305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-5.10)

Sec. 5-5.10. Value-based purchasing.

(a) The Department of Healthcare and Family Services, and, as appropriate, divisions within the Department of Human Services, shall confer with stakeholders to discuss development of alternative value-based payment models that move away from fee-for-service and reward health outcomes and improved quality and provide flexibility in how providers meet the needs of the individuals they serve. Stakeholders include providers, managed care organizations, and community-based and advocacy organizations. The approaches explored may be different for different types of services.

(b) The Department of Healthcare and Family Services and the Department of Human Services shall initiate discussions with mental health providers, substance abuse providers, managed care organizations, advocacy groups for individuals with behavioral health issues, and others, as appropriate, no later than July 1, 2019. A model for value-based purchasing for behavioral health providers shall be presented to the General Assembly by January 31, 2020. In developing this model, the Department of Healthcare and Family Services shall develop projections of the funding necessary for the model.

(Source: P.A. 101-209, eff. 8-5-19.)

(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 (Repealed).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 Repealed by P.A. 96-1530, eff. 2-16-11.)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) (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 or the MC/DD 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 or the MC/DD 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 Service Act shall enroll in that program. No entity participating in the federal Drug Pricing Program under Section 340B of the federal Public Health Service Act may exclude fee-for-service Medicaid from their participation in that program, however, entities defined in Section 1905(l)(2)(B) of the Social Security Act are excluded from this requirement. This subsection does not apply to outpatient drugs billed to Medicaid managed care organizations.

(Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)

(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 5/5-5.12b)

Sec. 5-5.12b. Critical access care pharmacy program.

(a) As used in this Section:

"Critical access care pharmacy" means an Illinois-based brick and mortar pharmacy that is located in a county with fewer than 50,000 residents and that owns fewer than 10 pharmacies.

"Critical access care pharmacy program payment" means the number of individual prescriptions a critical access care pharmacy fills during that quarter multiplied by the lesser of the individual payment amount or the dispensing reimbursement rate made by the Department under the medical assistance program as of April 1, 2018.

"Individual payment amount" means the dividend of 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter.

(b) Subject to appropriations, the Department shall establish a critical access care pharmacy program to ensure the sustainability of critical access pharmacies throughout the State of Illinois.

(c) The critical access care pharmacy program shall not exceed $10,000,000 annually and individual payment amounts per prescription shall not exceed the dispensing rate that the Department would have reimbursed under the Medical Assistance Program as of April 1, 2018.

(d) Quarterly, the Department shall determine the number of prescriptions filled by critical access care pharmacies reimbursed by Medicaid managed care organizations utilizing encounter data available to the Department. The Department shall determine the individual payment amount per prescription by dividing 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. If the individual payment amount per prescription as calculated using quarterly prescription amounts exceeds the reimbursement rate under the medical assistance program as of April 1, 2018, then the individual payment amount per prescription shall be the dispensing reimbursement rate under the medical assistance program as of April 1, 2018.

(e) Quarterly, the Department shall distribute to critical access care pharmacies a critical access care pharmacy program payment. The first payment shall be calculated utilizing the encounter data from the last quarter of State fiscal year 2018.

(f) The Department may adopt rules permitting an Illinois-based brick and mortar pharmacy that owns fewer than 10 pharmacies to receive critical access care pharmacy program payments in the same manner as a critical access care pharmacy, regardless of whether the pharmacy is located in a county with a population of less than 50,000.

(Source: P.A. 100-587, eff. 6-4-18.)

(305 ILCS 5/5-5.12c)

Sec. 5-5.12c. Managed care organization uniform electronic prior authorization form; prescription benefits.

(a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.

(b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, a managed care organization that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits.

(c) On or before July 1, 2020, the Department of Healthcare and Family Services shall develop a uniform electronic prior authorization form that shall be used by managed care organizations. Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits, and every managed care organization shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits.

(d) The Department of Healthcare and Family Services shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director of Healthcare and Family Services: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents managed care organizations, from at least one public meeting.

(e) The Department of Healthcare and Family Services, in development of the uniform electronic prior authorization form, shall take into consideration the following:

(1) existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the Department of Healthcare and Family Services; and

(2) national standards pertaining to electronic prior authorization.

(f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, a managed care organization fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours, then the prior authorization request shall be deemed to have been granted.

(Source: P.A. 101-463, eff. 1-1-20.)

(305 ILCS 5/5-5.12d)

Sec. 5-5.12d. Coverage for patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis provided by a pharmacist.

(a) Subject to approval by the federal Centers for Medicare and Medicaid Services, the medical assistance program, including both the fee-for-service and managed care medical assistance programs established under this Article, shall cover patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation.

(b) The Department shall establish a fee schedule for patient care services provided by a pharmacist under Sections 43 and 43.5 of the Pharmacy Practice Act and shall be covered and reimbursed at no less than 85% of the rate that the services are reimbursed when provided by a physician.

(c) The rate of reimbursement for patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation shall be at 85% of the fee schedule for physician services by the medical assistance program.

