(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.
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(2) Any rules of the Department of Human Services
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| 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.
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(3) All unexpended appropriations and balances and
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| 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.
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(4) Existing personnel and positions of the
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| 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.
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(5) All books, records, papers, documents, property
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| (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.
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(6) Whenever reports or notices are now required to
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| 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.
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(7) This amendatory Act of the 99th General Assembly
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| 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.
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(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)
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(A) "Youth" means a person under the age of 18.
(B) "Emerging adult" means a person who is 18
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(C) "Transition-age adult" means a person who is
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| 21 through 25 years of age.
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(2) The Department shall amend 89 Ill. Adm. Code 139
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| in accordance with this Section and consistent with the timelines outlined in this Section.
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(3) Implementation of any amended requirements shall
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| 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.
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(4) To align the Family Support Program with the
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| 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.
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(5) The Family Support Program shall align with the
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| following system of care principles:
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(A) Treatment and support services shall be based
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| on the results of an integrated behavioral health assessment and treatment plan using an instrument approved by the Department of Healthcare and Family Services.
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(B) Strong interagency collaboration between all
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| 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.
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(C) Individualized, strengths-based practices and
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| trauma-informed treatment approaches.
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(D) For a youth, full participation of the parent
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| 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.
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(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
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(2) Requirements for parental or legal guardian
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| 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.
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(3) Youth, emerging adults, and transition-age adults
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| 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.
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(4) School participation for emerging adults applying
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| 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.
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(5) School participation is not applicable to
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(i) Notification of Family Support Program and Specialized Family Support Program services.
(1) Within 12 months after the effective date of this
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| 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.
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(2) Upon a youth's, emerging adult's or
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| 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.
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(3) Psychiatric lockout as last resort.
(A) Prior to referring any youth to the
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| 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.
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(B) No state agency or hospital shall coach a
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| 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.
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(4) Development of new Family Support Program
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(A) Development of specialized therapeutic
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| 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.
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(B) Using the Department of Children and Family
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| 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.
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(C) Development of an age-appropriate therapeutic
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| 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.
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(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
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| 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.
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(2) Targeted use of residential treatment model
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| 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.
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(l) Exhausting third party insurance coverage first.
(A) A parent, legal guardian, emerging adult, or
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| 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.
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(B) The Department of Healthcare and Family Services
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| 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.
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(C) If private or public insurance coverage does not
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| cover the needed treatment or service, Family Support Program funds shall be used to cover the services offered through the Family Support Program.
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(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,
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| and transition-age adults who requested services under the Family Support Program and the Specialized Family Support Program and the services received.
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(2) The number and ages of youth, emerging adults,
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| and transition-age adults who requested services under the Specialized Family Support Program who were eligible for services based on the number of hospitalizations.
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(3) The number and ages of youth, emerging adults,
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| and transition-age adults who applied for Family Support Program or Specialized Family Support Program services but did not receive any services.
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(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.)
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(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 |
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(ii) RhoGAM injections.
(iii) Injectable 17-alpha-hydroxyprogesterone
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| caproate (commonly called 17P).
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(iv) Intrapartum (labor and delivery) services.
(v) Any other outpatient or inpatient service
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| relating to pregnancy or the 12 months following childbirth or fetal loss.
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(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
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| 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
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(B) the health plan has terminated a contract with
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| 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:
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(i) an institutional provider has repeatedly
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| failed to conduct discharge planning; or
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(ii) the provider's conduct adversely and
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| substantially impacts the health of Medicaid patients; or
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(iii) the provider's conduct constitutes fraud,
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(iv) the provider's conduct violates the code of
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| ethics governing his or her profession.
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(Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23 .)
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(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.
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(2) Cease payment for bed reserves in nursing
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| 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.
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(2.5) Cease payment for bed reserves for purposes of
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| inpatient hospitalizations to intermediate care facilities for persons with developmental disabilities, except in the instance of residents who are under 21 years of age.
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(3) Cease payment of the $10 per day add-on payment
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| to nursing facilities for certain residents with developmental disabilities.
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(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
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| 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.
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(2) Rates or payments, or the portion thereof, paid
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| 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.
