental costs, including one month's rent and a security deposit where such expenses are needed for relocation, and, where the Department determines appropriate, provide assistance to prevent an imminent eviction or foreclosure. These amounts may be described in established amounts or maximums. The Illinois Department may also describe, for each form of assistance authorized, the method by which the assistance shall be delivered, including but not limited to warrants or disbursing orders.
    Annual expenditures under this Section shall not exceed $2,000,000. The Illinois Department shall review such expenditures quarterly and shall, if necessary, reduce the amounts or nature of assistance authorized in order to assure that the limit is not exceeded.
(Source: P.A. 96-866, eff. 7-1-10.)

305 ILCS 5/4-13

    (305 ILCS 5/4-13) (from Ch. 23, par. 4-13)
    Sec. 4-13. (Repealed).
(Source: P.A. 83-1273. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-14

    (305 ILCS 5/4-14) (from Ch. 23, par. 4-14)
    Sec. 4-14. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)

305 ILCS 5/4-15

    (305 ILCS 5/4-15) (from Ch. 23, par. 4-15)
    Sec. 4-15. (Repealed).
(Source: Repealed by P.A. 89-131, eff. 7-14-95.)

305 ILCS 5/4-16

    (305 ILCS 5/4-16) (from Ch. 23, par. 4-16)
    Sec. 4-16. (Repealed).
(Source: P.A. 88-412. Repealed by P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-17

    (305 ILCS 5/4-17)
    Sec. 4-17. (Repealed).
(Source: P.A. 92-111, eff. 1-1-02. Repealed by P.A. 95-322, eff. 1-1-08.)

305 ILCS 5/4-18

    (305 ILCS 5/4-18)
    Sec. 4-18. (Repealed).
(Source: P.A. 89-626, eff. 8-9-96. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-19

    (305 ILCS 5/4-19)
    Sec. 4-19. (Repealed).
(Source: P.A. 90-538, eff. 12-1-97. Repealed by P.A. 92-111, eff. 1-1-02.)

305 ILCS 5/4-21

    (305 ILCS 5/4-21)
    Sec. 4-21. Sanctions.
    (a) The Illinois Department shall, by rule, establish a system of sanctions for persons who fail to cooperate, without good cause, with employment and training programs or other programs under this Article or Article IXA or who fail to cooperate with child support programs under this Article, Article X, or Title IV of the federal Social Security Act. The sanctions may discontinue all or part of the cash grant provided under this Article. The sanctions may be time limited or continue until the person cooperates in the program. The sanctions may be progressive in that a second, third, or further sanction may be progressively more severe or last longer.
    (b) The Illinois Department shall, by rule, define what constitutes failure to cooperate and what constitutes good cause which would excuse that failure.
(Source: P.A. 90-17, eff. 7-1-97.)

305 ILCS 5/4-22

    (305 ILCS 5/4-22)
    Sec. 4-22. Domestic and sexual violence.
    (a) The assessment process to develop the personal plan for achieving self-sufficiency shall include questions that screen for domestic and sexual violence issues. If the individual indicates that he or she is the victim of domestic or sexual violence and indicates a need to address domestic or sexual violence issues in order to reach self-sufficiency, the plan shall take this factor into account in determining the work, education, and training activities suitable to the client for achieving self-sufficiency. In addition, in such a case, specific steps needed to directly address the domestic or sexual violence issues may also be made part of the plan, including referral to an available domestic or sexual violence program. The Department shall conduct an individualized assessment and grant waivers of program requirements and other required activities for victims of domestic violence to the fullest extent allowed by 42 U.S.C. 602(a)(7)(A), and shall apply the same laws, regulations, and policies to victims of sexual violence. The duration of such waivers shall be initially determined and subsequently redetermined on a case-by-case basis. There shall be no limitation on the total number of months for which waivers under this Section may be granted, but continuing eligibility for a waiver shall be redetermined no less often than every 6 months.
    (b) The Illinois Department shall develop and monitor compliance procedures for its employees, contractors, and subcontractors to ensure that any information pertaining to any client who claims to be a past or present victim of domestic violence or an individual at risk of further domestic violence, whether provided by the victim or by a third party, will remain confidential.
    (c) The Illinois Department shall develop and implement a domestic violence training curriculum for Illinois Department employees who serve applicants for and recipients of aid under this Article. The curriculum shall be designed to better equip those employees to identify and serve domestic violence victims. The Illinois Department may enter into a contract for the development of the curriculum with one or more organizations providing services to domestic violence victims. The Illinois Department shall adopt rules necessary to implement this subsection.
(Source: P.A. 96-866, eff. 7-1-10.)

305 ILCS 5/4-23

    (305 ILCS 5/4-23)
    Sec. 4-23. Civil rights impact statement.
    (a) The Department of Human Services must submit to the Governor and the General Assembly on January 1 of each even-numbered year a written report that details the disparate impact of various provisions of the TANF program on people of different racial or ethnic groups who identify themselves in an application for benefits as any of the following:
        (1) American Indian or Alaska Native (a person having
    
origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment).
        (2) Asian (a person having origins in any of the
    
original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, but not limited to, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam).
        (3) Black or African American (a person having
    
origins in any of the black racial groups of Africa). Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American".
        (4) Hispanic or Latino (a person of Cuban, Mexican,
    
Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race).
        (5) Native Hawaiian or Other Pacific Islander (a
    
person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).
        (6) White (a person having origins in any of the
    
original peoples of Europe, the Middle East, or North Africa).
    (b) The report must at least compare the number of persons in each group:
        (1) who are receiving TANF assistance;
        (2) whose 60-month lifetime limit on receiving
    
assistance has expired;
        (3) who have left TANF due to earned income;
        (4) who have left TANF due to non-compliance with
    
program rules;
        (5) whose TANF grants have been reduced by sanctions
    
for non-compliance with program rules;
        (6) who have returned to TANF 6 months after leaving
    
due to earned income;
        (7) who have returned to TANF 12 months after leaving
    
due to earned income;
        (8) who have one or more children excluded from
    
receiving TANF cash assistance due to the child exclusion rule;
        (9) who have been granted an exemption from work
    
requirements; and
        (10) who are participating in post-secondary
    
education activities.
(Source: P.A. 97-396, eff. 1-1-12.)

305 ILCS 5/Art. V

 
    (305 ILCS 5/Art. V heading)
ARTICLE V. MEDICAL ASSISTANCE

305 ILCS 5/5-1

    (305 ILCS 5/5-1) (from Ch. 23, par. 5-1)
    Sec. 5-1. Declaration of purpose. It is the purpose of this Article to provide a program of essential medical care and rehabilitative services for persons receiving basic maintenance grants under this Code and for other persons who are unable, because of inadequate resources, to meet their essential medical needs.
    Preservation of health, alleviation of sickness, and correction of handicapping conditions for persons requiring maintenance support are essential if they are to have an opportunity to become self-supporting or to attain a greater capacity for self-care. For persons who are medically indigent but otherwise able to provide themselves with a livelihood, it is of special importance to maintain their incentives for continued independence and preserve their limited resources for ordinary maintenance needs to prevent their total or substantial dependency.
(Source: Laws 1967, p. 122.)

305 ILCS 5/5-1.1

    (305 ILCS 5/5-1.1) (from Ch. 23, par. 5-1.1)
    Sec. 5-1.1. Definitions. The terms defined in this Section shall have the meanings ascribed to them, except when the context otherwise requires.
    (a) "Nursing facility" means a facility, licensed by the Department of Public Health under the Nursing Home Care Act, that provides nursing facility services within the meaning of Title XIX of the federal Social Security Act.
    (b) "Intermediate care facility for the developmentally disabled" or "ICF/DD" means a facility, licensed by the Department of Public Health under the ID/DD Community Care Act, that is an intermediate care facility for the mentally retarded within the meaning of Title XIX of the federal Social Security Act.
    (c) "Standard services" means those services required for the care of all patients in the facility and shall, as a minimum, include the following: (1) administration; (2) dietary (standard); (3) housekeeping; (4) laundry and linen; (5) maintenance of property and equipment, including utilities; (6) medical records; (7) training of employees; (8) utilization review; (9) activities services; (10) social services; (11) disability services; and all other similar services required by either the laws of the State of Illinois or one of its political subdivisions or municipalities or by Title XIX of the Social Security Act.
    (d) "Patient services" means those which vary with the number of personnel; professional and para-professional skills of the personnel; specialized equipment, and reflect the intensity of the medical and psycho-social needs of the patients. Patient services shall as a minimum include: (1) physical services; (2) nursing services, including restorative nursing; (3) medical direction and patient care planning; (4) health related supportive and habilitative services and all similar services required by either the laws of the State of Illinois or one of its political subdivisions or municipalities or by Title XIX of the Social Security Act.
    (e) "Ancillary services" means those services which require a specific physician's order and defined as under the medical assistance program as not being routine in nature for skilled nursing facilities and ICF/DDs. Such services generally must be authorized prior to delivery and payment as provided for under the rules of the Department of Healthcare and Family Services.
    (f) "Capital" means the investment in a facility's assets for both debt and non-debt funds. Non-debt capital is the difference between an adjusted replacement value of the assets and the actual amount of debt capital.
    (g) "Profit" means the amount which shall accrue to a facility as a result of its revenues exceeding its expenses as determined in accordance with generally accepted accounting principles.
    (h) "Non-institutional services" means those services provided under paragraph (f) of Section 3 of the Disabled Persons Rehabilitation Act and those services provided under Section 4.02 of the Illinois Act on the Aging.
    (i) (Blank).
    (j) "Institutionalized person" means an individual who is an inpatient in an ICF/DD or nursing facility, or who is an inpatient in a medical institution receiving a level of care equivalent to that of an ICF/DD or nursing facility, or who is receiving services under Section 1915(c) of the Social Security Act.
    (k) "Institutionalized spouse" means an institutionalized person who is expected to receive services at the same level of care for at least 30 days and is married to a spouse who is not an institutionalized person.
    (l) "Community spouse" is the spouse of an institutionalized spouse.
    (m) "Health Benefits Service Package" means, subject to federal approval, benefits covered by the medical assistance program as determined by the Department by rule for individuals eligible for medical assistance under paragraph 18 of Section 5-2 of this Code.
    (n) "Federal poverty level" means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services. These guidelines set poverty levels by family size.
(Source: P.A. 97-227, eff. 1-1-12; 97-820, eff. 7-17-12; 98-104, eff. 7-22-13.)

305 ILCS 5/5-1.2

    (305 ILCS 5/5-1.2)
    Sec. 5-1.2. Recipient eligibility verification.
    (a) The Illinois Department shall initiate a statewide system by which providers and sites of medical care can electronically verify recipient eligibility for aid under this Article. High-volume providers and sites of medical care, as defined by the Illinois Department by rule, shall be required to participate in the eligibility verification system. Every non-high-volume provider and site of medical care shall be afforded the opportunity to participate in the eligibility verification system. The Illinois Department shall provide by rule for implementation of the system, which may be accomplished in phases over time and by geographic region, recipient classification, and provider type. The system shall initially be implemented in, but not limited to, the following zip codes in Cook County: 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60608, 60609, 60612, and 60616. The system shall be implemented within 6 months after approval by the federal government. The Illinois Department shall report to the General Assembly by December 31, 1994 on the status of the Illinois Department's application to the federal government for approval of this system. The recipient eligibility verification system may be coordinated with the Electronic Benefits Transfer system established by Section 11-3.1 of this Code and compatible with any of the methods for the delivery of medical care and services authorized by this Article. The system shall make available to providers the history of claims for medical services submitted to the Illinois Department for those services provided to the recipient. The Illinois Department shall develop safeguards to protect each recipient's health information from misuse or unauthorized disclosure.
    (b) The Illinois Department shall conduct a demonstration project in at least 2 geographic locations for the purpose of assessing the effectiveness of a recipient photo identification card in reducing abuses in the provision of services under this Article. In order to receive medical care, recipients included in this demonstration project must present a Medicaid card and photo identification card. The Illinois Department shall apply for any federal waivers or approvals necessary to conduct this demonstration project. The demonstration project shall become operational (i) 12 months after the effective date of this amendatory Act of 1994 or (ii) after the Illinois Department's receipt of all necessary federal waivers and approvals, whichever occurs later, and shall operate for 12 months.
    (c) Effective October 1, 2007, all changes in status of Medicaid recipients residing in Illinois nursing facilities after initial eligibility for Medicaid has been established shall be reported to the Department, using an Internet-based electronic data interchange system, by the nursing facilities, except for those changes made by personnel of the Department. Changes reported using the Internet-based electronic data interchange system shall be deemed valid and shall be used as the basis for future Medicaid payments unless Department approval of the transaction is required, or until such time as any review or audit conducted by the State establishes that the information is incorrect.
(Source: P.A. 95-458, eff. 8-27-07.)

305 ILCS 5/5-1.3

    (305 ILCS 5/5-1.3)
    Sec. 5-1.3. Payer of last resort. To the extent permissible under federal law, the State may pay for medical services only after payment from all other sources of payment have been exhausted, or after the Department has determined that pursuit of such payment is economically unfeasible. Applicants for, and recipients of, medical assistance under this Code shall disclose to the State all insurance coverage they have. To the extent permissible under federal law, the State shall require vendors of medical services to bill third-party payers for services that may be covered by those third-party payers prior to submission of a request for payment to the State. The Department shall, to the extent permissible under federal law, reject a request for payment of a medical service that should first have been submitted to a third-party payer.
(Source: P.A. 96-1501, eff. 1-25-11.)

305 ILCS 5/5-1.4

    (305 ILCS 5/5-1.4)
    Sec. 5-1.4. Moratorium on eligibility expansions. Beginning on January 25, 2011 (the effective date of Public Act 96-1501), there shall be a 4-year moratorium on the expansion of eligibility through increasing financial eligibility standards, or through increasing income disregards, or through the creation of new programs which would add new categories of eligible individuals under the medical assistance program in addition to those categories covered on January 1, 2011 or above the level of any subsequent reduction in eligibility. This moratorium shall not apply to expansions required as a federal condition of State participation in the medical assistance program or to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds. If the State of Illinois finds that the State has borne a cost related to such an expansion, the unit of local government shall reimburse the State. All federal funds associated with an expansion funded by a unit of local government shall be returned to the local government entity funding the expansion, pursuant to an intergovernmental agreement between the Department of Healthcare and Family Services and the local government entity. Within 10 calendar days of the effective date of this amendatory Act of the 97th General Assembly, the Department of Healthcare and Family Services shall formally advise the Centers for Medicare and Medicaid Services of the passage of this amendatory Act of the 97th General Assembly. The State is prohibited from submitting additional waiver requests that expand or allow for an increase in the classes of persons eligible for medical assistance under this Article to the federal government for its consideration beginning on the 20th calendar day following the effective date of this amendatory Act of the 97th General Assembly until January 25, 2015. This moratorium shall not apply to those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) and 42 U.S.C. 1396a(a)(10)(A)(i)(IX).
(Source: P.A. 97-687, eff. 6-14-12; 98-104, eff. 7-22-13.)

305 ILCS 5/5-2

    (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
    Sec. 5-2. Classes of Persons Eligible.
    Medical assistance under this Article shall be available to any of the following classes of persons in respect to whom a plan for coverage has been submitted to the Governor by the Illinois Department and approved by him. If changes made in this Section 5-2 require federal approval, they shall not take effect until such approval has been received:
        1. Recipients of basic maintenance grants under
    
Articles III and IV.
        2. Beginning January 1, 2014, persons otherwise
    
eligible for basic maintenance under Article III, excluding any eligibility requirements that are inconsistent with any federal law or federal regulation, as interpreted by the U.S. Department of Health and Human Services, but who fail to qualify thereunder on the basis of need, and who have insufficient income and resources to meet the costs of necessary medical care, including but not limited to the following:
            (a) All persons otherwise eligible for basic
        
maintenance under Article III but who fail to qualify under that Article on the basis of need and who meet either of the following requirements:
                (i) their income, as determined by the
            
Illinois Department in accordance with any federal requirements, is equal to or less than 100% of the federal poverty level; or
                (ii) their income, after the deduction of
            
costs incurred for medical care and for other types of remedial care, is equal to or less than 100% of the federal poverty level.
            (b) (Blank).
        3. (Blank).
        4. Persons not eligible under any of the preceding
    
paragraphs who fall sick, are injured, or die, not having sufficient money, property or other resources to meet the costs of necessary medical care or funeral and burial expenses.
        5.(a) Women during pregnancy and during the 60-day
    
period beginning on the last day of the pregnancy, together with their infants, whose income is at or below 200% of the federal poverty level. Until September 30, 2019, or sooner if the maintenance of effort requirements under the Patient Protection and Affordable Care Act are eliminated or may be waived before then, women during pregnancy and during the 60-day period beginning on the last day of the pregnancy, whose countable monthly income, after the deduction of costs incurred for medical care and for other types of remedial care as specified in administrative rule, is equal to or less than the Medical Assistance-No Grant(C) (MANG(C)) Income Standard in effect on April 1, 2013 as set forth in administrative rule.
        (b) The plan for coverage shall provide ambulatory
    
prenatal care to pregnant women during a presumptive eligibility period and establish an income eligibility standard that is equal to 200% of the federal poverty level, provided that costs incurred for medical care are not taken into account in determining such income eligibility.
        (c) The Illinois Department may conduct a
    
demonstration in at least one county that will provide medical assistance to pregnant women, together with their infants and children up to one year of age, where the income eligibility standard is set up to 185% of the nonfarm income official poverty line, as defined by the federal Office of Management and Budget. The Illinois Department shall seek and obtain necessary authorization provided under federal law to implement such a demonstration. Such demonstration may establish resource standards that are not more restrictive than those established under Article IV of this Code.
        6. (a) Children younger than age 19 when countable
    
income is at or below 133% of the federal poverty level. Until September 30, 2019, or sooner if the maintenance of effort requirements under the Patient Protection and Affordable Care Act are eliminated or may be waived before then, children younger than age 19 whose countable monthly income, after the deduction of costs incurred for medical care and for other types of remedial care as specified in administrative rule, is equal to or less than the Medical Assistance-No Grant(C) (MANG(C)) Income Standard in effect on April 1, 2013 as set forth in administrative rule.
        (b) Children and youth who are under temporary
    
custody or guardianship of the Department of Children and Family Services or who receive financial assistance in support of an adoption or guardianship placement from the Department of Children and Family Services.
        7. (Blank).
        8. As required under federal law, persons who are
    
eligible for Transitional Medical Assistance as a result of an increase in earnings or child or spousal support received. The plan for coverage for this class of persons shall:
            (a) extend the medical assistance coverage to the
        
extent required by federal law; and
            (b) offer persons who have initially received 6
        
months of the coverage provided in paragraph (a) above, the option of receiving an additional 6 months of coverage, subject to the following:
                (i) such coverage shall be pursuant to
            
provisions of the federal Social Security Act;
                (ii) such coverage shall include all services
            
covered under Illinois' State Medicaid Plan;
                (iii) no premium shall be charged for such
            
coverage; and
                (iv) such coverage shall be suspended in the
            
event of a person's failure without good cause to file in a timely fashion reports required for this coverage under the Social Security Act and coverage shall be reinstated upon the filing of such reports if the person remains otherwise eligible.
        9. Persons with acquired immunodeficiency syndrome
    
(AIDS) or with AIDS-related conditions with respect to whom there has been a determination that but for home or community-based services such individuals would require the level of care provided in an inpatient hospital, skilled nursing facility or intermediate care facility the cost of which is reimbursed under this Article. Assistance shall be provided to such persons to the maximum extent permitted under Title XIX of the Federal Social Security Act.
        10. Participants in the long-term care insurance
    
partnership program established under the Illinois Long-Term Care Partnership Program Act who meet the qualifications for protection of resources described in Section 15 of that Act.
        11. Persons with disabilities who are employed and
    
eligible for Medicaid, pursuant to Section 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, subject to federal approval, persons with a medically improved disability who are employed and eligible for Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of the Social Security Act, as provided by the Illinois Department by rule. In establishing eligibility standards under this paragraph 11, the Department shall, subject to federal approval:
            (a) set the income eligibility standard at not
        
lower than 350% of the federal poverty level;
            (b) exempt retirement accounts that the person
        
cannot access without penalty before the age of 59 1/2, and medical savings accounts established pursuant to 26 U.S.C. 220;
            (c) allow non-exempt assets up to $25,000 as to
        
those assets accumulated during periods of eligibility under this paragraph 11; and
            (d) continue to apply subparagraphs (b) and (c)
        
in determining the eligibility of the person under this Article even if the person loses eligibility under this paragraph 11.
        12. Subject to federal approval, persons who are
    
eligible for medical assistance coverage under applicable provisions of the federal Social Security Act and the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000. Those eligible persons are defined to include, but not be limited to, the following persons:
            (1) persons who have been screened for breast or
        
cervical cancer under the U.S. Centers for Disease Control and Prevention Breast and Cervical Cancer Program established under Title XV of the federal Public Health Services Act in accordance with the requirements of Section 1504 of that Act as administered by the Illinois Department of Public Health; and
            (2) persons whose screenings under the above
        
program were funded in whole or in part by funds appropriated to the Illinois Department of Public Health for breast or cervical cancer screening.
        "Medical assistance" under this paragraph 12 shall be
    
identical to the benefits provided under the State's approved plan under Title XIX of the Social Security Act. The Department must request federal approval of the coverage under this paragraph 12 within 30 days after the effective date of this amendatory Act of the 92nd General Assembly.
        In addition to the persons who are eligible for
    
medical assistance pursuant to subparagraphs (1) and (2) of this paragraph 12, and to be paid from funds appropriated to the Department for its medical programs, any uninsured person as defined by the Department in rules residing in Illinois who is younger than 65 years of age, who has been screened for breast and cervical cancer in accordance with standards and procedures adopted by the Department of Public Health for screening, and who is referred to the Department by the Department of Public Health as being in need of treatment for breast or cervical cancer is eligible for medical assistance benefits that are consistent with the benefits provided to those persons described in subparagraphs (1) and (2). Medical assistance coverage for the persons who are eligible under the preceding sentence is not dependent on federal approval, but federal moneys may be used to pay for services provided under that coverage upon federal approval.
        13. Subject to appropriation and to federal approval,
    
persons living with HIV/AIDS who are not otherwise eligible under this Article and who qualify for services covered under Section 5-5.04 as provided by the Illinois Department by rule.
        14. Subject to the availability of funds for this
    
purpose, the Department may provide coverage under this Article to persons who reside in Illinois who are not eligible under any of the preceding paragraphs and who meet the income guidelines of paragraph 2(a) of this Section and (i) have an application for asylum pending before the federal Department of Homeland Security or on appeal before a court of competent jurisdiction and are represented either by counsel or by an advocate accredited by the federal Department of Homeland Security and employed by a not-for-profit organization in regard to that application or appeal, or (ii) are receiving services through a federally funded torture treatment center. Medical coverage under this paragraph 14 may be provided for up to 24 continuous months from the initial eligibility date so long as an individual continues to satisfy the criteria of this paragraph 14. If an individual has an appeal pending regarding an application for asylum before the Department of Homeland Security, eligibility under this paragraph 14 may be extended until a final decision is rendered on the appeal. The Department may adopt rules governing the implementation of this paragraph 14.
        15. Family Care Eligibility.
            (a) On and after July 1, 2012, a parent or other
        
caretaker relative who is 19 years of age or older when countable income is at or below 133% of the federal poverty level. A person may not spend down to become eligible under this paragraph 15.
            (b) Eligibility shall be reviewed annually.
            (c) (Blank).
            (d) (Blank).
            (e) (Blank).
            (f) (Blank).
            (g) (Blank).
            (h) (Blank).
            (i) Following termination of an individual's
        
coverage under this paragraph 15, the individual must be determined eligible before the person can be re-enrolled.
        16. Subject to appropriation, uninsured persons who
    
are not otherwise eligible under this Section who have been certified and referred by the Department of Public Health as having been screened and found to need diagnostic evaluation or treatment, or both diagnostic evaluation and treatment, for prostate or testicular cancer. For the purposes of this paragraph 16, uninsured persons are those who do not have creditable coverage, as defined under the Health Insurance Portability and Accountability Act, or have otherwise exhausted any insurance benefits they may have had, for prostate or testicular cancer diagnostic evaluation or treatment, or both diagnostic evaluation and treatment. To be eligible, a person must furnish a Social Security number. A person's assets are exempt from consideration in determining eligibility under this paragraph 16. Such persons shall be eligible for medical assistance under this paragraph 16 for so long as they need treatment for the cancer. A person shall be considered to need treatment if, in the opinion of the person's treating physician, the person requires therapy directed toward cure or palliation of prostate or testicular cancer, including recurrent metastatic cancer that is a known or presumed complication of prostate or testicular cancer and complications resulting from the treatment modalities themselves. Persons who require only routine monitoring services are not considered to need treatment. "Medical assistance" under this paragraph 16 shall be identical to the benefits provided under the State's approved plan under Title XIX of the Social Security Act. Notwithstanding any other provision of law, the Department (i) does not have a claim against the estate of a deceased recipient of services under this paragraph 16 and (ii) does not have a lien against any homestead property or other legal or equitable real property interest owned by a recipient of services under this paragraph 16.
        17. Persons who, pursuant to a waiver approved by
    
the Secretary of the U.S. Department of Health and Human Services, are eligible for medical assistance under Title XIX or XXI of the federal Social Security Act. Notwithstanding any other provision of this Code and consistent with the terms of the approved waiver, the Illinois Department, may by rule:
            (a) Limit the geographic areas in which
        
the waiver program operates.
            (b) Determine the scope, quantity, duration, and
        
quality, and the rate and method of reimbursement, of the medical services to be provided, which may differ from those for other classes of persons eligible for assistance under this Article.
            (c) Restrict the persons' freedom in
        
choice of providers.
        18. Beginning January 1, 2014, persons aged 19 or
    
older, but younger than 65, who are not otherwise eligible for medical assistance under this Section 5-2, who qualify for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) and applicable federal regulations, and who have income at or below 133% of the federal poverty level plus 5% for the applicable family size as determined pursuant to 42 U.S.C. 1396a(e)(14) and applicable federal regulations. Persons eligible for medical assistance under this paragraph 18 shall receive coverage for the Health Benefits Service Package as that term is defined in subsection (m) of Section 5-1.1 of this Code. If Illinois' federal medical assistance percentage (FMAP) is reduced below 90% for persons eligible for medical assistance under this paragraph 18, eligibility under this paragraph 18 shall cease no later than the end of the third month following the month in which the reduction in FMAP takes effect.
        19. Beginning January 1, 2014, as required under 42
    
