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Illinois Senate Bill SB3268

Illinois 2023-2024 Regular Session

Illinois Senate Bill SB3268 Compare Versions

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1-Public Act 103-0593
21 SB3268 EnrolledLRB103 39338 KTG 69500 b SB3268 Enrolled LRB103 39338 KTG 69500 b
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4-AN ACT concerning public aid.
5-Be it enacted by the People of the State of Illinois,
6-represented in the General Assembly:
7-ARTICLE 5.
8-Section 5-5. The Illinois Public Aid Code is amended by
9-changing Section 5-5 as follows:
10-(305 ILCS 5/5-5)
11-Sec. 5-5. Medical services. The Illinois Department, by
12-rule, shall determine the quantity and quality of and the rate
13-of reimbursement for the medical assistance for which payment
14-will be authorized, and the medical services to be provided,
15-which may include all or part of the following: (1) inpatient
16-hospital services; (2) outpatient hospital services; (3) other
17-laboratory and X-ray services; (4) skilled nursing home
18-services; (5) physicians' services whether furnished in the
19-office, the patient's home, a hospital, a skilled nursing
20-home, or elsewhere; (6) medical care, or any other type of
21-remedial care furnished by licensed practitioners; (7) home
22-health care services; (8) private duty nursing service; (9)
23-clinic services; (10) dental services, including prevention
24-and treatment of periodontal disease and dental caries disease
25-for pregnant individuals, provided by an individual licensed
3+1 AN ACT concerning public aid.
4+2 Be it enacted by the People of the State of Illinois,
5+3 represented in the General Assembly:
6+4 ARTICLE 5.
7+5 Section 5-5. The Illinois Public Aid Code is amended by
8+6 changing Section 5-5 as follows:
9+7 (305 ILCS 5/5-5)
10+8 Sec. 5-5. Medical services. The Illinois Department, by
11+9 rule, shall determine the quantity and quality of and the rate
12+10 of reimbursement for the medical assistance for which payment
13+11 will be authorized, and the medical services to be provided,
14+12 which may include all or part of the following: (1) inpatient
15+13 hospital services; (2) outpatient hospital services; (3) other
16+14 laboratory and X-ray services; (4) skilled nursing home
17+15 services; (5) physicians' services whether furnished in the
18+16 office, the patient's home, a hospital, a skilled nursing
19+17 home, or elsewhere; (6) medical care, or any other type of
20+18 remedial care furnished by licensed practitioners; (7) home
21+19 health care services; (8) private duty nursing service; (9)
22+20 clinic services; (10) dental services, including prevention
23+21 and treatment of periodontal disease and dental caries disease
24+22 for pregnant individuals, provided by an individual licensed
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32-to practice dentistry or dental surgery; for purposes of this
33-item (10), "dental services" means diagnostic, preventive, or
34-corrective procedures provided by or under the supervision of
35-a dentist in the practice of his or her profession; (11)
36-physical therapy and related services; (12) prescribed drugs,
37-dentures, and prosthetic devices; and eyeglasses prescribed by
38-a physician skilled in the diseases of the eye, or by an
39-optometrist, whichever the person may select; (13) other
40-diagnostic, screening, preventive, and rehabilitative
41-services, including to ensure that the individual's need for
42-intervention or treatment of mental disorders or substance use
43-disorders or co-occurring mental health and substance use
44-disorders is determined using a uniform screening, assessment,
45-and evaluation process inclusive of criteria, for children and
46-adults; for purposes of this item (13), a uniform screening,
47-assessment, and evaluation process refers to a process that
48-includes an appropriate evaluation and, as warranted, a
49-referral; "uniform" does not mean the use of a singular
50-instrument, tool, or process that all must utilize; (14)
51-transportation and such other expenses as may be necessary;
52-(15) medical treatment of sexual assault survivors, as defined
53-in Section 1a of the Sexual Assault Survivors Emergency
54-Treatment Act, for injuries sustained as a result of the
55-sexual assault, including examinations and laboratory tests to
56-discover evidence which may be used in criminal proceedings
57-arising from the sexual assault; (16) the diagnosis and
58-
59-
60-treatment of sickle cell anemia; (16.5) services performed by
61-a chiropractic physician licensed under the Medical Practice
62-Act of 1987 and acting within the scope of his or her license,
63-including, but not limited to, chiropractic manipulative
64-treatment; and (17) any other medical care, and any other type
65-of remedial care recognized under the laws of this State. The
66-term "any other type of remedial care" shall include nursing
67-care and nursing home service for persons who rely on
68-treatment by spiritual means alone through prayer for healing.