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(3) Rates or payments for hospital services delivered
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| 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.
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(4) Rates or payments for hospital services delivered
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| 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.
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(5) Rates or payments for Nursing Facility Services
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| shall only be further adjusted pursuant to Section 5-5.2 of this Code.
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(6) Rates or payments for services delivered by long
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| 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.
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(7) Rates or payments for services provided under
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| capitation rates shall be adjusted taking into consideration the rates reduction and covered services required by Public Act 97-689.
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(8) For hospitals not previously described in this
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| 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).
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(9) For all other rates or payments for services
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| delivered by providers not specifically referenced in paragraphs (1) through (7), rates or payments shall be further reduced by 2.7%.
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(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.)
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(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 |
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(i) under common ownership with the college
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| of medicine of a non-public college or university;
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(ii) a freestanding hospital in which the
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| majority of the clinical chiefs of service or clinical department chairs are department chairmen in an affiliated non-public Illinois medical school; or
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(iii) a children's hospital which is
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| 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;
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(B) serve as the training site for at least 30
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| graduate medical education programs accredited by Accreditation Council for Graduate Medical Education;
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(C) facilitate the training on its campus or on
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| 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;
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(D) perform, either itself or through its
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| 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
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(E) expend directly or indirectly through an
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| 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.
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(2) Tier II. A public academic medical center must:
(A) be a hospital located in Illinois which is a
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| primary teaching hospital affiliated with;
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(i) University of Illinois School of Medicine
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(ii) University of Illinois School of
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(iii) University of Illinois School of
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(iv) University of Illinois School of
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(v) Southern Illinois University School of
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| Medicine in Springfield; and
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(B) contribute no less than $2,500,000 toward
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| medical research and education during the calendar year preceding the beginning of the State fiscal year.
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(3) Tier III. A major teaching hospital must:
(A) be an Illinois hospital with 100 or more
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| interns and residents or with a ratio of interns and residents to beds greater than or equal to 0.25; and
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(B) support at least one graduate medical
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| education program accredited by Accreditation Council for Graduate Medical Education.
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(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.)
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(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.
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(b) The Department shall place the following
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| 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.
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(c) The Department shall require prior approval of
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| 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.
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(d) The Department shall establish benchmarks for
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| 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.
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(e) The Department shall establish utilization
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| controls for the hospice program such that it shall not pay for other care services when an individual is in hospice.
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(f) For home health services, the Department shall
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| 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.
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(g) For the Home Services Program operated by the
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| 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.
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(h) Effective with inpatient hospital admissions on
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| 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.
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As used in this subsection (h):
"Provider-preventable condition" means a health care
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| acquired condition as defined under the federal Medicaid regulation found at 42 CFR 447.26 or an other provider-preventable condition.
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"Other provider-preventable condition" means a wrong
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| 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.
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(i) The Department shall implement cost savings
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| initiatives for advanced imaging services, cardiac imaging services, pain management services, and back surgery. Such initiatives shall be designed to achieve annual costs savings.
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(j) The Department shall ensure that beneficiaries
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| with a diagnosis of epilepsy or seizure disorder in Department records will not require prior approval for anticonvulsants.
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(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.)
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(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.
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(2) Provide client education services as determined
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| 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.
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(3) Provide that enrollees within the system may
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| choose the site for provision of services and the panel of health care providers.
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(4) Not discriminate in enrollment or disenrollment
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| practices among recipients of medical services or enrollees based on health status.
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(5) Provide a quality assurance and utilization
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| 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.
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(6) Issue a managed care community network
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| identification card to each enrollee upon enrollment. The card must contain all of the following:
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(A) The enrollee's health plan.
(B) The name and telephone number of the
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| enrollee's primary care physician or the site for receiving primary care services.
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(C) A telephone number to be used to confirm
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| eligibility for benefits and authorization for services that is available 24 hours per day, 7 days per week.
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(7) Ensure that every primary care physician and
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| 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.
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(8) Provide a procedure for handling complaints that
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| meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.
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(9) Maintain, retain, and make available to the
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| 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.
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(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.)
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