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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.


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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.)

305 ILCS 5/5-30.10

    (305 ILCS 5/5-30.10)
    Sec. 5-30.10. Electronic report submission. To preserve the quality of data and ensure productive oversight of Medicaid managed care organizations, all regular reports required, either by contract or statute, to be collected by the Department from managed care organizations shall be collected through a secure electronic format and medium as designated by the Department. The Department shall consider concerns raised by the contractor about potential burdens associated with producing the report. Ad hoc reports may be collected in alternative manners.
(Source: P.A. 100-1105, eff. 8-27-18; 101-81, eff. 7-12-19.)

305 ILCS 5/5-30.11

    (305 ILCS 5/5-30.11)
    Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when (1) ordered by a physician licensed to practice medicine in all its branches or a psychologist licensed by the Department of Financial and Professional Regulation and (2) evaluated by a behavior analyst as recognized by the Department or licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019. Pursuant to the flexibilities allowed by the federal Centers for Medicare and Medicaid Services to Illinois under the Medical Assistance Program, the Department shall enroll and reimburse qualified staff to perform applied behavior analysis services in advance of Illinois licensure activities performed by the Department of Financial and Professional Regulation. These services shall be covered if they are provided in a home or community setting or in an office-based setting. The Department may conduct annual on-site reviews of the services authorized under this Section. Provider enrollment shall occur no later than September 1, 2023.
(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22; 103-102, eff. 7-1-23.)

305 ILCS 5/5-30.12

    (305 ILCS 5/5-30.12)
    Sec. 5-30.12. Managed care claim rejection and denial management.
    (a) In order to provide greater transparency to managed care organizations (MCOs) and providers, the Department shall explore the availability of and, if reasonably available, procure technology that, for all electronic claims, with the exception of direct data entry claims, meets the following needs:
        (1) The technology shall allow the Department to
    
fully analyze the root cause of claims denials in the Medicaid managed care programs operated by the Department and expedite solutions that reduce the number of denials to the extent possible.
        (2) The technology shall create a single electronic
    
pipeline through which all claims from all providers submitted for adjudication by the Department or a managed care organization under contract with the Department shall be directed by clearing houses and providers or other claims submitting entities not using clearing houses prior to forwarding to the Department or the appropriate managed care organization.
        (3) The technology shall cause all HIPAA-compliant
    
responses to submitted claims, including rejections, denials, and payments, returned to the submitting provider to pass through the established single pipeline.
        (4) The technology shall give the Department the
    
ability to create edits to be placed at the front end of the pipeline that will reject claims back to the submitting provider with an explanation of why the claim cannot be properly adjudicated by the payer.
        (5) The technology shall allow the Department to
    
customize the language used to explain why a claim is being rejected and how the claim can be corrected for adjudication.
        (6) The technology shall send copies of all claims
    
and claim responses that pass through the pipeline, regardless of the payer to whom they are directed, to the Department's Enterprise Data Warehouse.
    (b) If the Department chooses to implement front end edits or customized responses to claims submissions, the MCOs and other stakeholders shall be consulted prior to implementation and providers shall be notified of edits at least 30 days prior to their effective date.
    (c) Neither the technology nor MCO policy shall require providers to submit claims through a process other than the pipeline. MCOs may request supplemental information needed for adjudication which cannot be contained in the claim file to be submitted separately to the MCOs.
    (d) The technology shall allow the Department to fully analyze and report on MCO claims processing and payment performance by provider type.
(Source: P.A. 101-209, eff. 8-5-19.)

305 ILCS 5/5-30.13

    (305 ILCS 5/5-30.13)
    Sec. 5-30.13. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information:
        (1) The administrative expenses paid to the Medicaid
    
managed care health plan.
        (2) The amount of money the Medicaid managed care
    
health plan has spent with Business Enterprise Program certified businesses.
        (3) The amount of money the Medicaid managed care
    
health plan has spent with minority-owned and women-owned businesses that are certified by other agencies or private organizations.
        (4) The amount of money the Medicaid managed care
    
health plan has spent with not-for-profit community-based organizations serving predominantly minority communities, as defined by the Department.
        (5) The proportion of minorities, people with
    
disabilities, and women that make up the staff of the Medicaid managed care health plan.
        (6) Recommendations for increasing expenditures with
    
minority-owned and women-owned businesses.
        (7) A list of the types of services to which the
    
