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Illinois Compiled Statutes

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

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

PUBLIC AID
(305 ILCS 5/) Illinois Public Aid Code.

305 ILCS 5/5-18

    (305 ILCS 5/5-18) (from Ch. 23, par. 5-18)
    Sec. 5-18. (Repealed).
(Source: P.A. 87-895. Repealed by P.A. 92-275, eff. 8-7-01.)

305 ILCS 5/5-18.5

    (305 ILCS 5/5-18.5)
    Sec. 5-18.5. Perinatal doula and evidence-based home visiting services.
    (a) As used in this Section:
    "Home visiting" means a voluntary, evidence-based strategy used to support pregnant people, infants, and young children and their caregivers to promote infant, child, and maternal health, to foster educational development and school readiness, and to help prevent child abuse and neglect. Home visitors are trained professionals whose visits and activities focus on promoting strong parent-child attachment to foster healthy child development.
    "Perinatal doula" means a trained provider who provides regular, voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period.
    "Perinatal doula training" means any doula training that focuses on providing support throughout the prenatal, labor and delivery, or postpartum period, and reflects the type of doula care that the doula seeks to provide.
    (b) Notwithstanding any other provision of this Article, perinatal doula services and evidence-based home visiting services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. Perinatal doula services include regular visits beginning in the prenatal period and continuing into the postnatal period, inclusive of continuous support during labor and delivery, that support healthy pregnancies and positive birth outcomes. Perinatal doula services may be embedded in an existing program, such as evidence-based home visiting. Perinatal doula services provided during the prenatal period may be provided weekly, services provided during the labor and delivery period may be provided for the entire duration of labor and the time immediately following birth, and services provided during the postpartum period may be provided up to 12 months postpartum.
    (b-5) Notwithstanding any other provision of this Article, beginning January 1, 2023, licensed certified professional midwife services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. The Department shall consult with midwives on reimbursement rates for midwifery services.
    (c) The Department of Healthcare and Family Services shall adopt rules to administer this Section. In this rulemaking, the Department shall consider the expertise of and consult with doula program experts, doula training providers, practicing doulas, and home visiting experts, along with State agencies implementing perinatal doula services and relevant bodies under the Illinois Early Learning Council. This body of experts shall inform the Department on the credentials necessary for perinatal doula and home visiting services to be eligible for Medicaid reimbursement and the rate of reimbursement for home visiting and perinatal doula services in the prenatal, labor and delivery, and postpartum periods. Every 2 years, the Department shall assess the rates of reimbursement for perinatal doula and home visiting services and adjust rates accordingly.
    (d) The Department shall seek such State plan amendments or waivers as may be necessary to implement this Section and shall secure federal financial participation for expenditures made by the Department in accordance with this Section.
(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)

305 ILCS 5/5-18.10

    (305 ILCS 5/5-18.10)
    Sec. 5-18.10. Reimbursement for postpartum visits.
    (a) In this Section:
    "Certified lactation counselor" means a health care professional in lactation counseling who has demonstrated the necessary skills, knowledge, and attitudes to provide clinical breastfeeding counseling and management support to families who are thinking about breastfeeding or who have questions or problems during the course of breastfeeding.
    "Certified nurse midwife" means a person who exceeds the competencies for a midwife contained in the Essential Competencies for Midwifery Practice, published by the International Confederation of Midwives, and who qualifies as an advanced practice registered nurse.
    "Community health worker" means a frontline public health worker who is a trusted member or has an unusually close understanding of the community served. This trusting relationship enables the community health worker to serve as a liaison, link, and intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
    "International board-certified lactation consultant" means a health care professional who is certified by the International Board of Lactation Consultant Examiners and specializes in the clinical management of breastfeeding.
    "Medical caseworker" means a health care professional who assists in the planning, coordination, monitoring, and evaluation of medical services for a patient with emphasis on quality of care, continuity of services, and affordability.
    "Perinatal doula" means a trained provider of regular and voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period.
    "Public health nurse" means a registered nurse who promotes and protects the health of populations using knowledge from nursing, social, and public health sciences.
    (b) The Illinois Department shall establish a medical assistance program to cover a universal postpartum visit within the first 3 weeks after childbirth and a comprehensive visit within 4 to 12 weeks postpartum for persons who are otherwise eligible for medical assistance under this Article. In addition, postpartum care services rendered by perinatal doulas, certified lactation counselors, international board-certified lactation consultants, public health nurses, certified nurse midwives, community health workers, and medical caseworkers shall be covered under the medical assistance program.
(Source: P.A. 102-665, eff. 10-8-21.)

305 ILCS 5/5-19

    (305 ILCS 5/5-19) (from Ch. 23, par. 5-19)
    Sec. 5-19. Healthy Kids Program.
    (a) Any child under the age of 21 eligible to receive Medical Assistance from the Illinois Department under Article V of this Code shall be eligible for Early and Periodic Screening, Diagnosis and Treatment services provided by the Healthy Kids Program of the Illinois Department under the Social Security Act, 42 U.S.C. 1396d(r).
    (b) Enrollment of Children in Medicaid. The Illinois Department shall provide for receipt and initial processing of applications for Medical Assistance for all pregnant women and children under the age of 21 at locations in addition to those used for processing applications for cash assistance, including disproportionate share hospitals, federally qualified health centers and other sites as selected by the Illinois Department.
    (c) Healthy Kids Examinations. The Illinois Department shall consider any examination of a child eligible for the Healthy Kids services provided by a medical provider meeting the requirements and complying with the rules and regulations of the Illinois Department to be reimbursed as a Healthy Kids examination.
    (d) Medical Screening Examinations.
        (1) The Illinois Department shall insure Medicaid
    
coverage for periodic health, vision, hearing, and dental screenings for children eligible for Healthy Kids services scheduled from a child's birth up until the child turns 21 years. The Illinois Department shall pay for vision, hearing, dental and health screening examinations for any child eligible for Healthy Kids services by qualified providers at intervals established by Department rules.
        (2) The Illinois Department shall pay for an
    
interperiodic health, vision, hearing, or dental screening examination for any child eligible for Healthy Kids services whenever an examination is:
            (A) requested by a child's parent, guardian, or
        
custodian, or is determined to be necessary or appropriate by social services, developmental, health, or educational personnel; or
            (B) necessary for enrollment in school; or
            (C) necessary for enrollment in a licensed day
        
care program, including Head Start; or
            (D) necessary for placement in a licensed child
        
welfare facility, including a foster home, group home or child care institution; or
            (E) necessary for attendance at a camping
        
program; or
            (F) necessary for participation in an organized
        
athletic program; or
            (G) necessary for enrollment in an early
        
childhood education program recognized by the Illinois State Board of Education; or
            (H) necessary for participation in a Women,
        
Infant, and Children (WIC) program; or
            (I) deemed appropriate by the Illinois Department.
    (e) Minimum Screening Protocols For Periodic Health Screening Examinations. Health Screening Examinations must include the following services:
        (1) Comprehensive Health and Development Assessment
    
including:
            (A) Development/Mental Health/Psychosocial
        
Assessment; and
            (B) Assessment of nutritional status including
        
tests for iron deficiency and anemia for children at the following ages: 9 months, 2 years, 8 years, and 18 years;
        (2) Comprehensive unclothed physical exam;
        (3) Appropriate immunizations at a minimum, as
    
required by the Secretary of the U.S. Department of Health and Human Services under 42 U.S.C. 1396d(r).
        (4) Appropriate laboratory tests including blood lead
    
levels appropriate for age and risk factors.
            (A) Anemia test.
            (B) Sickle cell test.
            (C) Tuberculin test at 12 months of age and every
        
