305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-13.5)

Sec. 5-13.5. (Repealed).

(Source: P.A. 88-670, eff. 12-2-94. Repealed by P.A. 102-1037, eff. 6-2-22.)

(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) (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)

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) (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) (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.)

(305 ILCS 5/5-16.2)

Sec. 5-16.2. Long range plan for case management. The Illinois Department shall develop a long range plan for the implementation of case management services, as defined in Section 5-16.1 of this Act, throughout Illinois. The long range plan shall include: (i) a geographic overview of the State and the proportion, as determined by the Department of Public Aid and the Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment; (ii) identification of high proportion areas; (iii) goals for reducing the likelihood of long-term welfare dependency; (iv) the time frames for accomplishing the identified goals; and (v) specific recommendations for administrative or legislative policies and programs necessary to complete the identified goals. The long range plan shall take into consideration other resources currently serving the identified population. The long range plan shall be completed no later than July 1, 1994, and provided to the Governor and the General Assembly in the form of a written report.

(Source: P.A. 88-70.)

(305 ILCS 5/5-16.3)

Sec. 5-16.3. (Repealed).

(Source: P.A. 90-742, eff. 8-13-98. Repealed by P.A. 92-370, eff. 8-15-01.)

(305 ILCS 5/5-16.4)

Sec. 5-16.4. (Repealed).

(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 99-933, eff. 1-27-17.)

(305 ILCS 5/5-16.5)

Sec. 5-16.5. Expedited payments.

(a) (Blank).

(b) In a county with a population of 3,000,000 or more, a managed care community network shall receive expedited payment of its capitated reimbursement for each of its managed care enrollees if both of the following criteria are met:

(1) At least 75% of its membership is composed of hospitals that are qualified on or after July 1, 1994 as disproportionate share hospitals.

(2) At least 75% of its managed care enrollees receive services at the disproportionate share hospitals or those hospitals' affiliated sites.

(c) For counties whose population is less than 3,000,000, the Illinois Department shall establish by rule the terms and conditions under which a managed care community network shall receive expedited payment, including a determination of the qualifying percentage criteria for disproportionate share hospitals and managed care enrollees within a network receiving services at disproportionate share hospitals or their affiliated sites.

(Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95.)

(305 ILCS 5/5-16.6)

Sec. 5-16.6. Provider compliance with certain requirements. The Illinois Department shall inquire of appropriate State agencies concerning the status of all providers' compliance with State income tax requirements, child support payments in accordance with Article X of this Code, and educational loans guaranteed by the Illinois State Scholarship Commission. The Illinois Department may suspend from participation in the medical assistance program, after reasonable notice and opportunity for a hearing in accordance with Section 12-4.25 of this Code, those providers not in compliance with these requirements, unless payment arrangements acceptable to the appropriate State agency are made.

(Source: P.A. 90-655, eff. 7-30-98.)

(305 ILCS 5/5-16.7)

Sec. 5-16.7. Post-parturition care. The medical assistance program shall provide the post-parturition care benefits required to be covered by a policy of accident and health insurance under Section 356s of the Illinois Insurance Code.

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 5/5-16.7a)

Sec. 5-16.7a. Reimbursement for epidural anesthesia services. In addition to other procedures authorized by the Department under this Code, the Department shall provide reimbursement to medical providers for epidural anesthesia services when ordered by the attending practitioner at the time of delivery.

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 5/5-16.8)

(Text of Section from P.A. 102-1117)

Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, and 356z.60 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.

The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.

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.

To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.

(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff. 1-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)

(Text of Section from P.A. 103-84, 103-91, and 103-420)

Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, and 356z.61 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.

The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.

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.

To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.

(Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24.)

(305 ILCS 5/5-16.9)

Sec. 5-16.9. Woman's health care provider. The medical assistance program is subject to the provisions of Section 356r of the Illinois Insurance Code. The Illinois Department shall adopt rules to implement the requirements of Section 356r of the Illinois Insurance Code in the medical assistance program including managed care components.