Medicaid managed care health plan is contemplating adding new vendors.
        (8) The certifications the Medicaid managed care
    
health plan accepts for minority-owned and women-owned businesses.
        (9) The point of contact for potential vendors
    
seeking to do business with the Medicaid managed care health plan.
    The Department shall publish the reports on its website and shall maintain each report on its website for 5 years. In May of 2020 and every May thereafter, the Department shall hold 2 annual public workshops, one in Chicago and one in Springfield. The workshops shall include each Medicaid managed care health plan and shall be open to vendor communities to discuss the submitted plans and to seek to connect vendors with the Medicaid managed care health plans.
(Source: P.A. 101-209, eff. 8-5-19; 102-558, eff. 8-20-21.)

305 ILCS 5/5-30.14

    (305 ILCS 5/5-30.14)
    Sec. 5-30.14. Medicaid managed care organizations; preferred drug lists.
    (a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy, and community-based organizations, providers, and entities with expertise in drug formulary development.
    (b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website. Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls.
    (c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall:
        (A) convene and meet no less than once per calendar
    
quarter;
        (B) provide regular opportunities for public comment;
    
and
        (C) comply with the provisions of the Open Meetings
    
Act.
    All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act.
    (2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation:
        (A) one pharmacist licensed to practice pharmacy in
    
Illinois who is recommended by a statewide organization representing pharmacists;
        (B) 4 physicians, recommended by a statewide
    
organization representing physicians, who are licensed to practice medicine in all its branches in Illinois, have knowledge of and adhere to best practice standards, and have experience treating Illinois Medicaid beneficiaries;
        (C) at least one clinician who specializes in the
    
prevention and treatment of HIV, recommended by an HIV healthcare advocacy organization;
        (D) at least one clinician recommended by a
    
healthcare advocacy organization that serves individuals who are affected by chronic diseases that require significant pharmaceutical treatments;
        (E) one clinician representing the Illinois
    
Department; and
        (F) one licensed psychiatrist, recommended by a
    
statewide organization representing psychiatrists, who has experience treating Illinois Medicaid beneficiaries.
    One non-voting clinician recommended by an association of Medicaid managed care health plans shall serve a term of 3 years on the Board without compensation.
    Organizations interested in nominating non-voting clinicians to advise the Board may submit requests to participate to the Illinois Department.
    A licensed physician recommended by the Rare Disease Commission who is a rare disease specialist and possesses scientific knowledge and medical training with respect to rare diseases and is familiar with drug and biological products and treatment shall be notified in advance to attend an Illinois Drug and Therapeutics Advisory Board meeting when a drug or biological product is scheduled to be reviewed in order to advise and make recommendations on drugs or biological products.
    (d) The Illinois Department shall adopt rules, to be in place no later than January 1, 2020, for the purpose of establishing and maintaining the Board.
(Source: P.A. 101-62, eff. 7-12-19; 102-558, eff. 8-20-21.)

305 ILCS 5/5-30.16

    (305 ILCS 5/5-30.16)
    Sec. 5-30.16. Medicaid Business Opportunity Commission.
    (a) The Medicaid Business Opportunity Commission is created within the Department of Healthcare and Family Services to develop a program to support and grow minority, women, and persons with disability owned businesses.
    (b) The Commission shall consist of the following members:
        (1) Two members appointed by the Illinois Legislative
    
Black Caucus.
        (2) Two members appointed by the Illinois Legislative
    
Latino Caucus.
        (3) Two members appointed by the Conference of Women
    
Legislators of the Illinois General Assembly.
        (4) Two members representing a statewide Medicaid
    
health plan association, appointed by the Governor.
        (5) One member representing the Department of
    
Healthcare and Family Services, appointed by the Governor.
        (6) Three members representing businesses currently
    
registered with the Business Enterprise Program, appointed by the Governor.
        (7) One member representing the disability
    
community, appointed by the Governor.
        (8) One member representing the Business Enterprise
    