(d) A pharmacist must be enrolled in the medical assistance program as an ordering and referring provider prior to providing patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation that is submitted by a pharmacy or pharmacist provider for reimbursement pursuant to this Section.

(e) The Department shall apply for any necessary federal waivers or approvals to implement this Section by January 1, 2023.

(f) This Section does not restrict or prohibit any services currently provided by pharmacists as authorized by law, including, but not limited to, pharmacist services provided under this Code or authorized under the Illinois Title XIX State Plan.

(g) The Department shall submit to the Joint Committee on Administrative Rules administrative rules for this Section as soon as practicable but no later than 6 months after federal approval is received.

(Source: P.A. 102-103, eff. 1-1-22; 102-813, eff. 5-13-22; 102-1051, eff. 1-1-23.)

(305 ILCS 5/5-5.12e)

Sec. 5-5.12e. Managed care organization prior authorization of health care services.

(a) As used in this Section, "health care service" has the meaning given to that term in the Prior Authorization Reform Act.

(b) Notwithstanding any other provision of law to the contrary, all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act.

(Source: P.A. 102-409, eff. 1-1-22; 102-813, eff. 5-13-22.)

(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)

Sec. 5-5.14. (Repealed).

(Source: Repealed by P.A. 88-85.)

(305 ILCS 5/5-5.14.5)

Sec. 5-5.14.5. Treatment; substance use disorder and mental health. The Department shall consult with stakeholders and General Assembly members for input on a plan to develop enhanced Medicaid rates for substance use disorder treatment and mental health treatment in underserved communities. The Department shall present the plan to General Assembly members within 3 months of the effective date of this amendatory Act of the 101st General Assembly, which will specifically address ensuring access to treatment in provider deserts. Within 4 months of the effective date of this amendatory Act of the 101st General Assembly, the Department shall submit a State plan amendment to create medical assistance enhanced rates to enhance access to those to community mental health services and substance abuse services for underserved communities. Subject to federal approval, the Department shall create medical assistance enhanced rates for community mental health services and substance abuse providers for underserved communities to enhance access to those communities.

(Source: P.A. 101-10, eff. 6-5-19.)

(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) (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) (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 residents of such facilities who have intellectual disabilities and 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. 99-143, eff. 7-27-15.)

(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)

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)

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)

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)

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)

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 Healthcare and Family 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. The Department of Healthcare and Family Services may exercise the authority under this Section as is necessary to administer Individual Care Grants as authorized under Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act.

(c) The Department of Healthcare and Family Services shall work collaboratively with the Department of Children and Family Services and the Division of Mental Health of 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.

(e) All rights, powers, duties, and responsibilities currently exercised by the Department of Human Services related to the Individual Care Grant program are transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services to be completed and implemented within 6 months after the effective date of this amendatory Act of the 99th General Assembly. For the purposes of the Successor Agency Act, the Department of Healthcare and Family Services is declared to be the successor agency of the Department of Human Services, but only with respect to the functions of the Department of Human Services that are transferred to the Department of Healthcare and Family Services under this amendatory Act of the 99th General Assembly.

(1) Each act done by the Department of Healthcare and Family Services in exercise of the transferred powers, duties, rights, and responsibilities shall have the same legal effect as if done by the Department of Human Services or its offices.

(2) Any rules of the Department of Human Services that relate to the functions and programs transferred by this amendatory Act of the 99th General Assembly that are in full force on the effective date of this amendatory Act of the 99th General Assembly shall become the rules of the Department of Healthcare and Family Services. All rules transferred under this amendatory Act of the 99th General Assembly are hereby amended such that the term "Department" shall be defined as the Department of Healthcare and Family Services and all references to the "Secretary" shall be changed to the "Director of Healthcare and Family Services or his or her designee". As soon as practicable hereafter, the Department of Healthcare and Family Services shall revise and clarify the rules to reflect the transfer of rights, powers, duties, and responsibilities affected by this amendatory Act of the 99th General Assembly, using the procedures for recodification of rules available under the Illinois Administrative Procedure Act, except that existing title, part, and section numbering for the affected rules may be retained. The Department of Healthcare and Family Services, consistent with its authority to do so as granted by this amendatory Act of the 99th General Assembly, shall propose and adopt any other rules under the Illinois Administrative Procedure Act as necessary to administer the Individual Care Grant program. These rules may include, but are not limited to, the application process and eligibility requirements for recipients.

(3) All unexpended appropriations and balances and other funds available for use in connection with any functions of the Individual Care Grant program shall be transferred for the use of the Department of Healthcare and Family Services to operate the Individual Care Grant program. Unexpended balances shall be expended only for the purpose for which the appropriation was originally made. The Department of Healthcare and Family Services shall exercise all rights, powers, duties, and responsibilities for operation of the Individual Care Grant program.