1-2 years thereafter unless the treating health care professional determines that testing is medically contraindicated.
            (D) Other -- The Illinois Department shall insure
        
that testing for HIV, drug exposure, and sexually transmitted diseases is provided for as clinically indicated.
        (5) Health Education. The Illinois Department shall
    
require providers to provide anticipatory guidance as recommended by the American Academy of Pediatrics.
        (6) Vision Screening. The Illinois Department shall
    
require providers to provide vision screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
        (7) Hearing Screening. The Illinois Department shall
    
require providers to provide hearing screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
        (8) Dental Screening. The Illinois Department shall
    
require providers to provide dental screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
    (f) Covered Medical Services. The Illinois Department shall provide coverage for all necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects, physical and mental illnesses, and conditions whether discovered by the screening services or not for all children eligible for Medical Assistance under Article V of this Code.
    (g) Notice of Healthy Kids Services.
        (1) The Illinois Department shall inform any child
    
eligible for Healthy Kids services and the child's family about the benefits provided under the Healthy Kids Program, including, but not limited to, the following: what services are available under Healthy Kids, including discussion of the periodicity schedules and immunization schedules, that services are provided at no cost to eligible children, the benefits of preventive health care, where the services are available, how to obtain them, and that necessary transportation and scheduling assistance is available.
        (2) The Illinois Department shall widely disseminate
    
information regarding the availability of the Healthy Kids Program throughout the State by outreach activities which shall include, but not be limited to, (i) the development of cooperation agreements with local school districts, public health agencies, clinics, hospitals and other health care providers, including developmental disability and mental health providers, and with charities, to notify the constituents of each of the Program and assist individuals, as feasible, with applying for the Program, (ii) using the media for public service announcements and advertisements of the Program, and (iii) developing posters advertising the Program for display in hospital and clinic waiting rooms.
        (3) The Illinois Department shall utilize accepted
    
methods for informing persons who are illiterate, blind, deaf, or cannot understand the English language, including but not limited to public services announcements and advertisements in the foreign language media of radio, television and newspapers.
        (4) The Illinois Department shall provide notice of
    
the Healthy Kids Program to every child eligible for Healthy Kids services and his or her family at the following times:
            (A) orally by the intake worker and in writing at
        
the time of application for Medical Assistance;
            (B) at the time the applicant is informed that he
        
or she is eligible for Medical Assistance benefits; and
            (C) at least 20 days before the date of any
        
periodic health, vision, hearing, and dental examination for any child eligible for Healthy Kids services. Notice given under this subparagraph (C) must state that a screening examination is due under the periodicity schedules and must advise the eligible child and his or her family that the Illinois Department will provide assistance in scheduling an appointment and arranging medical transportation.
    (h) Data Collection. The Illinois Department shall collect data in a usable form to track utilization of Healthy Kids screening examinations by children eligible for Healthy Kids services, including but not limited to data showing screening examinations and immunizations received, a summary of follow-up treatment received by children eligible for Healthy Kids services and the number of children receiving dental, hearing and vision services.
    (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) To ensure full access to the benefits set forth in this Section, on and after January 1, 2022, the Illinois Department shall ensure that provider and hospital reimbursements for immunization as required under this Section are no lower than 70% of the median regional maximum administration fee for the State of Illinois as established by the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services.
(Source: P.A. 102-43, eff. 7-6-21.)

305 ILCS 5/5-20

    (305 ILCS 5/5-20)
    Sec. 5-20. Electronic health care card. By December 31, 1994, the Illinois Department may develop and implement by rule an electronic health information system to process claims electronically and to electronically store Medicare and Medicaid patient records, medical histories, and billing information. The Illinois Department may issue each Medicare and Medicaid recipient a health card containing electronically coded information that will access the system, verify their Medicare or Medicaid status, and display how much the patient must pay in deductibles or copayments for a medical procedure. The Illinois Department may also develop safeguards to protect recipients' health information from misuse or unauthorized disclosure.
    On or before July 1, 2011, the Department shall cease issuing monthly MediPlan cards and shall instead issue permanent or semi-permanent member cards to individuals enrolled for medical assistance. Furthermore, the Department may employ any reasonable means by which providers may verify an individual's eligibility for medical assistance in place of MediPlan cards.
(Source: P.A. 96-940, eff. 1-1-11.)

305 ILCS 5/5-21

    (305 ILCS 5/5-21)
    Sec. 5-21. Immunization. By July 1, 1994, the Illinois Department shall, in cooperation with the Department of Public Health, establish and implement a pilot program that will provide immunization services for children on a walk-in basis at local public aid offices. The Director shall determine the number and location of the local public aid offices that will participate in the pilot program. The Illinois Department shall submit a report on the effectiveness of the program to the General Assembly on or before December 31, 1995. The Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Human Services, in cooperation with the Department of Public Health, shall continue to implement the pilot program after the effective date of this amendatory Act of 1996.
(Source: P.A. 95-331, eff. 8-21-07.)

305 ILCS 5/5-22

    (305 ILCS 5/5-22)
    Sec. 5-22. (Repealed).
(Source: P.A. 90-655, eff. 7-30-98. Repealed by P.A. 96-1123, eff. 1-1-11.)

305 ILCS 5/5-23

    (305 ILCS 5/5-23)
    Sec. 5-23. (Repealed).
(Source: P.A. 92-581, eff. 6-26-02. Repealed internally, eff. 7-1-03.)

305 ILCS 5/5-24

    (305 ILCS 5/5-24)
    Sec. 5-24. (Repealed).
(Source: P.A. 97-689, eff. 6-14-12. Repealed internally, eff. 1-1-14.)

305 ILCS 5/5-25

    (305 ILCS 5/5-25)
    Sec. 5-25. Pediatric asthma initiative.
    (a) During fiscal year 2006, the Department of Public Aid shall evaluate current standards of treatment of asthma for its beneficiaries. The review may include state-of-the-art programs in asthma disease management as well as evidence-based best practices for the early diagnosis, treatment, and control of asthma, particularly in children. The Department's review may include asthma disease management as one component of a comprehensive disease management model. The Department shall consult with the Department of Public Health and other State agencies, advocates, and providers in conducting this review. The Department's review shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The review shall also assess the available methods of implementing and funding asthma disease management and treatment within the Medicaid program.
    (b) After completing the review under subsection (a), the Department of Public Aid shall develop a pilot asthma disease management program. The pilot program shall be targeted to an area or areas with the highest prevalence of asthma. The Department shall consult with the Department of Public Health and other State agencies, federal health agencies, experts in asthma and immunology, providers, and consumers in developing the pilot program. The pilot program shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The pilot program shall be subject to specific appropriations or budget savings derived from the program due to reduced asthma-related hospitalizations or emergency room visits.
(Source: P.A. 94-328, eff. 7-26-05.)

305 ILCS 5/5-26

    (305 ILCS 5/5-26)
    Sec. 5-26. Federal Family Opportunity Act.
    (a) As used in this Section, "the federal Act" means the federal Family Opportunity Act, enacted as part of the Deficit Reduction Act of 2005.
    (b) Subject to appropriations for program administration and services, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall implement the Medical Assistance provisions of the federal Act as soon as possible after the effective date of this amendatory Act of the 95th General Assembly.
    (c) As soon as possible after the effective date of this amendatory Act of the 95th General Assembly, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall take all necessary and appropriate steps to try to secure (i) any available federal funds for a demonstration project regarding home and community-based alternatives to psychiatric residential treatment facilities for children, as authorized by the federal Act, and (ii) the location in Illinois of a family-to-family health information center, as authorized by the federal Act.
(Source: P.A. 97-48, eff. 6-28-11.)

305 ILCS 5/5-27

    (305 ILCS 5/5-27)
    Sec. 5-27. (Repealed).
(Source: P.A. 96-1372, eff. 7-29-10. Repealed internally, eff. 1-1-11.)

305 ILCS 5/5-28

    (305 ILCS 5/5-28)
    Sec. 5-28. Community transition resources. The Department of Healthcare and Family Services, in collaboration with all relevant agencies, shall develop a Community Transition Plan to allow nursing facility residents who are determined to be appropriate for transition to the community to access or acquire resources to support the transition. These strategies may include, but need not be limited to, enhancement of the Community Home Maintenance Allowance, retention of income from work, and incorporation of community transition services into existing home and community-based waiver programs.
(Source: P.A. 96-1372, eff. 7-29-10.)

305 ILCS 5/5-29

    (305 ILCS 5/5-29)
    Sec. 5-29. Income Limits and Parental Responsibility. In light of the unprecedented fiscal crisis confronting the State, it is the intent of the General Assembly to explore whether the income limits and income counting methods established for children under the Covering ALL KIDS Health Insurance Act, pursuant to this amendatory Act of the 96th General Assembly, should apply to medical assistance programs available to children made eligible under the Illinois Public Aid Code, including through home and community based services waiver programs authorized under Section 1915(c) of the Social Security Act, where parental income is currently not considered in determining a child's eligibility for medical assistance. The Department of Healthcare and Family Services is hereby directed, with the participation of the Department of Human Services and stakeholders, to conduct an analysis of these programs to determine parental cost sharing opportunities, how these opportunities may impact the children currently in the programs, waivers and on the waiting list, and any other factors which may increase efficiencies and decrease State costs. The Department is further directed to review how services under these programs and waivers may be provided by the use of a combination of skilled, unskilled, and uncompensated care and to advise as to what revisions to the Nurse Practice Act, and Acts regulating other relevant professions, are necessary to accomplish this combination of care. The Department shall submit a written analysis on the children's programs and waivers as part of the Department's annual Medicaid reports due to the General Assembly in 2011 and 2012.
(Source: P.A. 96-1501, eff. 1-25-11.)

