(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 (Repealed).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 Repealed by P.A. 102-1037, eff. 6-2-22.)
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(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.)
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(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.)
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(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.)
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(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 | ||
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(b) Providers participating in the program may be | ||
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(c) Providers eligible to participate in the program | ||
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(d) Each recipient required to participate in the | ||
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(e) A recipient may change his designated primary | ||
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(1) when the designated source becomes | ||
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(2) when the designated primary care provider | ||
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(3) in other situations, as the Illinois | ||
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(f) The Illinois Department shall, by rule, establish | ||
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(g) Only medical care services authorized by a | ||
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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.)
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(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 | ||
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(b) Providers participating in the program shall be | ||
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(c) Providers eligible to participate in the program | ||
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(d) Each eligible participant in an area where the | ||
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(e) A participant may change her designated case | ||
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(f) The Illinois Department shall, by rule, establish | ||
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(g) In accordance with rules adopted by the Illinois | ||
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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.)
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(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.)
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(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.)
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(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.)
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(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 | ||
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(2) At least 75% of its managed care enrollees | ||
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(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.)
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(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.)
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(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.)
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(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.)
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(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 | ||
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(2) All persons employed or otherwise engaged by a | ||
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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.)
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(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.)
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(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.)
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(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 | ||
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(B) That access to hospital care in this State by | ||
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(2) To help expand the availability of hospital care | ||
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(3) The Illinois Department may develop and implement | ||
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(b) The Illinois Department shall require hospitals certified to
participate in the federal Medicaid program to:
(1) provide equal access to available services to | ||
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(2) provide data and reports on the provision of | ||
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(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.)
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