(4) Existing personnel and positions of the Department of Human Services pertaining to the administration of the Individual Care Grant program shall be transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services. The status and rights of Department of Human Services employees engaged in the performance of the functions of the Individual Care Grant program shall not be affected by this amendatory Act of the 99th General Assembly. The rights of the employees, the State of Illinois, and its agencies under the Personnel Code and applicable collective bargaining agreements or under any pension, retirement, or annuity plan shall not be affected by this amendatory Act of the 99th General Assembly. All transferred employees who are members of collective bargaining units shall retain their seniority, continuous service, salary, and accrued benefits.

(5) All books, records, papers, documents, property (real and personal), contracts, and pending business pertaining to the powers, duties, rights, and responsibilities related to the functions of the Individual Care Grant program, including, but not limited to, material in electronic or magnetic format and necessary computer hardware and software, shall be delivered to the Department of Healthcare and Family Services; provided, however, that the delivery of this information shall not violate any applicable confidentiality constraints.

(6) Whenever reports or notices are now required to be made or given or papers or documents furnished or served by any person to or upon the Department of Human Services in connection with any of the functions transferred by this amendatory Act of the 99th General Assembly, the same shall be made, given, furnished, or served in the same manner to or upon the Department of Healthcare and Family Services.

(7) This amendatory Act of the 99th General Assembly shall not affect any act done, ratified, or canceled or any right occurring or established or any action or proceeding had or commenced in an administrative, civil, or criminal cause regarding the Department of Human Services before the effective date of this amendatory Act of the 99th General Assembly; and those actions or proceedings may be defended, prosecuted, and continued by the Department of Human Services.

(f) (Blank).

(g) Family Support Program. The Department of Healthcare and Family Services shall restructure the Family Support Program, formerly known as the Individual Care Grant program, to enable early treatment of youth, emerging adults, and transition-age adults with a serious mental illness or serious emotional disturbance.

(1) As used in this subsection and in subsections (h) through (s):

(A) "Youth" means a person under the age of 18.

(B) "Emerging adult" means a person who is 18 through 20 years of age.

(C) "Transition-age adult" means a person who is 21 through 25 years of age.

(2) The Department shall amend 89 Ill. Adm. Code 139 in accordance with this Section and consistent with the timelines outlined in this Section.

(3) Implementation of any amended requirements shall be completed within 8 months of the adoption of any amendment to 89 Ill. Adm. Code 139 that is consistent with the provisions of this Section.

(4) To align the Family Support Program with the Medicaid system of care, the services available to a youth, emerging adult, or transition-age adult through the Family Support Program shall include all Medicaid community-based mental health treatment services and all Family Support Program services included under 89 Ill. Adm. Code 139. No person receiving services through the Family Support Program or the Specialized Family Support Program shall become a Medicaid enrollee unless Medicaid eligibility criteria are met and the person is enrolled in Medicaid. No part of this Section creates an entitlement to services through the Family Support Program, the Specialized Family Support Program, or the Medicaid program.

(5) The Family Support Program shall align with the following system of care principles:

(A) Treatment and support services shall be based on the results of an integrated behavioral health assessment and treatment plan using an instrument approved by the Department of Healthcare and Family Services.

(B) Strong interagency collaboration between all State agencies the parent or legal guardian is involved with for services, including the Department of Healthcare and Family Services, the Department of Human Services, the Department of Children and Family Services, the Department of Juvenile Justice, and the Illinois State Board of Education.

(C) Individualized, strengths-based practices and trauma-informed treatment approaches.

(D) For a youth, full participation of the parent or legal guardian at all levels of treatment through a process that is family-centered and youth-focused. The process shall include consideration of the services and supports the parent, legal guardian, or caregiver requires for family stabilization, and shall connect such person or persons to services based on available insurance coverage.

(h) Eligibility for the Family Support Program. Eligibility criteria established under 89 Ill. Adm. Code 139 for the Family Support Program shall include the following:

(1) Individuals applying to the program must be under the age of 26.

(2) Requirements for parental or legal guardian involvement are applicable to youth and to emerging adults or transition-age adults who have a guardian appointed under Article XIa of the Probate Act.

(3) Youth, emerging adults, and transition-age adults are eligible for services under the Family Support Program upon their third inpatient admission to a hospital or similar treatment facility for the primary purpose of psychiatric treatment within the most recent 12 months and are hospitalized for the purpose of psychiatric treatment.

(4) School participation for emerging adults applying for services under the Family Support Program may be waived by request of the individual at the sole discretion of the Department of Healthcare and Family Services.

(5) School participation is not applicable to transition-age adults.

(i) Notification of Family Support Program and Specialized Family Support Program services.

(1) Within 12 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services, with meaningful stakeholder input through a working group of psychiatric hospitals, Family Support Program providers, family support organizations, the Community and Residential Services Authority, a statewide association representing a majority of hospitals, a statewide association representing physicians, and foster care alumni advocates, shall establish a clear process by which a youth's or emerging adult's parents, guardian, or caregiver, or the emerging adult or transition-age adult, is identified, notified, and educated about the Family Support Program and the Specialized Family Support Program upon a first psychiatric inpatient hospital admission, and any following psychiatric inpatient admissions. Notification and education may take place through a Family Support Program coordinator, a mobile crisis response provider, a Comprehensive Community Based Youth Services provider, the Community and Residential Services Authority, or any other designated provider or coordinator identified by the Department of Healthcare and Family Services. In developing this process, the Department of Healthcare and Family Services and the working group shall take into account the unique needs of emerging adults and transition-age adults without parental involvement who are eligible for services under the Family Support Program. The Department of Healthcare and Family Services and the working group shall ensure the appropriate provider or coordinator is required to assist individuals and their parents, guardians, or caregivers, as applicable, in the completion of the application or referral process for the Family Support Program or the Specialized Family Support Program.

