(305 ILCS 5/5D-1) (from Ch. 23, par. 5D-1)
Sec. 5D-1.
(Repealed). (Source: P.A. 89-21, eff. 7-1-95. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/5D-2) (from Ch. 23, par. 5D-2)
Sec. 5D-2.
(Repealed).
(Source: P.A. 88-88. Repealed by P.A. 93-659, eff. 2-3-04.)
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(305 ILCS 5/Art. V-E heading) ARTICLE V-E.
NURSING HOME
LICENSE FEE
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(305 ILCS 5/5E-5)
(Section scheduled to be repealed on July 1, 2024) Sec. 5E-5. Definitions. As used in this Article, unless the
context requires otherwise:
"Nursing home" means (i) a skilled nursing or intermediate long-term care
facility, whether public or private and whether organized for profit or
not-for-profit, that is subject to licensure by the Illinois Department
of Public Health under the Nursing Home Care Act, the ID/DD Community Care Act, or the MC/DD Act, including a
county nursing home directed and maintained under Section
5-1005 of the Counties Code, and (ii) a part of a hospital in
which skilled or intermediate long-term care services within the
meaning of Title XVIII or XIX of the Social Security Act are
provided; except that the term "nursing home" does not include a facility
operated solely as an intermediate care facility for the intellectually disabled
within the meaning of Title XIX of the Social Security Act or a specialized mental health rehabilitation facility.
"Nursing home provider" means (i) a person licensed
by the Department of Public Health to operate and maintain a
skilled nursing or intermediate long-term care facility which charges its
residents, a third party payor, Medicaid, or Medicare for skilled nursing or
intermediate long-term care services, or (ii) a hospital provider that
provides skilled or intermediate long-term care services within
the meaning of Title XVIII or XIX of the Social Security Act.
"Nursing home provider" does not include a person who operates or a provider who provides services within a specialized mental health rehabilitation facility. For purposes of this paragraph, "person" means any political
subdivision of the State, municipal corporation, individual,
firm, partnership, corporation, company, limited liability
company, association, joint stock association, or trust, or a
receiver, executor, trustee, guardian, or other representative
appointed by order of any court. "Hospital provider" means a
person licensed by the Department of Public Health to conduct,
operate, or maintain a hospital.
"Licensed bed days" shall be computed separately for each nursing home
operated or maintained by a nursing home provider and means, with respect to a
nursing home provider, the sum for all nursing home beds of the number of days
during a calendar quarter on which each bed is covered by a license issued to
that provider under the Nursing Home Care Act or the Hospital Licensing Act.
(Source: P.A. 99-180, eff. 7-29-15 .)
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(305 ILCS 5/5E-10)
(Section scheduled to be repealed on July 1, 2024)
Sec. 5E-10. Fee. Through June 30, 2022 or upon federal approval by the Centers for Medicare and Medicaid Services of the long-term care provider assessment described in subsection (a-1) of Section 5B-2 of this Code, whichever is later, every nursing home provider shall pay to the Illinois
Department, on or before September 10, December 10, March 10, and June 10, a
fee in the amount of $1.50 for each licensed nursing bed day for the calendar
quarter in which the payment is due. This fee shall not be billed or passed on
to any resident of a nursing home operated by the nursing home provider. All
fees received by the Illinois Department under this Section shall be deposited
into the Long-Term Care Provider Fund.
(Source: P.A. 102-1035, eff. 5-31-22.)
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(305 ILCS 5/5E-15)
(Section scheduled to be repealed on July 1, 2024)
Sec. 5E-15.
Administration.
Sections 5B-4 through 5B-10 of this Code, to
the extent not contradicted by or inconsistent with any provision of this
Article, are incorporated and adopted by reference
as though fully set forth in this Article, except that wherever those Sections
refer to Section 5B-2 of this Code, that reference is intended to mean Section
5E-10 of this Code.
(Source: P.A. 88-85; 88-88 .)
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(305 ILCS 5/5E-20) (Section scheduled to be repealed on July 1, 2024) Sec. 5E-20. Repealer. This Article 5E is repealed on July 1, 2024.