69-Notwithstanding any other provision of this Section, a
70-comprehensive tobacco use cessation program that includes
71-purchasing prescription drugs or prescription medical devices
72-approved by the Food and Drug Administration shall be covered
73-under the medical assistance program under this Article for
74-persons who are otherwise eligible for assistance under this
75-Article.
76-Notwithstanding any other provision of this Code,
77-reproductive health care that is otherwise legal in Illinois
78-shall be covered under the medical assistance program for
79-persons who are otherwise eligible for medical assistance
80-under this Article.
81-Notwithstanding any other provision of this Section, all
82-tobacco cessation medications approved by the United States
83-Food and Drug Administration and all individual and group
84-tobacco cessation counseling services and telephone-based
85-counseling services and tobacco cessation medications provided
86-
87-
88-through the Illinois Tobacco Quitline shall be covered under
89-the medical assistance program for persons who are otherwise
90-eligible for assistance under this Article. The Department
91-shall comply with all federal requirements necessary to obtain
92-federal financial participation, as specified in 42 CFR
93-433.15(b)(7), for telephone-based counseling services provided
94-through the Illinois Tobacco Quitline, including, but not
95-limited to: (i) entering into a memorandum of understanding or
96-interagency agreement with the Department of Public Health, as
97-administrator of the Illinois Tobacco Quitline; and (ii)
98-developing a cost allocation plan for Medicaid-allowable
99-Illinois Tobacco Quitline services in accordance with 45 CFR
100-95.507. The Department shall submit the memorandum of
101-understanding or interagency agreement, the cost allocation
102-plan, and all other necessary documentation to the Centers for
103-Medicare and Medicaid Services for review and approval.
104-Coverage under this paragraph shall be contingent upon federal
105-approval.
106-Notwithstanding any other provision of this Code, the
107-Illinois Department may not require, as a condition of payment
108-for any laboratory test authorized under this Article, that a
109-physician's handwritten signature appear on the laboratory
110-test order form. The Illinois Department may, however, impose
111-other appropriate requirements regarding laboratory test order
112-documentation.
113-Upon receipt of federal approval of an amendment to the
114-
115-
116-Illinois Title XIX State Plan for this purpose, the Department
117-shall authorize the Chicago Public Schools (CPS) to procure a
118-vendor or vendors to manufacture eyeglasses for individuals
119-enrolled in a school within the CPS system. CPS shall ensure
120-that its vendor or vendors are enrolled as providers in the
121-medical assistance program and in any capitated Medicaid
122-managed care entity (MCE) serving individuals enrolled in a
123-school within the CPS system. Under any contract procured
124-under this provision, the vendor or vendors must serve only
125-individuals enrolled in a school within the CPS system. Claims
126-for services provided by CPS's vendor or vendors to recipients
127-of benefits in the medical assistance program under this Code,
128-the Children's Health Insurance Program, or the Covering ALL
129-KIDS Health Insurance Program shall be submitted to the
130-Department or the MCE in which the individual is enrolled for
131-payment and shall be reimbursed at the Department's or the
132-MCE's established rates or rate methodologies for eyeglasses.
133-On and after July 1, 2012, the Department of Healthcare
134-and Family Services may provide the following services to
135-persons eligible for assistance under this Article who are
136-participating in education, training or employment programs
137-operated by the Department of Human Services as successor to
138-the Department of Public Aid:
139-(1) dental services provided by or under the
140-supervision of a dentist; and
141-(2) eyeglasses prescribed by a physician skilled in
142-
143-
144-the diseases of the eye, or by an optometrist, whichever
145-the person may select.