305 ILCS 5/5-30

    (305 ILCS 5/5-30)
    Sec. 5-30. Care coordination.
    (a) At least 50% of recipients eligible for comprehensive medical benefits in all medical assistance programs or other health benefit programs administered by the Department, including the Children's Health Insurance Program Act and the Covering ALL KIDS Health Insurance Act, shall be enrolled in a care coordination program by no later than January 1, 2015. For purposes of this Section, "coordinated care" or "care coordination" means delivery systems where recipients will receive their care from providers who participate under contract in integrated delivery systems that are responsible for providing or arranging the majority of care, including primary care physician services, referrals from primary care physicians, diagnostic and treatment services, behavioral health services, in-patient and outpatient hospital services, dental services, and rehabilitation and long-term care services. The Department shall designate or contract for such integrated delivery systems (i) to ensure enrollees have a choice of systems and of primary care providers within such systems; (ii) to ensure that enrollees receive quality care in a culturally and linguistically appropriate manner; and (iii) to ensure that coordinated care programs meet the diverse needs of enrollees with developmental, mental health, physical, and age-related disabilities.
    (b) Payment for such coordinated care shall be based on arrangements where the State pays for performance related to health care outcomes, the use of evidence-based practices, the use of primary care delivered through comprehensive medical homes, the use of electronic medical records, and the appropriate exchange of health information electronically made either on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements.
    (c) To qualify for compliance with this Section, the 50% goal shall be achieved by enrolling medical assistance enrollees from each medical assistance enrollment category, including parents, children, seniors, and people with disabilities to the extent that current State Medicaid payment laws would not limit federal matching funds for recipients in care coordination programs. In addition, services must be more comprehensively defined and more risk shall be assumed than in the Department's primary care case management program as of January 25, 2011 (the effective date of Public Act 96-1501).
    (d) The Department shall report to the General Assembly in a separate part of its annual medical assistance program report, beginning April, 2012 until April, 2016, on the progress and implementation of the care coordination program initiatives established by the provisions of Public Act 96-1501. The Department shall include in its April 2011 report a full analysis of federal laws or regulations regarding upper payment limitations to providers and the necessary revisions or adjustments in rate methodologies and payments to providers under this Code that would be necessary to implement coordinated care with full financial risk by a party other than the Department.
    (e) Integrated Care Program for individuals with chronic mental health conditions.
        (1) The Integrated Care Program shall encompass
    
services administered to recipients of medical assistance under this Article to prevent exacerbations and complications using cost-effective, evidence-based practice guidelines and mental health management strategies.
        (2) The Department may utilize and expand upon
    
existing contractual arrangements with integrated care plans under the Integrated Care Program for providing the coordinated care provisions of this Section.
        (3) Payment for such coordinated care shall be based
    
on arrangements where the State pays for performance related to mental health outcomes on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements such as provider-based care coordination.
        (4) The Department shall examine whether chronic
    
mental health management programs and services for recipients with specific chronic mental health conditions do any or all of the following:
            (A) Improve the patient's overall mental health
        
in a more expeditious and cost-effective manner.
            (B) Lower costs in other aspects of the medical
        
assistance program, such as hospital admissions, emergency room visits, or more frequent and inappropriate psychotropic drug use.
        (5) The Department shall work with the facilities and
    
any integrated care plan participating in the program to identify and correct barriers to the successful implementation of this subsection (e) prior to and during the implementation to best facilitate the goals and objectives of this subsection (e).
    (f) A hospital that is located in a county of the State in which the Department mandates some or all of the beneficiaries of the Medical Assistance Program residing in the county to enroll in a Care Coordination Program, as set forth in Section 5-30 of this Code, shall not be eligible for any non-claims based payments not mandated by Article V-A of this Code for which it would otherwise be qualified to receive, unless the hospital is a Coordinated Care Participating Hospital no later than 60 days after June 14, 2012 (the effective date of Public Act 97-689) or 60 days after the first mandatory enrollment of a beneficiary in a Coordinated Care program. For purposes of this subsection, "Coordinated Care Participating Hospital" means a hospital that meets one of the following criteria:
        (1) The hospital has entered into a contract to
    
provide hospital services with one or more MCOs to enrollees of the care coordination program.
        (2) The hospital has not been offered a contract by a
    
care coordination plan that the Department has determined to be a good faith offer and that pays at least as much as the Department would pay, on a fee-for-service basis, not including disproportionate share hospital adjustment payments or any other supplemental adjustment or add-on payment to the base fee-for-service rate, except to the extent such adjustments or add-on payments are incorporated into the development of the applicable MCO capitated rates.
    As used in this subsection (f), "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis.
    (g) No later than August 1, 2013, the Department shall issue a purchase of care solicitation for Accountable Care Entities (ACE) to serve any children and parents or caretaker relatives of children eligible for medical assistance under this Article. An ACE may be a single corporate structure or a network of providers organized through contractual relationships with a single corporate entity. The solicitation shall require that:
        (1) An ACE operating in Cook County be capable of
    
serving at least 40,000 eligible individuals in that county; an ACE operating in Lake, Kane, DuPage, or Will Counties be capable of serving at least 20,000 eligible individuals in those counties and an ACE operating in other regions of the State be capable of serving at least 10,000 eligible individuals in the region in which it operates. During initial periods of mandatory enrollment, the Department shall require its enrollment services contractor to use a default assignment algorithm that ensures if possible an ACE reaches the minimum enrollment levels set forth in this paragraph.
        (2) An ACE must include at a minimum the following
    
types of providers: primary care, specialty care, hospitals, and behavioral healthcare.
        (3) An ACE shall have a governance structure that
    
includes the major components of the health care delivery system, including one representative from each of the groups listed in paragraph (2).
        (4) An ACE must be an integrated delivery system,
    
including a network able to provide the full range of services needed by Medicaid beneficiaries and system capacity to securely pass clinical information across participating entities and to aggregate and analyze that data in order to coordinate care.
        (5) An ACE must be capable of providing both care
    
coordination and complex case management, as necessary, to beneficiaries. To be responsive to the solicitation, a potential ACE must outline its care coordination and complex case management model and plan to reduce the cost of care.
        (6) In the first 18 months of operation, unless the
    
ACE selects a shorter period, an ACE shall be paid care coordination fees on a per member per month basis that are projected to be cost neutral to the State during the term of their payment and, subject to federal approval, be eligible to share in additional savings generated by their care coordination.
        (7) In months 19 through 36 of operation, unless the
    
ACE selects a shorter period, an ACE shall be paid on a pre-paid capitation basis for all medical assistance covered services, under contract terms similar to Managed Care Organizations (MCO), with the Department sharing the risk through either stop-loss insurance for extremely high cost individuals or corridors of shared risk based on the overall cost of the total enrollment in the ACE. The ACE shall be responsible for claims processing, encounter data submission, utilization control, and quality assurance.
        (8) In the fourth and subsequent years of operation,
    