U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18 and younger than age 26 who are not otherwise eligible for medical assistance under paragraphs (1) through (17) of this Section who (i) were in foster care under the responsibility of the State on the date of attaining age 18 or on the date of attaining age 21 when a court has continued wardship for good cause as provided in Section 2-31 of the Juvenile Court Act of 1987 and (ii) received medical assistance under the Illinois Title XIX State Plan or waiver of such plan while in foster care.
    In implementing the provisions of Public Act 96-20, the Department is authorized to adopt only those rules necessary, including emergency rules. Nothing in Public Act 96-20 permits the Department to adopt rules or issue a decision that expands eligibility for the FamilyCare Program to a person whose income exceeds 185% of the Federal Poverty Level as determined from time to time by the U.S. Department of Health and Human Services, unless the Department is provided with express statutory authority.
    The eligibility of any such person for medical assistance under this Article is not affected by the payment of any grant under the Senior Citizens and Disabled Persons Property Tax Relief Act or any distributions or items of income described under subparagraph (X) of paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax Act.
    The Department shall by rule establish the amounts of assets to be disregarded in determining eligibility for medical assistance, which shall at a minimum equal the amounts to be disregarded under the Federal Supplemental Security Income Program. The amount of assets of a single person to be disregarded shall not be less than $2,000, and the amount of assets of a married couple to be disregarded shall not be less than $3,000.
    To the extent permitted under federal law, any person found guilty of a second violation of Article VIIIA shall be ineligible for medical assistance under this Article, as provided in Section 8A-8.
    The eligibility of any person for medical assistance under this Article shall not be affected by the receipt by the person of donations or benefits from fundraisers held for the person in cases of serious illness, as long as neither the person nor members of the person's family have actual control over the donations or benefits or the disbursement of the donations or benefits.
    Notwithstanding any other provision of this Code, if the United States Supreme Court holds Title II, Subtitle A, Section 2001(a) of Public Law 111-148 to be unconstitutional, or if a holding of Public Law 111-148 makes Medicaid eligibility allowed under Section 2001(a) inoperable, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after the effective date of this amendatory Act of the 97th General Assembly, and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible.
    Notwithstanding any other provision of this Code, if an Act of Congress that becomes a Public Law eliminates Section 2001(a) of Public Law 111-148, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after the effective date of this amendatory Act of the 97th General Assembly, and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible.
    Effective October 1, 2013, the determination of eligibility of persons who qualify under paragraphs 5, 6, 8, 15, 17, and 18 of this Section shall comply with the requirements of 42 U.S.C. 1396a(e)(14) and applicable federal regulations.
    The Department of Healthcare and Family Services, the Department of Human Services, and the Illinois health insurance marketplace shall work cooperatively to assist persons who would otherwise lose health benefits as a result of changes made under this amendatory Act of the 98th General Assembly to transition to other health insurance coverage.
(Source: P.A. 97-48, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333, eff. 8-12-11; 97-687, eff. 6-14-12; 97-689, eff. 6-14-12; 97-813, eff. 7-13-12; 98-104, eff. 7-22-13; 98-463, eff. 8-16-13.)

305 ILCS 5/5-2a

    (305 ILCS 5/5-2a)
    Sec. 5-2a. Medicaid State Plan; eligibility determination status. The Department shall conduct an analysis and deliver a report to the General Assembly by January 1, 2012 to evaluate the feasibility of changing Illinois' Medicaid State Plan from 209(b) status to the federal 1634 eligibility determination status for applicable individuals as provided in the Social Security Act. The report shall include a review of the current standard used by the Department, anticipated fiscal implications of converting to 1634 status, anticipated changes in caseloads resulting from a change to 1634 status, and any additional information deemed relevant by the Department to evaluate the feasibility of converting to 1634 status.
(Source: P.A. 97-173, eff. 7-22-11.)

305 ILCS 5/5-2b

    (305 ILCS 5/5-2b)
    Sec. 5-2b. Medically fragile and technology dependent children eligibility and program. Notwithstanding any other provision of law, on and after September 1, 2012, subject to federal approval, medical assistance under this Article shall be available to children who qualify as persons with a disability, as defined under the federal Supplemental Security Income program and who are medically fragile and technology dependent. The program shall allow eligible children to receive the medical assistance provided under this Article in the community and must maximize, to the fullest extent permissible under federal law, federal reimbursement and family cost-sharing, including co-pays, premiums, or any other family contributions, except that the Department shall be permitted to incentivize the utilization of selected services through the use of cost-sharing adjustments. The Department shall establish the policies, procedures, standards, services, and criteria for this program by rule.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)

305 ILCS 5/5-2.01

    (305 ILCS 5/5-2.01)
    Sec. 5-2.01. Medicaid accountability through transparency program.
    (a) Internet-based transparency program. The Director of the Department of Healthcare and Family Services shall be authorized to implement a program under which the Director shall make available through the Department's public Internet website information on medical claims reimbursed under the State's medical assistance program insofar as such information has been de-identified in accordance with regulations promulgated pursuant to the Illinois Health Insurance Portability and Accountability Act. In implementing the program, the Director shall ensure the following:
        (1) The information made so available shall be in a
    
format that is easily accessible, useable, and understandable to the public, including individuals interested in improving the quality of care provided to individuals eligible for items and services under this Article, researchers, health care providers, and individuals interested in reducing the prevalence of waste and fraud under this Article.
        (2) The information made so available shall be as
    
current as deemed practical by the Director and shall be updated at least once per calendar quarter.
        (3) The information made so available shall be
    
aggregated to a level to ensure patient confidentiality, but shall, to the extent feasible, allow for posting of information by provider or vendor name and county, number of individuals served, total patient visits, payment for bills submitted, average cost for bills submitted, adjustments to payments, and total amounts paid.
        (4) The Director periodically solicits comments from
    
a sampling of individuals who access the information through the program on how to best improve the utility of the program.
    (b) Use of contractor. For purposes of implementing the program under subsection (a) of this Section and ensuring the information made available through the program is periodically updated, the Director may select and enter into a contract with a public or private entity meeting the criteria and qualifications the Director determines appropriate.
    (c) Annual Reports. Not later than 12 months after the effective date of this amendatory Act of the 96th General Assembly and annually thereafter, the Director shall submit to the General Assembly a report on the status of the program authorized under subsection (a). The report shall include details including, but not limited to, the estimated or actual costs of developing and maintaining the reporting system, the actual or potential benefit or adverse consequences associated with the system, and, if applicable, the extent to which information made available through the program is accessed and the extent to which comments received under paragraph (4) of subsection (a) of this Section were used to improve the utility of the program.
(Source: P.A. 96-941, eff. 6-25-10.)

305 ILCS 5/5-2.03

    (305 ILCS 5/5-2.03)
    Sec. 5-2.03. Presumptive eligibility. Beginning on the effective date of this amendatory Act of the 96th General Assembly and except where federal law requires presumptive eligibility, no adult may be presumed eligible for medical assistance under this Code and the Department may not cover any service rendered to an adult unless the adult has completed an application for benefits, all required verifications have been received, and the Department or its designee has found the adult eligible for the date on which that service was provided. Nothing in this Section shall apply to pregnant women or to persons enrolled under the medical assistance program due to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds.
(Source: P.A. 96-1501, eff. 1-25-11; 97-687, eff. 6-14-12.)

305 ILCS 5/5-2.05

    (305 ILCS 5/5-2.05)
    Sec. 5-2.05. Children with disabilities.
    (a) The Department of Healthcare and Family Services, in conjunction with the Department of Human Services, may offer, to children with developmental disabilities or children with severe mental illness or severe emotional disorders who otherwise would not qualify for medical assistance under this Article due to family income, home-based and community-based services instead of institutional placement, as allowed under paragraph 7 of Section 5-2.
    (b) The Department of Healthcare and Family Services, in conjunction with the Department of Human Services and the Division of Specialized Care for Children, University of Illinois-Chicago, shall submit a bi-annual report to the Governor and the General Assembly no later than January 1 of every even-numbered year, beginning in 2008, regarding the status of existing services offered under paragraph 7 of Section 5-2. This report shall include, but not be limited to, the following information:
        (1) The number of persons who currently receive these
    
services.
        (2) The nature, scope, and cost of services.
        (3) The comparative cost of providing those services
    
in a hospital, skilled nursing facility, or intermediate care facility.
        (4) The funding sources for the provision of
    
services, including federal financial participation.
        (5) The qualifications, skills, and availability of
    
caregivers for children receiving services.
        (6) The number of children who have aged out of the
    
services offered under paragraph 7 of Section 5-2 during the 2 years immediately preceding the report.
(Source: P.A. 95-331, eff. 8-21-07; 95-622, eff. 9-17-07.)

305 ILCS 5/5-2.07

    (305 ILCS 5/5-2.07)
    Sec. 5-2.07. Use of Medicaid spend-down. No later than July 1, 2007, subject to federal approval of a State Medicaid Plan amendment, which shall be sought by the Department of Healthcare and Family Services or its successor agency, persons described in item 2(a) of Section 5-2, who fail to qualify for basic maintenance under Article III of this Code on the basis of need because of excess income or assets, or both, may establish eligibility for medical assistance by paying the amount of their monthly spend-down under this Article (as described in 42 CFR 435.831) to the Department of Healthcare and Family Services or its successor agency or by having a third party pay that amount to the Department on their behalf.
(Source: P.A. 94-847, eff. 1-1-07.)

305 ILCS 5/5-2.08

    (305 ILCS 5/5-2.08)
    Sec. 5-2.08. Spousal caregiver demonstration.
    (a) The Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall develop a demonstration project within the Home Services Program under which a spouse may be reimbursed for providing care to his or her spouse, who is eligible for services through the Home Services Program and who meets the criteria for this demonstration project. The demonstration project shall operate in selected counties and be limited to serving no more than 100 unduplicated persons in a State fiscal year.
    The components of the demonstration project shall include the following:
        (1) Authorization for a spouse to be reimbursed for
    
care provided to his or her otherwise eligible spouse through the Home Services Program.
        (2) The development of specific criteria for the
    
provision of services under the demonstration project. Criteria applicable to a spousal caregiver shall include, but need not be limited to, (i) a limitation on the total hours of a spousal caregiver's outside employment plus hours of providing care to his or her eligible spouse to ensure that the complete plan of care is delivered to the eligible spouse and (ii) limitations on a spousal caregiver's participation in the demonstration project if the caregiver has a known history of spousal abuse, neglect, or exploitation.
        (3) The determination of the personal care or similar
    
services for which payment may be made. Spousal caregivers shall be paid at the Personal Assistant level of care and pay rate. In those instances in which the eligible spouse requires specialized services (for example, services provided by a certified nursing assistant (CNA), licensed practical nurse (LPN), or registered nurse (RN)) and the spousal caregiver has the corresponding certification or licensure, the spousal caregiver shall be paid the higher rate for the specialized services only. The specialized services the eligible spouse is authorized to receive shall be defined and approved in the services plan.
        (4) The method for determining that the amount of
    
personal care or similar services provided by the spouse is "extraordinary care" that exceeds the ordinary care that would be provided to a spouse without a disability.
        (5) Limitations on the number of hours of personal
    
services that will be reimbursed.
        (6) Utilization of the Determination of Need
    
evaluation and other comprehensive assessment tools as criteria for determining eligibility and developing service plans under the demonstration project.
        (7) Determination of how or whether the provision of
    
personal care by the spouse is in the best interest of his or her spouse, who is an eligible participant in the demonstration project.
        (8) Use of procedures that ensure that payments are
    
made for services rendered.
        (9) Assurances that all other criteria of the
    
demonstration project are met.
        (10) Measurement of participant experiences.
        (11) Monthly in-home monitoring of the health and
    
safety of the eligible spouse.
        (12) Documentation of the marital relationship for
    
participation in the demonstration project.
        (13) Assurances that the eligible spouse is capable
    
of communicating his or her needs.
        (14) Enrollment of an alternative care provider to
    
ensure that there is no disruption of care to the eligible spouse.
        (15) Assurances that the spousal caregiver is
    
emotionally, physically, and cognitively able to provide the necessary care to the eligible spouse.
    (b) By July 1, 2009, the Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall begin development of the demonstration project. The Department of Human Services shall provide an interim report on or before March 1, 2010 to the Governor and the General Assembly that includes the progress on the development of the demonstration project and implementation timelines of the demonstration project and the criteria for the demonstration project.
    (c) The Department of Human Services shall report findings and recommendations by March 1, 2011 to the Governor and the General Assembly. The report shall include an explanation of the manner in which each demonstration project component listed in paragraphs (1) through (10) of subsection (a) is addressed. In addition, the report shall include (i) the estimated number of clients statewide who could utilize services and (ii) an analysis of the fiscal impact per client on the Department's new and existing costs under the Home Services Program.
(Source: P.A. 96-351, eff. 8-13-09.)

305 ILCS 5/5-2.1

    (305 ILCS 5/5-2.1) (from Ch. 23, par. 5-2.1)
    Sec. 5-2.1. Property transfers.
    (a) To the extent required under federal law, a person shall not make or have made a voluntary or involuntary assignment or transfer of any legal or equitable interests in real property or in personal property, whether vested, contingent or inchoate, for less than fair market value. A person's interest in real or personal property includes all income and assets to which the person is entitled or to which the person would be entitled if the person had not taken action to avoid receiving the interest.
    (b) (Blank).
    (c) (Blank).
    (d) (Blank).
    (e) (Blank).
(Source: P.A. 92-84, eff. 7-1-02.)

305 ILCS 5/5-2.1a

    (305 ILCS 5/5-2.1a)
    Sec. 5-2.1a. Treatment of trust amounts. To the extent required by federal law, the Department of Healthcare and Family Services shall provide by rule for the consideration of trusts and similar legal instruments or devices established by a person in the Illinois Department's determination of the person's eligibility for and the amount of assistance provided under this Article.
(Source: P.A. 98-651, eff. 6-16-14.)

305 ILCS 5/5-2.1d

    (305 ILCS 5/5-2.1d)
    Sec. 5-2.1d. Retroactive eligibility. An applicant for medical assistance may be eligible for up to 3 months prior to the date of application if the person would have been eligible for medical assistance at the time he or she received the services if he or she had applied, regardless of whether the individual is alive when the application for medical assistance is made. In determining financial eligibility for medical assistance for retroactive months, the Department shall consider the amount of income and resources and exemptions available to a person as of the first day of each of the backdated months for which eligibility is sought.
(Source: P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-2.2

    (305 ILCS 5/5-2.2) (from Ch. 23, par. 5-2.2)
    Sec. 5-2.2. Cooperation in establishing support obligation. A parent or other person having custody of the child or a spouse who fails or refuses to comply with the requirements of Title XIX of the federal Social Security Act, and the regulations duly promulgated thereunder, regarding establishment and enforcement of the child or spousal support obligation shall be ineligible for medical assistance and shall remain ineligible for medical assistance for as long as the failure or refusal persists.
    In addition to any other definition of failure or refusal to comply with the requirements of Title XIX of the federal Social Security Act, in the case of failure to attend court hearings, the parent or other person can show cooperation by attending a court hearing or, if a court hearing cannot be scheduled within 30 days following the court hearing that was missed, by signing a statement that the parent or other person is now willing to cooperate in the child support enforcement process and will appear at any later scheduled court date. The parent or other person can show cooperation by signing such a statement only once. If failure to attend the court hearing or other failure to cooperate results in the case being dismissed, such a statement may be signed after 2 months.
    No denial or termination of medical assistance pursuant to this Section shall commence during pregnancy of the parent or other person having custody of the child or for 30 days after the termination of such pregnancy. The termination of medical assistance may commence thereafter if the Illinois Department determines that the failure or refusal to comply with this Section persists. Postponement of denial or termination of medical assistance during pregnancy under this paragraph shall be effective only to the extent it does not conflict with federal law or regulation.
(Source: P.A. 85-1155.)

305 ILCS 5/5-2.3

    (305 ILCS 5/5-2.3)
    Sec. 5-2.3. Notice of rights concerning institutionalization. The Illinois Department shall prepare a notice to be given to every applicant for and recipient of medical assistance under this Article when the applicant or recipient, or the spouse of the applicant or recipient, or a person for whom the applicant or recipient is the primary caretaker, becomes an institutionalized person. The notice shall fully and completely inform the institutionalized person (and that person's spouse or primary caretaker, if applicable) of each individual's rights and obligations under this Code with respect to that institutionalization.
(Source: P.A. 88-162.)

305 ILCS 5/5-2.4

    (305 ILCS 5/5-2.4)
    Sec. 5-2.4. (Repealed).
(Source: P.A. 95-248, eff. 8-17-07. Repealed by P.A. 97-48, eff. 6-28-11.)

305 ILCS 5/5-3

    (305 ILCS 5/5-3) (from Ch. 23, par. 5-3)
    Sec. 5-3. Residence.) Any person who has established his residence in this State and lives therein, including any person who is a migrant worker, may qualify for medical assistance. A person who, while temporarily in this State, suffers injury or illness endangering his life and health and necessitating emergency care, may also qualify.
    Temporary absence from the State shall not disqualify a person from maintaining his eligibility under this Article.
    As used in this Section, "migrant worker" means any person residing temporarily and employed in Illinois who moves seasonally from one place to another for the purpose of employment in agricultural activities, including the planting, raising or harvesting of any agricultural or horticultural commodities and the handling, packing or processing of such commodities on the farm where produced or at the point of first processing, in animal husbandry, or in other activities connected with the care of animals. Dependents of such person shall be considered eligible if they are living with the person during his or her temporary residence and employment in Illinois.
    In order to be eligible for medical assistance under this section, each migrant worker shall show proof of citizenship or legal alien status.
(Source: P.A. 81-746.)

305 ILCS 5/5-4

    (305 ILCS 5/5-4) (from Ch. 23, par. 5-4)
    Sec. 5-4. Amount and nature of medical assistance.
    (a) The amount and nature of medical assistance shall be determined in accordance with the standards, rules, and regulations of the Department of Healthcare and Family Services, with due regard to the requirements and conditions in each case, including contributions available from legally responsible relatives. However, the amount and nature of such medical assistance shall not be affected by the payment of any grant under the Senior Citizens and Disabled Persons Property Tax Relief Act or any distributions or items of income described under subparagraph (X) of paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax Act. The amount and nature of medical assistance shall not be affected by the receipt of donations or benefits from fundraisers in cases of serious illness, as long as neither the person nor members of the person's family have actual control over the donations or benefits or the disbursement of the donations or benefits.
    In determining the income and resources available to the institutionalized spouse and to the community spouse, the Department of Healthcare and Family Services shall follow the procedures established by federal law. If an institutionalized spouse or community spouse refuses to comply with the requirements of Title XIX of the federal Social Security Act and the regulations duly promulgated thereunder by failing to provide the total value of assets, including income and resources, to the extent either the institutionalized spouse or community spouse has an ownership interest in them pursuant to 42 U.S.C. 1396r-5, such refusal may result in the institutionalized spouse being denied eligibility and continuing to remain ineligible for the medical assistance program based on failure to cooperate.
    Subject to federal approval, the community spouse resource allowance shall be established and maintained at the higher of $109,560 or the minimum level permitted pursuant to Section 1924(f)(2) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater. The monthly maintenance allowance for the community spouse shall be established and maintained at the higher of $2,739 per month or the minimum level permitted pursuant to Section 1924(d)(3) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater. Subject to the approval of the Secretary of the United States Department of Health and Human Services, the provisions of this Section shall be extended to persons who but for the provision of home or community-based services under Section 4.02 of the Illinois Act on the Aging, would require the level of care provided in an institution, as is provided for in federal law.
    (b) Spousal support for institutionalized spouses receiving medical assistance.
        (i) The Department may seek support for an
    
institutionalized spouse, who has assigned his or her right of support from his or her spouse to the State, from the resources and income available to the community spouse.
        (ii) The Department may bring an action in the
    
circuit court to establish support orders or itself establish administrative support orders by any means and procedures authorized in this Code, as applicable, except that the standard and regulations for determining ability to support in Section 10-3 shall not limit the amount of support that may be ordered.
        (iii) Proceedings may be initiated to obtain support,
    
or for the recovery of aid granted during the period such support was not provided, or both, for the obtainment of support and the recovery of the aid provided. Proceedings for the recovery of aid may be taken separately or they may be consolidated with actions to obtain support. Such proceedings may be brought in the name of the person or persons requiring support or may be brought in the name of the Department, as the case requires.
        (iv) The orders for the payment of moneys for the
    
support of the person shall be just and equitable and may direct payment thereof for such period or periods of time as the circumstances require, including support for a period before the date the order for support is entered. In no event shall the orders reduce the community spouse resource allowance below the level established in subsection (a) of this Section or an amount set after a fair hearing, whichever is greater, or reduce the monthly maintenance allowance for the community spouse below the level permitted pursuant to subsection (a) of this Section.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)

305 ILCS 5/5-4.1

    (305 ILCS 5/5-4.1) (from Ch. 23, par. 5-4.1)
    Sec. 5-4.1. Co-payments. The Department may by rule provide that recipients under any Article of this Code shall pay a fee as a co-payment for services. Co-payments shall be maximized to the extent permitted by federal law, except that the Department shall impose a co-pay of $2 on generic drugs. Provided, however, that any such rule must provide that no co-payment requirement can exist for renal dialysis, radiation therapy, cancer chemotherapy, or insulin, and other products necessary on a recurring basis, the absence of which would be life threatening, or where co-payment expenditures for required services and/or medications for chronic diseases that the Illinois Department shall by rule designate shall cause an extensive financial burden on the recipient, and provided no co-payment shall exist for emergency room encounters which are for medical emergencies. The Department shall seek approval of a State plan amendment that allows pharmacies to refuse to dispense drugs in circumstances where the recipient does not pay the required co-payment. Co-payments may not exceed $10 for emergency room use for a non-emergency situation as defined by the Department by rule and subject to federal approval.
(Source: P.A. 96-1501, eff. 1-25-11; 97-74, eff. 6-30-11; 97-689, eff. 6-14-12.)