146-On and after July 1, 2018, the Department of Healthcare
147-and Family Services shall provide dental services to any adult
148-who is otherwise eligible for assistance under the medical
149-assistance program. As used in this paragraph, "dental
150-services" means diagnostic, preventative, restorative, or
151-corrective procedures, including procedures and services for
152-the prevention and treatment of periodontal disease and dental
153-caries disease, provided by an individual who is licensed to
154-practice dentistry or dental surgery or who is under the
155-supervision of a dentist in the practice of his or her
156-profession.
157-On and after July 1, 2018, targeted dental services, as
158-set forth in Exhibit D of the Consent Decree entered by the
159-United States District Court for the Northern District of
160-Illinois, Eastern Division, in the matter of Memisovski v.
161-Maram, Case No. 92 C 1982, that are provided to adults under
162-the medical assistance program shall be established at no less
163-than the rates set forth in the "New Rate" column in Exhibit D
164-of the Consent Decree for targeted dental services that are
165-provided to persons under the age of 18 under the medical
166-assistance program.
167-Subject to federal approval, on and after January 1, 2025,
168-the rates paid for sedation evaluation and the provision of
169-deep sedation and intravenous sedation for the purpose of
170-
171-
172-dental services shall be increased by 33% above the rates in
173-effect on December 31, 2024. The rates paid for nitrous oxide
174-sedation shall not be impacted by this paragraph and shall
175-remain the same as the rates in effect on December 31, 2024.
176-Notwithstanding any other provision of this Code and
177-subject to federal approval, the Department may adopt rules to
178-allow a dentist who is volunteering his or her service at no
179-cost to render dental services through an enrolled
180-not-for-profit health clinic without the dentist personally
181-enrolling as a participating provider in the medical
182-assistance program. A not-for-profit health clinic shall
183-include a public health clinic or Federally Qualified Health
184-Center or other enrolled provider, as determined by the
185-Department, through which dental services covered under this
186-Section are performed. The Department shall establish a
187-process for payment of claims for reimbursement for covered
188-dental services rendered under this provision.
189-On and after January 1, 2022, the Department of Healthcare
190-and Family Services shall administer and regulate a
191-school-based dental program that allows for the out-of-office
192-delivery of preventative dental services in a school setting
193-to children under 19 years of age. The Department shall
194-establish, by rule, guidelines for participation by providers
195-and set requirements for follow-up referral care based on the
196-requirements established in the Dental Office Reference Manual
197-published by the Department that establishes the requirements
198-
199-
200-for dentists participating in the All Kids Dental School
201-Program. Every effort shall be made by the Department when
202-developing the program requirements to consider the different
203-geographic differences of both urban and rural areas of the
204-State for initial treatment and necessary follow-up care. No
205-provider shall be charged a fee by any unit of local government
206-to participate in the school-based dental program administered
207-by the Department. Nothing in this paragraph shall be
208-construed to limit or preempt a home rule unit's or school
209-district's authority to establish, change, or administer a
210-school-based dental program in addition to, or independent of,
211-the school-based dental program administered by the
212-Department.
213-The Illinois Department, by rule, may distinguish and
214-classify the medical services to be provided only in
215-accordance with the classes of persons designated in Section
216-5-2.
217-The Department of Healthcare and Family Services must
218-provide coverage and reimbursement for amino acid-based
219-elemental formulas, regardless of delivery method, for the
220-diagnosis and treatment of (i) eosinophilic disorders and (ii)
221-short bowel syndrome when the prescribing physician has issued
222-a written order stating that the amino acid-based elemental
223-formula is medically necessary.
224-The Illinois Department shall authorize the provision of,
225-and shall authorize payment for, screening by low-dose
226-
227-
228-mammography for the presence of occult breast cancer for
229-individuals 35 years of age or older who are eligible for
230-medical assistance under this Article, as follows:
231-(A) A baseline mammogram for individuals 35 to 39
232-years of age.
233-(B) An annual mammogram for individuals 40 years of
234-age or older.