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 5/5-16.10)

Sec. 5-16.10. Managed care entities; marketing. A managed health care entity providing services under this Article V may not engage in door-to-door marketing activities or marketing activities at an office of the Illinois Department or a county department in order to enroll recipients in the entity's health care delivery system. The Department shall adopt rules defining "marketing activities" prohibited by this Section.

Before a managed health care entity providing services under this Article V may market its health care delivery system to recipients, the Illinois Department must approve a marketing plan submitted by the entity to the Illinois Department. The Illinois Department shall adopt guidelines for approving marketing plans submitted by managed health care entities under this Section. Besides prohibiting door-to-door marketing activities and marketing activities at public aid offices, the guidelines shall include at least the following:

(1) A managed health care entity may not offer or provide any gift, favor, or other inducement in marketing its health care delivery system to integrated health care program enrollees. A managed health care entity may provide health care related items that are of nominal value and pre-approved by the Department to prospective enrollees. A managed health care entity may also provide to enrollees health care related items that have been pre-approved by the Department as an incentive to manage their health care appropriately.

(2) All persons employed or otherwise engaged by a managed health care entity to market the entity's health care delivery system to recipients or to supervise that marketing shall register with the Illinois Department.

The Inspector General appointed under Section 12-13.1 may conduct investigations to determine whether the marketing practices of managed health care entities providing services under this Article V comply with the guidelines.

(Source: P.A. 90-538, eff. 12-1-97.)

(305 ILCS 5/5-16.11)

Sec. 5-16.11. Uniform standards applied to managed care entities. Any managed care entity providing services under this Code shall use a pharmacy formulary that is no more restrictive than the Illinois Department's pharmaceutical program.

(Source: P.A. 92-370, eff. 8-15-01.)

(305 ILCS 5/5-16.12)

Sec. 5-16.12. Managed Care Reform and Patient Rights Act. The medical assistance program and other programs administered by the Department are subject to the provisions of the Managed Care Reform and Patient Rights Act. The Department may adopt rules to implement those provisions. These rules shall require compliance with that Act in the medical assistance managed care programs and other programs administered by the Department. The medical assistance fee-for-service program is not subject to the provisions of the Managed Care Reform and Patient Rights Act.

Nothing in the Managed Care Reform and Patient Rights Act shall be construed to mean that the Department is a health care plan as defined in that Act simply because the Department enters into contractual relationships with health care plans.

(Source: P.A. 91-617, eff. 1-1-00.)

(305 ILCS 5/5-16.13)

Sec. 5-16.13. (Repealed).

(Source: P.A. 93-674, eff. 6-10-04. Repealed internally, eff. 12-31-04.)

(305 ILCS 5/5-17) (from Ch. 23, par. 5-17)

Sec. 5-17. Programs to improve access to hospital care.

(a) (1) The General Assembly finds:

(A) That while hospitals have traditionally provided charitable care to indigent patients, this burden is not equally borne by all hospitals operating in this State. Some hospitals continue to provide significant amounts of care to low-income persons while others provide very little such care; and

(B) That access to hospital care in this State by the indigent citizens of Illinois would be seriously impaired by the closing of hospitals that provide significant amounts of care to low-income persons.

(2) To help expand the availability of hospital care for all citizens of this State, it is the policy of the State to implement programs that more equitably distribute the burden of providing hospital care to Illinois' low-income population and that improve access to health care in Illinois.

(3) The Illinois Department may develop and implement a program that lessens the burden of providing hospital care to Illinois' low-income population, taking into account the costs that must be incurred by hospitals providing significant amounts of care to low-income persons, and may develop adjustments to increase rates to improve access to health care in Illinois. The Illinois Department shall prescribe by rule the criteria, standards and procedures for effecting such adjustments in the rates of hospital payments for services provided to eligible low-income persons (under Articles V, VI and VII of this Code) under this Article.

(b) The Illinois Department shall require hospitals certified to participate in the federal Medicaid program to:

(1) provide equal access to available services to low-income persons who are eligible for assistance under Articles V, VI and VII of this Code;

(2) provide data and reports on the provision of uncompensated care.

(c) From the effective date of this amendatory Act of 1992 until July 1, 1992, nothing in this Section 5-17 shall be construed as creating a private right of action on behalf of any individual.

(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.)