(Source: P.A. 102-1035, eff. 5-31-22.) |
(305 ILCS 5/Art. V-F heading) ARTICLE V-F. MEDICARE-MEDICAID ALIGNMENT INITIATIVE (MMAI) NURSING HOME RESIDENTS' MANAGED CARE RIGHTS LAW
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-1) Sec. 5F-1. Short title. This Article may be referred to as the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home Residents' Managed Care Rights Law.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-5) Sec. 5F-5. Findings. The General Assembly finds that elderly Illinoisans residing in a nursing home have the right to: (1) quality health care regardless of the payer; (2) receive medically necessary care prescribed by | ||
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(3) a simple appeal process when care is denied; and (4) make decisions about their care and where they | ||
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(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-10) Sec. 5F-10. Scope. This Article applies to policies and contracts amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 98th General Assembly for the nursing home component of the Medicare-Medicaid Alignment Initiative and the Managed Long-Term Services and Support Program. This Article does not diminish a managed care organization's duties and responsibilities under other federal or State laws or rules adopted under those laws and the 3-way Medicare-Medicaid Alignment Initiative contract and the Managed Long-Term Services and Support Program contract.
(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17 .) |
(305 ILCS 5/5F-15) Sec. 5F-15. Definitions. As used in this Article: "Appeal" means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services, such that a delay would adversely affect the health of the enrollee or on any amounts the enrollee must pay for a service, as defined under 42 CFR 422.566(b). These procedures include reconsiderations by the managed care organization and, if necessary, an independent review entity as provided by the Health Carrier External Review Act, hearings before administrative law judges, review by the Medicare Appeals Council, and judicial review. "Demonstration Project" means the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project. "Department" means the Department of Healthcare and Family Services. "Enrollee" means an individual who resides in a nursing home or is qualified to be admitted to a nursing home and is enrolled with a managed care organization participating in the Demonstration Project. "Health care services" means the diagnosis, treatment, and prevention of disease and includes medication, primary care, nursing or medical care, mental health treatment, psychiatric rehabilitation, memory loss services, physical, occupational, and speech rehabilitation, enhanced care, medical supplies and equipment and the repair of such equipment, and assistance with activities of daily living. "Managed care organization" or "MCO" means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services. "Medical professional" means a physician, physician assistant, or nurse practitioner. "Medically necessary" means health care services that a medical professional, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or its symptoms, and that are: (i) in accordance with the generally accepted standards of medical practice; (ii) clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease; and (iii) not primarily for the convenience of the patient, a medical professional, other health care provider, caregiver, family member, or other interested party. "Nursing home" means a facility licensed under the Nursing Home Care Act. "Nurse practitioner" means an individual properly licensed as a nurse practitioner under the Nurse Practice Act. "Physician" means an individual licensed to practice in all branches of medicine under the Medical Practice Act of 1987. "Physician assistant" means an individual properly licensed under the Physician Assistant Practice Act of 1987. "Resident" means an enrollee who is receiving personal or medical care, including, but not limited to, mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a nursing home. "RAI Manual" means the most recent Resident Assessment Instrument Manual, published by the Centers for Medicare and Medicaid Services. "Resident's representative" means a person designated in writing by a resident to be the resident's representative or the resident's guardian, as described by the Nursing Home Care Act. "SNFist" means a medical professional specializing in the care of individuals residing in nursing homes employed by or under contract with a MCO. "Transition period" means a period of time immediately following enrollment into the Demonstration Project or an enrollee's movement from one managed care organization to another managed care organization or one care setting to another care setting.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-20) Sec. 5F-20. Network adequacy. (a) Every managed care organization shall allow every nursing home in its service area an opportunity to be a network contracted facility at the plan's standard terms, conditions, and rates. Either party may opt to limit the contract to existing residents only. (b) With the exception of subsection (c) of this Section, a managed care organization shall only terminate or refuse to renew a contract with a nursing home if the nursing home fails to meet quality standards if the following conditions are met: (1) the quality standards are made known to the | ||
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(2) the quality standards can be objectively | ||
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(3) the nursing home is measured on at least a | ||
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(4) a nursing home that the MCO has determined did | ||
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(5) the Department may attempt to mediate a dispute | ||
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(c) A managed care organization may terminate or refuse to renew a contract with a nursing home for a material breach of the contract, including, but not limited to, failure to grant reasonable and timely access to the MCO's care coordinators, SNFists and other providers, termination from the Medicare or Medicaid program, or revocation of license.
(Source: P.A. 98-651, eff. 6-16-14.) |
(305 ILCS 5/5F-25) Sec. 5F-25. Care coordination. Care coordination provided to all enrollees in the Demonstration Project shall conform to the following requirements: (1) care coordination services shall be | ||
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(2) all enrollees in the Demonstration Project shall | ||
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(3) decisions shall be based on the enrollee's best | ||
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(Source: P.A. 98-651, eff. 6-16-14.) |