235-(C) A mammogram at the age and intervals considered
236-medically necessary by the individual's health care
237-provider for individuals under 40 years of age and having
238-a family history of breast cancer, prior personal history
239-of breast cancer, positive genetic testing, or other risk
240-factors.
241-(D) A comprehensive ultrasound screening and MRI of an
242-entire breast or breasts if a mammogram demonstrates
243-heterogeneous or dense breast tissue or when medically
244-necessary as determined by a physician licensed to
245-practice medicine in all of its branches.
246-(E) A screening MRI when medically necessary, as
247-determined by a physician licensed to practice medicine in
248-all of its branches.
249-(F) A diagnostic mammogram when medically necessary,
250-as determined by a physician licensed to practice medicine
251-in all its branches, advanced practice registered nurse,
252-or physician assistant.
253-The Department shall not impose a deductible, coinsurance,
254-
255-
256-copayment, or any other cost-sharing requirement on the
257-coverage provided under this paragraph; except that this
258-sentence does not apply to coverage of diagnostic mammograms
259-to the extent such coverage would disqualify a high-deductible
260-health plan from eligibility for a health savings account
261-pursuant to Section 223 of the Internal Revenue Code (26
262-U.S.C. 223).
263-All screenings shall include a physical breast exam,
264-instruction on self-examination and information regarding the
265-frequency of self-examination and its value as a preventative
266-tool.
267-For purposes of this Section:
268-"Diagnostic mammogram" means a mammogram obtained using
269-diagnostic mammography.
270-"Diagnostic mammography" means a method of screening that
271-is designed to evaluate an abnormality in a breast, including
272-an abnormality seen or suspected on a screening mammogram or a
273-subjective or objective abnormality otherwise detected in the
274-breast.
275-"Low-dose mammography" means the x-ray examination of the
276-breast using equipment dedicated specifically for mammography,
277-including the x-ray tube, filter, compression device, and
278-image receptor, with an average radiation exposure delivery of
279-less than one rad per breast for 2 views of an average size
280-breast. The term also includes digital mammography and
281-includes breast tomosynthesis.
282-
283-
284-"Breast tomosynthesis" means a radiologic procedure that
285-involves the acquisition of projection images over the
286-stationary breast to produce cross-sectional digital
287-three-dimensional images of the breast.
288-If, at any time, the Secretary of the United States
289-Department of Health and Human Services, or its successor
290-agency, promulgates rules or regulations to be published in
291-the Federal Register or publishes a comment in the Federal
292-Register or issues an opinion, guidance, or other action that
293-would require the State, pursuant to any provision of the
294-Patient Protection and Affordable Care Act (Public Law
295-111-148), including, but not limited to, 42 U.S.C.
296-18031(d)(3)(B) or any successor provision, to defray the cost
297-of any coverage for breast tomosynthesis outlined in this
298-paragraph, then the requirement that an insurer cover breast
299-tomosynthesis is inoperative other than any such coverage
300-authorized under Section 1902 of the Social Security Act, 42
301-U.S.C. 1396a, and the State shall not assume any obligation
302-for the cost of coverage for breast tomosynthesis set forth in
303-this paragraph.
304-On and after January 1, 2016, the Department shall ensure
305-that all networks of care for adult clients of the Department
306-include access to at least one breast imaging Center of
307-Imaging Excellence as certified by the American College of
308-Radiology.
309-On and after January 1, 2012, providers participating in a
310-
311-
312-quality improvement program approved by the Department shall
313-be reimbursed for screening and diagnostic mammography at the
314-same rate as the Medicare program's rates, including the
315-increased reimbursement for digital mammography and, after
316-January 1, 2023 (the effective date of Public Act 102-1018),
317-breast tomosynthesis.
318-The Department shall convene an expert panel including
319-representatives of hospitals, free-standing mammography
320-facilities, and doctors, including radiologists, to establish
321-quality standards for mammography.
322-On and after January 1, 2017, providers participating in a
323-breast cancer treatment quality improvement program approved
324-by the Department shall be reimbursed for breast cancer
325-treatment at a rate that is no lower than 95% of the Medicare
326-program's rates for the data elements included in the breast
327-cancer treatment quality program.