an ACE shall convert to a Managed Care Community Network (MCCN), as defined in this Article, or Health Maintenance Organization pursuant to the Illinois Insurance Code, accepting full-risk capitation payments.
    The Department shall allow potential ACE entities 5 months from the date of the posting of the solicitation to submit proposals. After the solicitation is released, in addition to the MCO rate development data available on the Department's website, subject to federal and State confidentiality and privacy laws and regulations, the Department shall provide 2 years of de-identified summary service data on the targeted population, split between children and adults, showing the historical type and volume of services received and the cost of those services to those potential bidders that sign a data use agreement. The Department may add up to 2 non-state government employees with expertise in creating integrated delivery systems to its review team for the purchase of care solicitation described in this subsection. Any such individuals must sign a no-conflict disclosure and confidentiality agreement and agree to act in accordance with all applicable State laws.
    During the first 2 years of an ACE's operation, the Department shall provide claims data to the ACE on its enrollees on a periodic basis no less frequently than monthly.
    Nothing in this subsection shall be construed to limit the Department's mandate to enroll 50% of its beneficiaries into care coordination systems by January 1, 2015, using all available care coordination delivery systems, including Care Coordination Entities (CCE), MCCNs, or MCOs, nor be construed to affect the current CCEs, MCCNs, and MCOs selected to serve seniors and persons with disabilities prior to that date.
    Nothing in this subsection precludes the Department from considering future proposals for new ACEs or expansion of existing ACEs at the discretion of the Department.
    (h) Department contracts with MCOs and other entities reimbursed by risk based capitation shall have a minimum medical loss ratio of 85%, shall require the entity to establish an appeals and grievances process for consumers and providers, and shall require the entity to provide a quality assurance and utilization review program. Entities contracted with the Department to coordinate healthcare regardless of risk shall be measured utilizing the same quality metrics. The quality metrics may be population specific. Any contracted entity serving at least 5,000 seniors or people with disabilities or 15,000 individuals in other populations covered by the Medical Assistance Program that has been receiving full-risk capitation for a year shall be accredited by a national accreditation organization authorized by the Department within 2 years after the date it is eligible to become accredited. The requirements of this subsection shall apply to contracts with MCOs entered into or renewed or extended after June 1, 2013.
    (h-5) The Department shall monitor and enforce compliance by MCOs with agreements they have entered into with providers on issues that include, but are not limited to, timeliness of payment, payment rates, and processes for obtaining prior approval. The Department may impose sanctions on MCOs for violating provisions of those agreements that include, but are not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. As used in this subsection (h-5), "MCO" has the meaning ascribed to that term in Section 5-30.1 of this Code.
    (i) Unless otherwise required by federal law, Medicaid Managed Care Entities and their respective business associates shall not disclose, directly or indirectly, including by sending a bill or explanation of benefits, information concerning the sensitive health services received by enrollees of the Medicaid Managed Care Entity to any person other than covered entities and business associates, which may receive, use, and further disclose such information solely for the purposes permitted under applicable federal and State laws and regulations if such use and further disclosure satisfies all applicable requirements of such laws and regulations. The Medicaid Managed Care Entity or its respective business associates may disclose information concerning the sensitive health services if the enrollee who received the sensitive health services requests the information from the Medicaid Managed Care Entity or its respective business associates and authorized the sending of a bill or explanation of benefits. Communications including, but not limited to, statements of care received or appointment reminders either directly or indirectly to the enrollee from the health care provider, health care professional, and care coordinators, remain permissible. Medicaid Managed Care Entities or their respective business associates may communicate directly with their enrollees regarding care coordination activities for those enrollees.
    For the purposes of this subsection, the term "Medicaid Managed Care Entity" includes Care Coordination Entities, Accountable Care Entities, Managed Care Organizations, and Managed Care Community Networks.
    For purposes of this subsection, the term "sensitive health services" means mental health services, substance abuse treatment services, reproductive health services, family planning services, services for sexually transmitted infections and sexually transmitted diseases, and services for sexual assault or domestic abuse. Services include prevention, screening, consultation, examination, treatment, or follow-up.
    For purposes of this subsection, "business associate", "covered entity", "disclosure", and "use" have the meanings ascribed to those terms in 45 CFR 160.103.
    Nothing in this subsection shall be construed to relieve a Medicaid Managed Care Entity or the Department of any duty to report incidents of sexually transmitted infections to the Department of Public Health or to the local board of health in accordance with regulations adopted under a statute or ordinance or to report incidents of sexually transmitted infections as necessary to comply with the requirements under Section 5 of the Abused and Neglected Child Reporting Act or as otherwise required by State or federal law.
    The Department shall create policy in order to implement the requirements in this subsection.
    (j) Managed Care Entities (MCEs), including MCOs and all other care coordination organizations, shall develop and maintain a written language access policy that sets forth the standards, guidelines, and operational plan to ensure language appropriate services and that is consistent with the standard of meaningful access for populations with limited English proficiency. The language access policy shall describe how the MCEs will provide all of the following required services:
        (1) Translation (the written replacement of text from
    
one language into another) of all vital documents and forms as identified by the Department.
        (2) Qualified interpreter services (the oral
    
communication of a message from one language into another by a qualified interpreter).
        (3) Staff training on the language access policy,
    
including how to identify language needs, access and provide language assistance services, work with interpreters, request translations, and track the use of language assistance services.
        (4) Data tracking that identifies the language need.
        (5) Notification to participants on the availability
    
of language access services and on how to access such services.
    (k) The Department shall actively monitor the contractual relationship between Managed Care Organizations (MCOs) and any dental administrator contracted by an MCO to provide dental services. The Department shall adopt appropriate dental Healthcare Effectiveness Data and Information Set (HEDIS) measures and shall include the Annual Dental Visit (ADV) HEDIS measure in its Health Plan Comparison Tool and Illinois Medicaid Plan Report Card that is available on the Department's website for enrolled individuals.
    The Department shall collect from each MCO specific information about the types of contracted, broad-based care coordination occurring between the MCO and any dental administrator, including, but not limited to, pregnant women and diabetic patients in need of oral care.
(Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff. 6-4-18.)

305 ILCS 5/5-30.1

    (305 ILCS 5/5-30.1)
    Sec. 5-30.1. Managed care protections.
    (a) As used in this Section:
    "Managed care organization" or "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis.
    "Emergency services" include:
        (1) emergency services, as defined by Section 10 of
    
the Managed Care Reform and Patient Rights Act;
        (2) emergency medical screening examinations, as
    
defined by Section 10 of the Managed Care Reform and Patient Rights Act;
        (3) post-stabilization medical services, as defined
    
by Section 10 of the Managed Care Reform and Patient Rights Act; and
        (4) emergency medical conditions, as defined by
    
Section 10 of the Managed Care Reform and Patient Rights Act.
    (b) As provided by Section 5-16.12, managed care organizations are subject to the provisions of the Managed Care Reform and Patient Rights Act.
    (c) An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid fee-for-service program methodology, 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.
    (d) An MCO shall pay for all post-stabilization services as a covered service in any of the following situations:
        (1) the MCO authorized such services;
        (2) such services were administered to maintain the
    
enrollee's stabilized condition within one hour after a request to the MCO for authorization of further post-stabilization services;
        (3) the MCO did not respond to a request to authorize
    
such services within one hour;
        (4) the MCO could not be contacted; or
        (5) the MCO and the treating provider, if the
    
treating provider is a non-affiliated provider, could not reach an agreement concerning the enrollee's care and an affiliated provider was unavailable for a consultation, in which case the MCO must pay for such services rendered by the treating non-affiliated provider until an affiliated provider was reached and either concurred with the treating non-affiliated provider's plan of care or assumed responsibility for the enrollee's care. Such payment shall be made at the default rate of reimbursement paid under Illinois Medicaid fee-for-service program methodology, 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 that such adjustments are incorporated in the development of the applicable MCO capitated rates.
    (e) The following requirements apply to MCOs in determining payment for all emergency services:
        (1) MCOs shall not impose any requirements for prior
    
approval of emergency services.
        (2) The MCO shall cover emergency services provided
    
to enrollees who are temporarily away from their residence and outside the contracting area to the extent that the enrollees would be entitled to the emergency services if they still were within the contracting area.
        (3) The MCO shall have no obligation to cover medical
    
services provided on an emergency basis that are not covered services under the contract.
        (4) The MCO shall not condition coverage for
    
emergency services on the treating provider notifying the MCO of the enrollee's screening and treatment within 10 days after presentation for emergency services.
        (5) The determination of the attending emergency
    
physician, or the provider actually treating the enrollee, of whether an enrollee is sufficiently stabilized for discharge or transfer to another facility, shall be binding on the MCO. The MCO shall cover emergency services for all enrollees whether the emergency services are provided by an affiliated or non-affiliated provider.
        (6) The MCO's financial responsibility for
    
post-stabilization care services it has not pre-approved ends when:
            (A) a plan physician with privileges at the
        
treating hospital assumes responsibility for the enrollee's care;
            (B) a plan physician assumes responsibility for
        
the enrollee's care through transfer;
            (C) a contracting entity representative and the
        
treating physician reach an agreement concerning the enrollee's care; or
            (D) the enrollee is discharged.
    (f) Network adequacy and transparency.
        (1) The Department shall:
            (A) ensure that an adequate provider network is
        
in place, taking into consideration health professional shortage areas and medically underserved areas;
            (B) publicly release an explanation of its
        
process for analyzing network adequacy;
            (C) periodically ensure that an MCO continues to
        
have an adequate network in place;
            (D) require MCOs, including Medicaid Managed Care
        
Entities as defined in Section 5-30.2, to meet provider directory requirements under Section 5-30.3;
            (E) require MCOs to ensure that any
        
Medicaid-certified provider under contract with an MCO and previously submitted on a roster on the date of service is paid for any medically necessary, Medicaid-covered, and authorized service rendered to any of the MCO's enrollees, regardless of inclusion on the MCO's published and publicly available directory of available providers; and
            (F) require MCOs, including Medicaid Managed
        