305 ILCS 5/5-4.2

    (305 ILCS 5/5-4.2) (from Ch. 23, par. 5-4.2)
    Sec. 5-4.2. Ambulance services payments.
    (a) For ambulance services provided to a recipient of aid under this Article on or after January 1, 1993, the Illinois Department shall reimburse ambulance service providers at rates calculated in accordance with this Section. It is the intent of the General Assembly to provide adequate reimbursement for ambulance services so as to ensure adequate access to services for recipients of aid under this Article and to provide appropriate incentives to ambulance service providers to provide services in an efficient and cost-effective manner. Thus, it is the intent of the General Assembly that the Illinois Department implement a reimbursement system for ambulance services that, to the extent practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, is consistent with the payment principles of Medicare. To ensure uniformity between the payment principles of Medicare and Medicaid, the Illinois Department shall follow, to the extent necessary and practicable and subject to the availability of funds appropriated by the General Assembly for this purpose, the statutes, laws, regulations, policies, procedures, principles, definitions, guidelines, and manuals used to determine the amounts paid to ambulance service providers under Title XVIII of the Social Security Act (Medicare).
    (b) For ambulance services provided to a recipient of aid under this Article on or after January 1, 1996, the Illinois Department shall reimburse ambulance service providers based upon the actual distance traveled if a natural disaster, weather conditions, road repairs, or traffic congestion necessitates the use of a route other than the most direct route.
    (c) For purposes of this Section, "ambulance services" includes medical transportation services provided by means of an ambulance, medi-car, service car, or taxi.
    (c-1) For purposes of this Section, "ground ambulance service" means medical transportation services that are described as ground ambulance services by the Centers for Medicare and Medicaid Services and provided in a vehicle that is licensed as an ambulance by the Illinois Department of Public Health pursuant to the Emergency Medical Services (EMS) Systems Act.
    (c-2) For purposes of this Section, "ground ambulance service provider" means a vehicle service provider as described in the Emergency Medical Services (EMS) Systems Act that operates licensed ambulances for the purpose of providing emergency ambulance services, or non-emergency ambulance services, or both. For purposes of this Section, this includes both ambulance providers and ambulance suppliers as described by the Centers for Medicare and Medicaid Services.
    (d) This Section does not prohibit separate billing by ambulance service providers for oxygen furnished while providing advanced life support services.
    (e) Beginning with services rendered on or after July 1, 2008, all providers of non-emergency medi-car and service car transportation must certify that the driver and employee attendant, as applicable, have completed a safety program approved by the Department to protect both the patient and the driver, prior to transporting a patient. The provider must maintain this certification in its records. The provider shall produce such documentation upon demand by the Department or its representative. Failure to produce documentation of such training shall result in recovery of any payments made by the Department for services rendered by a non-certified driver or employee attendant. Medi-car and service car providers must maintain legible documentation in their records of the driver and, as applicable, employee attendant that actually transported the patient. Providers must recertify all drivers and employee attendants every 3 years.
    Notwithstanding the requirements above, any public transportation provider of medi-car and service car transportation that receives federal funding under 49 U.S.C. 5307 and 5311 need not certify its drivers and employee attendants under this Section, since safety training is already federally mandated.
    (f) With respect to any policy or program administered by the Department or its agent regarding approval of non-emergency medical transportation by ground ambulance service providers, including, but not limited to, the Non-Emergency Transportation Services Prior Approval Program (NETSPAP), the Department shall establish by rule a process by which ground ambulance service providers of non-emergency medical transportation may appeal any decision by the Department or its agent for which no denial was received prior to the time of transport that either (i) denies a request for approval for payment of non-emergency transportation by means of ground ambulance service or (ii) grants a request for approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than the ground ambulance service provider would have received as compensation for the level of service requested. The rule shall be filed by December 15, 2012 and shall provide that, for any decision rendered by the Department or its agent on or after the date the rule takes effect, the ground ambulance service provider shall have 60 days from the date the decision is received to file an appeal. The rule established by the Department shall be, insofar as is practical, consistent with the Illinois Administrative Procedure Act. The Director's decision on an appeal under this Section shall be a final administrative decision subject to review under the Administrative Review Law.
    (f-5) Beginning 90 days after July 20, 2012 (the effective date of Public Act 97-842), (i) no denial of a request for approval for payment of non-emergency transportation by means of ground ambulance service, and (ii) no approval of non-emergency transportation by means of ground ambulance service at a level of service that entitles the ground ambulance service provider to a lower level of compensation from the Department than would have been received at the level of service submitted by the ground ambulance service provider, may be issued by the Department or its agent unless the Department has submitted the criteria for determining the appropriateness of the transport for first notice publication in the Illinois Register pursuant to Section 5-40 of the Illinois Administrative Procedure Act.
    (g) Whenever a patient covered by a medical assistance program under this Code or by another medical program administered by the Department is being discharged from a facility, a physician discharge order as described in this Section shall be required for each patient whose discharge requires medically supervised ground ambulance services. Facilities shall develop procedures for a physician with medical staff privileges to provide a written and signed physician discharge order. The physician discharge order shall specify the level of ground ambulance services needed and complete a medical certification establishing the criteria for approval of non-emergency ambulance transportation, as published by the Department of Healthcare and Family Services, that is met by the patient. This order and the medical certification shall be completed prior to ordering an ambulance service and prior to patient discharge.
    Pursuant to subsection (E) of Section 12-4.25 of this Code, the Department is entitled to recover overpayments paid to a provider or vendor, including, but not limited to, from the discharging physician, the discharging facility, and the ground ambulance service provider, in instances where a non-emergency ground ambulance service is rendered as the result of improper or false certification.
    (h) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-584, eff. 8-26-11; 97-689, eff. 6-14-12; 97-842, eff. 7-20-12; 98-463, eff. 8-16-13.)

305 ILCS 5/5-4.20

    (305 ILCS 5/5-4.20)
    Sec. 5-4.20. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.21

    (305 ILCS 5/5-4.21)
    Sec. 5-4.21. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.22

    (305 ILCS 5/5-4.22)
    Sec. 5-4.22. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.23

    (305 ILCS 5/5-4.23)
    Sec. 5-4.23. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.24

    (305 ILCS 5/5-4.24)
    Sec. 5-4.24. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.25

    (305 ILCS 5/5-4.25)
    Sec. 5-4.25. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.26

    (305 ILCS 5/5-4.26)
    Sec. 5-4.26. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.27

    (305 ILCS 5/5-4.27)
    Sec. 5-4.27. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.28

    (305 ILCS 5/5-4.28)
    Sec. 5-4.28. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.29

    (305 ILCS 5/5-4.29)
    Sec. 5-4.29. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.30

    (305 ILCS 5/5-4.30)
    Sec. 5-4.30. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.31

    (305 ILCS 5/5-4.31)
    Sec. 5-4.31. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.32

    (305 ILCS 5/5-4.32)
    Sec. 5-4.32. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.33

    (305 ILCS 5/5-4.33)
    Sec. 5-4.33. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.34

    (305 ILCS 5/5-4.34)
    Sec. 5-4.34. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.35

    (305 ILCS 5/5-4.35)
    Sec. 5-4.35. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.36

    (305 ILCS 5/5-4.36)
    Sec. 5-4.36. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.37

    (305 ILCS 5/5-4.37)
    Sec. 5-4.37. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.38

    (305 ILCS 5/5-4.38)
    Sec. 5-4.38. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-4.39

    (305 ILCS 5/5-4.39)
    Sec. 5-4.39. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-5

    (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
    (Text of Section from P.A. 98-651)
    Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant women, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State, but not including abortions, or induced miscarriages or premature births, unless, in the opinion of a physician, such procedures are necessary for the preservation of the life of the woman seeking such treatment, or except an induced premature birth intended to produce a live viable child and such procedure is necessary for the health of the mother or her unborn child. The Illinois Department, by rule, shall prohibit any physician from providing medical assistance to anyone eligible therefor under this Code where such physician has been found guilty of performing an abortion procedure in a wilful and wanton manner upon a woman who was not pregnant at the time such abortion procedure was performed. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing.
    Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article.
    Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation.
    Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses.
    On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid:
        (1) dental services provided by or under the
    
supervision of a dentist; and
        (2) eyeglasses prescribed by a physician skilled in
    
the diseases of the eye, or by an optometrist, whichever the person may select.
    Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
    The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2.
    The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
    The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for women 35 years of age or older who are eligible for medical assistance under this Article, as follows:
        (A) A baseline mammogram for women 35 to 39 years of
    
age.
        (B) An annual mammogram for women 40 years of age or
    
older.
        (C) A mammogram at the age and intervals considered
    
medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
        (D) A comprehensive ultrasound screening of an entire
    
breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
    All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section, "low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography.
    On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography.
    The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards.
    Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities.
    The Department shall establish a methodology to remind women who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography.
    The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
    The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
    Any medical or health care provider shall immediately recommend, to any pregnant woman who is being provided prenatal services and is suspected of drug abuse or is addicted as defined in the Alcoholism and Other Drug Abuse and Dependency Act, referral to a local substance abuse treatment provider licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services.
    All medical providers providing medical assistance to pregnant women under this Code shall receive information from the Department on the availability of services under the Drug Free Families with a Future or any comparable program providing case management services for addicted women, including information on appropriate referrals for other social services that may be needed by addicted women in addition to treatment for addiction.
    The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance.
    Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department.
    The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization.
    The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    
providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.
        (2) The Department may elect to consider and
    
negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    
Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.
    Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers.
    The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section.
    The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after the effective date of this amendatory Act of 1984, the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12.
    The rules and regulations of the Illinois Department shall require that a written statement including the required opinion of a physician shall accompany any claim for reimbursement for abortions, or induced miscarriages or premature births. This statement shall indicate what procedures were used in providing such medical services.
    Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013, the effective date of Public Act 98-104, establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
    The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article.
    The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department.
    Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty.
    The Department has the discretion to limit the conditional enrollment period for vendors based upon category of risk of the vendor.
    Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law.
    The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period.
    To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions:
        (1) In the case of a provider whose enrollment is in
    
process by the Illinois Department, the 180-day period shall not begin until the date on the written notice from the Illinois Department that the provider enrollment is complete.
        (2) In the case of errors attributable to the
    
Illinois Department or any of its claims processing intermediaries which result in an inability to receive, process, or adjudicate a claim, the 180-day period shall not begin until the provider has been notified of the error.
        (3) In the case of a provider for whom the Illinois
    
Department initiates the monthly billing process.
        (4) In the case of a provider operated by a unit of
    
local government with a population exceeding 3,000,000 when local government funds finance federal participation for claims payments.
    For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
    In the case of long term care facilities, within 5 days of receipt by the facility of required prescreening information, data for new admissions shall be entered into the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or successor system, and within 15 days of receipt by the facility of required prescreening information, admission documents shall be submitted through MEDI or REV or shall be submitted directly to the Department of Human Services using required admission forms. Effective September 1, 2014, admission documents, including all prescreening information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
    Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
    To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
    The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
    Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
    The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department.
    The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
    The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code.
    The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    
medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    
the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    
those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    
Illinois Department.
    The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The filing of one copy of the report with the Speaker, one copy with the Minority Leader and one copy with the Clerk of the House of Representatives, one copy with the President, one copy with the Minority Leader and one copy with the Secretary of the Senate, one copy with the Legislative Research Unit, and such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act shall be deemed sufficient to comply with this Section.
    Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
    Because kidney transplantation can be an appropriate, cost effective alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation.
(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14.)
 
    (Text of Section from P.A. 98-756)
    Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant women, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State, but not including abortions, or induced miscarriages or premature births, unless, in the opinion of a physician, such procedures are necessary for the preservation of the life of the woman seeking such treatment, or except an induced premature birth intended to produce a live viable child and such procedure is necessary for the health of the mother or her unborn child. The Illinois Department, by rule, shall prohibit any physician from providing medical assistance to anyone eligible therefor under this Code where such physician has been found guilty of performing an abortion procedure in a wilful and wanton manner upon a woman who was not pregnant at the time such abortion procedure was performed. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing.
    Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article.
    Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation.
    On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid:
        (1) dental services provided by or under the
    
supervision of a dentist; and
        (2) eyeglasses prescribed by a physician skilled in
    
the diseases of the eye, or by an optometrist, whichever the person may select.
    Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
    The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2.
    The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
    The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for women 35 years of age or older who are eligible for medical assistance under this Article, as follows:
        (A) A baseline mammogram for women 35 to 39 years of
    
age.
        (B) An annual mammogram for women 40 years of age or
    
older.
        (C) A mammogram at the age and intervals considered
    
medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
        (D) A comprehensive ultrasound screening of an entire
    
breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
    All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section, "low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography.
    On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography.
    The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards.
    Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities.
    The Department shall establish a methodology to remind women who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography.
    The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
    The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
    Any medical or health care provider shall immediately recommend, to any pregnant woman who is being provided prenatal services and is suspected of drug abuse or is addicted as defined in the Alcoholism and Other Drug Abuse and Dependency Act, referral to a local substance abuse treatment provider licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services.
    All medical providers providing medical assistance to pregnant women under this Code shall receive information from the Department on the availability of services under the Drug Free Families with a Future or any comparable program providing case management services for addicted women, including information on appropriate referrals for other social services that may be needed by addicted women in addition to treatment for addiction.
    The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance.
    Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department.
    The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization.
    The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    
providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.
        (2) The Department may elect to consider and
    
negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    
Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.
    Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers.
    The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section.
    The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after the effective date of this amendatory Act of 1984, the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12.
    The rules and regulations of the Illinois Department shall require that a written statement including the required opinion of a physician shall accompany any claim for reimbursement for abortions, or induced miscarriages or premature births. This statement shall indicate what procedures were used in providing such medical services.
    Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
    The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article.
    The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department.
    Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty.
    The Department has the discretion to limit the conditional enrollment period for vendors based upon category of risk of the vendor.
    Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law.
    The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period.
    To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions:
        (1) In the case of a provider whose enrollment is in
    
process by the Illinois Department, the 180-day period shall not begin until the date on the written notice from the Illinois Department that the provider enrollment is complete.
        (2) In the case of errors attributable to the
    
Illinois Department or any of its claims processing intermediaries which result in an inability to receive, process, or adjudicate a claim, the 180-day period shall not begin until the provider has been notified of the error.
        (3) In the case of a provider for whom the Illinois
    
Department initiates the monthly billing process.
        (4) In the case of a provider operated by a unit of
    
local government with a population exceeding 3,000,000 when local government funds finance federal participation for claims payments.
    For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
    In the case of long term care facilities, admission documents shall be submitted within 30 days of an admission to the facility through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System, or shall be submitted directly to the Department of Human Services using required admission forms. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
    Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
    To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
    The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
    Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
    The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department.
    The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
    The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code.
    The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    
medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    
the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    
those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    
Illinois Department.
    The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The filing of one copy of the report with the Speaker, one copy with the Minority Leader and one copy with the Clerk of the House of Representatives, one copy with the President, one copy with the Minority Leader and one copy with the Secretary of the Senate, one copy with the Legislative Research Unit, and such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act shall be deemed sufficient to comply with this Section.
    Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-756, eff. 7-16-14.)
 
    (Text of Section from P.A. 98-963)
    Sec. 5-5. Medical services. The Illinois Department, by rule, shall determine the quantity and quality of and the rate of reimbursement for the medical assistance for which payment will be authorized, and the medical services to be provided, which may include all or part of the following: (1) inpatient hospital services; (2) outpatient hospital services; (3) other laboratory and X-ray services; (4) skilled nursing home services; (5) physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing home, or elsewhere; (6) medical care, or any other type of remedial care furnished by licensed practitioners; (7) home health care services; (8) private duty nursing service; (9) clinic services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant women, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in the diseases of the eye, or by an optometrist, whichever the person may select; (13) other diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14) transportation and such other expenses as may be necessary; (15) medical treatment of sexual assault survivors, as defined in Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for injuries sustained as a result of the sexual assault, including examinations and laboratory tests to discover evidence which may be used in criminal proceedings arising from the sexual assault; (16) the diagnosis and treatment of sickle cell anemia; and (17) any other medical care, and any other type of remedial care recognized under the laws of this State, but not including abortions, or induced miscarriages or premature births, unless, in the opinion of a physician, such procedures are necessary for the preservation of the life of the woman seeking such treatment, or except an induced premature birth intended to produce a live viable child and such procedure is necessary for the health of the mother or her unborn child. The Illinois Department, by rule, shall prohibit any physician from providing medical assistance to anyone eligible therefor under this Code where such physician has been found guilty of performing an abortion procedure in a wilful and wanton manner upon a woman who was not pregnant at the time such abortion procedure was performed. The term "any other type of remedial care" shall include nursing care and nursing home service for persons who rely on treatment by spiritual means alone through prayer for healing.
    Notwithstanding any other provision of this Section, a comprehensive tobacco use cessation program that includes purchasing prescription drugs or prescription medical devices approved by the Food and Drug Administration shall be covered under the medical assistance program under this Article for persons who are otherwise eligible for assistance under this Article.
    Notwithstanding any other provision of this Code, the Illinois Department may not require, as a condition of payment for any laboratory test authorized under this Article, that a physician's handwritten signature appear on the laboratory test order form. The Illinois Department may, however, impose other appropriate requirements regarding laboratory test order documentation.
    On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to persons eligible for assistance under this Article who are participating in education, training or employment programs operated by the Department of Human Services as successor to the Department of Public Aid:
        (1) dental services provided by or under the
    
supervision of a dentist; and
        (2) eyeglasses prescribed by a physician skilled in
    
the diseases of the eye, or by an optometrist, whichever the person may select.
    Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
    The Illinois Department, by rule, may distinguish and classify the medical services to be provided only in accordance with the classes of persons designated in Section 5-2.
    The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
    The Illinois Department shall authorize the provision of, and shall authorize payment for, screening by low-dose mammography for the presence of occult breast cancer for women 35 years of age or older who are eligible for medical assistance under this Article, as follows:
        (A) A baseline mammogram for women 35 to 39 years of
    
age.
        (B) An annual mammogram for women 40 years of age or
    
older.
        (C) A mammogram at the age and intervals considered
    
medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
        (D) A comprehensive ultrasound screening of an entire
    
breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
    All screenings shall include a physical breast exam, instruction on self-examination and information regarding the frequency of self-examination and its value as a preventative tool. For purposes of this Section, "low-dose mammography" means the x-ray examination of the breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, and image receptor, with an average radiation exposure delivery of less than one rad per breast for 2 views of an average size breast. The term also includes digital mammography.
    On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography.
    The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards.
    Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities.
    The Department shall establish a methodology to remind women who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography.
    The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
    The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
    Any medical or health care provider shall immediately recommend, to any pregnant woman who is being provided prenatal services and is suspected of drug abuse or is addicted as defined in the Alcoholism and Other Drug Abuse and Dependency Act, referral to a local substance abuse treatment provider licensed by the Department of Human Services or to a licensed hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services shall assure coverage for the cost of treatment of the drug abuse or addiction for pregnant recipients in accordance with the Illinois Medicaid Program in conjunction with the Department of Human Services.
    All medical providers providing medical assistance to pregnant women under this Code shall receive information from the Department on the availability of services under the Drug Free Families with a Future or any comparable program providing case management services for addicted women, including information on appropriate referrals for other social services that may be needed by addicted women in addition to treatment for addiction.
    The Illinois Department, in cooperation with the Departments of Human Services (as successor to the Department of Alcoholism and Substance Abuse) and Public Health, through a public awareness campaign, may provide information concerning treatment for alcoholism and drug abuse and addiction, prenatal health care, and other pertinent programs directed at reducing the number of drug-affected infants born to recipients of medical assistance.
    Neither the Department of Healthcare and Family Services nor the Department of Human Services shall sanction the recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations governing the dispensing of health services under this Article as it shall deem appropriate. The Department should seek the advice of formal professional advisory committees appointed by the Director of the Illinois Department for the purpose of providing regular advice on policy and administrative matters, information dissemination and educational activities for medical and health care providers, and consistency in procedures to the Illinois Department.
    The Illinois Department may develop and contract with Partnerships of medical providers to arrange medical services for persons eligible under Section 5-2 of this Code. Implementation of this Section may be by demonstration projects in certain geographic areas. The Partnership shall be represented by a sponsor organization. The Department, by rule, shall develop qualifications for sponsors of Partnerships. Nothing in this Section shall be construed to require that the sponsor organization be a medical organization.
    The sponsor must negotiate formal written contracts with medical providers for physician services, inpatient and outpatient hospital care, home health services, treatment for alcoholism and substance abuse, and other services determined necessary by the Illinois Department by rule for delivery by Partnerships. Physician services must include prenatal and obstetrical care. The Illinois Department shall reimburse medical services delivered by Partnership providers to clients in target areas according to provisions of this Article and the Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    
providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.
        (2) The Department may elect to consider and
    
negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    
Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.
    Medical providers shall be required to meet certain qualifications to participate in Partnerships to ensure the delivery of high quality medical services. These qualifications shall be determined by rule of the Illinois Department and may be higher than qualifications for participation in the medical assistance program. Partnership sponsors may prescribe reasonable additional qualifications for participation by medical providers, only with the prior written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of practitioners, hospitals, and other providers of medical services by clients. In order to ensure patient freedom of choice, the Illinois Department shall immediately promulgate all rules and take all other necessary actions so that provided services may be accessed from therapeutically certified optometrists to the full extent of the Illinois Optometric Practice Act of 1987 without discriminating between service providers.
    The Department shall apply for a waiver from the United States Health Care Financing Administration to allow for the implementation of Partnerships under this Section.
    The Illinois Department shall require health care providers to maintain records that document the medical care and services provided to recipients of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall require health care providers to make available, when authorized by the patient, in writing, the medical records in a timely fashion to other health care providers who are treating or serving persons eligible for Medical Assistance under this Article. All dispensers of medical services shall be required to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, details and receipt of the health care provided to persons eligible for medical assistance under this Code, in accordance with regulations promulgated by the Illinois Department. The rules and regulations shall require that proof of the receipt of prescription drugs, dentures, prosthetic devices and eyeglasses by eligible persons under this Section accompany each claim for reimbursement submitted by the dispenser of such medical services. No such claims for reimbursement shall be approved for payment by the Illinois Department without such proof of receipt, unless the Illinois Department shall have put into effect and shall be operating a system of post-payment audit and review which shall, on a sampling basis, be deemed adequate by the Illinois Department to assure that such drugs, dentures, prosthetic devices and eyeglasses for which payment is being made are actually being received by eligible recipients. Within 90 days after the effective date of this amendatory Act of 1984, the Illinois Department shall establish a current list of acquisition costs for all prosthetic devices and any other items recognized as medical equipment and supplies reimbursable under this Article and shall update such list on a quarterly basis, except that the acquisition costs of all prescription drugs shall be updated no less frequently than every 30 days as required by Section 5-5.12.
    The rules and regulations of the Illinois Department shall require that a written statement including the required opinion of a physician shall accompany any claim for reimbursement for abortions, or induced miscarriages or premature births. This statement shall indicate what procedures were used in providing such medical services.
    Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
    Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after the effective date of this amendatory Act of the 98th General Assembly, establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
    The Illinois Department shall require all dispensers of medical services, other than an individual practitioner or group of practitioners, desiring to participate in the Medical Assistance program established under this Article to disclose all financial, beneficial, ownership, equity, surety or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services in this State under this Article.
    The Illinois Department may require that all dispensers of medical services desiring to participate in the medical assistance program established under this Article disclose, under such terms and conditions as the Illinois Department may by rule establish, all inquiries from clients and attorneys regarding medical bills paid by the Illinois Department, which inquiries could indicate potential existence of claims or liens for the Illinois Department.
    Enrollment of a vendor shall be subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty.
    The Department has the discretion to limit the conditional enrollment period for vendors based upon category of risk of the vendor.
    Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law.
    The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period.
    To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions:
        (1) In the case of a provider whose enrollment is in
    
process by the Illinois Department, the 180-day period shall not begin until the date on the written notice from the Illinois Department that the provider enrollment is complete.
        (2) In the case of errors attributable to the
    
Illinois Department or any of its claims processing intermediaries which result in an inability to receive, process, or adjudicate a claim, the 180-day period shall not begin until the provider has been notified of the error.
        (3) In the case of a provider for whom the Illinois
    
Department initiates the monthly billing process.
        (4) In the case of a provider operated by a unit of
    
local government with a population exceeding 3,000,000 when local government funds finance federal participation for claims payments.
    For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
    In the case of long term care facilities, admission documents shall be submitted within 30 days of an admission to the facility through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System, or shall be submitted directly to the Department of Human Services using required admission forms. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
    Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
    To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
    The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
    Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
    The Illinois Department shall establish policies, procedures, standards and criteria by rule for the acquisition, repair and replacement of orthotic and prosthetic devices and durable medical equipment. Such rules shall provide, but not be limited to, the following services: (1) immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of durable medical equipment in a cost-effective manner, taking into consideration the recipient's medical prognosis, the extent of the recipient's needs, and the requirements and costs for maintaining such equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and use alternative or substitute devices or equipment pending repairs or replacements of any device or equipment previously authorized for such recipient by the Department.
    The Department shall execute, relative to the nursing home prescreening project, written inter-agency agreements with the Department of Human Services and the Department on Aging, to effect the following: (i) intake procedures and common eligibility criteria for those persons who are receiving non-institutional services; and (ii) the establishment and development of non-institutional services in areas of the State where they are not currently available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
    The Illinois Department shall develop and operate, in cooperation with other State Departments and agencies and in compliance with applicable federal laws and regulations, appropriate and effective systems of health care evaluation and programs for monitoring of utilization of health care services and facilities, as it affects persons eligible for medical assistance under this Code.
    The Illinois Department shall report annually to the General Assembly, no later than the second Friday in April of 1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    
medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    
the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    
those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    
Illinois Department.
    The period covered by each report shall be the 3 years ending on the June 30 prior to the report. The report shall include suggested legislation for consideration by the General Assembly. The filing of one copy of the report with the Speaker, one copy with the Minority Leader and one copy with the Clerk of the House of Representatives, one copy with the President, one copy with the Minority Leader and one copy with the Secretary of the Senate, one copy with the Legislative Research Unit, and such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act shall be deemed sufficient to comply with this Section.
    Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-963, eff. 8-15-14.)