328-The Department shall convene an expert panel, including
329-representatives of hospitals, free-standing breast cancer
330-treatment centers, breast cancer quality organizations, and
331-doctors, including breast surgeons, reconstructive breast
332-surgeons, oncologists, and primary care providers to establish
333-quality standards for breast cancer treatment.
334-Subject to federal approval, the Department shall
335-establish a rate methodology for mammography at federally
336-qualified health centers and other encounter-rate clinics.
337-These clinics or centers may also collaborate with other
338-
339-
340-hospital-based mammography facilities. By January 1, 2016, the
341-Department shall report to the General Assembly on the status
342-of the provision set forth in this paragraph.
343-The Department shall establish a methodology to remind
344-individuals who are age-appropriate for screening mammography,
345-but who have not received a mammogram within the previous 18
346-months, of the importance and benefit of screening
347-mammography. The Department shall work with experts in breast
348-cancer outreach and patient navigation to optimize these
349-reminders and shall establish a methodology for evaluating
350-their effectiveness and modifying the methodology based on the
351-evaluation.
352-The Department shall establish a performance goal for
353-primary care providers with respect to their female patients
354-over age 40 receiving an annual mammogram. This performance
355-goal shall be used to provide additional reimbursement in the
356-form of a quality performance bonus to primary care providers
357-who meet that goal.
358-The Department shall devise a means of case-managing or
359-patient navigation for beneficiaries diagnosed with breast
360-cancer. This program shall initially operate as a pilot
361-program in areas of the State with the highest incidence of
362-mortality related to breast cancer. At least one pilot program
363-site shall be in the metropolitan Chicago area and at least one
364-site shall be outside the metropolitan Chicago area. On or
365-after July 1, 2016, the pilot program shall be expanded to
366-
367-
368-include one site in western Illinois, one site in southern
369-Illinois, one site in central Illinois, and 4 sites within
370-metropolitan Chicago. An evaluation of the pilot program shall
371-be carried out measuring health outcomes and cost of care for
372-those served by the pilot program compared to similarly
373-situated patients who are not served by the pilot program.
374-The Department shall require all networks of care to
375-develop a means either internally or by contract with experts
376-in navigation and community outreach to navigate cancer
377-patients to comprehensive care in a timely fashion. The
378-Department shall require all networks of care to include
379-access for patients diagnosed with cancer to at least one
380-academic commission on cancer-accredited cancer program as an
381-in-network covered benefit.
382-The Department shall provide coverage and reimbursement
383-for a human papillomavirus (HPV) vaccine that is approved for
384-marketing by the federal Food and Drug Administration for all
385-persons between the ages of 9 and 45. Subject to federal
386-approval, the Department shall provide coverage and
387-reimbursement for a human papillomavirus (HPV) vaccine for
388-persons of the age of 46 and above who have been diagnosed with
389-cervical dysplasia with a high risk of recurrence or
390-progression. The Department shall disallow any
391-preauthorization requirements for the administration of the
392-human papillomavirus (HPV) vaccine.
393-On or after July 1, 2022, individuals who are otherwise
394-
395-
396-eligible for medical assistance under this Article shall
397-receive coverage for perinatal depression screenings for the
398-12-month period beginning on the last day of their pregnancy.
399-Medical assistance coverage under this paragraph shall be
400-conditioned on the use of a screening instrument approved by
401-the Department.
402-Any medical or health care provider shall immediately
403-recommend, to any pregnant individual who is being provided
404-prenatal services and is suspected of having a substance use
405-disorder as defined in the Substance Use Disorder Act,
406-referral to a local substance use disorder treatment program
407-licensed by the Department of Human Services or to a licensed
408-hospital which provides substance abuse treatment services.
409-The Department of Healthcare and Family Services shall assure
410-coverage for the cost of treatment of the drug abuse or
411-addiction for pregnant recipients in accordance with the
412-Illinois Medicaid Program in conjunction with the Department
413-of Human Services.