Care Entities as defined in Section 5-30.2, to meet each of the requirements under subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act; with necessary exceptions to the MCO's network to ensure that admission and treatment with a provider or at a treatment facility in accordance with the network adequacy standards in paragraph (3) of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act is limited to providers or facilities that are Medicaid certified.
        (2) Each MCO shall confirm its receipt of information
    
submitted specific to physician or dentist additions or physician or dentist deletions from the MCO's provider network within 3 days after receiving all required information from contracted physicians or dentists, and electronic physician and dental directories must be updated consistent with current rules as published by the Centers for Medicare and Medicaid Services or its successor agency.
    (g) Timely payment of claims.
        (1) The MCO shall pay a claim within 30 days of
    
receiving a claim that contains all the essential information needed to adjudicate the claim.
        (2) The MCO shall notify the billing party of its
    
inability to adjudicate a claim within 30 days of receiving that claim.
        (3) The MCO shall pay a penalty that is at least
    
equal to the timely payment interest penalty imposed under Section 368a of the Illinois Insurance Code for any claims not timely paid.
            (A) When an MCO is required to pay a timely
        
payment interest penalty to a provider, the MCO must calculate and pay the timely payment interest penalty that is due to the provider within 30 days after the payment of the claim. In no event shall a provider be required to request or apply for payment of any owed timely payment interest penalties.
            (B) Such payments shall be reported separately
        
from the claim payment for services rendered to the MCO's enrollee and clearly identified as interest payments.
        (4)(A) The Department shall require MCOs to expedite
    
payments to providers identified on the Department's expedited provider list, determined in accordance with 89 Ill. Adm. Code 140.71(b), on a schedule at least as frequently as the providers are paid under the Department's fee-for-service expedited provider schedule.
        (B) Compliance with the expedited provider
    
requirement may be satisfied by an MCO through the use of a Periodic Interim Payment (PIP) program that has been mutually agreed to and documented between the MCO and the provider, if the PIP program ensures that any expedited provider receives regular and periodic payments based on prior period payment experience from that MCO. Total payments under the PIP program may be reconciled against future PIP payments on a schedule mutually agreed to between the MCO and the provider.
        (C) The Department shall share at least monthly its
    
expedited provider list and the frequency with which it pays providers on the expedited list.
    (g-5) Recognizing that the rapid transformation of the Illinois Medicaid program may have unintended operational challenges for both payers and providers:
        (1) in no instance shall a medically necessary
    
covered service rendered in good faith, based upon eligibility information documented by the provider, be denied coverage or diminished in payment amount if the eligibility or coverage information available at the time the service was rendered is later found to be inaccurate in the assignment of coverage responsibility between MCOs or the fee-for-service system, except for instances when an individual is deemed to have not been eligible for coverage under the Illinois Medicaid program; and
        (2) the Department shall, by December 31, 2016, adopt
    
rules establishing policies that shall be included in the Medicaid managed care policy and procedures manual addressing payment resolutions in situations in which a provider renders services based upon information obtained after verifying a patient's eligibility and coverage plan through either the Department's current enrollment system or a system operated by the coverage plan identified by the patient presenting for services:
            (A) such medically necessary covered services
        
shall be considered rendered in good faith;
            (B) such policies and procedures shall be
        
developed in consultation with industry representatives of the Medicaid managed care health plans and representatives of provider associations representing the majority of providers within the identified provider industry; and
            (C) such rules shall be published for a review
        
and comment period of no less than 30 days on the Department's website with final rules remaining available on the Department's website.
        The rules on payment resolutions shall include, but
    
not be limited to:
            (A) the extension of the timely filing period;
            (B) retroactive prior authorizations; and
            (C) guaranteed minimum payment rate of no less
        
than the current, as of the date of service, fee-for-service rate, plus all applicable add-ons, when the resulting service relationship is out of network.
        The rules shall be applicable for both MCO coverage
    
and fee-for-service coverage.
    If the fee-for-service system is ultimately determined to have been responsible for coverage on the date of service, the Department shall provide for an extended period for claims submission outside the standard timely filing requirements.
    (g-6) MCO Performance Metrics Report.
        (1) The Department shall publish, on at least a
    
quarterly basis, each MCO's operational performance, including, but not limited to, the following categories of metrics:
            (A) claims payment, including timeliness and
        
accuracy;
            (B) prior authorizations;
            (C) grievance and appeals;
            (D) utilization statistics;
            (E) provider disputes;
            (F) provider credentialing; and
            (G) member and provider customer service.
        (2) The Department shall ensure that the metrics
    
report is accessible to providers online by January 1, 2017.
        (3) The metrics shall be developed in consultation
    
with industry representatives of the Medicaid managed care health plans and representatives of associations representing the majority of providers within the identified industry.
        (4) Metrics shall be defined and incorporated into
    
the applicable Managed Care Policy Manual issued by the Department.
    (g-7) MCO claims processing and performance analysis. In order to monitor MCO payments to hospital providers, pursuant to Public Act 100-580, the Department shall post an analysis of MCO claims processing and payment performance on its website every 6 months. Such analysis shall include a review and evaluation of a representative sample of hospital claims that are rejected and denied for clean and unclean claims and the top 5 reasons for such actions and timeliness of claims adjudication, which identifies the percentage of claims adjudicated within 30, 60, 90, and over 90 days, and the dollar amounts associated with those claims.
    (g-8) Dispute resolution process. The Department shall maintain a provider complaint portal through which a provider can submit to the Department unresolved disputes with an MCO. An unresolved dispute means an MCO's decision that denies in whole or in part a claim for reimbursement to a provider for health care services rendered by the provider to an enrollee of the MCO with which the provider disagrees. Disputes shall not be submitted to the portal until the provider has availed itself of the MCO's internal dispute resolution process. Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the Department of Healthcare and Family Services' complaint portal no sooner than 30 days after submitting to the MCO's internal process and not later than 30 days after the unsatisfactory resolution of the internal MCO process or 60 days after submitting the dispute to the MCO internal process. Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy. Within 10 business days of receipt of a complaint, the Department shall present such disputes to the appropriate MCO, which shall then have 30 days to issue its written proposal to resolve the dispute. The Department may grant one 30-day extension of this time frame to one of the parties to resolve the dispute. If the dispute remains unresolved at the end of this time frame or the provider is not satisfied with the MCO's written proposal to resolve the dispute, the provider may, within 30 days, request the Department to review the dispute and make a final determination. Within 30 days of the request for Department review of the dispute, both the provider and the MCO shall present all relevant information to the Department for resolution and make individuals with knowledge of the issues available to the Department for further inquiry if needed. Within 30 days of receiving the relevant information on the dispute, or the lapse of the period for submitting such information, the Department shall issue a written decision on the dispute based on contractual terms between the provider and the MCO, contractual terms between the MCO and the Department of Healthcare and Family Services and applicable Medicaid policy. The decision of the Department shall be final. By January 1, 2020, the Department shall establish by rule further details of this dispute resolution process. Disputes between MCOs and providers presented to the Department for resolution are not contested cases, as defined in Section 1-30 of the Illinois Administrative Procedure Act, conferring any right to an administrative hearing.
    (g-9)(1) The Department shall publish annually on its website a report on the calculation of each managed care organization's medical loss ratio showing the following:
        (A) Premium revenue, with appropriate adjustments.
        (B) Benefit expense, setting forth the aggregate
    
amount spent for the following:
            (i) Direct paid claims.
            (ii) Subcapitation payments.
            (iii) Other claim payments.
            (iv) Direct reserves.
            (v) Gross recoveries.
            (vi) Expenses for activities that improve health
        
care quality as allowed by the Department.
    (2) The medical loss ratio shall be calculated consistent with federal law and regulation following a claims runout period determined by the Department.
    (g-10)(1) "Liability effective date" means the date on which an MCO becomes responsible for payment for medically necessary and covered services rendered by a provider to one of its enrollees in accordance with the contract terms between the MCO and the provider. The liability effective date shall be the later of:
        (A) The execution date of a network participation
    
contract agreement.
        (B) The date the provider or its representative
    
submits to the MCO the complete and accurate standardized roster form for the provider in the format approved by the Department.
        (C) The provider effective date contained within the
    