Council, appointed by the Governor.
    (c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
    (d) The members of the Commission shall receive no compensation for their services as members of the Commission.
    (e) The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission.
    (f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
    (g) The Commission shall:
        (1) Develop a recommendation on a Medicaid Business
    
Opportunity Program for Minority, Women, and Persons with Disability Owned business contracting requirements to be included in the contracts between the Department of Healthcare and Family Services and the Managed Care entities for the provision of Medicaid Services.
        (2) Make recommendations on the process by which
    
vendors or providers would be certified as eligible to be included in the program and appropriate eligibility standards relative to the healthcare industry.
        (3) Make a recommendation on whether to include not
    
for profit organizations, diversity councils, or diversity chambers as eligible for certification.
        (4) Make a recommendation on whether diverse staff
    
shall be considered within the goals set for managed care entities.
        (5) Make a recommendation on whether a new platform
    
for certification is necessary to administer this program or if the existing platform for the Business Enterprise Program is capable of including recommended changes coming from this Commission.
        (6) Make a recommendation on the ongoing activity of
    
the Commission including structure, frequency of meetings, and agendas to ensure ongoing oversight of the program by the Commission.
    (h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program.
    (i) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)

305 ILCS 5/5-30.17

    (305 ILCS 5/5-30.17)
    Sec. 5-30.17. Medicaid Managed Care Oversight Commission.
    (a) The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program.
    (b) The Commission shall consist of the following members:
        (1) One member of the Senate, appointed by the
    
Senate President, who shall serve as co-chair.
        (2) One member of the House of Representatives,
    
appointed by the Speaker of the House of Representatives, who shall serve as co-chair.
        (3) One member of the House of Representatives,
    
appointed by the Minority Leader of the House of Representatives.
        (4) One member of the Senate, appointed by the
    
Senate Minority Leader.
        (5) One member representing the Department of
    
Healthcare and Family Services, appointed by the Governor.
        (6) One member representing the Department of
    
Public Health, appointed by the Governor.
        (7) One member representing the Department of Human
    
Services, appointed by the Governor.
        (8) One member representing the Department of
    
Children and Family Services, appointed by the Governor.
        (9) One member of a statewide association
    
representing Medicaid managed care plans, appointed by the Governor.
        (10) One member of a statewide association
    
representing a majority of hospitals, appointed by the Governor.
        (11) Two academic experts on Medicaid managed care
    
programs, appointed by the Governor.
        (12) One member of a statewide association
    
representing primary care providers, appointed by the Governor.
        (13) One member of a statewide association
    
representing behavioral health providers, appointed by the Governor.
        (14) Members representing Federally Qualified Health
    
Centers, a long-term care association, a dental association, pharmacies, pharmacists, a developmental disability association, a Medicaid consumer advocate, a Medicaid consumer, an association representing physicians, a behavioral health association, and an association representing pediatricians, appointed by the Governor.
        (15) A member of a statewide association representing
    
only safety-net hospitals, appointed by the Governor.
    (c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
    (d) The members of the Commission shall receive no compensation for their services as members of the Commission.
    (e) The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
    (f) The Commission shall:
        (1) review data on health outcomes of Medicaid
    
managed care members;
        (2) review current care coordination and case
    
management efforts and make recommendations on expanding care coordination to additional populations with a focus on the social determinants of health;
        (3) review and assess the appropriateness of
    
metrics used in the Pay-for-Performance programs;
        (4) review the Department's prior authorization and
    
utilization management requirements and recommend adaptations for the Medicaid population;
        (5) review managed care performance in meeting
    
diversity contracting goals and the use of funds dedicated to meeting such goals, including, but not limited to, contracting requirements set forth in the Business Enterprise for Minorities, Women, and Persons with Disabilities Act; recommend strategies to increase compliance with diversity contracting goals in collaboration with the Chief Procurement Officer for General Services and the Business Enterprise Council for Minorities, Women, and Persons with Disabilities; and recoup any misappropriated funds for diversity contracting;
        (6) review data on the effectiveness of
    
processing to medical providers;
        (7) review member access to health care services in
    
the Medicaid Program, including specialty care services;
        (8) review value-based and other alternative
    
payment methodologies to make recommendations to enhance program efficiency and improve health outcomes;
        (9) review the compliance of all managed care
    
entities in State contracts and recommend reasonable financial penalties for any noncompliance;
        (10) produce an annual report detailing the
    