305 ILCS 5/5-5.01

    (305 ILCS 5/5-5.01) (from Ch. 23, par. 5-5.01)
    Sec. 5-5.01. The Department of Healthcare and Family Services may establish and implement a pilot project for determining the feasibility of authorizing medical assistance payments for the costs of diagnosis and treatment of Alzheimer's disease.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/5-5.01a

    (305 ILCS 5/5-5.01a)
    Sec. 5-5.01a. Supportive living facilities program. The Department shall establish and provide oversight for a program of supportive living facilities that seek to promote resident independence, dignity, respect, and well-being in the most cost-effective manner.
    A supportive living facility is either a free-standing facility or a distinct physical and operational entity within a nursing facility. A supportive living facility integrates housing with health, personal care, and supportive services and is a designated setting that offers residents their own separate, private, and distinct living units.
    Sites for the operation of the program shall be selected by the Department based upon criteria that may include the need for services in a geographic area, the availability of funding, and the site's ability to meet the standards.
    Beginning July 1, 2014, subject to federal approval, the Medicaid rates for supportive living facilities shall be equal to the supportive living facility Medicaid rate effective on June 30, 2014 increased by 8.85%. Once the assessment imposed at Article V-G of this Code is determined to be a permissible tax under Title XIX of the Social Security Act, the Department shall increase the Medicaid rates for supportive living facilities effective on July 1, 2014 by 9.09%. The Department shall apply this increase retroactively to coincide with the imposition of the assessment in Article V-G of this Code in accordance with the approval for federal financial participation by the Centers for Medicare and Medicaid Services.
    The Department may adopt rules to implement this Section. Rules that establish or modify the services, standards, and conditions for participation in the program shall be adopted by the Department in consultation with the Department on Aging, the Department of Rehabilitation Services, and the Department of Mental Health and Developmental Disabilities (or their successor agencies).
    Facilities or distinct parts of facilities which are selected as supportive living facilities and are in good standing with the Department's rules are exempt from the provisions of the Nursing Home Care Act and the Illinois Health Facilities Planning Act.
(Source: P.A. 98-651, eff. 6-16-14.)

305 ILCS 5/5-5.02

    (305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)
    Sec. 5-5.02. Hospital reimbursements.
    (a) Reimbursement to Hospitals; July 1, 1992 through September 30, 1992. Notwithstanding any other provisions of this Code or the Illinois Department's Rules promulgated under the Illinois Administrative Procedure Act, reimbursement to hospitals for services provided during the period July 1, 1992 through September 30, 1992, shall be as follows:
        (1) For inpatient hospital services rendered, or if
    
applicable, for inpatient hospital discharges occurring, on or after July 1, 1992 and on or before September 30, 1992, the Illinois Department shall reimburse hospitals for inpatient services under the reimbursement methodologies in effect for each hospital, and at the inpatient payment rate calculated for each hospital, as of June 30, 1992. For purposes of this paragraph, "reimbursement methodologies" means all reimbursement methodologies that pertain to the provision of inpatient hospital services, including, but not limited to, any adjustments for disproportionate share, targeted access, critical care access and uncompensated care, as defined by the Illinois Department on June 30, 1992.
        (2) For the purpose of calculating the inpatient
    
payment rate for each hospital eligible to receive quarterly adjustment payments for targeted access and critical care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period July 1, 1992 through September 30, 1992, shall be 25% of the annual adjustment payments calculated for each eligible hospital, as of June 30, 1992. The Illinois Department shall determine by rule the adjustment payments for targeted access and critical care beginning October 1, 1992.
        (3) For the purpose of calculating the inpatient
    
payment rate for each hospital eligible to receive quarterly adjustment payments for uncompensated care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period August 1, 1992 through September 30, 1992, shall be one-sixth of the total uncompensated care adjustment payments calculated for each eligible hospital for the uncompensated care rate year, as defined by the Illinois Department, ending on July 31, 1992. The Illinois Department shall determine by rule the adjustment payments for uncompensated care beginning October 1, 1992.
    (b) Inpatient payments. For inpatient services provided on or after October 1, 1993, in addition to rates paid for hospital inpatient services pursuant to the Illinois Health Finance Reform Act, as now or hereafter amended, or the Illinois Department's prospective reimbursement methodology, or any other methodology used by the Illinois Department for inpatient services, the Illinois Department shall make adjustment payments, in an amount calculated pursuant to the methodology described in paragraph (c) of this Section, to hospitals that the Illinois Department determines satisfy any one of the following requirements:
        (1) Hospitals that are described in Section 1923 of
    
the federal Social Security Act, as now or hereafter amended, except that for rate year 2015 and after a hospital described in Section 1923(b)(1)(B) of the federal Social Security Act and qualified for the payments described in subsection (c) of this Section for rate year 2014 provided the hospital continues to meet the description in Section 1923(b)(1)(B) in the current determination year; or
        (2) Illinois hospitals that have a Medicaid inpatient
    
utilization rate which is at least one-half a standard deviation above the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department; or
        (3) Illinois hospitals that on July 1, 1991 had a
    
Medicaid inpatient utilization rate, as defined in paragraph (h) of this Section, that was at least the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department and which were located in a planning area with one-third or fewer excess beds as determined by the Health Facilities and Services Review Board, and that, as of June 30, 1992, were located in a federally designated Health Manpower Shortage Area; or
        (4) Illinois hospitals that:
            (A) have a Medicaid inpatient utilization rate
        
that is at least equal to the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department; and
            (B) also have a Medicaid obstetrical inpatient
        
utilization rate that is at least one standard deviation above the mean Medicaid obstetrical inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department for obstetrical services; or
        (5) Any children's hospital, which means a hospital
    
devoted exclusively to caring for children. A hospital which includes a facility devoted exclusively to caring for children shall be considered a children's hospital to the degree that the hospital's Medicaid care is provided to children if either (i) the facility devoted exclusively to caring for children is separately licensed as a hospital by a municipality prior to February 28, 2013 or (ii) the hospital has been designated by the State as a Level III perinatal care facility, has a Medicaid Inpatient Utilization rate greater than 55% for the rate year 2003 disproportionate share determination, and has more than 10,000 qualified children days as defined by the Department in rulemaking.
    (c) Inpatient adjustment payments. The adjustment payments required by paragraph (b) shall be calculated based upon the hospital's Medicaid inpatient utilization rate as follows:
        (1) hospitals with a Medicaid inpatient utilization
    
rate below the mean shall receive a per day adjustment payment equal to $25;
        (2) hospitals with a Medicaid inpatient utilization
    
rate that is equal to or greater than the mean Medicaid inpatient utilization rate but less than one standard deviation above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $25 plus $1 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds the mean Medicaid inpatient utilization rate;
        (3) hospitals with a Medicaid inpatient utilization
    
rate that is equal to or greater than one standard deviation above the mean Medicaid inpatient utilization rate but less than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $40 plus $7 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds one standard deviation above the mean Medicaid inpatient utilization rate; and
        (4) hospitals with a Medicaid inpatient utilization
    
rate that is equal to or greater than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $90 plus $2 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds 1.5 standard deviations above the mean Medicaid inpatient utilization rate.
    (d) Supplemental adjustment payments. In addition to the adjustment payments described in paragraph (c), hospitals as defined in clauses (1) through (5) of paragraph (b), excluding county hospitals (as defined in subsection (c) of Section 15-1 of this Code) and a hospital organized under the University of Illinois Hospital Act, shall be paid supplemental inpatient adjustment payments of $60 per day. For purposes of Title XIX of the federal Social Security Act, these supplemental adjustment payments shall not be classified as adjustment payments to disproportionate share hospitals.
    (e) The inpatient adjustment payments described in paragraphs (c) and (d) shall be increased on October 1, 1993 and annually thereafter by a percentage equal to the lesser of (i) the increase in the DRI hospital cost index for the most recent 12 month period for which data are available, or (ii) the percentage increase in the statewide average hospital payment rate over the previous year's statewide average hospital payment rate. The sum of the inpatient adjustment payments under paragraphs (c) and (d) to a hospital, other than a county hospital (as defined in subsection (c) of Section 15-1 of this Code) or a hospital organized under the University of Illinois Hospital Act, however, shall not exceed $275 per day; that limit shall be increased on October 1, 1993 and annually thereafter by a percentage equal to the lesser of (i) the increase in the DRI hospital cost index for the most recent 12-month period for which data are available or (ii) the percentage increase in the statewide average hospital payment rate over the previous year's statewide average hospital payment rate.
    (f) Children's hospital inpatient adjustment payments. For children's hospitals, as defined in clause (5) of paragraph (b), the adjustment payments required pursuant to paragraphs (c) and (d) shall be multiplied by 2.0.
    (g) County hospital inpatient adjustment payments. For county hospitals, as defined in subsection (c) of Section 15-1 of this Code, there shall be an adjustment payment as determined by rules issued by the Illinois Department.
    (h) For the purposes of this Section the following terms shall be defined as follows:
        (1) "Medicaid inpatient utilization rate" means a
    
fraction, the numerator of which is the number of a hospital's inpatient days provided in a given 12-month period to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act, and the denominator of which is the total number of the hospital's inpatient days in that same period.
        (2) "Mean Medicaid inpatient utilization rate" means
    
the total number of Medicaid inpatient days provided by all Illinois Medicaid-participating hospitals divided by the total number of inpatient days provided by those same hospitals.
        (3) "Medicaid obstetrical inpatient utilization rate"
    
means the ratio of Medicaid obstetrical inpatient days to total Medicaid inpatient days for all Illinois hospitals receiving Medicaid payments from the Illinois Department.
    (i) Inpatient adjustment payment limit. In order to meet the limits of Public Law 102-234 and Public Law 103-66, the Illinois Department shall by rule adjust disproportionate share adjustment payments.
    (j) University of Illinois Hospital inpatient adjustment payments. For hospitals organized under the University of Illinois Hospital Act, there shall be an adjustment payment as determined by rules adopted by the Illinois Department.
    (k) The Illinois Department may by rule establish criteria for and develop methodologies for adjustment payments to hospitals participating under this Article.
    (l) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)

305 ILCS 5/5-5.03

    (305 ILCS 5/5-5.03)
    Sec. 5-5.03. Trauma center adjustment.
    (a) For inpatient admissions on or after October 1, 1992 for trauma injuries as defined in the Emergency Medical Services (EMS) Systems Act, in addition to any other payments made under this Code, the Illinois Department shall make adjustment payments, in an amount calculated under subsection (b) of this Section, to hospitals located in the State of Illinois that are recognized as Level I trauma centers (adult or pediatric) and to certain Level II trauma centers as determined by the Illinois Department.
    (b) Trauma center adjustment calculation.
        (1) The funds used to make trauma center adjustment
    
payments to qualifying trauma centers shall consist of:
            (A) At least 50% of the amount of moneys
        
deposited each State fiscal year into the Trauma Center Fund created in the State treasury; and
            (B) All federal matching funds received by the
        
Illinois Department as a result of expenditures made by the Illinois Department as required by this Section.
        (2) The trauma center adjustment payments shall be
    
made to qualifying trauma centers on a quarterly basis. In determining the payment methodology for trauma center adjustment payments, the Illinois Department shall divide the available funds from the Trauma Center Fund for each quarter by the total number of the Medicaid trauma admissions as determined by the Illinois Department for the same quarter of the Trauma Center base year. The result of that calculation shall be the amount of the quarterly trauma center adjustment payment to be paid to qualifying trauma centers.
        (3) Disbursements from the Trauma Center Fund shall
    
be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.
        (4) Trauma center adjustment payments shall not be
    
treated as payments for hospital services under Title XIX of the Social Security Act for purposes of the calculation of the intergovernmental transfer provided for in Section 15-3(a) of the Code.
    (c) Definitions. As used in this Section, unless the context requires otherwise:
    "Trauma center adjustment year" means, beginning October 1, 1992, the 12 month period beginning on October 1 of the year and ending September 30 of the following year.
    "Trauma center base year" means State Fiscal Year 1991 for trauma center adjustment payments calculated for the October 1, 1992 trauma center adjustment year, State Fiscal Year 1992 for trauma center adjustment payments calculated for the October 1, 1993 trauma center adjustment year, and so on for each succeeding State Fiscal Year for trauma center adjustment payments calculated for the trauma center adjustment year beginning October 1 of that State Fiscal Year.
(Source: P.A. 87-1229.)

305 ILCS 5/5-5.04

    (305 ILCS 5/5-5.04)
    Sec. 5-5.04. Persons living with HIV/AIDS. The Department of Public Aid may seek federal approval to expand access to health care for persons living with HIV/AIDS. Implementation of this Section is subject to appropriation.
(Source: P.A. 94-629, eff. 1-1-06.)

305 ILCS 5/5-5.05

    (305 ILCS 5/5-5.05)
    Sec. 5-5.05. Hospitals; psychiatric services.
    (a) On and after July 1, 2008, the inpatient, per diem rate to be paid to a hospital for inpatient psychiatric services shall be $363.77.
    (b) For purposes of this Section, "hospital" means the following:
        (1) Advocate Christ Hospital, Oak Lawn, Illinois.
        (2) Barnes-Jewish Hospital, St. Louis, Missouri.
        (3) BroMenn Healthcare, Bloomington, Illinois.
        (4) Jackson Park Hospital, Chicago, Illinois.
        (5) Katherine Shaw Bethea Hospital, Dixon, Illinois.
        (6) Lawrence County Memorial Hospital, Lawrenceville,
    
Illinois.
        (7) Advocate Lutheran General Hospital, Park Ridge,
    
Illinois.
        (8) Mercy Hospital and Medical Center, Chicago,
    
Illinois.
        (9) Methodist Medical Center of Illinois, Peoria,
    
Illinois.
        (10) Provena United Samaritans Medical Center,
    
Danville, Illinois.
        (11) Rockford Memorial Hospital, Rockford, Illinois.
        (12) Sarah Bush Lincoln Health Center, Mattoon,
    
Illinois.
        (13) Provena Covenant Medical Center, Urbana,
    
Illinois.
        (14) Rush-Presbyterian-St. Luke's Medical Center,
    
Chicago, Illinois.
        (15) Mt. Sinai Hospital, Chicago, Illinois.
        (16) Gateway Regional Medical Center, Granite City,
    
Illinois.
        (17) St. Mary of Nazareth Hospital, Chicago, Illinois.
        (18) Provena St. Mary's Hospital, Kankakee, Illinois.
        (19) St. Mary's Hospital, Decatur, Illinois.
        (20) Memorial Hospital, Belleville, Illinois.
        (21) Swedish Covenant Hospital, Chicago, Illinois.
        (22) Trinity Medical Center, Rock Island, Illinois.
        (23) St. Elizabeth Hospital, Chicago, Illinois.
        (24) Richland Memorial Hospital, Olney, Illinois.
        (25) St. Elizabeth's Hospital, Belleville, Illinois.
        (26) Samaritan Health System, Clinton, Iowa.
        (27) St. John's Hospital, Springfield, Illinois.
        (28) St. Mary's Hospital, Centralia, Illinois.
        (29) Loretto Hospital, Chicago, Illinois.
        (30) Kenneth Hall Regional Hospital, East St. Louis,
    
Illinois.
        (31) Hinsdale Hospital, Hinsdale, Illinois.
        (32) Pekin Hospital, Pekin, Illinois.
        (33) University of Chicago Medical Center, Chicago,
    
Illinois.
        (34) St. Anthony's Health Center, Alton, Illinois.
        (35) OSF St. Francis Medical Center, Peoria, Illinois.
        (36) Memorial Medical Center, Springfield, Illinois.
        (37) A hospital with a distinct part unit for
    
psychiatric services that begins operating on or after July 1, 2008.
    For purposes of this Section, "inpatient psychiatric services" means those services provided to patients who are in need of short-term acute inpatient hospitalization for active treatment of an emotional or mental disorder.
    (c) No rules shall be promulgated to implement this Section. For purposes of this Section, "rules" is given the meaning contained in Section 1-70 of the Illinois Administrative Procedure Act.
    (d) This Section shall not be in effect during any period of time that the State has in place a fully operational hospital assessment plan that has been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
    (e) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.06

    (305 ILCS 5/5-5.06)
    Sec. 5-5.06. Dental home initiative. The Department, in cooperation with the dental community and other affected organizations such as Head Start, shall work to develop and promote the concept of a dental home for children covered under this Article. Included in this dental home outreach should be an effort to ensure an ongoing relationship between the patient and the dentist with an effort to provide comprehensive, coordinated, oral health care so that all children covered under this Article have access to preventative and restorative oral health care.
(Source: P.A. 97-283, eff. 8-9-11.)

305 ILCS 5/5-5.1

    (305 ILCS 5/5-5.1) (from Ch. 23, par. 5-5.1)
    Sec. 5-5.1. Grouping of Facilities. The Department of Healthcare and Family Services shall, for purposes of payment, provide for groupings of nursing facilities. Factors to be considered in grouping facilities may include, but are not limited to, size, age, patient mix or geographical area.
    The groupings developed under this Section shall be considered in determining reasonable cost reimbursement formulas. However, this Section shall not preclude the Department from recognizing and evaluating the cost of capital on a facility-by-facility basis.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/5-5.2

    (305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)
    (Text of Section from P.A. 98-651)
    Sec. 5-5.2. Payment.
    (a) All nursing facilities that are grouped pursuant to Section 5-5.1 of this Act shall receive the same rate of payment for similar services.
    (b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the long-term care providers.
    (c) Notwithstanding any other provisions of this Code, the methodologies for reimbursement of nursing services as provided under this Article shall no longer be applicable for bills payable for nursing services rendered on or after a new reimbursement system based on the Resource Utilization Groups (RUGs) has been fully operationalized, which shall take effect for services provided on or after January 1, 2014.
    (d) The new nursing services reimbursement methodology utilizing RUG-IV 48 grouper model, which shall be referred to as the RUGs reimbursement system, taking effect January 1, 2014, shall be based on the following:
        (1) The methodology shall be resident-driven,
    
facility-specific, and cost-based.
        (2) Costs shall be annually rebased and case mix
    
index quarterly updated. The nursing services methodology will be assigned to the Medicaid enrolled residents on record as of 30 days prior to the beginning of the rate period in the Department's Medicaid Management Information System (MMIS) as present on the last day of the second quarter preceding the rate period.
        (3) Regional wage adjustors based on the Health
    
Service Areas (HSA) groupings and adjusters in effect on April 30, 2012 shall be included.
        (4) Case mix index shall be assigned to each
    
resident class based on the Centers for Medicare and Medicaid Services staff time measurement study in effect on July 1, 2013, utilizing an index maximization approach.
        (5) The pool of funds available for distribution by
    
case mix and the base facility rate shall be determined using the formula contained in subsection (d-1).
    (d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate.
        (1) Base rate spending pool shall be:
            (A) The base year resident days which are
        
calculated by multiplying the number of Medicaid residents in each nursing home as indicated in the MDS data defined in paragraph (4) by 365.
            (B) Each facility's nursing component per diem
        
in effect on July 1, 2012 shall be multiplied by subsection (A).
            (C) Thirteen million is added to the product of
        
subparagraph (A) and subparagraph (B) to adjust for the exclusion of nursing homes defined in paragraph (5).
        (2) For each nursing home with Medicaid residents as
    
indicated by the MDS data defined in paragraph (4), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each home this calculation is the product of:
            (A) Base year resident days as calculated in
        
subparagraph (A) of paragraph (1).
            (B) The nursing home's regional wage adjustor
        
based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.
            (C) Facility weighted case mix which is the
        
number of Medicaid residents as indicated by the MDS data defined in paragraph (4) multiplied by the associated case weight for the RUG-IV 48 grouper model using standard RUG-IV procedures for index maximization.
            (D) The sum of the products calculated for each
        
nursing home in subparagraphs (A) through (C) above shall be the base year case mix, rate adjusted weighted days.
        (3) The Statewide RUG-IV nursing base per diem rate:
            (A) on January 1, 2014 shall be the quotient of
        
the paragraph (1) divided by the sum calculated under subparagraph (D) of paragraph (2); and
            (B) on and after July 1, 2014, shall be the
        
amount calculated under subparagraph (A) of this paragraph (3) plus $1.76.
        (4) Minimum Data Set (MDS) comprehensive assessments
    
for Medicaid residents on the last day of the quarter used to establish the base rate.
        (5) Nursing facilities designated as of July 1, 2012
    
by the Department as "Institutions for Mental Disease" shall be excluded from all calculations under this subsection. The data from these facilities shall not be used in the computations described in paragraphs (1) through (4) above to establish the base rate.
    (e) Beginning July 1, 2014, the Department shall allocate funding in the amount up to $10,000,000 for per diem add-ons to the RUGS methodology for dates of service on and after July 1, 2014:
        (1) $0.63 for each resident who scores in I4200
    
Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
        (2) $2.67 for each resident who scores either a "1"
    
or "2" in any items S1200A through S1200I and also scores in RUG groups PA1, PA2, BA1, or BA2.
    (e-1) (Blank).
    (e-2) For dates of services beginning January 1, 2014, the RUG-IV nursing component per diem for a nursing home shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index, and the regional wage adjustor. Transition rates for services provided between January 1, 2014 and December 31, 2014 shall be as follows:
        (1) The transition RUG-IV per diem nursing rate for
    
nursing homes whose rate calculated in this subsection (e-2) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
            (A) The nursing component rate in effect July
        
1, 2012; plus
            (B) The difference of the RUG-IV nursing
        
component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.88.
        (2) The transition RUG-IV per diem nursing rate for
    
nursing homes whose rate calculated in this subsection (e-2) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
            (A) The nursing component rate in effect July
        
1, 2012; plus
            (B) The difference of the RUG-IV nursing
        
component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.13.
    (f) Notwithstanding any other provision of this Code, on and after July 1, 2012, reimbursement rates associated with the nursing or support components of the current nursing facility rate methodology shall not increase beyond the level effective May 1, 2011 until a new reimbursement system based on the RUGs IV 48 grouper model has been fully operationalized.
    (g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows:
        (1) Individual nursing rates for residents classified
    
in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter ending March 31, 2012 shall be reduced by 10%;
        (2) Individual nursing rates for residents classified
    
in all other RUG IV groups shall be reduced by 1.0%;
        (3) Facility rates for the capital and support
    
components shall be reduced by 1.7%.
    (h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall have the nursing, socio-developmental, capital, and support components of their reimbursement rate effective May 1, 2011 reduced in total by 2.7%.
    (i) On and after July 1, 2014, the reimbursement rates for the support component of the nursing facility rate for facilities licensed under the Nursing Home Care Act as skilled or intermediate care facilities shall be the rate in effect on June 30, 2014 increased by 8.17%.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section 6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. 7-22-13; 98-651, eff. 6-16-14.)
 