Department's provider enrollment subsystem within the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) System.
    (2) The standardized roster form may be submitted to the MCO at the same time that the provider submits an enrollment application to the Department through IMPACT.
    (3) By October 1, 2019, the Department shall require all MCOs to update their provider directory with information for new practitioners of existing contracted providers within 30 days of receipt of a complete and accurate standardized roster template in the format approved by the Department provided that the provider is effective in the Department's provider enrollment subsystem within the IMPACT system. Such provider directory shall be readily accessible for purposes of selecting an approved health care provider and comply with all other federal and State requirements.
    (g-11) The Department shall work with relevant stakeholders on the development of operational guidelines to enhance and improve operational performance of Illinois' Medicaid managed care program, including, but not limited to, improving provider billing practices, reducing claim rejections and inappropriate payment denials, and standardizing processes, procedures, definitions, and response timelines, with the goal of reducing provider and MCO administrative burdens and conflict. The Department shall include a report on the progress of these program improvements and other topics in its Fiscal Year 2020 annual report to the General Assembly.
    (g-12) Notwithstanding any other provision of law, if the Department or an MCO requires submission of a claim for payment in a non-electronic format, a provider shall always be afforded a period of no less than 90 business days, as a correction period, following any notification of rejection by either the Department or the MCO to correct errors or omissions in the original submission.
    Under no circumstances, either by an MCO or under the State's fee-for-service system, shall a provider be denied payment for failure to comply with any timely submission requirements under this Code or under any existing contract, unless the non-electronic format claim submission occurs after the initial 180 days following the latest date of service on the claim, or after the 90 business days correction period following notification to the provider of rejection or denial of payment.
    (h) The Department shall not expand mandatory MCO enrollment into new counties beyond those counties already designated by the Department as of June 1, 2014 for the individuals whose eligibility for medical assistance is not the seniors or people with disabilities population until the Department provides an opportunity for accountable care entities and MCOs to participate in such newly designated counties.
    (h-5) Leading indicator data sharing. By January 1, 2024, the Department shall obtain input from the Department of Human Services, the Department of Juvenile Justice, the Department of Children and Family Services, the State Board of Education, managed care organizations, providers, and clinical experts to identify and analyze key indicators from assessments and data sets available to the Department that can be shared with managed care organizations and similar care coordination entities contracted with the Department as leading indicators for elevated behavioral health crisis risk for children. To the extent permitted by State and federal law, the identified leading indicators shall be shared with managed care organizations and similar care coordination entities contracted with the Department within 6 months of identification for the purpose of improving care coordination with the early detection of elevated risk. Leading indicators shall be reassessed annually with stakeholder input.
    (i) The requirements of this Section apply to contracts with accountable care entities and MCOs entered into, amended, or renewed after June 16, 2014 (the effective date of Public Act 98-651).
    (j) Health care information released to managed care organizations. A health care provider shall release to a Medicaid managed care organization, upon request, and subject to the Health Insurance Portability and Accountability Act of 1996 and any other law applicable to the release of health information, the health care information of the MCO's enrollee, if the enrollee has completed and signed a general release form that grants to the health care provider permission to release the recipient's health care information to the recipient's insurance carrier.
    (k) The Department of Healthcare and Family Services, managed care organizations, a statewide organization representing hospitals, and a statewide organization representing safety-net hospitals shall explore ways to support billing departments in safety-net hospitals.
    (l) The requirements of this Section added by Public Act 102-4 shall apply to services provided on or after the first day of the month that begins 60 days after April 27, 2021 (the effective date of Public Act 102-4).
(Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff. 5-13-22; 103-546, eff. 8-11-23.)

305 ILCS 5/5-30.2

    (305 ILCS 5/5-30.2)
    Sec. 5-30.2. Monthly reports; managed care enrollment.
    (a) As used in this Section, "Medicaid Managed Care Entity" means a Managed Care Organization (MCO), a Managed Care Community Network (MCCN), an Accountable Care Entity (ACE), or a Care Coordination Entity (CCE) contracted by the Department.
    (b) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of persons in the State's medical assistance program. In addition, as soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of recipients of medical assistance into a Medicaid Managed Care Entity contracted by the Department. As soon as practical if the data is reasonably available, but no later than January 1, 2017, the monthly reports shall include all of the following information for the medical assistance program generally and, separately, for each Medicaid Managed Care Entity contracted by the Department:
        (1) Total enrollment.
        (2) The number of persons enrolled in the medical
    
assistance program under items 18 and 19 of Section 5-2.
        (3) The number of children enrolled.
        (4) The number of parents and caretakers of minor
    
children enrolled.
        (5) The number of women enrolled on the basis of
    
pregnancy.
        (6) The number of seniors enrolled.
        (7) The number of persons enrolled on the basis of
    
disability.
    (c) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website detailing the percentage of persons enrolled in each Medicaid Managed Care Entity that was assigned using an auto-assignment algorithm. This percentage should also report the type of enrollee who was assigned using an auto-assignment algorithm, including, but not limited to, persons enrolled in the medical assistance program in each of the groups listed in subsection (b) of this Section.
    (d) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include data on the 2 most recently available months and data comparing the most recently available month to that month in the prior year.
    (e) As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include a breakdown of language preference for enrollees by English, Spanish, and the next 4 most commonly used languages.
    (f) The Department must annually publish on its website each Medicaid Managed Care Entity's quality metrics outcomes and must make public an independent annual quality review report on the State's Medicaid managed care delivery system.
(Source: P.A. 99-86, eff. 7-21-15.)

305 ILCS 5/5-30.3

    (305 ILCS 5/5-30.3)
    Sec. 5-30.3. Empowering meaningful patient choice in Medicaid Managed Care.
    (a) Definitions. As used in this Section:
    "Client enrollment services broker" means a vendor the Department contracts with to carry out activities related to Medicaid recipients' enrollment, disenrollment, and renewal with Medicaid Managed Care Entities.
    "Composite domains" means the synthesized categories reflecting the standardized quality performance measures included in the consumer quality comparison tool. At a minimum, these composite domains shall display Medicaid Managed Care Entities' individual Plan performance on standardized quality, timeliness, and access measures.
    "Consumer quality comparison tool" means an online and paper tool developed by the Department with input from interested stakeholders reflecting the performance of Medicaid Managed Care Entity Plans on standardized quality performance measures. This tool shall be designed in a consumer-friendly and easily understandable format.
    "Covered services" means those health care services to which a covered person is entitled to under the terms of the Medicaid Managed Care Entity Plan.
    "Facilities" includes, but is not limited to, federally qualified health centers, skilled nursing facilities, and rehabilitation centers.
    "Hospitals" includes, but is not limited to, acute care, rehabilitation, children's, and cancer hospitals.
    "Integrated provider directory" means a searchable database bringing together network data from multiple Medicaid Managed Care Entities that is available through client enrollment services.
    "Medicaid eligibility redetermination" means the process by which the eligibility of a Medicaid recipient is reviewed by the Department to determine if the recipient's medical benefits will continue, be modified, or terminated.
    "Medicaid Managed Care Entity" has the same meaning as defined in Section 5-30.2 of this Code.
    (b) Provider directory transparency.
        (1) Each Medicaid Managed Care Entity shall:
            (A) Make available on the entity's website a
        
provider directory in a machine readable file and format.
            (B) Make provider directories publicly accessible
        
without the necessity of providing a password, a username, or personally identifiable information.
            (C) Comply with all federal and State statutes
        
and regulations, including 42 CFR 438.10, pertaining to provider directories within Medicaid Managed Care.
            (D) Request, at least annually, provider office
        
hours for each of the following provider types:
                (i) Health care professionals, including
            
dental and vision providers.
                (ii) Hospitals.
                (iii) Facilities, other than hospitals.
                (iv) Pharmacies, other than hospitals.
                (v) Durable medical equipment suppliers,
            
other than hospitals.
            Medicaid Managed Care Entities shall publish the
        
provider office hours in the provider directory upon receipt.
            (E) Confirm with the Medicaid Managed Care
        
Entity's contracted providers who have not submitted claims within the past 6 months that the contracted providers intend to remain in the network and correct any incorrect provider directory information as necessary.
            (F) Ensure that in situations in which a Medicaid
        
Managed Care Entity Plan enrollee receives covered services from a non-participating provider due to a material misrepresentation in a Medicaid Managed Care Entity's online electronic provider directory, the Medicaid Managed Care Entity Plan enrollee shall not be held responsible for any costs resulting from that material misrepresentation.
            (G) Conspicuously display an e-mail address and a
        
toll-free telephone number to which any individual may report any inaccuracy in the provider directory. If the Medicaid Managed Care Entity receives a report from any person who specifically identifies provider directory information as inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic directory.
        (2) The Department shall:
            (A) Regularly monitor Medicaid Managed Care
        