(2) Upon a youth's, emerging adult's or transition-age adult's second psychiatric inpatient hospital admission, prior to hospital discharge, the hospital must, if it is aware of the patient's prior psychiatric inpatient hospital admission, ensure that the youth's parents, guardian, or caregiver, or the emerging adult or transition-age adult, has been notified of the Family Support Program and the Specialized Family Support Program.

(3) Psychiatric lockout as last resort.

(A) Prior to referring any youth to the Department of Children and Family Services for the filing of a petition in accordance with subparagraph (c) of paragraph (1) of Section 2-4 of the Juvenile Court Act of 1987 alleging that the youth is dependent because the youth was left in a psychiatric hospital beyond medical necessity, the hospital shall attempt to contact the youth and the youth's parents, guardian, or caregiver about the Family Support Program and the Specialized Family Support Program and shall assist with connections to the designated Family Support Program coordinator in the service area by providing educational materials developed by the Department of Healthcare and Family Services. Once this process has begun, any such youth shall be considered a youth for whom an application for the Family Support Program is pending with the Department of Healthcare and Family Services or an active application for the Family Support Program was being reviewed by the Department for the purposes of subsection (a) of Section 2-4b of the Juvenile Court Act of 1987, or for the purposes of subsection (a) of Section 5-711 of the Juvenile Court Act of 1987.

(B) No state agency or hospital shall coach a parent or guardian of a youth in a psychiatric hospital inpatient unit to lock out or otherwise relinquish custody of a youth to the Department of Children and Family Services for the sole purpose of obtaining necessary mental health treatment for the youth. In the absence of abuse or neglect, a psychiatric lockout or custody relinquishment to the Department of Children and Family Services shall only be considered as the option of last resort. Nothing in this Section shall prohibit discussion of medical treatment options or a referral to legal counsel.

(4) Development of new Family Support Program services.

(A) Development of specialized therapeutic residential treatment for youth and emerging adults with high-acuity mental health conditions. Through a working group led by the Department of Healthcare and Family Services that includes the Department of Children and Family Services and residential treatment providers for youth and emerging adults, the Department of Healthcare and Family Services, within 12 months after the effective date of this amendatory Act of the 101st General Assembly, shall develop a plan for the development of specialized therapeutic residential treatment beds similar to a qualified residential treatment program, as defined in the federal Family First Prevention Services Act, for youth in the Family Support Program with high-acuity mental health needs. The Department of Healthcare and Family Services and the Department of Children and Family Services shall work together to maximize federal funding through Medicaid and Title IV-E of the Social Security Act in the development and implementation of this plan.

(B) Using the Department of Children and Family Services' beyond medical necessity data over the last 5 years and any other relevant, available data, the Department of Healthcare and Family Services shall assess the estimated number of these specialized high-acuity residential treatment beds that are needed in each region of the State based on the number of youth remaining in psychiatric hospitals beyond medical necessity and the number of youth placed out-of-state who need this level of care. The Department of Healthcare and Family Services shall report the results of this assessment to the General Assembly by no later than December 31, 2020.

(C) Development of an age-appropriate therapeutic residential treatment model for emerging adults and transition-age adults. Within 30 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services, in partnership with the Department of Human Services' Division of Mental Health and with significant and meaningful stakeholder input through a working group of providers and other stakeholders, shall develop a supportive housing model for emerging adults and transition-age adults receiving services through the Family Support Program who need residential treatment and support to enable recovery. Such a model shall be age-appropriate and shall allow the residential component of the model to be in a community-based setting combined with intensive community-based mental health services.

(j) Workgroup to develop a plan for improving access to substance use treatment. The Department of Healthcare and Family Services and the Department of Human Services' Division of Substance Use Prevention and Recovery shall co-lead a working group that includes Family Support Program providers, family support organizations, and other stakeholders over a 12-month period beginning in the first quarter of calendar year 2020 to develop a plan for increasing access to substance use treatment services for youth, emerging adults, and transition-age adults who are eligible for Family Support Program services.

(k) Appropriation. Implementation of this Section shall be limited by the State's annual appropriation to the Family Support Program. Spending within the Family Support Program appropriation shall be further limited for the new Family Support Program services to be developed accordingly:

(1) Targeted use of specialized therapeutic residential treatment for youth and emerging adults with high-acuity mental health conditions through appropriation limitation. No more than 12% of all annual Family Support Program funds shall be spent on this level of care in any given state fiscal year.