    (Text of Section from P.A. 98-727)
    Sec. 5-5.2. Payment.
    (a) All nursing facilities that are grouped pursuant to Section 5-5.1 of this Act shall receive the same rate of payment for similar services.
    (b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the long-term care providers.
    (c) Notwithstanding any other provisions of this Code, the methodologies for reimbursement of nursing services as provided under this Article shall no longer be applicable for bills payable for nursing services rendered on or after a new reimbursement system based on the Resource Utilization Groups (RUGs) has been fully operationalized, which shall take effect for services provided on or after January 1, 2014.
    (d) The new nursing services reimbursement methodology utilizing RUG-IV 48 grouper model, which shall be referred to as the RUGs reimbursement system, taking effect January 1, 2014, shall be based on the following:
        (1) The methodology shall be resident-driven,
    
facility-specific, and cost-based.
        (2) Costs shall be annually rebased and case mix
    
index quarterly updated. The nursing services methodology will be assigned to the Medicaid enrolled residents on record as of 30 days prior to the beginning of the rate period in the Department's Medicaid Management Information System (MMIS) as present on the last day of the second quarter preceding the rate period based upon the Assessment Reference Date of the Minimum Data Set (MDS).
        (3) Regional wage adjustors based on the Health
    
Service Areas (HSA) groupings and adjusters in effect on April 30, 2012 shall be included.
        (4) Case mix index shall be assigned to each
    
resident class based on the Centers for Medicare and Medicaid Services staff time measurement study in effect on July 1, 2013, utilizing an index maximization approach.
        (5) The pool of funds available for distribution by
    
case mix and the base facility rate shall be determined using the formula contained in subsection (d-1).
    (d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate.
        (1) Base rate spending pool shall be:
            (A) The base year resident days which are
        
calculated by multiplying the number of Medicaid residents in each nursing home as indicated in the MDS data defined in paragraph (4) by 365.
            (B) Each facility's nursing component per diem
        
in effect on July 1, 2012 shall be multiplied by subsection (A).
            (C) Thirteen million is added to the product of
        
subparagraph (A) and subparagraph (B) to adjust for the exclusion of nursing homes defined in paragraph (5).
        (2) For each nursing home with Medicaid residents as
    
indicated by the MDS data defined in paragraph (4), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each home this calculation is the product of:
            (A) Base year resident days as calculated in
        
subparagraph (A) of paragraph (1).
            (B) The nursing home's regional wage adjustor
        
based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.
            (C) Facility weighted case mix which is the
        
number of Medicaid residents as indicated by the MDS data defined in paragraph (4) multiplied by the associated case weight for the RUG-IV 48 grouper model using standard RUG-IV procedures for index maximization.
            (D) The sum of the products calculated for each
        
nursing home in subparagraphs (A) through (C) above shall be the base year case mix, rate adjusted weighted days.
        (3) The Statewide RUG-IV nursing base per diem rate
    
on January 1, 2014 shall be the quotient of the paragraph (1) divided by the sum calculated under subparagraph (D) of paragraph (2).
        (4) Minimum Data Set (MDS) comprehensive assessments
    
for Medicaid residents on the last day of the quarter used to establish the base rate.
        (5) Nursing facilities designated as of July 1, 2012
    
by the Department as "Institutions for Mental Disease" shall be excluded from all calculations under this subsection. The data from these facilities shall not be used in the computations described in paragraphs (1) through (4) above to establish the base rate.
    (e) Notwithstanding any other provision of this Code, the Department shall by rule develop a reimbursement methodology reflective of the intensity of care and services requirements of low need residents in the lowest RUG IV groupers and corresponding regulations. Only that portion of the RUGs Reimbursement System spending pool described in subsection (d-1) attributed to the groupers as of July 1, 2013 for which the methodology in this Section is developed may be diverted for this purpose. The Department shall submit the rules no later than January 1, 2014 for an implementation date no later than January 1, 2015. If the Department does not implement this reimbursement methodology by the required date, the nursing component per diem on January 1, 2015 for residents classified in RUG-IV groups PA1, PA2, BA1, and BA2 shall be the blended rate of the calculated RUG-IV nursing component per diem and the nursing component per diem in effect on July 1, 2012. This blended rate shall be applied only to nursing homes whose resident population is greater than or equal to 70% of the total residents served and whose RUG-IV nursing component per diem rate is less than the nursing component per diem in effect on July 1, 2012. This blended rate shall be in effect until the reimbursement methodology is implemented or until July 1, 2019, whichever is sooner.
    (e-1) Notwithstanding any other provision of this Article, rates established pursuant to this subsection shall not apply to any and all nursing facilities designated by the Department as "Institutions for Mental Disease" and shall be excluded from the RUGs Reimbursement System applicable to facilities not designated as "Institutions for the Mentally Diseased" by the Department.
    (e-2) For dates of services beginning January 1, 2014, the RUG-IV nursing component per diem for a nursing home shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index, and the regional wage adjustor. Transition rates for services provided between January 1, 2014 and December 31, 2014 shall be as follows:
        (1) The transition RUG-IV per diem nursing rate for
    
nursing homes whose rate calculated in this subsection (e-2) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
            (A) The nursing component rate in effect July
        
1, 2012; plus
            (B) The difference of the RUG-IV nursing
        
component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.88.
        (2) The transition RUG-IV per diem nursing rate for
    
nursing homes whose rate calculated in this subsection (e-2) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
            (A) The nursing component rate in effect July
        
1, 2012; plus
            (B) The difference of the RUG-IV nursing
        
component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.13.
    (f) Notwithstanding any other provision of this Code, on and after July 1, 2012, reimbursement rates associated with the nursing or support components of the current nursing facility rate methodology shall not increase beyond the level effective May 1, 2011 until a new reimbursement system based on the RUGs IV 48 grouper model has been fully operationalized.
    (g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows:
        (1) Individual nursing rates for residents classified
    
in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter ending March 31, 2012 shall be reduced by 10%;
        (2) Individual nursing rates for residents classified
    
in all other RUG IV groups shall be reduced by 1.0%;
        (3) Facility rates for the capital and support
    
components shall be reduced by 1.7%.
    (h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall have the nursing, socio-developmental, capital, and support components of their reimbursement rate effective May 1, 2011 reduced in total by 2.7%.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section 6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. 7-22-13; 98-727, eff. 7-16-14.)
 
    (Text of Section from P.A. 98-756)
    Sec. 5-5.2. Payment.
    (a) All nursing facilities that are grouped pursuant to Section 5-5.1 of this Act shall receive the same rate of payment for similar services.
    (b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the long-term care providers.
    (c) Notwithstanding any other provisions of this Code, the methodologies for reimbursement of nursing services as provided under this Article shall no longer be applicable for bills payable for nursing services rendered on or after a new reimbursement system based on the Resource Utilization Groups (RUGs) has been fully operationalized, which shall take effect for services provided on or after January 1, 2014.
    (d) The new nursing services reimbursement methodology utilizing RUG-IV 48 grouper model, which shall be referred to as the RUGs reimbursement system, taking effect January 1, 2014, shall be based on the following:
        (1) The methodology shall be resident-driven,
    
facility-specific, and cost-based.
        (2) Costs shall be annually rebased and case mix
    
index quarterly updated. The nursing services methodology will be assigned to the Medicaid enrolled residents on record as of 30 days prior to the beginning of the rate period in the Department's Medicaid Management Information System (MMIS) as present on the last day of the second quarter preceding the rate period.
        (3) Regional wage adjustors based on the Health
    
Service Areas (HSA) groupings and adjusters in effect on April 30, 2012 shall be included.
        (4) Case mix index shall be assigned to each
    
resident class based on the Centers for Medicare and Medicaid Services staff time measurement study in effect on July 1, 2013, utilizing an index maximization approach.
        (5) The pool of funds available for distribution by
    
case mix and the base facility rate shall be determined using the formula contained in subsection (d-1).
    (d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate.
        (1) Base rate spending pool shall be:
            (A) The base year resident days which are
        
calculated by multiplying the number of Medicaid residents in each nursing home as indicated in the MDS data defined in paragraph (4) by 365.
            (B) Each facility's nursing component per diem
        
in effect on July 1, 2012 shall be multiplied by subsection (A).
            (C) Thirteen million is added to the product of
        
subparagraph (A) and subparagraph (B) to adjust for the exclusion of nursing homes defined in paragraph (5).
        (2) For each nursing home with Medicaid residents as
    
indicated by the MDS data defined in paragraph (4), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each home this calculation is the product of:
            (A) Base year resident days as calculated in
        
subparagraph (A) of paragraph (1).
            (B) The nursing home's regional wage adjustor
        
based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.
            (C) Facility weighted case mix which is the
        
number of Medicaid residents as indicated by the MDS data defined in paragraph (4) multiplied by the associated case weight for the RUG-IV 48 grouper model using standard RUG-IV procedures for index maximization.
            (D) The sum of the products calculated for each
        
nursing home in subparagraphs (A) through (C) above shall be the base year case mix, rate adjusted weighted days.
        (3) The Statewide RUG-IV nursing base per diem rate
    
on January 1, 2014 shall be the quotient of the paragraph (1) divided by the sum calculated under subparagraph (D) of paragraph (2).
        (4) Minimum Data Set (MDS) comprehensive assessments
    
for Medicaid residents on the last day of the quarter used to establish the base rate.
        (5) Nursing facilities designated as of July 1, 2012
    
by the Department as "Institutions for Mental Disease" shall be excluded from all calculations under this subsection. The data from these facilities shall not be used in the computations described in paragraphs (1) through (4) above to establish the base rate.
    (e) Notwithstanding any other provision of this Code, the Department shall by rule develop a reimbursement methodology reflective of the intensity of care and services requirements of low need residents in the lowest RUG IV groupers and corresponding regulations. Only that portion of the RUGs Reimbursement System spending pool described in subsection (d-1) attributed to the groupers as of July 1, 2013 for which the methodology in this Section is developed may be diverted for this purpose. The Department shall submit the rules no later than January 1, 2014 for an implementation date no later than January 1, 2015. If the Department does not implement this reimbursement methodology by the required date, the nursing component per diem on January 1, 2015 for residents classified in RUG-IV groups PA1, PA2, BA1, and BA2 shall be the blended rate of the calculated RUG-IV nursing component per diem and the nursing component per diem in effect on July 1, 2012. This blended rate shall be applied only to nursing homes whose resident population is greater than or equal to 70% of the total residents served and whose RUG-IV nursing component per diem rate is less than the nursing component per diem in effect on July 1, 2012. This blended rate shall be in effect until the reimbursement methodology is implemented or until July 1, 2019, whichever is sooner.
    (e-1) Notwithstanding any other provision of this Article, rates established pursuant to this subsection shall not apply to any and all nursing facilities designated by the Department as "Institutions for Mental Disease" and shall be excluded from the RUGs Reimbursement System applicable to facilities not designated as "Institutions for the Mentally Diseased" by the Department.
    (e-2) For dates of services beginning January 1, 2014, the RUG-IV nursing component per diem for a nursing home shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index, and the regional wage adjustor. Transition rates for services provided between January 1, 2014 and December 31, 2014 shall be as follows:
        (1) The transition RUG-IV per diem nursing rate for
    
nursing homes whose rate calculated in this subsection (e-2) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
            (A) The nursing component rate in effect July
        
1, 2012; plus
            (B) The difference of the RUG-IV nursing
        
component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.88.
        (2) The transition RUG-IV per diem nursing rate for
    
nursing homes whose rate calculated in this subsection (e-2) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
            (A) The nursing component rate in effect July
        
1, 2012; plus
            (B) The difference of the RUG-IV nursing
        
component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.13.
    (f) Notwithstanding any other provision of this Code, on and after July 1, 2012, reimbursement rates associated with the nursing or support components of the current nursing facility rate methodology shall not increase beyond the level effective May 1, 2011 until a new reimbursement system based on the RUGs IV 48 grouper model has been fully operationalized.
    (g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows:
        (1) Individual nursing rates for residents classified
    
in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter ending March 31, 2012 shall be reduced by 10%;
        (2) Individual nursing rates for residents classified
    
in all other RUG IV groups shall be reduced by 1.0%;
        (3) Facility rates for the capital and support
    
components shall be reduced by 1.7%.
    (h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall have the nursing, socio-developmental, capital, and support components of their reimbursement rate effective May 1, 2011 reduced in total by 2.7%.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section 6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. 7-22-13; 98-756, eff. 7-16-14.)

305 ILCS 5/5-5.3

    (305 ILCS 5/5-5.3) (from Ch. 23, par. 5-5.3)
    Sec. 5-5.3. Conditions of Payment - Prospective Rates - Accounting Principles. This amendatory Act establishes certain conditions for the Department of Healthcare and Family Services in instituting rates for the care of recipients of medical assistance in nursing facilities and ICF/DDs. Such conditions shall assure a method under which the payment for nursing facility and ICF/DD services provided to recipients under the Medical Assistance Program shall be on a reasonable cost related basis, which is prospectively determined at least annually by the Department of Public Aid (now Healthcare and Family Services). The annually established payment rate shall take effect on July 1 in 1984 and subsequent years. There shall be no rate increase during calendar year 1983 and the first six months of calendar year 1984.
    The determination of the payment shall be made on the basis of generally accepted accounting principles that shall take into account the actual costs to the facility of providing nursing facility and ICF/DD services to recipients under the medical assistance program.
    The resultant total rate for a specified type of service shall be an amount which shall have been determined to be adequate to reimburse allowable costs of a facility that is economically and efficiently operated. The Department shall establish an effective date for each facility or group of facilities after which rates shall be paid on a reasonable cost related basis which shall be no sooner than the effective date of this amendatory Act of 1977.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.4

    (305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)
    Sec. 5-5.4. Standards of Payment - Department of Healthcare and Family Services. The Department of Healthcare and Family Services shall develop standards of payment of nursing facility and ICF/DD services in facilities providing such services under this Article which:
    (1) Provide for the determination of a facility's payment for nursing facility or ICF/DD services on a prospective basis. The amount of the payment rate for all nursing facilities certified by the Department of Public Health under the ID/DD Community Care Act or the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities, Long Term Care for Under Age 22 facilities, Skilled Nursing facilities, or Intermediate Care facilities under the medical assistance program shall be prospectively established annually on the basis of historical, financial, and statistical data reflecting actual costs from prior years, which shall be applied to the current rate year and updated for inflation, except that the capital cost element for newly constructed facilities shall be based upon projected budgets. The annually established payment rate shall take effect on July 1 in 1984 and subsequent years. No rate increase and no update for inflation shall be provided on or after July 1, 1994, unless specifically provided for in this Section. The changes made by Public Act 93-841 extending the duration of the prohibition against a rate increase or update for inflation are effective retroactive to July 1, 2004.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 1998 shall include an increase of 3%. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 1998 shall include an increase of 3% plus $1.10 per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2006 shall include an increase of 3%. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2009 shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive staff.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 1999 shall include an increase of 1.6% plus $3.00 per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 1999 shall include an increase of 1.6% and, for services provided on or after October 1, 1999, shall be increased by $4.00 per resident-day, as defined by the Department.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 2000 shall include an increase of 2.5% per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 2000 shall include an increase of 2.5% per resident-day, as defined by the Department.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, a new payment methodology must be implemented for the nursing component of the rate effective July 1, 2003. The Department of Public Aid (now Healthcare and Family Services) shall develop the new payment methodology using the Minimum Data Set (MDS) as the instrument to collect information concerning nursing home resident condition necessary to compute the rate. The Department shall develop the new payment methodology to meet the unique needs of Illinois nursing home residents while remaining subject to the appropriations provided by the General Assembly. A transition period from the payment methodology in effect on June 30, 2003 to the payment methodology in effect on July 1, 2003 shall be provided for a period not exceeding 3 years and 184 days after implementation of the new payment methodology as follows:
        (A) For a facility that would receive a lower nursing
    
component rate per patient day under the new system than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be held at the level in effect on the date immediately preceding the date that the Department implements the new payment methodology until a higher nursing component rate of reimbursement is achieved by that facility.
        (B) For a facility that would receive a higher
    
nursing component rate per patient day under the payment methodology in effect on July 1, 2003 than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be adjusted.
        (C) Notwithstanding paragraphs (A) and (B), the
    
nursing component rate per patient day for the facility shall be adjusted subject to appropriations provided by the General Assembly.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on March 1, 2001 shall include a statewide increase of 7.85%, as defined by the Department.
    Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, except facilities participating in the Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, the numerator of the ratio used by the Department of Healthcare and Family Services to compute the rate payable under this Section using the Minimum Data Set (MDS) methodology shall incorporate the following annual amounts as the additional funds appropriated to the Department specifically to pay for rates based on the MDS nursing component methodology in excess of the funding in effect on December 31, 2006:
        (i) For rates taking effect January 1, 2007,
    
$60,000,000.
        (ii) For rates taking effect January 1, 2008,
    
$110,000,000.
        (iii) For rates taking effect January 1, 2009,
    
$194,000,000.
        (iv) For rates taking effect April 1, 2011, or the
    
first day of the month that begins at least 45 days after the effective date of this amendatory Act of the 96th General Assembly, $416,500,000 or an amount as may be necessary to complete the transition to the MDS methodology for the nursing component of the rate. Increased payments under this item (iv) are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.
    Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the support component of the rates taking effect on January 1, 2008 shall be computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on April 1, 2002 shall include a statewide increase of 2.0%, as defined by the Department. This increase terminates on July 1, 2002; beginning July 1, 2002 these rates are reduced to the level of the rates in effect on March 31, 2002, as defined by the Department.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports on file with the Department of Public Aid no later than April 1, 2000, updated for inflation to January 1, 2001. For rates effective July 1, 2001 only, rates shall be the greater of the rate computed for July 1, 2001 or the rate effective on June 30, 2001.
    Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the Illinois Department shall determine by rule the rates taking effect on July 1, 2002, which shall be 5.9% less than the rates in effect on June 30, 2002.
    Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, if the payment methodologies required under Section 5A-12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take effect only upon approval and implementation of the payment methodologies required under Section 5A-12.
    Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004.
    Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2009, the per diem support component of the rates effective on January 1, 2008, computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006, shall be increased to the amount that would have been derived using standard Department of Healthcare and Family Services methods, procedures, and inflators.
    Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as intermediate care facilities that are federally defined as Institutions for Mental Disease, or facilities licensed by the Department of Public Health under the Specialized Mental Health Rehabilitation Act of 2013, a socio-development component rate equal to 6.6% of the facility's nursing component rate as of January 1, 2006 shall be established and paid effective July 1, 2006. The socio-development component of the rate shall be increased by a factor of 2.53 on the first day of the month that begins at least 45 days after January 11, 2008 (the effective date of Public Act 95-707). As of August 1, 2008, the socio-development component rate shall be equal to 6.6% of the facility's nursing component rate as of January 1, 2006, multiplied by a factor of 3.53. For services provided on or after April 1, 2011, or the first day of the month that begins at least 45 days after the effective date of this amendatory Act of the 96th General Assembly, whichever is later, the Illinois Department may by rule adjust these socio-development component rates, and may use different adjustment methodologies for those facilities participating, and those not participating, in the Illinois Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, but in no case may such rates be diminished below those in effect on August 1, 2008.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or as long-term care facilities for residents under 22 years of age, the rates taking effect on July 1, 2003 shall include a statewide increase of 4%, as defined by the Department.
    For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on the first day of the month that begins at least 45 days after the effective date of this amendatory Act of the 95th General Assembly shall include a statewide increase of 2.5%, as defined by the Department.
    Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2005, facility rates shall be increased by the difference between (i) a facility's per diem property, liability, and malpractice insurance costs as reported in the cost report filed with the Department of Public Aid and used to establish rates effective July 1, 2001 and (ii) those same costs as reported in the facility's 2002 cost report. These costs shall be passed through to the facility without caps or limitations, except for adjustments required under normal auditing procedures.
    Rates established effective each July 1 shall govern payment for services rendered throughout that fiscal year, except that rates established on July 1, 1996 shall be increased by 6.8% for services provided on or after January 1, 1997. Such rates will be based upon the rates calculated for the year beginning July 1, 1990, and for subsequent years thereafter until June 30, 2001 shall be based on the facility cost reports for the facility fiscal year ending at any point in time during the previous calendar year, updated to the midpoint of the rate year. The cost report shall be on file with the Department no later than April 1 of the current rate year. Should the cost report not be on file by April 1, the Department shall base the rate on the latest cost report filed by each skilled care facility and intermediate care facility, updated to the midpoint of the current rate year. In determining rates for services rendered on and after July 1, 1985, fixed time shall not be computed at less than zero. The Department shall not make any alterations of regulations which would reduce any component of the Medicaid rate to a level below what that component would have been utilizing in the rate effective on July 1, 1984.
    (2) Shall take into account the actual costs incurred by facilities in providing services for recipients of skilled nursing and intermediate care services under the medical assistance program.
    (3) Shall take into account the medical and psycho-social characteristics and needs of the patients.
    (4) Shall take into account the actual costs incurred by facilities in meeting licensing and certification standards imposed and prescribed by the State of Illinois, any of its political subdivisions or municipalities and by the U.S. Department of Health and Human Services pursuant to Title XIX of the Social Security Act.
    The Department of Healthcare and Family Services shall develop precise standards for payments to reimburse nursing facilities for any utilization of appropriate rehabilitative personnel for the provision of rehabilitative services which is authorized by federal regulations, including reimbursement for services provided by qualified therapists or qualified assistants, and which is in accordance with accepted professional practices. Reimbursement also may be made for utilization of other supportive personnel under appropriate supervision.
    The Department shall develop enhanced payments to offset the additional costs incurred by a facility serving exceptional need residents and shall allocate at least $4,000,000 of the funds collected from the assessment established by Section 5B-2 of this Code for such payments. For the purpose of this Section, "exceptional needs" means, but need not be limited to, ventilator care and traumatic brain injury care. The enhanced payments for exceptional need residents under this paragraph are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.
    Beginning January 1, 2014 the methodologies for reimbursement of nursing facility services as provided under this Section 5-5.4 shall no longer be applicable for services provided on or after January 1, 2014.
    No payment increase under this Section for the MDS methodology, exceptional care residents, or the socio-development component rate established by Public Act 96-1530 of the 96th General Assembly and funded by the assessment imposed under Section 5B-2 of this Code shall be due and payable until after the Department notifies the long-term care providers, in writing, that the payment methodologies to long-term care providers required under this Section have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and the waivers under 42 CFR 433.68 for the assessment imposed by this Section, if necessary, have been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. Upon notification to the Department of approval of the payment methodologies required under this Section and the waivers granted under 42 CFR 433.68, all increased payments otherwise due under this Section prior to the date of notification shall be due and payable within 90 days of the date federal approval is received.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-10, eff. 6-14-11; 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-584, eff. 8-26-11; 97-689, eff. 6-14-12; 97-813, eff. 7-13-12; 98-24, eff. 6-19-13; 98-104, eff. 7-22-13; 98-756, eff. 7-16-14.)

305 ILCS 5/5-5.4a

    (305 ILCS 5/5-5.4a)
    Sec. 5-5.4a. (Repealed).
(Source: P.A. 96-1530, eff. 2-16-11. Repealed by P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.4b

    (305 ILCS 5/5-5.4b)
    Sec. 5-5.4b. Publicly owned or publicly operated nursing facilities. The Illinois Department may by rule establish alternative reimbursement methodologies for nursing facilities that are owned or operated by a county, a township, a municipality, a hospital district, or any other local government in Illinois.
(Source: P.A. 93-20, eff. 6-20-03.)

305 ILCS 5/5-5.4c

    (305 ILCS 5/5-5.4c)
    Sec. 5-5.4c. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.4d

    (305 ILCS 5/5-5.4d)
    Sec. 5-5.4d. MDS payment methodology; quarterly rate adjustments.
    (a) On and after July 1, 2009, and until April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be calculated and adjusted quarterly. The Department of Healthcare and Family Services may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section. For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare.
    (b) On April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be frozen to allow the Department of Healthcare and Family Services to develop a rate methodology based on a federally mandated long term care data collection system. The rates in effect prior to and through the quarter ending March 31, 2011, shall continue to be subject to follow-up audits and retroactive rate adjustments pursuant to administrative rules of the Department for reviews of accuracy and resident assessment information. The reimbursement methodology for a Class I Institution for Mental Diseases shall also be frozen pending review of a federally mandated long term care data collection system.
(Source: P.A. 96-743, eff. 8-25-09; 96-959, eff. 7-1-10.)