Commission's findings based upon its review of research conducted under this Section, including specific recommendations, if any, and any other information the Commission may deem proper in furtherance of its duties under this Section;
        (11) review provider availability and make
    
recommendations to increase providers where needed, including reviewing the regulatory environment and making recommendations for reforms;
        (12) review capacity for culturally competent
    
services, including translation services among providers; and
        (13) review and recommend changes to the safety-net
    
hospital definition to create different classifications of safety-net hospitals.
    (f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding processing.
    (g) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)

305 ILCS 5/5-30a

    (305 ILCS 5/5-30a)
    Sec. 5-30a. Exemptions from managed care enrollment; children. Notwithstanding any other provision of law, the Department shall not require any of the following children to enroll in or transition to the State's managed care medical assistance program:
        (1) Children who are authorized by the Department to
    
receive in-home shift nursing services as required by the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions under 42 CFR 441.50 et seq.
        (2) Children made eligible for medical assistance
    
through any home and community-based services waiver program for medically fragile and technology dependent children authorized under Section 1915(c) of the Social Security Act.
    Any children who meet the criteria under paragraph (1) or (2) and who are enrolled in the State's managed care medical assistance program on or before the effective date of this amendatory Act of the 100th General Assembly shall be given the option to disenroll from the State's managed care medical assistance program and receive medical assistance coverage under the State's traditional fee-for-service program.
(Source: P.A. 100-990, eff. 1-1-19.)

305 ILCS 5/5-30b

    (305 ILCS 5/5-30b)
    Sec. 5-30b. Exemptions from managed care; ground ambulance services. Notwithstanding any other provision of law, beginning on the effective date of this amendatory Act of the 102nd General Assembly, the Department shall exempt ground ambulance services as described in subsections (c-1) and (c-2) of Section 5-4.2. These services shall continue to be paid under the State's traditional fee-for-service program.
(Source: P.A. 102-661, eff. 1-1-22.)

305 ILCS 5/5-30d

    (305 ILCS 5/5-30d)
    Sec. 5-30d. Increased funding for transportation services. Beginning no later than January 1, 2023 and subject to federal approval, the amount allocated to fund rates for medi-car, service car, and attendant services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $24,000,000.
(Source: P.A. 102-1037, eff. 6-2-22.)

305 ILCS 5/5-31

    (305 ILCS 5/5-31)
    Sec. 5-31. Medicaid Research and Education Support Fund.
    (a) There is created in the State treasury the Medicaid Research and Education Support Fund. Interest earned by the Fund shall be credited to the Fund. The Fund shall not be used to replace any moneys appropriated to the Medicaid program by the General Assembly.
    (b) The Fund is created for the purpose of receiving moneys, donations, and grants from private and public colleges and universities and disbursing moneys only for the following purposes, notwithstanding any other provision of law, for making payments to hospitals as required under Section 5-32 of this Code and any amounts which are reimbursable to the federal government for payments from this Fund which are required to be paid by State warrant.
    Disbursements from the Fund shall be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.
    (c) The Fund shall consist of the following:
        (1) All moneys collected or received by the Illinois
    
Department from donations and grants from private and public colleges and universities.
        (2) All federal matching funds received by the
    
Illinois Department as a result of expenditures made by the Illinois Department that are attributable to moneys deposited in the Fund.
        (3) Any interest or penalty levied in conjunction
    
with the administration of this Section.
        (4) Moneys transferred from another fund in the State
    
treasury.
        (5) All other moneys received for the Fund from any
    
other source, including interest earned thereon.
    (d) Interfund transfers from the Medicaid Research and Education Support Fund are prohibited.
(Source: P.A. 98-104, eff. 7-22-13.)