(2) Targeted use of residential treatment model established for emerging adults and transition-age adults through appropriation limitation. No more than one-quarter of all annual Family Support Program funds shall be spent on this level of care in any given state fiscal year.

(l) Exhausting third party insurance coverage first.

(A) A parent, legal guardian, emerging adult, or transition-age adult with private insurance coverage shall work with the Department of Healthcare and Family Services, or its designee, to identify insurance coverage for any and all benefits covered by their plan. If insurance cost-sharing by any method for treatment is cost-prohibitive for the parent, legal guardian, emerging adult, or transition-age adult, Family Support Program funds may be applied as a payer of last resort toward insurance cost-sharing for purposes of using private insurance coverage to the fullest extent for the recommended treatment. If the Department, or its agent, has a concern relating to the parent's, legal guardian's, emerging adult's, or transition-age adult's insurer's compliance with Illinois or federal insurance requirements relating to the coverage of mental health or substance use disorders, it shall refer all relevant information to the applicable regulatory authority.

(B) The Department of Healthcare and Family Services shall use Medicaid funds first for an individual who has Medicaid coverage if the treatment or service recommended using an integrated behavioral health assessment and treatment plan (using the instrument approved by the Department of Healthcare and Family Services) is covered by Medicaid.

(C) If private or public insurance coverage does not cover the needed treatment or service, Family Support Program funds shall be used to cover the services offered through the Family Support Program.

(m) Service authorization. A youth, emerging adult, or transition-age adult enrolled in the Family Support Program or the Specialized Family Support Program shall be eligible to receive a mental health treatment service covered by the applicable program if the medical necessity criteria established by the Department of Healthcare and Family Services are met.

(n) Streamlined application. The Department of Healthcare and Family Services shall revise the Family Support Program applications and the application process to reflect the changes made to this Section by this amendatory Act of the 101st General Assembly within 8 months after the adoption of any amendments to 89 Ill. Adm. Code 139.

(o) Study of reimbursement policies during planned and unplanned absences of youth and emerging adults in Family Support Program residential treatment settings. The Department of Healthcare and Family Services shall undertake a study of those standards of the Department of Children and Family Services and other states for reimbursement of residential treatment during planned and unplanned absences to determine if reimbursing residential providers for such unplanned absences positively impacts the availability of residential treatment for youth and emerging adults. The Department of Healthcare and Family Services shall begin the study on July 1, 2019 and shall report its findings and the results of the study to the General Assembly, along with any recommendations for or against adopting a similar policy, by December 31, 2020.

(p) Public awareness and educational campaign for all relevant providers. The Department of Healthcare and Family Services shall engage in a public awareness campaign to educate hospitals with psychiatric units, crisis response providers such as Screening, Assessment and Support Services providers and Comprehensive Community Based Youth Services agencies, schools, and other community institutions and providers across Illinois on the changes made by this amendatory Act of the 101st General Assembly to the Family Support Program. The Department of Healthcare and Family Services shall produce written materials geared for the appropriate target audience, develop webinars, and conduct outreach visits over a 12-month period beginning after implementation of the changes made to this Section by this amendatory Act of the 101st General Assembly.

(q) Maximizing federal matching funds for the Family Support Program and the Specialized Family Support Program. The Department of Healthcare and Family Services, as the sole Medicaid State agency, shall seek approval from the federal Centers for Medicare and Medicaid Services within 12 months after the effective date of this amendatory Act of the 101st General Assembly to draw additional federal Medicaid matching funds for individuals served under the Family Support Program or the Specialized Family Support Program who are not covered by the Department's medical assistance programs. The Department of Children and Family Services, as the State agency responsible for administering federal funds pursuant to Title IV-E of the Social Security Act, shall submit a State Plan to the federal government within 12 months after the effective date of this amendatory Act of the 101st General Assembly to maximize the use of federal Title IV-E prevention funds through the federal Family First Prevention Services Act, to provide mental health and substance use disorder treatment services and supports, including, but not limited to, the provision of short-term crisis and transition beds post-hospitalization for youth who are at imminent risk of entering Illinois' youth welfare system solely due to the inability to access mental health or substance use treatment services.

(r) Outcomes and data reported annually to the General Assembly. Beginning in 2021, the Department of Healthcare and Family Services shall submit an annual report to the General Assembly that includes the following information with respect to the time period covered by the report:

(1) The number and ages of youth, emerging adults, and transition-age adults who requested services under the Family Support Program and the Specialized Family Support Program and the services received.

(2) The number and ages of youth, emerging adults, and transition-age adults who requested services under the Specialized Family Support Program who were eligible for services based on the number of hospitalizations.

(3) The number and ages of youth, emerging adults, and transition-age adults who applied for Family Support Program or Specialized Family Support Program services but did not receive any services.

(s) Rulemaking authority. Unless a timeline is otherwise specified in a subsection, if amendments to 89 Ill. Adm. Code 139 are needed for implementation of this Section, such amendments shall be filed by the Department of Healthcare and Family Services within one year after the effective date of this amendatory Act of the 101st General Assembly.