Entities to ensure that they are compliant with the requirements under paragraph (1) of subsection (b).
            (B) Require that the client enrollment services
        
broker use the Medicaid provider number for all providers with a Medicaid Provider number to populate the provider information in the integrated provider directory.
            (C) Ensure that each Medicaid Managed Care Entity
        
shall, at minimum, make the information in subparagraph (D) of paragraph (1) of subsection (b) available to the client enrollment services broker.
            (D) Ensure that the client enrollment services
        
broker shall, at minimum, have the information in subparagraph (D) of paragraph (1) of subsection (b) available and searchable through the integrated provider directory on its website as soon as possible but no later than January 1, 2017.
            (E) Require the client enrollment services broker
        
to conspicuously display near the integrated provider directory an email address and a toll-free telephone number provided by the Department to which any individual may report inaccuracies in the integrated provider directory. If the Department receives a report that identifies an inaccuracy in the integrated provider directory, the Department shall provide the information about the reported inaccuracy to the appropriate Medicaid Managed Care Entity within 3 business days after the reported inaccuracy is received.
    (c) Formulary transparency.
        (1) Medicaid Managed Care Entities shall publish on
    
their respective websites a formulary for each Medicaid Managed Care Entity Plan offered and make the formularies easily understandable and publicly accessible without the necessity of providing a password, a username, or personally identifiable information.
        (2) Medicaid Managed Care Entities shall provide
    
printed formularies upon request.
        (3) Electronic and print formularies shall display:
            (A) the medications covered (both generic and
        
name brand);
            (B) if the medication is preferred or not
        
preferred, and what each term means;
            (C) what tier each medication is in and the
        
meaning of each tier;
            (D) any utilization controls including, but not
        
limited to, step therapy, prior approval, dosage limits, gender or age restrictions, quantity limits, or other policies that affect access to medications;
            (E) any required cost-sharing;
            (F) a glossary of key terms and explanation of
        
utilization controls and cost-sharing requirements;
            (G) a key or legend for all utilization controls
        
visible on every page in which specific medication coverage information is displayed; and
            (H) directions explaining the process or
        
processes a consumer may follow to obtain more information if a medication the consumer requires is not covered or listed in the formulary.
        (4) Each Medicaid Managed Care Entity shall display
    
conspicuously with each electronic and printed medication formulary an e-mail address and a toll-free telephone number to which any individual may report any inaccuracy in the formulary. If the Medicaid Managed Care Entity receives a report that the formulary information is inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic formulary.
        (5) Each Medicaid Managed Care Entity shall include a
    
disclosure in the electronic and requested print formularies that provides the date of publication, a statement that the formulary is up to date as of publication, and contact information for questions and requests to receive updated information.
        (6) The client enrollment services broker's website
    
shall display prominently a website URL link to each Medicaid Managed Care Entity's Plan formulary. If a Medicaid enrollee calls the client enrollment services broker with questions regarding formularies, the client enrollment services broker shall offer a brief description of what a formulary is and shall refer the Medicaid enrollee to the appropriate Medicaid Managed Care Entity regarding his or her questions about a specific entity's formulary.
    (d) Grievances and appeals. The Department shall display prominently on its website consumer-oriented information describing how a Medicaid enrollee can file a complaint or grievance, request a fair hearing for any adverse action taken by the Department or a Medicaid Managed Care Entity, and access free legal assistance or other assistance made available by the State for Medicaid enrollees to pursue an action.
    (e) Medicaid redetermination information. The Department shall require the client enrollment services broker to display prominently on the client enrollment services broker's website a description of where a Medicaid enrollee can access information regarding the Medicaid redetermination process.
    (f) Medicaid care coordination information. The client enrollment services broker shall display prominently on its website, in an easily understandable format, consumer-oriented information regarding the role of care coordination services within Medicaid Managed Care. Such information shall include, but shall not be limited to:
        (1) a basic description of the role of care
    
coordination services and examples of specific care coordination activities; and
        (2) how a Medicaid enrollee may request care
    
coordination services from a Medicaid Managed Care Entity.
    (g) Consumer quality comparison tool.
        (1) The Department shall create a consumer quality
    
comparison tool to assist Medicaid enrollees with Medicaid Managed Care Entity Plan selection. This tool shall provide Medicaid Managed Care Entities' individual Plan performance on a set of standardized quality performance measures. The Department shall ensure that this tool shall be accessible in both a print and online format, with the online format allowing for individuals to access additional detailed Plan performance information.
        (2) At a minimum, a printed version of the consumer
    
quality comparison tool shall be provided by the Department on an annual basis to Medicaid enrollees who are required by the Department to enroll in a Medicaid Managed Care Entity Plan during an enrollee's open enrollment period. The consumer quality comparison tool shall also meet all of the following criteria:
            (A) Display Medicaid Managed Care Entities'
        
individual Plan performance on at least 4 composite domains that reflect Plan quality, timeliness, and access. The composite domains shall draw from the most current available performance data sets including, but not limited to:
                (i) Healthcare Effectiveness Data and
            
Information Set (HEDIS) measures.
                (ii) Core Set of Children's Health Care
            
Quality measures as required under the Children's Health Insurance Program Reauthorization Act (CHIPRA).
                (iii) Adult Core Set measures.
                (iv) Consumer Assessment of Healthcare
            
Providers and Systems (CAHPS) survey results.
                (v) Additional performance measures the
            
Department deems appropriate to populate the composite domains.
            (B) Use a quality rating system developed by the
        
Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.
            (C) Be customized to reflect the specific
        
Medicaid Managed Care Entities' Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
            (D) Include contact information for the client
        
enrollment services broker and contact information for Medicaid Managed Care Entities available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
            (E) Include guiding questions designed to assist
        
individuals selecting a Medicaid Managed Care Entity Plan.
        (3) At a minimum, the online version of the consumer
    
quality comparison tool shall meet all of the following criteria:
            (A) Display Medicaid Managed Care Entities'
        
individual Plan performance for the same composite domains selected by the Department in the printed version of the consumer quality comparison tool. The Department may display additional composite domains in the online version of the consumer quality comparison tool as appropriate.
            (B) Display Medicaid Managed Care Entities'
        
individual Plan performance on each of the standardized performance measures that contribute to each composite domain displayed on the online version of the consumer quality comparison tool.
            (C) Use a quality rating system developed by the
        
Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.
            (D) Include the specific Medicaid Managed Care
        
Entity Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
            (E) Include a sort function to view Medicaid
        
Managed Care Entities' individual Plan performance by quality rating and by standardized quality performance measures.
            (F) Include contact information for the client
        
enrollment services broker and for each Medicaid Managed Care Entity.
            (G) Include guiding questions designed to assist
        
individuals in selecting a Medicaid Managed Care Entity Plan.
            (H) Prominently display current notice of quality
        
performance sanctions against Medicaid Managed Care Entities. Notice of the sanctions shall remain present on the online version of the consumer quality comparison tool until the sanctions are lifted.
        (4) The online version of the consumer quality
    
comparison tool shall be displayed prominently on the client enrollment services broker's website.
        (5) In the development of the consumer quality
    
comparison tool, the Department shall establish and publicize a formal process to collect and consider written and oral feedback from consumers, advocates, and stakeholders on aspects of the consumer quality comparison tool, including, but not limited to, the following:
            (A) The standardized data sets and surveys,
        
specific performance measures, and composite domains represented in the consumer quality comparison tool.
            (B) The format and presentation of the consumer
        
quality comparison tool.
            (C) The methods undertaken by the Department to
        
notify Medicaid enrollees of the availability of the consumer quality comparison tool.
        (6) The Department shall review and update as
    
appropriate the composite domains and performance measures represented in the print and online versions of the consumer quality comparison tool at least once every 3 years. During the Department's review process, the Department shall solicit engagement in the public feedback process described in paragraph (5).
        (7) The Department shall ensure that the consumer
    
quality comparison tool is available for consumer use as soon as possible but no later than January 1, 2018.
    (h) The Department may adopt rules and take any other appropriate action necessary to implement its responsibilities under this Section.
(Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.)

305 ILCS 5/5-30.4

    (305 ILCS 5/5-30.4)
    Sec. 5-30.4. Provider inquiry portal. The Department shall establish, no later than January 1, 2018, a web-based portal to accept inquiries and requests for assistance from managed care organizations under contract with the State and providers under contract with managed care organizations to provide direct care.
(Source: P.A. 99-719, eff. 1-1-17; 100-201, eff. 8-18-17.)

305 ILCS 5/5-30.5

    (305 ILCS 5/5-30.5)
    Sec. 5-30.5. Managed care; automatic assignment. The Department shall, within a reasonable period of time after relevant data from managed care entities has been collected and analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes into account quality scores and other operational proficiency criteria developed, defined, and adopted by the Department, to automatically assign Medicaid enrollees served under the Family Health Plan and the Integrated Care Program and those Medicaid enrollees eligible for medical assistance pursuant to the Patient Protection and Affordable Care Act (Public Law 111-148) into managed care entities, including Accountable Care Entities, Managed Care Community Networks, and Managed Care Organizations. The quality metrics used shall be measurable for all entities. The algorithm shall not use the quality and proficiency metrics to reassign enrollees out of any plan in which they are enrolled at the time and shall only be used if the client has not voluntarily selected a primary care physician and a managed care entity or care coordination entity. Clients shall have one opportunity within 90 calendar days after auto-assignment by algorithm to select a different managed care entity. The algorithm developed and implemented shall favor assignment into managed care entities with the highest quality scores and levels of compliance with the operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists.
(Source: P.A. 99-898, eff. 1-1-17; 100-201, eff. 8-18-17.)