305 ILCS 5/5-32

    (305 ILCS 5/5-32)
    Sec. 5-32. Medicaid research and education enhancement payments.
    (a) The Department shall make Medicaid enhancement payments to Tier I and Tier II academic medical centers as defined in Section 5-5e.2 of this Code identified as primary affiliates by any university or college that makes a donation to the Medicaid Research and Education Support Fund.
    (b) By April 30 of each year, a university or college that intends to make a donation to the Medicaid Research and Education Support Fund for the upcoming State fiscal year must notify the Department of this intent and identify a primary Tier I or Tier II academic medical center as defined in Section 5-5e.2 of this Code.
    (c) Only Tier I and Tier II academic medical centers as defined in Section 5-5e.2 of this Code identified by a university or college as required under subsection (b) of this Section are eligible to receive payments under this Section.
    (d) Reimbursement methodology. The Department shall develop a reimbursement methodology consistent with this Section for distribution of moneys from the funds in a manner that would allow distributions from these funds to be matchable under Title XIX of the Social Security Act. The Department may enhance payment rates to any combination of Medicaid inpatient or outpatient Medicaid services. The Department may enhance Medicaid physician services for physicians employed by Tier I or Tier II academic medical centers as defined in Section 5-5e.2 of this Code qualified to receive payment under this Section if the Department and the Tier I or Tier II academic medical centers as defined in Section 5-5e.2 of this Code agree prior to the start of the State fiscal year for which payments are made. The Department shall promulgate rules necessary to make these distributions matchable.
    (e) The Department of Healthcare and Family Services must submit a State Medicaid Plan Amendment to the Centers for Medicare and Medicaid Services to implement the payments under this Section within 60 days of the effective date of this amendatory Act of the 98th General Assembly.
    (f) Reimbursements or payments by the State. Nothing in this Section may be used to reduce reimbursements or payments by the State to a hospital under any other Act.
(Source: P.A. 98-104, eff. 7-22-13.)

305 ILCS 5/5-33

    (305 ILCS 5/5-33)
    Sec. 5-33. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)

305 ILCS 5/5-34

    (305 ILCS 5/5-34)
    Sec. 5-34. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)

305 ILCS 5/5-35

    (305 ILCS 5/5-35)
    Sec. 5-35. Personal needs allowance. For a person who is a resident in a facility licensed under the ID/DD Community Care Act, the Community-Integrated Living Arrangements Licensure and Certification Act, the Specialized Mental Health Rehabilitation Act of 2013, or the MC/DD Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the State shall pay an amount in addition to the minimum monthly personal needs allowance authorized under Section 1902(q) of Title XIX of the Social Security Act (42 U.S.C. 1396(q)) so that the person's total monthly personal needs allowance from both State and federal sources equals $60.
(Source: P.A. 100-23, eff. 7-6-17.)

305 ILCS 5/5-35.5

    (305 ILCS 5/5-35.5)
    Sec. 5-35.5. Personal needs allowance; nursing home residents. Subject to federal approval, on and after January 1, 2024, for a person who is a resident in a facility licensed under the Nursing Home Care Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the monthly personal needs allowance shall be $60.
(Source: P.A. 103-102, eff. 1-1-24.)

305 ILCS 5/5-36

    (305 ILCS 5/5-36)
    Sec. 5-36. Pharmacy benefits.
    (a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law.
    (2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies:
        (A) the Department shall approve any contract between
    
a third-party administrator and a pharmacy;
        (B) the Department's third-party administrator shall
    
not change the terms of a contract between a third-party administrator and a pharmacy without written approval by the Department; and
        (C) the Department's third-party administrator shall
    
not create, modify, implement, or indirectly establish any fee on a pharmacy, pharmacist, or a recipient of medical assistance without written approval by the Department.
    (b) The provisions of this Section shall not apply to outpatient pharmacy services provided by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b or any pharmacy owned by or contracted with the covered entity. A Medicaid managed care organization shall, either directly or through a pharmacy benefit manager, administer and reimburse outpatient pharmacy claims submitted by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b, its owned pharmacies, and contracted pharmacies in accordance with the contractual agreements the Medicaid managed care organization or its pharmacy benefit manager has with such facilities and pharmacies and in accordance with subsection (h-5).
    (b-5) Any pharmacy benefit manager that contracts with a Medicaid managed care organization to administer and reimburse pharmacy claims as provided in this Section must be registered with the Director of Insurance in accordance with Section 513b2 of the Illinois Insurance Code.
    (c) On at least an annual basis, the Director of the Department of Healthcare and Family Services shall submit a report beginning no later than one year after January 1, 2020 (the effective date of Public Act 101-452) that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section.
    (d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department.
    (e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information:
        (1) whether the pharmacy benefit manager has a
    