(Source: P.A. 101-461, eff. 1-1-20; 101-616, eff. 12-20-19.)

(305 ILCS 5/5-5.24)

Sec. 5-5.24. Prenatal and perinatal care.

(a) 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 and maternal health. These services may include comprehensive risk assessments for pregnant individuals, individuals with infants, and infants, lactation counseling, nutrition counseling, childbirth support, psychosocial counseling, treatment and prevention of periodontal disease, language translation, nurse home visitation, and other support services that have been proven to improve birth and maternal health 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.

(b)(1) As used in this subsection:

"Affiliated provider" means a provider who is enrolled in the medical assistance program and has an active contract with a managed care organization.

"Non-affiliated provider" means a provider who is enrolled in the medical assistance program but does not have a contract with an MCO.

"Preventive prenatal and perinatal health care services" means services described in subsection (a) including the following non-emergent diagnostic and ancillary services:

(i) Diagnostic labs and imaging, including level II ultrasounds.

(ii) RhoGAM injections.

(iii) Injectable 17-alpha-hydroxyprogesterone caproate (commonly called 17P).

(iv) Intrapartum (labor and delivery) services.

(v) Any other outpatient or inpatient service relating to pregnancy or the 12 months following childbirth or fetal loss.

(2) In order to maximize the accessibility of preventive prenatal and perinatal health care services, the Department of Healthcare and Family Services shall amend its managed care contracts such that an MCO must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid under the Illinois Medicaid fee-for-service program methodology for such services, including all policy adjusters, including, but not limited to, Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates, unless a different rate was agreed upon by the health plan and the non-affiliated provider.

(3) In cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the requirements under paragraph (2) shall not apply if the services were not emergency services, as defined in Section 5-30.1, and:

(A) the non-affiliated provider is a perinatal hospital and has, within the 12 months preceding the date of service, rejected a contract that was offered in good faith by the health plan as determined by the Department; or

(B) the health plan has terminated a contract with the non-affiliated provider for cause, and the Department has not deemed the termination to have been without merit. The Department may deem that a determination for cause has merit if:

(i) an institutional provider has repeatedly failed to conduct discharge planning; or

(ii) the provider's conduct adversely and substantially impacts the health of Medicaid patients; or

(iii) the provider's conduct constitutes fraud, waste, or abuse; or

(iv) the provider's conduct violates the code of ethics governing his or her profession.

(Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23.)

(305 ILCS 5/5-5.25)

Sec. 5-5.25. Access to behavioral health, medical, and epilepsy treatment services.

(a) The General Assembly finds that providing access to behavioral health, medical, and epilepsy treatment services in a timely manner will improve the quality of life for persons suffering from illness and will contain health care costs by avoiding the need for more costly inpatient hospitalization.

(b) The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. 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; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.

(c) The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services' Division of Alcoholism and Substance Abuse.

(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. 101-81, eff. 7-12-19; 102-207, eff. 7-30-21.)

(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 5/5-5.27)

Sec. 5-5.27. Coverage for clinical trials.

(a) The medical assistance program shall provide coverage for routine care costs that are incurred in the course of an approved clinical trial if the medical assistance program would provide coverage for the same routine care costs not incurred in a clinical trial. "Routine care cost" shall be defined by the Department by rule.

(b) The coverage that must be provided under this Section is subject to the terms, conditions, restrictions, exclusions, and limitations that apply generally under the medical assistance program, including terms, conditions, restrictions, exclusions, or limitations that apply to health care services rendered by participating providers and nonparticipating providers.

(c) Implementation of this Section shall be contingent upon federal approval. Upon receipt of federal approval, if required, the Department shall adopt any rules necessary to implement this Section.

(d) As used in this Section:

"Approved clinical trial" means a phase I, II, III, or IV clinical trial involving the prevention, detection, or treatment of cancer or any other life-threatening disease or condition if one or more of the following conditions apply:

(1) the Department makes a determination that the study or investigation is an approved clinical trial;

(2) the study or investigation is conducted under an investigational new drug application or an investigational device exemption reviewed by the federal Food and Drug Administration;

(3) the study or investigation is a drug trial that is exempt from having an investigational new drug application or an investigational device exemption from the federal Food and Drug Administration; or

(4) the study or investigation is approved or funded (which may include funding through in-kind contributions) by:

(A) the National Institutes of Health;

(B) the Centers for Disease Control and Prevention;

(C) the Agency for Healthcare Research and Quality;

(D) the Patient-Centered Outcomes Research Institute;

(E) the federal Centers for Medicare and Medicaid Services;

(F) a cooperative group or center of any of the entities described in subparagraphs (A) through (E) or the United States Department of Defense or the United States Department of Veterans Affairs;

(G) a qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants; or

(H) the United States Department of Veterans Affairs, the United States Department of Defense, or the United States Department of Energy, provided that review and approval of the study or investigation occurs through a system of peer review that is comparable to the peer review of studies performed by the National Institutes of Health, including an unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.

"Care method" means the use of a particular drug or device in a particular manner.

"Life-threatening disease or condition" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

(Source: P.A. 101-649, eff. 7-7-20.)