305 ILCS 5/5-5.4e

    (305 ILCS 5/5-5.4e)
    Sec. 5-5.4e. Nursing facilities; ventilator rates. On and after October 1, 2009, the Department of Healthcare and Family Services shall adopt rules to provide medical assistance reimbursement under this Article for the care of persons on ventilators in skilled nursing facilities licensed under the Nursing Home Care Act and certified to participate under the medical assistance program. Accordingly, necessary amendments to the rules implementing the Minimum Data Set (MDS) payment methodology shall also be made to provide a separate per diem ventilator rate based on days of service. The Department may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section. For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 96-743, eff. 8-25-09; 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.4f

    (305 ILCS 5/5-5.4f)
    Sec. 5-5.4f. Intermediate care facilities for the developmentally disabled quality workforce initiative.
    (a) Legislative intent. Individuals with developmental disabilities who live in community-based settings rely on direct support staff for a variety of supports and services essential to the ability to reach their full potential. A stable, well-trained direct support workforce is critical to the well-being of these individuals. State and national studies have documented high rates of turnover among direct support workers and confirmed that improvements in wages can help reduce turnover and develop a more stable and committed workforce. This Section would increase the wages and benefits for direct care workers supporting individuals with developmental disabilities and provide accountability by ensuring that additional resources go directly to these workers.
    (b) Reimbursement. Notwithstanding any provision of Section 5-5.4, in order to attract and retain a stable, qualified, and healthy workforce, beginning July 1, 2010, the Department of Healthcare and Family Services may reimburse an individual intermediate care facility for the developmentally disabled for spending incurred to provide improved wages and benefits to its employees serving the individuals residing in the facility. Reimbursement shall be based upon patient days reported in the facility's most recent cost report. Subject to available appropriations, this reimbursement shall be made according to the following criteria:
        (1) The Department shall reimburse the facility to
    
compensate for spending on improved wages and benefits for its eligible employees. Eligible employees include employees engaged in direct care work.
        (2) In order to qualify for reimbursement under
    
this Section, a facility must submit to the Department, before January 1 of each year, documentation of a written, legally binding commitment to increase spending for the purpose of providing improved wages and benefits to its eligible employees during the next year. The commitment must be binding as to both existing and future staff. The commitment must include a method of enforcing the commitment that is available to the employees or their representative and is expeditious, uses a neutral decision-maker, and is economical for the employees. The Department must also receive documentation of the facility's provision of written notice of the commitment and the availability of the enforcement mechanism to the employees or their representative.
        (3) Reimbursement shall be based on the amount of
    
increased spending to be incurred by the facility for improving wages and benefits that exceeds the spending reported in the cost report currently used by the Department. Reimbursement shall be calculated as follows: the per diem equivalent of the quarterly difference between the cost to provide improved wages and benefits for covered eligible employees as identified in the legally binding commitment and the previous period cost of wages and benefits as reported in the cost report currently used by the Department, subject to the limitations identified in paragraph (2) of this subsection. In no event shall the per diem increase be in excess of $5.00 for any 12 month period for an intermediate care facility for the developmentally disabled with more than 16 beds, or in excess of $6.00 for any 12 month period for an intermediate care facility for the developmentally disabled with 16 beds or less.
        (4) Any intermediate care facility for the
    
developmentally disabled is eligible to receive reimbursement under this Section. A facility's eligibility to receive reimbursement shall continue as long as the facility maintains eligibility under paragraph (2) of this subsection and the reimbursement program continues to exist.
    (c) Audit. Reimbursement under this Section is subject to audit by the Department and shall be reduced or eliminated in the case of any facility that does not honor its commitment to increase spending to improve the wages and benefits of its employees or that decreases such spending.
(Source: P.A. 96-1124, eff. 7-20-10; 97-333, eff. 8-12-11.)

305 ILCS 5/5-5.4g

    (305 ILCS 5/5-5.4g)
    Sec. 5-5.4g. Minimum Data Set (MDS) Compliance Review; preliminary findings. The Department shall establish by rule a procedure for sharing preliminary Minimum Data Set (MDS) Compliance Review findings with nursing facilities prior to completion of the on-site review. The procedure shall include, but not be limited to, notification to a nursing facility of specific areas of missing documentation required under 89 Ill. Adm. Code 147.75 and the federally mandated resident assessment instrument as specified in 42 CFR 483.20 likely to be determined deficient upon conclusion of the Department's quality assurance review process. Prior to the conclusion of the on-site review, the facility shall be given the opportunity to address the specific areas of missing documentation. A facility disputing any rate change may submit an appeal request pursuant to provisions established at 89 Ill. Adm. Code 140.830. An appeal hearing may be requested if the facility believes that the basis for reducing the facility's MDS rate was in error. The facility may not offer any additional documentation during the appeal hearing, but may identify documentation provided during the on-site review that may support a specific area of documentation deemed deficient by the Department.
(Source: P.A. 96-1317, eff. 7-27-10; 97-333, eff. 8-12-11.)

305 ILCS 5/5-5.4h

    (305 ILCS 5/5-5.4h)
    Sec. 5-5.4h. Medicaid reimbursement for long-term care facilities for persons under 22 years of age.
    (a) Facilities licensed as long-term care facilities for persons under 22 years of age that serve severely and chronically ill pediatric patients shall have a specific reimbursement system designed to recognize the characteristics and needs of the patients they serve.
    (b) For dates of services starting July 1, 2013 and until a new reimbursement system is designed, long-term care facilities for persons under 22 years of age that meet the following criteria:
        (1) serve exceptional care patients; and
        (2) have 30% or more of their patients receiving
    
ventilator care;
shall receive Medicaid reimbursement on a 30-day expedited schedule.
    (c) Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting July 1, 2014 and until a new reimbursement system is designed, long-term care facilities for persons under 22 years of age which meet the criteria in subsection (b) of this Section shall receive a per diem rate for clinically complex residents of $304. Clinically complex residents on a ventilator shall receive a per diem rate of $669.
    (d) To qualify for the per diem rate of $669 for clinically complex residents on a ventilator pursuant to subsection (c), facilities shall have a policy documenting their method of routine assessment of a resident's weaning potential with interventions implemented noted in the resident's record.
    (e) For the purposes of this Section, a resident is considered clinically complex if the resident requires at least one of the following medical services:
        (1) Tracheostomy care with dependence on mechanical
    
ventilation for a minimum of 6 hours each day.
        (2) Tracheostomy care requiring suctioning at least
    
every 6 hours, room air mist or oxygen as needed, and dependence on one of the treatment procedures listed under paragraph (4) excluding the procedure listed in subparagraph (A) of paragraph (4).
        (3) Total parenteral nutrition or other intravenous
    
nutritional support and one of the treatment procedures listed under paragraph (4).
        (4) The following treatment procedures apply to the
    
conditions in paragraphs (2) and (3) of this subsection:
            (A) Intermittent suctioning at least every 8
        
hours and room air mist or oxygen as needed.
            (B) Continuous intravenous therapy including
        
administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent via a peripheral or central line, without continuous infusion.
            (C) Peritoneal dialysis treatments requiring at
        
least 4 exchanges every 24 hours.
            (D) Tube feeding via nasogastric or gastrostomy
        
tube.
            (E) Other medical technologies required
        
continuously, which in the opinion of the attending physician require the services of a professional nurse.
(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14.)

305 ILCS 5/5-5.5

    (305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5)
    Sec. 5-5.5. Elements of Payment Rate.
    (a) The Department of Healthcare and Family Services shall develop a prospective method for determining payment rates for nursing facility and ICF/DD services in nursing facilities composed of the following cost elements:
        (1) Standard Services, with the cost of this
    
component being determined by taking into account the actual costs to the facilities of these services subject to cost ceilings to be defined in the Department's rules.
        (2) Resident Services, with the cost of this
    
component being determined by taking into account the actual costs, needs and utilization of these services, as derived from an assessment of the resident needs in the nursing facilities.
        (3) Ancillary Services, with the payment rate being
    
developed for each individual type of service. Payment shall be made only when authorized under procedures developed by the Department of Healthcare and Family Services.
        (4) Nurse's Aide Training, with the cost of this
    
component being determined by taking into account the actual cost to the facilities of such training.
        (5) Real Estate Taxes, with the cost of this
    
component being determined by taking into account the figures contained in the most currently available cost reports (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1984 and June 30, 1985, and with the cost of this component being determined by taking into account the actual 1983 taxes for which the nursing homes were assessed (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1985 and June 30, 1986.
    (b) In developing a prospective method for determining payment rates for nursing facility and ICF/DD services in nursing facilities and ICF/DDs, the Department of Healthcare and Family Services shall consider the following cost elements:
        (1) Reasonable capital cost determined by utilizing
    
incurred interest rate and the current value of the investment, including land, utilizing composite rates, or by utilizing such other reasonable cost related methods determined by the Department. However, beginning with the rate reimbursement period effective July 1, 1987, the Department shall be prohibited from establishing, including, and implementing any depreciation factor in calculating the capital cost element.
        (2) Profit, with the actual amount being produced and
    
accruing to the providers in the form of a return on their total investment, on the basis of their ability to economically and efficiently deliver a type of service. The method of payment may assure the opportunity for a profit, but shall not guarantee or establish a specific amount as a cost.
    (c) The Illinois Department may implement the amendatory changes to this Section made by this amendatory Act of 1991 through the use of emergency rules in accordance with the provisions of Section 5.02 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the adoption of rules to implement the amendatory changes to this Section made by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare.
    (d) No later than January 1, 2001, the Department of Public Aid shall file with the Joint Committee on Administrative Rules, pursuant to the Illinois Administrative Procedure Act, a proposed rule, or a proposed amendment to an existing rule, regarding payment for appropriate services, including assessment, care planning, discharge planning, and treatment provided by nursing facilities to residents who have a serious mental illness.
    (e) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 96-1123, eff. 1-1-11; 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.5a

    (305 ILCS 5/5-5.5a) (from Ch. 23, par. 5-5.5a)
    Sec. 5-5.5a. Kosher kitchen and food service.
    (a) The Department of Healthcare and Family Services may develop in its rate structure for nursing facilities an accommodation for fully kosher kitchen and food service operations, rabbinically approved or certified on an annual basis for a facility in which the only kitchen or all kitchens are fully kosher (a fully kosher facility). Beginning in the fiscal year after the fiscal year when this amendatory Act of 1990 becomes effective, the rate structure may provide for an additional payment to such facility not to exceed 50 cents per resident per day if 60% or more of the residents in the facility request kosher foods or food products prepared in accordance with Jewish religious dietary requirements for religious purposes in a fully kosher facility. Based upon food cost reports of the Illinois Department of Agriculture regarding kosher and non-kosher food available in the various regions of the State, this rate structure may be periodically adjusted by the Department but may not exceed the maximum authorized under this subsection (a).
    (b) The Department shall by rule determine how a facility with a fully kosher kitchen and food service may be determined to be eligible and apply for the rate accommodation specified in subsection (a).
(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)

305 ILCS 5/5-5.6

    (305 ILCS 5/5-5.6) (from Ch. 23, par. 5-5.6)
    Sec. 5-5.6. Federal Requirements. All reimbursement rates established pursuant to this Act must be consistent with the criteria for nursing facility reimbursement established by the Federal government for approval of matching funds under Title XIX of the Federal Social Security Act.
(Source: P.A. 80-1142.)

305 ILCS 5/5-5.6a

    (305 ILCS 5/5-5.6a)
    Sec. 5-5.6a. (Repealed).
(Source: P.A. 85-1440. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-5.6b

    (305 ILCS 5/5-5.6b) (from Ch. 23, par. 5-5.6b)
    Sec. 5-5.6b. Prohibition against double payment. If any resident of a nursing facility or ICF/DD is admitted to such facility on the basis that the charges for such resident's care will be paid from private funds, and the source of payment for such care thereafter changes from private funds to payments under this Article, the facility shall, upon receiving the first such payment under this Article, notify the Illinois Department of such source of private funds for such recipient and repay to the source of private funds any amounts received from such source as payment for care for which payment also was made under this Article. Private funds shall not include third party resources such as insurance or Medicare benefits or payments made by responsible relatives.
(Source: P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-5.7

    (305 ILCS 5/5-5.7) (from Ch. 23, par. 5-5.7)
    Sec. 5-5.7. Cost Reports - Audits. The Department of Healthcare and Family Services shall work with the Department of Public Health to use cost report information currently being collected under provisions of the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, and the ID/DD Community Care Act. The Department of Healthcare and Family Services may, in conjunction with the Department of Public Health, develop in accordance with generally accepted accounting principles a uniform chart of accounts which each facility providing services under the medical assistance program shall adopt, after a reasonable period.
    Facilities licensed under the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, or the ID/DD Community Care Act and providers of adult developmental training services certified by the Department of Human Services pursuant to Section 15.2 of the Mental Health and Developmental Disabilities Administrative Act which provide services to clients eligible for medical assistance under this Article are responsible for submitting the required annual cost report to the Department of Healthcare and Family Services.
    The Department of Healthcare and Family Services shall audit the financial and statistical records of each provider participating in the medical assistance program as a nursing facility, a specialized mental health rehabilitation facility, or an ICF/DD over a 3 year period, beginning with the close of the first cost reporting year. Following the end of this 3-year term, audits of the financial and statistical records will be performed each year in at least 20% of the facilities participating in the medical assistance program with at least 10% being selected on a random sample basis, and the remainder selected on the basis of exceptional profiles. All audits shall be conducted in accordance with generally accepted auditing standards.
    The Department of Healthcare and Family Services shall establish prospective payment rates for categories or levels of services within each licensure class, in order to more appropriately recognize the individual needs of patients in nursing facilities.
    The Department of Healthcare and Family Services shall provide, during the process of establishing the payment rate for nursing facility, specialized mental health rehabilitation facility, or ICF/DD services, or when a substantial change in rates is proposed, an opportunity for public review and comment on the proposed rates prior to their becoming effective.
(Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813, eff. 7-13-12; 98-104, eff. 7-22-13.)

305 ILCS 5/5-5.8

    (305 ILCS 5/5-5.8) (from Ch. 23, par. 5-5.8)
    Sec. 5-5.8. Report on nursing home reimbursement. The Illinois Department shall report annually to the General Assembly, no later than the first Monday in April of 1982, and each year thereafter, in regard to:
    (a) the rate structure used by the Illinois Department to reimburse nursing facilities;
    (b) changes in the rate structure for reimbursing nursing facilities;
    (c) the administrative and program costs of reimbursing nursing facilities;
    (d) the availability of beds in nursing facilities for public aid recipients; and
    (e) the number of closings of nursing facilities, and the reasons for those closings.
    The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader and the Clerk of the House of Representatives and the President, the Minority Leader and the Secretary of the Senate and the Legislative Research Unit, as required by Section 3.1 of "An Act to revise the law in relation to the General Assembly", approved February 25, 1874, as amended, and filing such additional copies with the State Government Report Distribution Center for the General Assembly as is required under paragraph (t) of Section 7 of the State Library Act.
(Source: P.A. 84-1438.)

305 ILCS 5/5-5.8a

    (305 ILCS 5/5-5.8a)
    Sec. 5-5.8a. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 96-1123, eff. 1-1-11.)

305 ILCS 5/5-5.8b

    (305 ILCS 5/5-5.8b) (from Ch. 23, par. 5-5.8b)
    Sec. 5-5.8b. Payment to Campus Facilities. There is hereby established a separate payment category for campus facilities. A "campus facility" is defined as an entity which consists of a long term care facility (or group of facilities if the facilities are on the same contiguous parcel of real estate) which meets all of the following criteria as of May 1, 1987: the entity provides care for both children and adults; residents of the entity reside in three or more separate buildings with congregate and small group living arrangements on a single campus; the entity provides three or more separate licensed levels of care; the entity (or a part of the entity) is enrolled with the Department of Healthcare and Family Services as a provider of long term care services and receives payments from that Department; the entity (or a part of the entity) receives funding from the Department of Human Services; and the entity (or a part of the entity) holds a current license as a child care institution issued by the Department of Children and Family Services.
    The Department of Healthcare and Family Services, the Department of Human Services, and the Department of Children and Family Services shall develop jointly a rate methodology or methodologies for campus facilities. Such methodology or methodologies may establish a single rate to be paid by all the agencies, or a separate rate to be paid by each agency, or separate components to be paid to different parts of the campus facility. All campus facilities shall receive the same rate of payment for similar services. Any methodology developed pursuant to this section shall take into account the actual costs to the facility of providing services to residents, and shall be adequate to reimburse the allowable costs of a campus facility which is economically and efficiently operated. Any methodology shall be established on the basis of historical, financial, and statistical data submitted by campus facilities, and shall take into account the actual costs incurred by campus facilities in providing services, and in meeting licensing and certification standards imposed and prescribed by the State of Illinois, any of its political subdivisions or municipalities and by the United States Department of Health and Human Services. Rates may be established on a prospective or retrospective basis. Any methodology shall provide reimbursement for appropriate payment elements, including the following: standard services, patient services, real estate taxes, and capital costs.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.11

    (305 ILCS 5/5-5.11)
    Sec. 5-5.11. (Repealed).
(Source: P.A. 83-748. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-5.12

    (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
    Sec. 5-5.12. Pharmacy payments.
    (a) Every request submitted by a pharmacy for reimbursement under this Article for prescription drugs provided to a recipient of aid under this Article shall include the name of the prescriber or an acceptable identification number as established by the Department.
    (b) Pharmacies providing prescription drugs under this Article shall be reimbursed at a rate which shall include a professional dispensing fee as determined by the Illinois Department, plus the current acquisition cost of the prescription drug dispensed. The Illinois Department shall update its information on the acquisition costs of all prescription drugs no less frequently than every 30 days. However, the Illinois Department may set the rate of reimbursement for the acquisition cost, by rule, at a percentage of the current average wholesale acquisition cost.
    (c) (Blank).
    (d) The Department shall review utilization of narcotic medications in the medical assistance program and impose utilization controls that protect against abuse.
    (e) When making determinations as to which drugs shall be on a prior approval list, the Department shall include as part of the analysis for this determination, the degree to which a drug may affect individuals in different ways based on factors including the gender of the person taking the medication.
    (f) The Department shall cooperate with the Department of Public Health and the Department of Human Services Division of Mental Health in identifying psychotropic medications that, when given in a particular form, manner, duration, or frequency (including "as needed") in a dosage, or in conjunction with other psychotropic medications to a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act, may constitute a chemical restraint or an "unnecessary drug" as defined by the Nursing Home Care Act or Titles XVIII and XIX of the Social Security Act and the implementing rules and regulations. The Department shall require prior approval for any such medication prescribed for a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act, that appears to be a chemical restraint or an unnecessary drug. The Department shall consult with the Department of Human Services Division of Mental Health in developing a protocol and criteria for deciding whether to grant such prior approval.
    (g) The Department may by rule provide for reimbursement of the dispensing of a 90-day supply of a generic or brand name, non-narcotic maintenance medication in circumstances where it is cost effective.
    (g-5) On and after July 1, 2012, the Department may require the dispensing of drugs to nursing home residents be in a 7-day supply or other amount less than a 31-day supply. The Department shall pay only one dispensing fee per 31-day supply.
    (h) Effective July 1, 2011, the Department shall discontinue coverage of select over-the-counter drugs, including analgesics and cough and cold and allergy medications.
    (h-5) On and after July 1, 2012, the Department shall impose utilization controls, including, but not limited to, prior approval on specialty drugs, oncolytic drugs, drugs for the treatment of HIV or AIDS, immunosuppressant drugs, and biological products in order to maximize savings on these drugs. The Department may adjust payment methodologies for non-pharmacy billed drugs in order to incentivize the selection of lower-cost drugs. For drugs for the treatment of AIDS, the Department shall take into consideration the potential for non-adherence by certain populations, and shall develop protocols with organizations or providers primarily serving those with HIV/AIDS, as long as such measures intend to maintain cost neutrality with other utilization management controls such as prior approval. For hemophilia, the Department shall develop a program of utilization review and control which may include, in the discretion of the Department, prior approvals. The Department may impose special standards on providers that dispense blood factors which shall include, in the discretion of the Department, staff training and education; patient outreach and education; case management; in-home patient assessments; assay management; maintenance of stock; emergency dispensing timeframes; data collection and reporting; dispensing of supplies related to blood factor infusions; cold chain management and packaging practices; care coordination; product recalls; and emergency clinical consultation. The Department may require patients to receive a comprehensive examination annually at an appropriate provider in order to be eligible to continue to receive blood factor.
    (i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
    (j) On and after July 1, 2012, the Department shall impose limitations on prescription drugs such that the Department shall not provide reimbursement for more than 4 prescriptions, including 3 brand name prescriptions, for distinct drugs in a 30-day period, unless prior approval is received for all prescriptions in excess of the 4-prescription limit. Drugs in the following therapeutic classes shall not be subject to prior approval as a result of the 4-prescription limit: immunosuppressant drugs, oncolytic drugs, anti-retroviral drugs, and, on or after July 1, 2014, antipsychotic drugs. On or after July 1, 2014, the Department may exempt children with complex medical needs enrolled in a care coordination entity contracted with the Department to solely coordinate care for such children, if the Department determines that the entity has a comprehensive drug reconciliation program.
    (k) No medication therapy management program implemented by the Department shall be contrary to the provisions of the Pharmacy Practice Act.
    (l) Any provider enrolled with the Department that bills the Department for outpatient drugs and is eligible to enroll in the federal Drug Pricing Program under Section 340B of the federal Public Health Services Act shall enroll in that program. No entity participating in the federal Drug Pricing Program under Section 340B of the federal Public Health Services Act may exclude Medicaid from their participation in that program, although the Department may exclude entities defined in Section 1905(l)(2)(B) of the Social Security Act from this requirement.
(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333, eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12; 97-813, eff. 7-13-12; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14.)

305 ILCS 5/5-5.12a

    (305 ILCS 5/5-5.12a)
    Sec. 5-5.12a. Title XIX waiver; pharmacy assistance program. The Illinois Department may seek a waiver of otherwise applicable requirements of Title XIX of the federal Social Security Act in order to claim federal financial participation for a pharmacy assistance program for persons aged 65 and over with income levels at or less than 250% of the federal poverty level. The Illinois Department may provide by rule for all other requirements of the program, including cost sharing, as permitted by an approved waiver and without regard to any provision of this Code to the contrary. The benefits may be no more restrictive than the Pharmacy Assistance Program in effect on May 31, 2001. Benefits provided under the waiver are subject to appropriation.
    The Illinois Department may not implement the waiver until cost neutrality is demonstrated for the State relative to the final Pharmacy Assistance Program appropriation for the fiscal year beginning July 1, 2001. Implementation of the waiver shall terminate on June 30, 2007.
(Source: P.A. 92-10, eff. 6-11-01.)

305 ILCS 5/5-5.13

    (305 ILCS 5/5-5.13) (from Ch. 23, par. 5-5.13)
    Sec. 5-5.13. The Illinois Department shall establish procedures for the expedited review, for purposes of inclusion in the Illinois Public Aid formulary, of any drug for the treatment of acquired immunodeficiency syndrome (AIDS) which the federal Food and Drug Administration has indicated is subject to a treatment investigational new drug application.
(Source: P.A. 88-85.)

305 ILCS 5/5-5.14

    (305 ILCS 5/5-5.14)
    Sec. 5-5.14. (Repealed).
(Source: Repealed by P.A. 88-85.)

305 ILCS 5/5-5.15

    (305 ILCS 5/5-5.15)
    Sec. 5-5.15. (Repealed).
(Source: P.A. 83-1509. Repealed by P.A. 96-1501, eff. 1-25-11.)

305 ILCS 5/5-5.16

    (305 ILCS 5/5-5.16) (from Ch. 23, par. 5-5.16)
    Sec. 5-5.16. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed internally, eff. 7-1-98.)

305 ILCS 5/5-5.17

    (305 ILCS 5/5-5.17) (from Ch. 23, par. 5-5.17)
    Sec. 5-5.17. Separate reimbursement rate. The Illinois Department may by rule establish a separate reimbursement rate to be paid to long term care facilities for adult developmental training services as defined in Section 15.2 of the Mental Health and Developmental Disabilities Administrative Act which are provided to intellectually disabled residents of such facilities who receive aid under this Article. Any such reimbursement shall be based upon cost reports submitted by the providers of such services and shall be paid by the long term care facility to the provider within such time as the Illinois Department shall prescribe by rule, but in no case less than 3 business days after receipt of the reimbursement by such facility from the Illinois Department. The Illinois Department may impose a penalty upon a facility which does not make payment to the provider of adult developmental training services within the time so prescribed, up to the amount of payment not made to the provider.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-227, eff. 1-1-12; 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.18

    (305 ILCS 5/5-5.18)
    Sec. 5-5.18. Diagnosis accompanying request for reimbursement. Every request submitted by a physician for reimbursement under this Article for services provided to a recipient of aid under this Article shall include the physician's diagnosis of the recipient's illness or other condition requiring those services. The diagnosis shall be either written out or expressed in a code approved by the Illinois Department.
(Source: P.A. 88-554, eff. 7-26-94.)

305 ILCS 5/5-5.19

    (305 ILCS 5/5-5.19)
    Sec. 5-5.19. Reimbursement request records. The Illinois Department shall file all requests for reimbursement for medical services provided under this Article according to both (i) the name of the service provider and (ii) the name of the recipient of aid under this Article to whom the medical services were provided.
(Source: P.A. 88-554, eff. 7-26-94.)

305 ILCS 5/5-5.20

    (305 ILCS 5/5-5.20)
    Sec. 5-5.20. Clinic payments. For services provided by federally qualified health centers as defined in Section 1905 (l)(2)(B) of the federal Social Security Act, on or after April 1, 1989, and as long as required by federal law, the Illinois Department shall reimburse those health centers for those services according to a prospective cost-reimbursement methodology.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.21

    (305 ILCS 5/5-5.21)
    Sec. 5-5.21. (Repealed).
(Source: P.A. 89-415, eff. 1-1-96. Repealed by P.A. 96-1530, eff. 2-16-11.)