contract, agreement, or other arrangement with a pharmaceutical manufacturer to exclusively dispense or provide a drug to a managed care organization's enrollees, and the aggregate amounts of consideration of economic benefits collected or received pursuant to that arrangement;
        (2) the percentage of claims payments made by the
    
pharmacy benefit manager to pharmacies owned, managed, or controlled by the pharmacy benefit manager or any of the pharmacy benefit manager's management companies, parent companies, subsidiary companies, or jointly held companies;
        (3) the aggregate amount of the fees or assessments
    
imposed on, or collected from, pharmacy providers; and
        (4) the average annualized percentage of revenue
    
collected by the pharmacy benefit manager as a result of each contract it has executed with a managed care organization contracted by the Department to provide medical assistance benefits which is not paid by the pharmacy benefit manager to pharmacy providers and pharmaceutical manufacturers or labelers or in order to perform administrative functions pursuant to its contracts with managed care organizations.
    (f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value. The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable.
    (g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification. As used in this Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies.
    (h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider:
        (1) a provision prohibiting the provider from
    
informing a patient of a less costly alternative to a prescribed medication; or
        (2) a provision that prohibits the provider from
    
dispensing a particular amount of a prescribed medication, if the pharmacy benefit manager allows that amount to be dispensed through a pharmacy owned or controlled by the pharmacy benefit manager, unless the prescription drug is subject to restricted distribution by the United States Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.
    (h-5) Unless required by law, a Medicaid managed care organization or pharmacy benefit manager administering or managing benefits on behalf of a Medicaid managed care organization shall not refuse to contract with a 340B entity or 340B pharmacy for refusing to accept less favorable payment terms or reimbursement methodologies when compared to similarly situated non-340B entities and shall not include in a contract with a 340B entity or 340B pharmacy a provision that:
        (1) imposes any fee, chargeback, or rate adjustment
    
that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
        (2) imposes any fee, chargeback, or rate adjustment
    
that exceeds the fee, chargeback, or rate adjustment that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
        (3) prevents or interferes with an individual's
    
choice to receive a prescription drug from a 340B entity or 340B pharmacy through any legally permissible means;
        (4) excludes a 340B entity or 340B pharmacy from a
    
pharmacy network on the basis of whether the 340B entity or 340B pharmacy participates in the 340B drug discount program;
        (5) prevents a 340B entity or 340B pharmacy from
    
using a drug purchased under the 340B drug discount program so long as the drug recipient is a patient of the 340B entity; nothing in this Section exempts a 340B pharmacy from following the Department's preferred drug list or from any prior approval requirements of the Department or the Medicaid managed care organization that are imposed on the drug for all pharmacies; or
        (6) any other provision that discriminates against a
    
340B entity or 340B pharmacy by treating a 340B entity or 340B pharmacy differently than non-340B entities or non-340B pharmacies for any reason relating to the entity's participation in the 340B drug discount program.
    A provision that violates this subsection in any contract between a Medicaid managed care organization or its pharmacy benefit manager and a 340B entity entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
    In this subsection (h-5):
    "340B entity" means a covered entity as defined in 42 U.S.C. 256b(a)(4) authorized to participate in the 340B drug discount program.
    "340B pharmacy" means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
    (i) Nothing in this Section shall be construed to prohibit a pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy provider as for a pharmacy owned, controlled, or otherwise associated with the pharmacy benefit manager.
    (j) A pharmacy benefit manager shall establish and implement a process for the resolution of disputes arising out of this Section, which shall be approved by the Department.
    (k) The Department shall adopt rules establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.
(Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)

305 ILCS 5/5-36.1

    (305 ILCS 5/5-36.1)
    Sec. 5-36.1. Earned income for residents of community-integrated living arrangements.
    (a) Beginning no later than July 1, 2021, residents of facilities licensed under the Community-Integrated Living Arrangements Licensure and Certification Act who are determined to be eligible for medical assistance under this Code and who are enrolled in the State's home and community-based services waiver program for adults with developmental disabilities shall retain all earned income from employment or community day services activities.
    (b) No portion of earned income shall be applied toward the facilities rate reimbursement methodology. The Department of Human Services shall ensure the rates of payments paid to facilities under the Code are held harmless.
(Source: P.A. 102-343, eff. 8-13-21.)