(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 Rehabilitation of Persons with Disabilities Act and Section 4 of the Illinois Act on the Aging.

(Source: P.A. 99-143, eff. 7-27-15.)

(305 ILCS 5/5-5a.1)

Sec. 5-5a.1. Telehealth services for persons with intellectual and developmental disabilities. The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 1915(c) of the Social Security Act to incorporate telehealth services administered by a provider of telehealth services that demonstrates knowledge and experience in providing medical and emergency services for persons with intellectual and developmental disabilities. The Department shall pay administrative fees associated with implementing telehealth services for all persons with intellectual and developmental disabilities who are receiving services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities.

(Source: P.A. 103-102, eff. 7-1-23.)

(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 5/5-5b.1)

Sec. 5-5b.1. Reimbursement rates; Fiscal Year 2015 reductions.

(a) Except as provided in subsection (b), notwithstanding any other provision of this Code to the contrary, and subject to rescission if not federally approved, providers of the following services shall have their reimbursement rates or dispensing fees reduced for the remainder of State fiscal year 2015 by an amount equivalent to a 2.25% reduction in appropriations from the General Revenue Fund for the medical assistance program for the full fiscal year:

(1) Nursing facility services delivered by a nursing facility licensed under the Nursing Home Care Act.

(2) Home health services.

(3) Services delivered by a facility designated as a Children's Habilitation Center.

(4) Services delivered by a supportive living facility as defined in Section 5-5.01a.

(5) Services delivered by a specialized mental health rehabilitation facility licensed under the Specialized Mental Health Rehabilitation Act of 2013.

(6) Ambulance services.

(7) Pharmacy services.

(8) Services delivered by a federally qualified health center as defined in Section 1905 (l)(2)(B) of the federal Social Security Act.

(9) Services delivered by a Managed Care Entity, with the exception of the rate paid to Managed Care Entities for services attributed to hospitals.

(10) Services for the treatment of hemophilia.

(11) Primary care physician services.

(12) Dental services.

(13) Optometric services.

(14) Podiatry services.

(15) Hospice care, including routine home care, continuous home care, inpatient respite care, and general inpatient care.

(16) Laboratory services or services provided by independent laboratories.

(17) Durable medical equipment and supplies.

(18) Renal dialysis services.

(19) Birth Center Services.

(20) Emergency services other than those offered by or in a hospital.

(b) No provider shall be exempt from the rate reductions authorized under this Section, except that, rates or payments, or the portion thereof, paid to a provider that is operated by a unit of local government that provides the non-federal share of such services shall not be reduced as provided in this Section.

(c) To the extent practical and subject to rescission if not federally approved, the reductions required under this Section must be applied uniformly among and within each group, class, subgroup, or category of providers listed in this Section.

(d) In order to provide for the expeditious and timely implementation of the provisions of this Section, emergency rules to implement any provision of this Section may be adopted by the Department in accordance with subsection (s) of Section 5-45 of the Illinois Administrative Procedure Act.

(Source: P.A. 99-2, eff. 3-26-15.)

(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)

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)

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 Public Act 97-689. 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 and before July 1, 2019.

(2) Cease payment for bed reserves in nursing facilities and specialized mental health rehabilitation facilities; for purposes of therapeutic home visits for individuals scoring as TBI on the MDS 3.0, beginning June 1, 2015, the Department shall approve payments for bed reserves in nursing facilities and specialized mental health rehabilitation facilities that have at least a 90% occupancy level and at least 80% of their residents are Medicaid eligible. Payment shall be at a daily rate of 75% of an individual's current Medicaid per diem and shall not exceed 10 days in a calendar month.

(2.5) Cease payment for bed reserves for purposes of inpatient hospitalizations to intermediate care facilities for persons with developmental 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, except as provided in Section 5-5b.1.

(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, except as provided in Section 5-5b.1.

(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, except as provided in Section 5-5b.1.

(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, except as provided in Section 5-5b.1.

(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 or the MC/DD 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 Public Act 97-689.

(8) For hospitals not previously described in this subsection, the rates or payments for hospital services provided before July 1, 2021, shall be further reduced by 3.5%, except for payments authorized under Section 5A-12.4 of this Code. For hospital services provided on or after July 1, 2021, all rates for hospital services previously reduced pursuant to Public Act 97-689 shall be increased to reflect the discontinuation of any hospital rate reductions authorized in this paragraph (8).

(9) For all other rates or payments for services delivered by providers not specifically referenced in paragraphs (1) through (7), 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) (Blank).

(f) (Blank).

(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; 102-16, eff. 6-17-21; 102-687, eff. 12-17-21.)

(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 December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2011 or October 1, 2012 shall be a Safety-Net Hospital.

(c-5) Beginning July 1, 2020 and ending on December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2020 and was designated a federal rural referral center under 42 CFR 412.96 as of October 1, 2020 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. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21; 102-886, eff. 5-17-22.)

(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)

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 service 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.