305 ILCS 5/5-5.22

    (305 ILCS 5/5-5.22)
    Sec. 5-5.22. (Repealed).
(Source: P.A. 92-725, eff. 7-25-02. Repealed by P.A. 94-838, eff. 6-6-06.)

305 ILCS 5/5-5.23

    (305 ILCS 5/5-5.23)
    Sec. 5-5.23. Children's mental health services.
    (a) The Department of Healthcare and Family Services, by rule, shall require the screening and assessment of a child prior to any Medicaid-funded admission to an inpatient hospital for psychiatric services to be funded by Medicaid. The screening and assessment shall include a determination of the appropriateness and availability of out-patient support services for necessary treatment. The Department, by rule, shall establish methods and standards of payment for the screening, assessment, and necessary alternative support services.
    (b) The Department of Healthcare and Family Services, to the extent allowable under federal law, shall secure federal financial participation for Individual Care Grant expenditures made by the Department of Human Services for the Medicaid optional service authorized under Section 1905(h) of the federal Social Security Act, pursuant to the provisions of Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act.
    (c) The Department of Healthcare and Family Services shall work jointly with the Department of Human Services to implement subsections (a) and (b).
    (d) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.24

    (305 ILCS 5/5-5.24)
    Sec. 5-5.24. Prenatal and perinatal care. The Department of Healthcare and Family Services may provide reimbursement under this Article for all prenatal and perinatal health care services that are provided for the purpose of preventing low-birthweight infants, reducing the need for neonatal intensive care hospital services, and promoting perinatal health. These services may include comprehensive risk assessments for pregnant women, women with infants, and infants, lactation counseling, nutrition counseling, childbirth support, psychosocial counseling, treatment and prevention of periodontal disease, and other support services that have been proven to improve birth outcomes. The Department shall maximize the use of preventive prenatal and perinatal health care services consistent with federal statutes, rules, and regulations. The Department of Public Aid (now Department of Healthcare and Family Services) shall develop a plan for prenatal and perinatal preventive health care and shall present the plan to the General Assembly by January 1, 2004. On or before January 1, 2006 and every 2 years thereafter, the Department shall report to the General Assembly concerning the effectiveness of prenatal and perinatal health care services reimbursed under this Section in preventing low-birthweight infants and reducing the need for neonatal intensive care hospital services. Each such report shall include an evaluation of how the ratio of expenditures for treating low-birthweight infants compared with the investment in promoting healthy births and infants in local community areas throughout Illinois relates to healthy infant development in those areas.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.25

    (305 ILCS 5/5-5.25)
    Sec. 5-5.25. Access to psychiatric mental health services. The General Assembly finds that providing access to psychiatric mental health services in a timely manner will improve the quality of life for persons suffering from mental illness and will contain health care costs by avoiding the need for more costly inpatient hospitalization. The Department of Healthcare and Family Services shall reimburse psychiatrists and federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act for mental health services provided by psychiatrists, as authorized by Illinois law, to recipients via telepsychiatry. The Department, by rule, shall establish (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located, and (ii) a method to reimburse providers for mental health services provided by telepsychiatry.
    On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12.)

305 ILCS 5/5-5.26

    (305 ILCS 5/5-5.26)
    Sec. 5-5.26. Multiple sclerosis; home services; waiver. The Department of Healthcare and Family Services shall apply for a waiver of federal law and regulations to the extent necessary to claim federal financial participation for medical assistance for services provided under the Department of Human Services' Home Services Program for persons with multiple sclerosis who are (i) over 60 years of age, and (ii) have assets not exceeding $17,500. In determining whether a person's assets meet this requirement, the Department must disregard retirement assets up to a total of $500,000 and disregard all life insurance assets.
(Source: P.A. 95-744, eff. 7-18-08.)

305 ILCS 5/5-5a

    (305 ILCS 5/5-5a) (from Ch. 23, par. 5-5a)
    Sec. 5-5a. Waiver for home and community-based services. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow payment for home and community-based services under this Article.
    The Department, in cooperation with the Department on Aging, the Department of Human Services and any other relevant State, local or federal government agency, may establish a nursing home pre-screening program to determine whether the applicant, eligible for medical assistance under this Article, may use home and community-based services as a reasonable, lower-cost alternative form of care. For the purpose of this Section, "home and community-based services" may include, but are not limited to, those services provided under subsection (f) of Section 3 of the Disabled Persons Rehabilitation Act and Section 4 of the Illinois Act on the Aging.
(Source: P.A. 89-507, eff. 7-1-97; 89-626, eff. 8-9-96.)

305 ILCS 5/5-5b

    (305 ILCS 5/5-5b) (from Ch. 23, par. 5-5b)
    Sec. 5-5b. Payment Reductions.
    (a) Notwithstanding any other Section in this Code establishing a methodology for determining payment rates or dispensing fees for non-institutional services provided under this Code, the Illinois Department is authorized to reduce those payment rates or dispensing fees with due regard for and subject to budgetary limitations to the extent permitted by federal law.
    (b) The Illinois Department may implement this Section as added by this amendatory Act of 1991 through the use of emergency rules in accordance with the provisions of Section 5.02 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the adoption of rules to implement this Section as added by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare.
(Source: P.A. 87-14.)

305 ILCS 5/5-5c

    (305 ILCS 5/5-5c)
    Sec. 5-5c. Waiver for home and community-based services for traumatic brain injury (TBI) patients. The Department shall apply for a waiver from the United States Health Care Financing Administration to allow payment for home and community-based services under this Article for traumatic brain injury patients.
    The Department shall submit a Home and Community-Based Services TBI Waiver request to the United States Health Care Financing Administration by January 1, 1998. The waiver shall be requested pursuant to Section 1915(c) of the Social Security Act. The Department shall request a waiver of Section 1902(a)(10)(B) of the Social Security Act in order to target home and community-based services to individuals with a traumatic brain injury meeting the Medicaid eligibility criteria set forth in appendices to the Prototype Waiver request.
    Under the waiver, the Department, in cooperation with the Department of Human Services and any other relevant State, local, or federal government agency, may establish a nursing facility pre-screening program to determine whether an applicant who is eligible for medical assistance under this Article and has a traumatic brain injury may use home and community-based services as a reasonable, lower-cost alternative form of care. If a waiver request has not been submitted by January 1, 1998 the Department shall submit the TBI Prototype Waiver request to the United States Health Care Financing Administration.
(Source: P.A. 90-335, eff. 8-8-97.)

305 ILCS 5/5-5d

    (305 ILCS 5/5-5d)
    Sec. 5-5d. Enhanced transition and follow-up services. The Department of Healthcare and Family Services shall apply for any necessary waivers pursuant to Section 1915(c) of the Social Security Act to facilitate the transition from one residential setting to another and follow-up services. Nothing in this Section shall be construed as limiting current similar programs by the Department of Human Services or the Department on Aging.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/5-5e

    (305 ILCS 5/5-5e)
    Sec. 5-5e. Adjusted rates of reimbursement.
    (a) Rates or payments for services in effect on June 30, 2012 shall be adjusted and services shall be affected as required by any other provision of this amendatory Act of the 97th General Assembly. In addition, the Department shall do the following:
        (1) Delink the per diem rate paid for supportive
    
living facility services from the per diem rate paid for nursing facility services, effective for services provided on or after May 1, 2011.
        (2) Cease payment for bed reserves in nursing
    
facilities and specialized mental health rehabilitation facilities.
        (2.5) Cease payment for bed reserves for purposes of
    
inpatient hospitalizations to intermediate care facilities for persons with development disabilities, except in the instance of residents who are under 21 years of age.
        (3) Cease payment of the $10 per day add-on payment
    
to nursing facilities for certain residents with developmental disabilities.
    (b) After the application of subsection (a), notwithstanding any other provision of this Code to the contrary and to the extent permitted by federal law, on and after July 1, 2012, the rates of reimbursement for services and other payments provided under this Code shall further be reduced as follows:
        (1) Rates or payments for physician services, dental
    
services, or community health center services reimbursed through an encounter rate, and services provided under the Medicaid Rehabilitation Option of the Illinois Title XIX State Plan shall not be further reduced.
        (2) Rates or payments, or the portion thereof, paid
    
to a provider that is operated by a unit of local government or State University that provides the non-federal share of such services shall not be further reduced.
        (3) Rates or payments for hospital services delivered
    
by a hospital defined as a Safety-Net Hospital under Section 5-5e.1 of this Code shall not be further reduced.
        (4) Rates or payments for hospital services delivered
    
by a Critical Access Hospital, which is an Illinois hospital designated as a critical care hospital by the Department of Public Health in accordance with 42 CFR 485, Subpart F, shall not be further reduced.
        (5) Rates or payments for Nursing Facility Services
    
shall only be further adjusted pursuant to Section 5-5.2 of this Code.
        (6) Rates or payments for services delivered by long
    
term care facilities licensed under the ID/DD Community Care Act and developmental training services shall not be further reduced.
        (7) Rates or payments for services provided under
    
capitation rates shall be adjusted taking into consideration the rates reduction and covered services required by this amendatory Act of the 97th General Assembly.
        (8) For hospitals not previously described in this
    
subsection, the rates or payments for hospital services shall be further reduced by 3.5%, except for payments authorized under Section 5A-12.4 of this Code.
        (9) For all other rates or payments for services
    
delivered by providers not specifically referenced in paragraphs (1) through (8), rates or payments shall be further reduced by 2.7%.
    (c) Any assessment imposed by this Code shall continue and nothing in this Section shall be construed to cause it to cease.
    (d) Notwithstanding any other provision of this Code to the contrary, subject to federal approval under Title XIX of the Social Security Act, for dates of service on and after July 1, 2014, rates or payments for services provided for the purpose of transitioning children from a hospital to home placement or other appropriate setting by a children's community-based health care center authorized under the Alternative Health Care Delivery Act shall be $683 per day.
    (e) Notwithstanding any other provision of this Code to the contrary, subject to federal approval under Title XIX of the Social Security Act, for dates of service on and after July 1, 2014, rates or payments for home health visits shall be $72.
    (f) Notwithstanding any other provision of this Code to the contrary, subject to federal approval under Title XIX of the Social Security Act, for dates of service on and after July 1, 2014, rates or payments for the certified nursing assistant component of the home health agency rate shall be $20.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; 98-651, eff. 6-16-14.)

305 ILCS 5/5-5e.1

    (305 ILCS 5/5-5e.1)
    Sec. 5-5e.1. Safety-Net Hospitals.
    (a) A Safety-Net Hospital is an Illinois hospital that:
        (1) is licensed by the Department of Public Health as
    
a general acute care or pediatric hospital; and
        (2) is a disproportionate share hospital, as
    
described in Section 1923 of the federal Social Security Act, as determined by the Department; and
        (3) meets one of the following:
            (A) has a MIUR of at least 40% and a charity
        
percent of at least 4%; or
            (B) has a MIUR of at least 50%.
    (b) Definitions. As used in this Section:
        (1) "Charity percent" means the ratio of (i) the
    
hospital's charity charges for services provided to individuals without health insurance or another source of third party coverage to (ii) the Illinois total hospital charges, each as reported on the hospital's OBRA form.
        (2) "MIUR" means Medicaid Inpatient Utilization Rate
    
and is defined as a fraction, the numerator of which is the number of a hospital's inpatient days provided in the hospital's fiscal year ending 3 years prior to the rate year, to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act, 42 USC 1396a et seq., excluding those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of Section 5-2 of this Article, and the denominator of which is the total number of the hospital's inpatient days in that same period, excluding those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of Section 5-2 of this Article.
        (3) "OBRA form" means form HFS-3834, OBRA '93 data
    
collection form, for the rate year.
        (4) "Rate year" means the 12-month period beginning
    
on October 1.
    (c) Beginning July 1, 2012 and ending on June 30, 2018, a hospital that would have qualified for the rate year beginning October 1, 2011, shall be a Safety-Net Hospital.
    (d) No later than August 15 preceding the rate year, each hospital shall submit the OBRA form to the Department. Prior to October 1, the Department shall notify each hospital whether it has qualified as a Safety-Net Hospital.
    (e) The Department may promulgate rules in order to implement this Section.
    (f) Nothing in this Section shall be construed as limiting the ability of the Department to include the Safety-Net Hospitals in the hospital rate reform mandated by Section 14-11 of this Code and implemented under Section 14-12 of this Code and by administrative rulemaking.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; 98-651, eff. 6-16-14.)

305 ILCS 5/5-5e.2

    (305 ILCS 5/5-5e.2)
    Sec. 5-5e.2. Academic medical centers and major teaching hospital status.
    (a) Hospitals dedicated to medical research and medical education shall be classified each State fiscal year in 3 tiers based on specific criteria:
        (1) Tier I. A private academic medical center must:
            (A) be a hospital located in Illinois which is
        
either:
                (i) under common ownership with the college
            
of medicine of a non-public college or university;
                (ii) a freestanding hospital in which the
            
majority of the clinical chiefs of service or clinical department chairs are department chairmen in an affiliated non-public Illinois medical school; or
                (iii) a children's hospital which is
            
separately incorporated and non-integrated into the academic medical center hospital but which is the pediatric partner for an academic medical center hospital and which serves as the primary teaching hospital for pediatrics for its affiliated Illinois medical school. A hospital identified herein is deemed to meet the additional Tier I criteria if its partner academic medical center hospital meets the Tier I criteria;
            (B) serve as the training site for at least 30
        
graduate medical education programs accredited by Accreditation Council for Graduate Medical Education;
            (C) facilitate the training on its campus or on
        
affiliated off-campus sites no less than 500 medical students, interns, residents, and fellows during the calendar year preceding the beginning of the State fiscal year;
            (D) perform, either itself or through its
        
affiliated university, at least $12,000,000 in medical research funded through grants or contracts from the National Institutes of Health either directly or, with respect to hospitals described in item (ii) of subparagraph (A) of this paragraph, have as its affiliated non-public Illinois medical school a medical school that performs either itself or through its affiliated University medical research funded using at least $12,000,000 in grants or contracts from the National Institutes of Health; and
            (E) expend directly or indirectly through an
        
affiliated non-public medical school or as part of a hospital system as defined in paragraph (4) of subsection (h) of Section 3-8 of the Service Use Tax Act no less than $5,000,000 toward medical research and education during the calendar year preceding the beginning of the State fiscal year.
        (2) Tier II. A public academic medical center must:
            (A) be a hospital located in Illinois which is a
        
primary teaching hospital affiliated with;
                (i) University of Illinois School of Medicine
            
at Chicago; or
                (ii) University of Illinois School of
            
Medicine at Peoria; or
                (iii) University of Illinois School of
            
Medicine at Rockford; or
                (iv) University of Illinois School of
            
Medicine at Urbana; or
                (v) Southern Illinois University School of
            
Medicine in Springfield; and
            (B) contribute no less than $2,500,000 toward
        
medical research and education during the calendar year preceding the beginning of the State fiscal year.
        (3) Tier III. A major teaching hospital must:
            (A) be an Illinois hospital with 100 or more
        
interns and residents or with a ratio of interns and residents to beds greater than or equal to 0.25; and
            (B) support at least one graduate medical
        
education program accredited by Accreditation Council for Graduate Medical Education.
    (b) All hospitals seeking to qualify for Tier I, Tier II, or Tier III recognition must annually submit a report to the Department with supporting documentation and attesting to meeting the requirements in this Section. Such reporting must also describe each hospital's education and research activities for the preceding year.
(Source: P.A. 98-104, eff. 7-22-13.)

305 ILCS 5/5-5f

    (305 ILCS 5/5-5f)
    Sec. 5-5f. Elimination and limitations of medical assistance services. Notwithstanding any other provision of this Code to the contrary, on and after July 1, 2012:
        (a) The following services shall no longer be a
    
covered service available under this Code: group psychotherapy for residents of any facility licensed under the Nursing Home Care Act or the Specialized Mental Health Rehabilitation Act of 2013; and adult chiropractic services.
        (b) The Department shall place the following
    
limitations on services: (i) the Department shall limit adult eyeglasses to one pair every 2 years; (ii) the Department shall set an annual limit of a maximum of 20 visits for each of the following services: adult speech, hearing, and language therapy services, adult occupational therapy services, and physical therapy services; on or after October 1, 2014, the annual maximum limit of 20 visits shall expire but the Department shall require prior approval for all individuals for speech, hearing, and language therapy services, occupational therapy services, and physical therapy services; (iii) the Department shall limit adult podiatry services to individuals with diabetes; on or after October 1, 2014, podiatry services shall not be limited to individuals with diabetes; (iv) the Department shall pay for caesarean sections at the normal vaginal delivery rate unless a caesarean section was medically necessary; (v) the Department shall limit adult dental services to emergencies; beginning July 1, 2013, the Department shall ensure that the following conditions are recognized as emergencies: (A) dental services necessary for an individual in order for the individual to be cleared for a medical procedure, such as a transplant; (B) extractions and dentures necessary for a diabetic to receive proper nutrition; (C) extractions and dentures necessary as a result of cancer treatment; and (D) dental services necessary for the health of a pregnant woman prior to delivery of her baby; on or after July 1, 2014, adult dental services shall no longer be limited to emergencies, and dental services necessary for the health of a pregnant woman prior to delivery of her baby shall continue to be covered; and (vi) effective July 1, 2012, the Department shall place limitations and require concurrent review on every inpatient detoxification stay to prevent repeat admissions to any hospital for detoxification within 60 days of a previous inpatient detoxification stay. The Department shall convene a workgroup of hospitals, substance abuse providers, care coordination entities, managed care plans, and other stakeholders to develop recommendations for quality standards, diversion to other settings, and admission criteria for patients who need inpatient detoxification, which shall be published on the Department's website no later than September 1, 2013.
        (c) The Department shall require prior approval of
    
the following services: wheelchair repairs costing more than $400, coronary artery bypass graft, and bariatric surgery consistent with Medicare standards concerning patient responsibility. Wheelchair repair prior approval requests shall be adjudicated within one business day of receipt of complete supporting documentation. Providers may not break wheelchair repairs into separate claims for purposes of staying under the $400 threshold for requiring prior approval. The wholesale price of manual and power wheelchairs, durable medical equipment and supplies, and complex rehabilitation technology products and services shall be defined as actual acquisition cost including all discounts.
        (d) The Department shall establish benchmarks for
    
hospitals to measure and align payments to reduce potentially preventable hospital readmissions, inpatient complications, and unnecessary emergency room visits. In doing so, the Department shall consider items, including, but not limited to, historic and current acuity of care and historic and current trends in readmission. The Department shall publish provider-specific historical readmission data and anticipated potentially preventable targets 60 days prior to the start of the program. In the instance of readmissions, the Department shall adopt policies and rates of reimbursement for services and other payments provided under this Code to ensure that, by June 30, 2013, expenditures to hospitals are reduced by, at a minimum, $40,000,000.
        (e) The Department shall establish utilization
    
controls for the hospice program such that it shall not pay for other care services when an individual is in hospice.
        (f) For home health services, the Department shall
    
require Medicare certification of providers participating in the program and implement the Medicare face-to-face encounter rule. The Department shall require providers to implement auditable electronic service verification based on global positioning systems or other cost-effective technology.
        (g) For the Home Services Program operated by the
    
Department of Human Services and the Community Care Program operated by the Department on Aging, the Department of Human Services, in cooperation with the Department on Aging, shall implement an electronic service verification based on global positioning systems or other cost-effective technology.
        (h) Effective with inpatient hospital admissions on
    
or after July 1, 2012, the Department shall reduce the payment for a claim that indicates the occurrence of a provider-preventable condition during the admission as specified by the Department in rules. The Department shall not pay for services related to an other provider-preventable condition.
        As used in this subsection (h):
        "Provider-preventable condition" means a health care
    
acquired condition as defined under the federal Medicaid regulation found at 42 CFR 447.26 or an other provider-preventable condition.
        "Other provider-preventable condition" means a wrong
    
surgical or other invasive procedure performed on a patient, a surgical or other invasive procedure performed on the wrong body part, or a surgical procedure or other invasive procedure performed on the wrong patient.
        (i) The Department shall implement cost savings
    
initiatives for advanced imaging services, cardiac imaging services, pain management services, and back surgery. Such initiatives shall be designed to achieve annual costs savings.
        (j) The Department shall ensure that beneficiaries
    
with a diagnosis of epilepsy or seizure disorder in Department records will not require prior approval for anticonvulsants.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section 6-240, eff. 7-22-13; 98-104, Article 9, Section 9-5, eff. 7-22-13; 98-651, eff. 6-16-14; 98-756, eff. 7-16-14.)

305 ILCS 5/5-6

    (305 ILCS 5/5-6) (from Ch. 23, par. 5-6)
    Sec. 5-6. Obligations incurred prior to death of a recipient. Obligations incurred but not paid for at the time of a recipient's death for services authorized under Section 5-5, including medical and other care in facilities as defined in the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, or the ID/DD Community Care Act, or in like facilities not required to be licensed under that Act, may be paid, subject to the rules and regulations of the Illinois Department, after the death of the recipient.
(Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813, eff. 7-13-12; 98-104, eff. 7-22-13.)

305 ILCS 5/5-7

    (305 ILCS 5/5-7) (from Ch. 23, par. 5-7)
    Sec. 5-7. (Repealed).
(Source: P.A. 81-487. Repealed by P.A. 93-20, eff. 6-20-03.)

305 ILCS 5/5-8

    (305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
    Sec. 5-8. Practitioners. In supplying medical assistance, the Illinois Department may provide for the legally authorized services of (i) persons licensed under the Medical Practice Act of 1987, as amended, except as hereafter in this Section stated, whether under a general or limited license, (ii) persons licensed or registered under other laws of this State to provide dental, medical, pharmaceutical, optometric, podiatric, or nursing services, or other remedial care recognized under State law, and (iii) persons licensed under other laws of this State as a clinical social worker. The Department may not provide for legally authorized services of any physician who has been convicted of having performed an abortion procedure in a wilful and wanton manner on a woman who was not pregnant at the time such abortion procedure was performed. The utilization of the services of persons engaged in the treatment or care of the sick, which persons are not required to be licensed or registered under the laws of this State, is not prohibited by this Section.
(Source: P.A. 95-518, eff. 8-28-07.)

305 ILCS 5/5-9

    (305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
    Sec. 5-9. Choice of Medical Dispensers. Applicants and recipients shall be entitled to free choice of those qualified practitioners, hospitals, nursing homes, and other dispensers of medical services meeting the requirements and complying with the rules and regulations of the Illinois Department. However, the Director of Healthcare and Family Services may, after providing reasonable notice and opportunity for hearing, deny, suspend or terminate any otherwise qualified person, firm, corporation, association, agency, institution, or other legal entity, from participation as a vendor of goods or services under the medical assistance program authorized by this Article if the Director finds such vendor of medical services in violation of this Act or the policy or rules and regulations issued pursuant to this Act. Any physician who has been convicted of performing an abortion procedure in a wilful and wanton manner upon a woman who was not pregnant at the time such abortion procedure was performed shall be automatically removed from the list of physicians qualified to participate as a vendor of medical services under the medical assistance program authorized by this Article.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/5-10

    (305 ILCS 5/5-10) (from Ch. 23, par. 5-10)
    Sec. 5-10. Entitlement to Social Services. Persons receiving medical assistance shall be entitled to receive, under Article IX and the Illinois Act on the Aging, such rehabilitative, training or other social services as are appropriate to their condition.
(Source: P.A. 92-651, eff. 7-11-02.)