305 ILCS 5/5-30.6

    (305 ILCS 5/5-30.6)
    Sec. 5-30.6. Managed care organization contracts procurement requirement. Beginning on March 12, 2018 (the effective date of Public Act 100-580), any new contract between the Department and a managed care organization as defined in Section 5-30.1 shall be procured in accordance with the Illinois Procurement Code.
    (a) Application.
        (1) This Section does not apply to the State of
    
Illinois Medicaid Managed Care Organization Request for Proposals (2018-24-001) or any agreement, regardless of what it may be called, related to or arising from this procurement, including, but not limited to, contracts, renewals, renegotiated contracts, amendments, and change orders.
        (2) This Section does not apply to Medicare-Medicaid
    
Alignment Initiative contracts executed under Article V-F of this Code.
    (b) In the event any provision of this Section or of the Illinois Procurement Code is inconsistent with applicable federal law or would have the effect of foreclosing the use, potential use, or receipt of federal financial participation, the applicable federal law or funding condition shall prevail, but only to the extent of such inconsistency.
(Source: P.A. 100-580, eff. 3-12-18; 101-81, eff. 7-12-19.)

305 ILCS 5/5-30.7

    (305 ILCS 5/5-30.7)
    Sec. 5-30.7. Encounter data guidelines; provider fee schedule.
    (a) No later than 60 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall publish on its website comprehensive written guidance on the submission of encounter data by managed care organizations. This information shall be updated and published as needed, but at least quarterly. The Department shall inform providers and managed care organizations of any updates via provider notices.
    (b) The Department shall publish on its website provider fee schedules on both a portable document format (PDF) and EXCEL format. The portable document format shall serve as the ultimate source if there is a discrepancy.
(Source: P.A. 100-580, eff. 3-12-18.)

305 ILCS 5/5-30.8

    (305 ILCS 5/5-30.8)
    Sec. 5-30.8. Managed care organization rate transparency.
    (a) For the establishment of managed care organization (MCO) capitation base rate payments from the State, including, but not limited to: (i) hospital fee schedule reforms and updates, (ii) rates related to a single State-mandated preferred drug list, (iii) rate updates related to the State's preferred drug list, (iv) inclusion of coverage for children with special needs, (v) inclusion of coverage for children within the child welfare system, (vi) annual MCO capitation rates, and (vii) any retroactive provider fee schedule adjustments or other changes required by legislation or other actions, the Department of Healthcare and Family Services shall implement a capitation base rate setting process beginning on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following elements of transparency:
        (1) The Department shall include participating
    
MCOs and a statewide trade association representing a majority of participating MCOs in meetings to discuss the impact to base capitation rates as a result of any new or updated hospital fee schedules or other provider fee schedules. Additionally, the Department shall share any data or reports used to develop MCO capitation rates with participating MCOs. This data shall be comprehensive enough for MCO actuaries to recreate and verify the accuracy of the capitation base rate build-up.
        (2) The Department shall not limit the number of
    
experts that each MCO is allowed to bring to the draft capitation base rate meeting or the final capitation base rate review meeting. Draft and final capitation base rate review meetings shall be held in at least 2 locations.
        (3) The Department and its contracted actuary shall
    
meet with all participating MCOs simultaneously and together along with consulting actuaries contracted with statewide trade association representing a majority of Medicaid health plans at the request of the plans. Participating MCOs shall additionally, at their request, be granted individual capitation rate development meetings with the Department.
        (4) (Blank).
        (4.5) Effective for calendar year 2024, a quality
    
withhold program may be established by the Department for the HealthChoice Illinois Managed Care Program or any successor program. If such program withholds a portion of the actuarially certified capitation rates, the program must meet the following criteria: (i) benchmarks must be discussed publicly, based on predetermined quality standards that align with the Department's federally approved quality strategy, and set by publication on the Department's website at least 4 months prior to the start of the calendar year; (ii) incentive measures and benchmarks must be reasonable and attainable within the measurement year; and (iii) no less than 75% of the metrics shall be tied to nationally recognized measures. Any non-nationally recognized measures shall be in the reporting category for at least 2 years of experience and evaluation for consistency among MCOs prior to setting a performance baseline. The Department shall provide MCOs with biannual industry average data on the quality withhold measures. If all the money withheld is not earned back by individual MCOs, the Department shall reallocate unearned funds among the MCOs in one or both of the following manners: based upon their quality performance or for quality and equity improvement projects. Nothing in this paragraph prohibits the Department and the MCOs from establishing any other quality performance program.
        (5) Upon request, the Department shall
    
provide written responses to questions regarding MCO capitation base rates, the capitation base development methodology, and MCO capitation rate data, and all other requests regarding capitation rates from MCOs. Upon request, the Department shall also provide to the MCOs materials used in incorporating provider fee schedules into base capitation rates.
    (b) For the development of capitation base rates for new capitation rate years:
        (1) The Department shall take into account emerging
    
experience in the development of the annual MCO capitation base rates, including, but not limited to, current-year cost and utilization trends observed by MCOs in an actuarially sound manner and in accordance with federal law and regulations.
        (2) No later than January 1 of each year, the
    
Department shall release an agreed upon annual calendar that outlines dates for capitation rate setting meetings for that year. The calendar shall include at least the following meetings and deadlines:
            (A) An initial meeting for the Department to
        
review MCO data and draft rate assumptions to be used in the development of capitation base rates for the following year.
            (B) A draft rate meeting after the Department
        
provides the MCOs with the draft capitation base rates to discuss, review, and seek feedback regarding the draft capitation base rates.
        (3) Prior to the submission of final capitation
    
rates to the federal Centers for Medicare and Medicaid Services, the Department shall provide the MCOs with a final actuarial report including the final capitation base rates for the following year and subsequently conduct a final capitation base review meeting. Final capitation rates shall be marked final.
    (c) For the development of capitation base rates reflecting policy changes:
        (1) Unless contrary to federal law and regulation,
    
the Department must provide notice to MCOs of any significant operational policy change no later than 60 days prior to the effective date of an operational policy change in order to give MCOs time to prepare for and implement the operational policy change and to ensure that the quality and delivery of enrollee health care is not disrupted. "Operational policy change" means a change to operational requirements such as reporting formats, encounter submission definitional changes, or required provider interfaces made at the sole discretion of the Department and not required by legislation with a retroactive effective date. Nothing in this Section shall be construed as a requirement to delay or prohibit implementation of policy changes that impact enrollee benefits as determined in the sole discretion of the Department.
        (2) No later than 60 days after the effective
    
date of the policy change or program implementation, the Department shall meet with the MCOs regarding the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of that data that shall be utilized to develop capitation base rates.
        (3) No later than 60 days after the effective date of
    
the policy change or program implementation, the Department shall meet with MCOs to review data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change, and shall provide opportunities for questions to be asked and answered.
        (4) No later than 60 days after the effective
    
date of the policy change or program implementation, the Department shall provide the MCOs with draft capitation base rates and shall also conduct a draft capitation base rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.
    (d) For the development of capitation base rates for retroactive policy or fee schedule changes:
        (1) The Department shall meet with the MCOs regarding
    
the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of the data that shall be utilized to develop capitation base rates.
        (2) The Department shall meet with MCOs to review
    
data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change. The Department shall provide opportunities for questions to be asked and answered.
        (3) The Department shall provide the MCOs with draft
    
capitation rates and shall also conduct a draft rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.
        (4) The Department shall inform MCOs no less than
    
quarterly of upcoming benefit and policy changes to the Medicaid program.
    (e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.
(Source: P.A. 103-102, eff. 1-1-24.)

305 ILCS 5/5-30.9

    (305 ILCS 5/5-30.9)
    Sec. 5-30.9. Disenrollment requirements; managed care organization. Disenrollment of a Medicaid enrollee from a managed care organization under contract with the Department shall be in accordance with the requirements of 42 CFR 438.56 whenever a contract is terminated between a Medicaid managed care health plan and a primary care provider that results in a disruption to the Medicaid enrollee's provider-beneficiary relationship.
(Source: P.A. 100-950, eff. 8-19-18; 101-81, eff. 7-12-19.)