(b) The Department shall place the following limitations on services: (i) the Department shall limit adult eyeglasses to one pair every 2 years; however, the limitation does not apply to an individual who needs different eyeglasses following a surgical procedure such as cataract surgery; (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 may 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 through June 30, 2021, 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 $750, 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 $750 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. 101-209, eff. 8-5-19; 102-43, Article 5, Section 5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21; 102-813, eff. 5-13-22.)

(305 ILCS 5/5-5g)

Sec. 5-5g. Long-term care patient; resident status. Long-term care providers shall submit all changes in resident status, including, but not limited to, death, discharge, changes in patient credit, third party liability, and Medicare coverage, to the Department through the Medical Electronic Data Interchange System, the Recipient Eligibility Verification System, or the Electronic Data Interchange System established under 89 Ill. Adm. Code 140.55(b) in compliance with the schedule below:

(1) 15 calendar days after a resident's death;

(2) 15 calendar days after a resident's discharge;

(3) 45 calendar days after being informed of a change in the resident's income;

(4) 45 calendar days after being informed of a change in a resident's third party liability;

(5) 45 calendar days after a resident's move to exceptional care services; and

(6) 45 calendar days after a resident's need for services requiring reimbursement under the ventilator or traumatic brain injury enhanced rate.

(Source: P.A. 100-665, eff. 8-2-18.)

(305 ILCS 5/5-5h)

Sec. 5-5h. Long-term acute care hospital base rates.

(a) The base per diem rate paid to long-term acute care hospitals for Medicaid services on and after January 1, 2020 must be $60 more than the base rate in effect on June 30, 2019.

(b) Nothing in this Section shall change the rates authorized under Section 5A-12.6 or the Long-Term Acute Care Hospital Quality Improvement Transfer Program Act.

(Source: P.A. 101-10, eff. 6-5-19.)

(305 ILCS 5/5-5i)

Sec. 5-5i. Rate increase for speech, physical, and occupational therapy services. Subject to federal approval, beginning January 1, 2024, the Department shall increase reimbursement rates for speech therapy services, physical therapy services, and occupational therapy services provided by licensed speech-language pathologists and speech-language pathology assistants, physical therapists and physical therapy assistants, and occupational therapists and certified occupational therapy assistants, including those in their clinical fellowship, by 14.2%.

(Source: P.A. 103-102, eff. 1-1-24.)

(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, the ID/DD Community Care Act, or the MC/DD 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. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)

(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) (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 under the Nurse Practice Act as advanced practice registered nurses, regardless of whether or not the persons have written collaborative agreements, (iii) 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, (iv) persons licensed under other laws of this State as a clinical social worker, and (v) persons licensed under other laws of this State as physician assistants. The Department shall adopt rules, no later than 90 days after January 1, 2017 (the effective date of Public Act 99-621), for the legally authorized services of persons licensed under other laws of this State as a clinical social worker. The Department shall provide for the legally authorized services of persons licensed under the Professional Counselor and Clinical Professional Counselor Licensing and Practice Act as clinical professional counselors and for the legally authorized services of persons licensed under the Marriage and Family Therapy Licensing Act as marriage and family therapists. 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. 102-43, eff. 7-6-21.)

(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.

(Source: P.A. 100-538, eff. 1-1-18.)

(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) (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)

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)

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) (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) (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 persons with intellectual disabilities, 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 is a child with a permanent total disability. 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 or blind persons or persons with disabilities receiving aid under Articles V, VII and VII-A of the 1949 Code.

(Source: P.A. 99-143, eff. 7-27-15.)

(305 ILCS 5/5-13.1)

Sec. 5-13.1. Cost-effectiveness waiver, hardship waivers, and making information about waivers more accessible.

(a) It is the intent of the General Assembly to ease the burden of liens and estate recovery for correctly paid benefits for participants, applicants, and their families and heirs, and to make information about waivers more widely available.

(b) The Department shall waive estate recovery under Sections 3-9 and 5-13 where recovery would not be cost-effective, would work an undue hardship, or for any other just reason, and shall make information about waivers and estate recovery easily accessible.

(1) Cost-effectiveness waiver. Subject to federal approval, the Department shall waive any claim against the first $25,000 of any estate to prevent substantial and unreasonable hardship. The Department shall consider the gross assets in the estate, including, but not limited to, the net value of real estate less mortgages or liens with priority over the Department's claims. The Department may increase the cost-effectiveness threshold in the future.

(2) Undue hardship waiver. The Department may develop additional hardship waiver standards in addition to those already employed, including, but not limited to, waivers aimed at preserving income-producing real property or a modest home as defined by rule.

(3) Accessible information. The Department shall make information about estate recovery and hardship waivers easily accessible. The Department shall maintain information about how to request a hardship waiver on its website in English, Spanish, and the next 4 most commonly used languages, including a short guide and simple form to facilitate requesting hardship exemptions in each language. On an annual basis, the Department shall publicly report on the number of estate recovery cases that are pursued and the number of undue hardship exemptions granted, including demographic data of the deceased beneficiaries where available.

(Source: P.A. 102-1037, eff. 6-2-22.)

(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)

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.)