305 ILCS 5/5-36.5

    (305 ILCS 5/5-36.5)
    Sec. 5-36.5. Education on mental health and substance use treatment services for children and young adults. The Department of Healthcare and Family Services shall develop a layman's guide to the mental health and substance use treatment services available in Illinois through the Medical Assistance Program and through the Family Support Program, or other publicly funded programs, similar to what Massachusetts developed, to help families understand what services are available to them when they have a child in need of treatment or support. The guide shall be in easy-to-understand language, be prominently available on the Department of Healthcare and Family Services' website, and be part of a statewide communications campaign to ensure families are aware of Family Support Program services. It shall briefly explain the service and whether it is covered by the Medical Assistance Program, the Family Support Program, or any other public funding source. Within one year after January 1, 2020 (the effective date of Public Act 101-461), the Department of Healthcare and Family Services shall complete this guide, have it available on its website, and launch the communications campaign.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.)

305 ILCS 5/5-37

    (305 ILCS 5/5-37)
    Sec. 5-37. Billing mechanism for preventive mental health services delivered to children.
    (a) The General Assembly finds:
        (1) It is common for children to have mental health
    
needs but to not have a full-blown diagnosis of a mental illness. Examples include, but are not limited to, children who have mild or emerging symptoms of a mental health condition (such as meeting some but not all the criteria for a diagnosis, including, but not limited to, symptoms of depression, attentional deficits, anxiety or prodromal symptoms of bipolar disorder or schizophrenia); cutting or engaging in other forms of self-harm; or experiencing violence or trauma).
        (2) The federal requirement that Medicaid-covered
    
children have access to Early and Periodic Screening, Diagnostic and Treatment services includes ensuring that Medicaid-covered children who have a mental health need but do not have a mental health diagnosis have access to treatment.
        (3) The Department of Healthcare and Family Services'
    
existing policy acknowledges this federal requirement by allowing for Medicaid billing for mental health services for children who have a need for services but who do not have a mental health diagnosis in Section 207.3.3 of the Community-Based Behavioral Services Provider Handbook. However, the current policy of the Department of Healthcare and Family Services requires clinicians to specify a diagnosis code and make a notation in the child's medical record that the service is preventive. This effectively requires the clinician to associate a diagnosis with the child and is a major barrier for services because many clinicians rightly are unwilling to document a mental health diagnosis in the medical record when a diagnosis is not medically appropriate.
    (b) Consistent with the existing policy of the Department of Healthcare and Family Services and the federal Early and Periodic Screening, Diagnostic and Treatment requirement, within 3 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services shall convene a working group that includes children's mental health providers to receive input on recommendations to develop a medically appropriate and practical solution that enables mental health providers and professionals to deliver and receive reimbursement for medically necessary mental health services provided to a Medicaid-eligible child under age 21 that has a mental health need but does not have a mental health diagnosis in order to prevent the development of a serious mental health condition. The working group shall ensure that the recommended solution works in practice and does not deter clinicians from delivering prevention and early treatment to children with mental health needs but who do not have a diagnosed mental illness. The Department of Healthcare and Family Services shall meet with this working group at least 4 times prior to finalizing the solution to enable and allow for mental health services for a child without a mental health diagnosis for purposes of prevention and early treatment when recommended by a licensed practitioner of the healing arts. If the Department of Healthcare and Family Services determines that an Illinois Title XIX State Plan amendment is necessary to implement this Section, the State Plan amendment shall be filed with the federal Centers for Medicare and Medicaid Services by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly. If rulemaking is required to implement this Section, the rule shall be filed by the Department of Healthcare and Family Services with the Joint Committee on Administrative Rules by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly, or if federal approval is required, within 6 months after federal approval. If federal approval is required but not granted, this Section shall become inoperative.
(Source: P.A. 101-461, eff. 1-1-20.)