305 ILCS 5/5-11

    (305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
    Sec. 5-11. Co-operative arrangements; contracts with other State agencies, health care and rehabilitation organizations, and fiscal intermediaries.
    (a) The Illinois Department may enter into co-operative arrangements with State agencies responsible for administering or supervising the administration of health services and vocational rehabilitation services to the end that there may be maximum utilization of such services in the provision of medical assistance.
    The Illinois Department shall, not later than June 30, 1993, enter into one or more co-operative arrangements with the Department of Mental Health and Developmental Disabilities providing that the Department of Mental Health and Developmental Disabilities will be responsible for administering or supervising all programs for services to persons in community care facilities for persons with developmental disabilities, including but not limited to intermediate care facilities, that are supported by State funds or by funding under Title XIX of the federal Social Security Act. The responsibilities of the Department of Mental Health and Developmental Disabilities under these agreements are transferred to the Department of Human Services as provided in the Department of Human Services Act.
    The Department may also contract with such State health and rehabilitation agencies and other public or private health care and rehabilitation organizations to act for it in supplying designated medical services to persons eligible therefor under this Article. Any contracts with health services or health maintenance organizations shall be restricted to organizations which have been certified as being in compliance with standards promulgated pursuant to the laws of this State governing the establishment and operation of health services or health maintenance organizations. The Department shall renegotiate the contracts with health maintenance organizations and managed care community networks that took effect August 1, 2003, so as to produce $70,000,000 savings to the Department net of resulting increases to the fee-for-service program for State fiscal year 2006. The Department may also contract with insurance companies or other corporate entities serving as fiscal intermediaries in this State for the Federal Government in respect to Medicare payments under Title XVIII of the Federal Social Security Act to act for the Department in paying medical care suppliers. The provisions of Section 9 of "An Act in relation to State finance", approved June 10, 1919, as amended, notwithstanding, such contracts with State agencies, other health care and rehabilitation organizations, or fiscal intermediaries may provide for advance payments.
    (b) For purposes of this subsection (b), "managed care community network" means an entity, other than a health maintenance organization, that is owned, operated, or governed by providers of health care services within this State and that provides or arranges primary, secondary, and tertiary managed health care services under contract with the Illinois Department exclusively to persons participating in programs administered by the Illinois Department.
    The Illinois Department may certify managed care community networks, including managed care community networks owned, operated, managed, or governed by State-funded medical schools, as risk-bearing entities eligible to contract with the Illinois Department as Medicaid managed care organizations. The Illinois Department may contract with those managed care community networks to furnish health care services to or arrange those services for individuals participating in programs administered by the Illinois Department. The rates for those provider-sponsored organizations may be determined on a prepaid, capitated basis. A managed care community network may choose to contract with the Illinois Department to provide only pediatric health care services. The Illinois Department shall by rule adopt the criteria, standards, and procedures by which a managed care community network may be permitted to contract with the Illinois Department and shall consult with the Department of Insurance in adopting these rules.
    A county provider as defined in Section 15-1 of this Code may contract with the Illinois Department to provide primary, secondary, or tertiary managed health care services as a managed care community network without the need to establish a separate entity and shall be deemed a managed care community network for purposes of this Code only to the extent it provides services to participating individuals. A county provider is entitled to contract with the Illinois Department with respect to any contracting region located in whole or in part within the county. A county provider is not required to accept enrollees who do not reside within the county.
    In order to (i) accelerate and facilitate the development of integrated health care in contracting areas outside counties with populations in excess of 3,000,000 and counties adjacent to those counties and (ii) maintain and sustain the high quality of education and residency programs coordinated and associated with local area hospitals, the Illinois Department may develop and implement a demonstration program from managed care community networks owned, operated, managed, or governed by State-funded medical schools. The Illinois Department shall prescribe by rule the criteria, standards, and procedures for effecting this demonstration program.
    A managed care community network that contracts with the Illinois Department to furnish health care services to or arrange those services for enrollees participating in programs administered by the Illinois Department shall do all of the following:
        (1) Provide that any provider affiliated with the
    
managed care community network may also provide services on a fee-for-service basis to Illinois Department clients not enrolled in such managed care entities.
        (2) Provide client education services as determined
    
and approved by the Illinois Department, including but not limited to (i) education regarding appropriate utilization of health care services in a managed care system, (ii) written disclosure of treatment policies and restrictions or limitations on health services, including, but not limited to, physical services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, and radiological examinations, and (iii) written notice that the enrollee may receive from another provider those covered services that are not provided by the managed care community network.
        (3) Provide that enrollees within the system may
    
choose the site for provision of services and the panel of health care providers.
        (4) Not discriminate in enrollment or disenrollment
    
practices among recipients of medical services or enrollees based on health status.
        (5) Provide a quality assurance and utilization
    
review program that meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.
        (6) Issue a managed care community network
    
identification card to each enrollee upon enrollment. The card must contain all of the following:
            (A) The enrollee's health plan.
            (B) The name and telephone number of the
        
enrollee's primary care physician or the site for receiving primary care services.
            (C) A telephone number to be used to confirm
        
eligibility for benefits and authorization for services that is available 24 hours per day, 7 days per week.
        (7) Ensure that every primary care physician and
    
pharmacy in the managed care community network meets the standards established by the Illinois Department for accessibility and quality of care. The Illinois Department shall arrange for and oversee an evaluation of the standards established under this paragraph (7) and may recommend any necessary changes to these standards.
        (8) Provide a procedure for handling complaints that
    
meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.
        (9) Maintain, retain, and make available to the
    
Illinois Department records, data, and information, in a uniform manner determined by the Illinois Department, sufficient for the Illinois Department to monitor utilization, accessibility, and quality of care.
        (10) (Blank).
    The Illinois Department shall contract with an entity or entities to provide external peer-based quality assurance review for the managed health care programs administered by the Illinois Department. The entity shall meet all federal requirements for an external quality review organization.
    Each managed care community network must demonstrate its ability to bear the financial risk of serving individuals under this program. The Illinois Department shall by rule adopt standards for assessing the solvency and financial soundness of each managed care community network. Any solvency and financial standards adopted for managed care community networks shall be no more restrictive than the solvency and financial standards adopted under Section 1856(a) of the Social Security Act for provider-sponsored organizations under Part C of Title XVIII of the Social Security Act.
    The Illinois Department may implement the amendatory changes to this Code made by this amendatory Act of 1998 through the use of emergency rules in accordance with Section 5-45 of the Illinois Administrative Procedure Act. For purposes of that Act, the adoption of rules to implement these changes is deemed an emergency and necessary for the public interest, safety, and welfare.
    (c) Not later than June 30, 1996, the Illinois Department shall enter into one or more cooperative arrangements with the Department of Public Health for the purpose of developing a single survey for nursing facilities, including but not limited to facilities funded under Title XVIII or Title XIX of the federal Social Security Act or both, which shall be administered and conducted solely by the Department of Public Health. The Departments shall test the single survey process on a pilot basis, with both the Departments of Public Aid and Public Health represented on the consolidated survey team. The pilot will sunset June 30, 1997. After June 30, 1997, unless otherwise determined by the Governor, a single survey shall be implemented by the Department of Public Health which would not preclude staff from the Department of Healthcare and Family Services (formerly Department of Public Aid) from going on-site to nursing facilities to perform necessary audits and reviews which shall not replicate the single State agency survey required by this Act. This Section shall not apply to community or intermediate care facilities for persons with developmental disabilities.
    (d) Nothing in this Code in any way limits or otherwise impairs the authority or power of the Illinois Department to enter into a negotiated contract pursuant to this Section with a managed care community network or a health maintenance organization, as defined in the Health Maintenance Organization Act, that provides for termination or nonrenewal of the contract without cause, upon notice as provided in the contract, and without a hearing.
(Source: P.A. 95-331, eff. 8-21-07; 96-1501, eff. 1-25-11.)

305 ILCS 5/5-11.1

    (305 ILCS 5/5-11.1)
    Sec. 5-11.1. Cooperative arrangements; contracts. The Illinois Department may enter into cooperative arrangements with State agencies responsible for administering or supervising the administration of health services and vocational rehabilitation services to maximize utilization of these services in the provision of medical assistance.
    The Illinois Department shall, not later than June 30, 1994, enter into one or more cooperative arrangements with the Department of Mental Health and Developmental Disabilities providing that the Department of Mental Health and Developmental Disabilities will be responsible for administering or supervising all programs for services to persons in community care facilities for persons with mental illness, including but not limited to intermediate care facilities, that are supported by State funds or by funding under Title XIX of the federal Social Security Act. The responsibilities of the Department of Mental Health and Developmental Disabilities under these agreements are transferred to the Department of Human Services as provided in the Department of Human Services Act.
    The Department may also contract with State health and rehabilitation agencies and other public or private health care and rehabilitation organizations to act for it in supplying designated medical services to persons eligible under this Section. Any contracts with health services or health maintenance organizations shall be restricted to organizations which have been certified as being in compliance with standards promulgated under the laws of this State governing the establishment and operation of health services or health maintenance organizations. The Department may also contract with insurance companies or other corporate entities serving as fiscal intermediaries in this State for the federal government in respect to Medicare payments under Title XVIII of the federal Social Security Act to act for the Department in paying medical care suppliers. Nothing in this Section shall be construed to abrogate any existing doctor/patient relationships with Department of Healthcare and Family Services recipients or the free choice of clients or their guardians to select a physician to provide medical care. The provisions of Section 9 of the State Finance Act notwithstanding, such contracts with State agencies, other health care and rehabilitation organizations, or fiscal intermediaries may provide for advance payments.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/5-11a

    (305 ILCS 5/5-11a)
    Sec. 5-11a. Health Benefit Information Systems.
    (a) It is the intent of the General Assembly to support unified electronic systems initiatives that will improve management of information related to medical assistance programs. This will include improved management capabilities and new systems for Eligibility, Verification, and Enrollment (EVE) that will simplify and increase efficiencies in and access to the medical assistance programs and ensure program integrity. The Department of Healthcare and Family Services, in coordination with the Department of Human Services and other appropriate state agencies, shall develop a plan by July 1, 2011, that will:
        (1) Subject to federal and State privacy and
    
confidentiality laws and regulations, meet standards for timely eligibility verification and enrollment, and annual redetermination of eligibility, of applicants for and recipients of means-tested health benefits sponsored by the State, including medical assistance under this Code.
        (2) Receive and update data electronically from the
    
Social Security Administration, the U.S. Postal Service, the Illinois Secretary of State, the Department of Revenue, the Department of Employment Security, and other governmental entities, as appropriate and to the extent allowed by law, for verification of any factor of eligibility for medical assistance and for updating addresses of applicants and recipients of medical assistance and other health benefit programs administered by the Department. Data relevant to eligibility shall be provided for no other purpose than to verify the eligibility of new applicants or current recipients of health benefits provided by the State. Data shall be requested or provided for any individual only insofar as that new applicant or current recipient's circumstances are relevant to that individual's or another individual's eligibility for State-sponsored health benefits.
        (3) Meet federal requirements for timely installation
    
by January 1, 2014 to provide integration with a Health Benefits Exchange pursuant to the requirements of the federal Affordable Care Act and the Reconciliation Act and any subsequent amendments thereto and to ensure capture of the maximum available federal financial participation (FFP).
        (4) Meet federal requirements for compliance with
    
architectural standards, including, but not limited to, (i) the use of a module development as outlined by the Medicaid Information Technology Architecture standards, (ii) the use of federally approved open-interfaces where they exist, (iii) the use or the creation of open-interfaces where necessary, and (iv) the use of rules technology that can dynamically accept and modify rules in standard formats.
        (5) Include plans to ensure coordination with the
    
State of Illinois Framework Project that will (i) expedite and simplify access to services provided by Illinois human services programs; (ii) streamline administration and data sharing; (iii) enhance planning capacity, program evaluation, and fraud detection or prevention with access to cross-agency data; and (iv) simplify service reporting for contracted providers.
    (b) The Department of Healthcare and Family Services shall continue to plan for and implement a new Medicaid Management Information System (MMIS) and upgrade the capabilities of the MMIS data warehouse. Upgrades shall include, among other things, enhanced capabilities in data analysis including the ability to identify risk factors that could impact the treatment and resulting quality of care, and tools that perform predictive analytics on data applying to newborns, women with high risk pregnancies, and other populations served by the Department.
    (c) The Department of Healthcare and Family Services shall report in its annual Medical Assistance program report each April through April, 2015 on the progress and implementation of this plan.
(Source: P.A. 96-1501, eff. 1-25-11.)

305 ILCS 5/5-12

    (305 ILCS 5/5-12) (from Ch. 23, par. 5-12)
    Sec. 5-12. Funeral and burial. Upon the death of a recipient who qualified under class 2, 3 or 4 of Section 5-2, if his estate is insufficient to pay his funeral and burial expenses and if no other resources, including assistance from legally responsible relatives, are available for such purposes, there shall be paid, in accordance with the standards, rules and regulations of the Illinois Department of Human Services, such reasonable amounts as may be necessary to meet the costs of the funeral, burial space, and cemetery charges, or to reimburse any person not financially responsible for the deceased who has voluntarily made expenditures for such costs.
(Source: P.A. 92-651, eff. 7-11-02.)

305 ILCS 5/5-13

    (305 ILCS 5/5-13) (from Ch. 23, par. 5-13)
    Sec. 5-13. Claim against estate of recipients. To the extent permitted under the federal Social Security Act, the amount expended under this Article (1) for a person of any age who is an inpatient in a nursing facility, an intermediate care facility for the intellectually disabled, or other medical institution, or (2) for a person aged 55 or more, shall be a claim against the person's estate or a claim against the estate of the person's spouse, regardless of the order of death, but no recovery may be had thereon until after the death of the surviving spouse, if any, and then only at such time when there is no surviving child who is under age 21, or blind, or permanently and totally disabled. This Section, however, shall not bar recovery at the death of the person of amounts of medical assistance paid to or in his behalf to which he was not entitled; provided that such recovery shall not be enforced against any real estate while it is occupied as a homestead by the surviving spouse or other dependent, if no claims by other creditors have been filed against the estate, or if such claims have been filed, they remain dormant for failure of prosecution or failure of the claimant to compel administration of the estate for the purpose of payment. The term "estate", as used in this Section, with respect to a deceased person, means all real and personal property and other assets included within the person's estate, as that term is used in the Probate Act of 1975; however, in the case of a deceased person who has received (or is entitled to receive) benefits under a long-term care insurance policy in connection with which assets or resources are disregarded to the extent that payments are made or because the deceased person received (or was entitled to receive) benefits under a long-term care insurance policy, "estate" also includes any other real and personal property and other assets in which the deceased person had any legal title or interest at the time of his or her death (to the extent of that interest), including assets conveyed to a survivor, heir, or assignee of the deceased person through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement. The term "homestead", as used in this Section, means the dwelling house and contiguous real estate occupied by a surviving spouse or relative, as defined by the rules and regulations of the Illinois Department, regardless of the value of the property.
    A claim arising under this Section against assets conveyed to a survivor, heir, or assignee of the deceased person through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangement is not effective until the claim is recorded or filed in the manner provided for a notice of lien in Section 3-10.2. The claim is subject to the same requirements and conditions to which liens on real property interests are subject under Sections 3-10.1 through 3-10.10. A claim arising under this Section attaches to interests owned or subsequently acquired by the estate of a recipient or the estate of a recipient's surviving spouse. The transfer or conveyance of any real or personal property of the estate as defined in this Section shall be subject to the fraudulent transfer conditions that apply to real property in Section 3-11 of this Code.
    The provisions of this Section shall not affect the validity of claims against estates for medical assistance provided prior to January 1, 1966 to aged, blind, or disabled persons receiving aid under Articles V, VII and VII-A of the 1949 Code.
(Source: P.A. 97-227, eff. 1-1-12.)

305 ILCS 5/5-13.2

    (305 ILCS 5/5-13.2)
    Sec. 5-13.2. Notice of claim for payment or against estate. If the Illinois Department determines, more than 120 days after a person becomes an institutionalized person, that (i) the institutionalized person, the institutionalized person's spouse, or any other person is required under this Code to reimburse the Illinois Department for any part of the amount of medical assistance provided under this Article to or on behalf of the institutionalized person or (ii) the institutionalized person's estate is liable for any amount of medical assistance provided to or on behalf of the institutionalized person, the Illinois Department shall not make any claim for payment of that amount on demand, but rather shall establish, in cooperation with the institutionalized person (and that person's spouse or primary caretaker, if applicable), a schedule for payment of the amount owed to the Illinois Department.
(Source: P.A. 88-162; 88-670, eff. 12-2-94.)

305 ILCS 5/5-13.5

    (305 ILCS 5/5-13.5)
    Sec. 5-13.5. Lien on real property interests. The State shall have a lien on all legal and equitable interests of recipients in real property, whether vested or contingent, including legal and equitable rights and interests of the recipient to coal, gas, oil, iron, and other underground mineral resources, for medical assistance paid under this Article and for payments made to preserve the lien, to the extent those liens are allowed under the federal Social Security Act. The lien shall attach to those interests owned or subsequently acquired by persons who were recipients on or after the effective date of this amendatory Act of 1993. The liens shall be recorded and filed and are otherwise subject to all the conditions of Sections 3-10.1 through 3-10.10 of this Code.
(Source: P.A. 88-85; 88-670, eff. 12-2-94.)

305 ILCS 5/5-14

    (305 ILCS 5/5-14) (from Ch. 23, par. 5-14)
    Sec. 5-14. Exemption for Townships. Nothing in this Article shall be construed as requiring townships to provide, in whole or in part, medical assistance to persons who are not residents of the State of Illinois.
    In all instances under this Article where medical aid or assistance to a person who is not a resident of this State would otherwise be in whole or in part, the responsibility of a township, the Illinois Department shall be responsible for such aid or assistance.
    The Illinois Department shall, by rule or regulation, insure that provision of such aid or assistance to a non-resident is identical to the uniform standard of eligibility established by the Illinois Department.
(Source: P.A. 81-519.)

305 ILCS 5/5-15

    (305 ILCS 5/5-15) (from Ch. 23, par. 5-15)
    Sec. 5-15. (a) The Illinois Department is authorized to contract with community based organizations serving low income communities for a three year period to demonstrate how and the extent to which preventive health programs can decrease utilization of medical care services and/or improve health status.
    (b) As used in this Section (1) a community based organization is an organization established as a not-for-profit corporation under laws of the State of Illinois which serves a defined geographic community and is governed by members of that community; and (2) a preventive health program is any program, service or intervention the purpose of which is to identify, resolve, or ameliorate problems which contribute to the utilization of medical services.
    (c) The Illinois Department is authorized, for evaluation purposes, to release names of recipients and other pertinent identification and medical utilization information to the community organizations under contract.
    (d) Contractors shall maintain strict confidentiality of information released by the Illinois Department by following guidelines established by the Illinois Department, which shall require that recipients sign a release for any further use or disclosure of such information.
(Source: P.A. 93-632, eff. 2-1-04.)

305 ILCS 5/5-15.5

    (305 ILCS 5/5-15.5)
    Sec. 5-15.5. Preventive physical examinations; demonstration program.
    (a) The Illinois Department may establish and implement a demonstration program of preventive physical examinations over a 3-year period commencing on January 1, 1994, for persons receiving assistance under Article IV of this Code and persons eligible for assistance under this Article who are otherwise eligible for assistance under Article IV but who fail to qualify for cash assistance under Article IV on the basis of need. Notwithstanding any other provision of this Section, however, persons who are pregnant or who are less than 21 years of age shall not be eligible to participate in the demonstration program. The demonstration program may be implemented for recipients in at least 2 counties, one with a population of not more than 650,000 as determined by the 1990 federal census, and one with a population of not more than 100,000 as determined by the 1990 federal census. The Illinois Department may establish by rule the nature and scope of the preventive physical examinations required under this Section, except that the services may include, as appropriate, blood pressure reading, complete blood test appropriate to the population and risk factors, family planning, nutrition counselling, smoking evaluation, temperature, urinalysis, chest x-ray, tuberculosis screening, and appropriate referrals.
    (b) Participation in the demonstration program shall be voluntary, and eligible recipients shall not be subject to sanctions for refusing or failing to submit to a preventive physical examination or any portion of such an examination. The Illinois Department may by rule limit each eligible recipient to one examination during the demonstration period.
    (c) For the purpose of carrying out its responsibilities under this Section, the Illinois Department is authorized to enter into cooperative arrangements with for-profit and non-profit medical clinics and hospitals, local health departments, and other providers of medical services. The Illinois Department of Public Health shall cooperate in the development and establishment of this demonstration program. During the period of the demonstration program, the Illinois Department of Public Aid shall study the cost benefit of providing preventive physical examinations to the targeted group of recipients of public aid.
    (d) Implementation of the demonstration program shall be contingent on the receipt of all necessary federal waivers.
(Source: P.A. 88-396.)

305 ILCS 5/5-16

    (305 ILCS 5/5-16) (from Ch. 23, par. 5-16)
    Sec. 5-16. Managed Care. The Illinois Department may develop and implement a Primary Care Sponsor System consistent with the provisions of this Section. The purpose of this managed care delivery system shall be to contain the costs of providing medical care to Medicaid recipients by having one provider responsible for managing all aspects of a recipient's medical care. This managed care system shall have the following characteristics:
        (a) The Department, by rule, shall establish criteria
    
to determine which clients must participate in this program;
        (b) Providers participating in the program may be
    
paid an amount per patient per month, to be set by the Illinois Department, for managing each recipient's medical care;
        (c) Providers eligible to participate in the program
    
shall be physicians licensed to practice medicine in all its branches, and the Illinois Department may terminate a provider's participation if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department;
        (d) Each recipient required to participate in the
    
program must select from a panel of primary care providers or networks established by the Department in their communities;
        (e) A recipient may change his designated primary
    
care provider:
            (1) when the designated source becomes
        
unavailable, as the Illinois Department shall determine by rule; or
            (2) when the designated primary care provider
        
notifies the Illinois Department that it wishes to withdraw from any obligation as primary care provider; or
            (3) in other situations, as the Illinois
        
Department shall provide by rule;
        (f) The Illinois Department shall, by rule, establish
    
procedures for providing medical services when the designated source becomes unavailable or wishes to withdraw from any obligation as primary care provider taking into consideration the need for emergency or temporary medical assistance and ensuring that the recipient has continuous and unrestricted access to medical care from the date on which such unavailability or withdrawal becomes effective until such time as the recipient designates a primary care source;
        (g) Only medical care services authorized by a
    
recipient's designated provider, except for emergency services, services performed by a provider that is owned or operated by a county and that provides non-emergency services without regard to ability to pay and such other services as provided by the Illinois Department, shall be subject to payment by the Illinois Department. The Illinois Department shall enter into an intergovernmental agreement with each county that owns or operates such a provider to develop and implement policies to minimize the provision of medical care services provided by county owned or operated providers pursuant to the foregoing exception.
    The Illinois Department shall seek and obtain necessary authorization provided under federal law to implement such a program including the waiver of any federal regulations.
    The Illinois Department may implement the amendatory changes to this Section made by this amendatory Act of 1991 through the use of emergency rules in accordance with the provisions of Section 5.02 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the adoption of rules to implement the amendatory changes to this Section made by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare.
    The Illinois Department may establish a managed care system demonstration program, on a limited basis, as described in this Section. The demonstration program shall terminate on June 30, 1997. Within 30 days after the end of each year of the demonstration program's operation, the Illinois Department shall report to the Governor and the General Assembly concerning the operation of the demonstration program.
(Source: P.A. 87-14; 88-490.)

305 ILCS 5/5-16.1

    (305 ILCS 5/5-16.1) (from Ch. 23, par. 5-16.1)
    Sec. 5-16.1. Case Management Services. The Illinois Department may develop, implement and evaluate a Case Management Services Program which provides services consistent with the provisions of this Section, and the Inter-Agency Agreement between the Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Public Health, for a targeted population on a less than Statewide basis in the State of Illinois. The purpose of this Case Management Services Program shall be to assist eligible participants in gaining access to needed medical, social, educational and other services thereby reducing the likelihood of long-term welfare dependency. The Case Management Services Program shall have the following characteristics:
        (a) It shall be conducted for a period of no less
    
than 5 consecutive fiscal years in one urban area containing a high proportion, as determined by Department of Healthcare and Family Services and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment and in one rural area containing a high proportion, as determined by Department of Healthcare and Family Services and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment.
        (b) Providers participating in the program shall be
    
paid an amount per patient per month, to be set by the Illinois Department, for the case management services provided.
        (c) Providers eligible to participate in the program
    
shall be nurses or social workers, licensed to practice in Illinois, who comply with the rules and regulations established by the Illinois Department and the Inter-Agency Agreement between the Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Public Health. The Illinois Department may terminate a provider's participation in the program if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department.
        (d) Each eligible participant in an area where the
    
Case Management Services Program is being conducted may voluntarily designate a case manager, of her own choosing to assume responsibility for her care.
        (e) A participant may change her designated case
    
manager provided that she informs the Illinois Department by the 20th day of the month in order for the change to be effective in the following month.
        (f) The Illinois Department shall, by rule, establish
    
procedures for providing case management services when the designated source becomes unavailable or wishes to withdraw from any obligation as case management services provider.
        (g) In accordance with rules adopted by the Illinois
    
Department, a participant may discontinue participation in the program upon timely notice to the Illinois Department, in which case the participant shall remain eligible for assistance under all applicable provisions of Article V of this Code.
    The Illinois Department shall take any necessary steps to obtain authorization or waiver under federal law to implement a Case Management Services Program. Participation shall be voluntary for the provider and the recipient.
(Source: P.A. 95-331, eff. 8-21-07.)