414-All medical providers providing medical assistance to
415-pregnant individuals under this Code shall receive information
416-from the Department on the availability of services under any
417-program providing case management services for addicted
418-individuals, including information on appropriate referrals
419-for other social services that may be needed by addicted
420-individuals in addition to treatment for addiction.
421-The Illinois Department, in cooperation with the
422-
423-
424-Departments of Human Services (as successor to the Department
425-of Alcoholism and Substance Abuse) and Public Health, through
426-a public awareness campaign, may provide information
427-concerning treatment for alcoholism and drug abuse and
428-addiction, prenatal health care, and other pertinent programs
429-directed at reducing the number of drug-affected infants born
430-to recipients of medical assistance.
431-Neither the Department of Healthcare and Family Services
432-nor the Department of Human Services shall sanction the
433-recipient solely on the basis of the recipient's substance
434-abuse.
435-The Illinois Department shall establish such regulations
436-governing the dispensing of health services under this Article
437-as it shall deem appropriate. The Department should seek the
438-advice of formal professional advisory committees appointed by
439-the Director of the Illinois Department for the purpose of
440-providing regular advice on policy and administrative matters,
441-information dissemination and educational activities for
442-medical and health care providers, and consistency in
443-procedures to the Illinois Department.
444-The Illinois Department may develop and contract with
445-Partnerships of medical providers to arrange medical services
446-for persons eligible under Section 5-2 of this Code.
447-Implementation of this Section may be by demonstration
448-projects in certain geographic areas. The Partnership shall be
449-represented by a sponsor organization. The Department, by
450-
451-
452-rule, shall develop qualifications for sponsors of
453-Partnerships. Nothing in this Section shall be construed to
454-require that the sponsor organization be a medical
455-organization.
456-The sponsor must negotiate formal written contracts with
457-medical providers for physician services, inpatient and
458-outpatient hospital care, home health services, treatment for
459-alcoholism and substance abuse, and other services determined
460-necessary by the Illinois Department by rule for delivery by
461-Partnerships. Physician services must include prenatal and
462-obstetrical care. The Illinois Department shall reimburse
463-medical services delivered by Partnership providers to clients
464-in target areas according to provisions of this Article and
465-the Illinois Health Finance Reform Act, except that:
466-(1) Physicians participating in a Partnership and
467-providing certain services, which shall be determined by
468-the Illinois Department, to persons in areas covered by
469-the Partnership may receive an additional surcharge for
470-such services.
471-(2) The Department may elect to consider and negotiate
472-financial incentives to encourage the development of
473-Partnerships and the efficient delivery of medical care.
474-(3) Persons receiving medical services through
475-Partnerships may receive medical and case management
476-services above the level usually offered through the
477-medical assistance program.
478-
479-
480-Medical providers shall be required to meet certain
481-qualifications to participate in Partnerships to ensure the
482-delivery of high quality medical services. These
483-qualifications shall be determined by rule of the Illinois
484-Department and may be higher than qualifications for
485-participation in the medical assistance program. Partnership
486-sponsors may prescribe reasonable additional qualifications
487-for participation by medical providers, only with the prior
488-written approval of the Illinois Department.
489-Nothing in this Section shall limit the free choice of
490-practitioners, hospitals, and other providers of medical
491-services by clients. In order to ensure patient freedom of
492-choice, the Illinois Department shall immediately promulgate
493-all rules and take all other necessary actions so that
494-provided services may be accessed from therapeutically
495-certified optometrists to the full extent of the Illinois
496-Optometric Practice Act of 1987 without discriminating between
497-service providers.
498-The Department shall apply for a waiver from the United
499-States Health Care Financing Administration to allow for the
500-implementation of Partnerships under this Section.
501-The Illinois Department shall require health care
502-providers to maintain records that document the medical care
503-and services provided to recipients of Medical Assistance
504-under this Article. Such records must be retained for a period
505-of not less than 6 years from the date of service or as
506-
507-
508-provided by applicable State law, whichever period is longer,
509-except that if an audit is initiated within the required
510-retention period then the records must be retained until the
511-audit is completed and every exception is resolved. The
512-Illinois Department shall require health care providers to
513-make available, when authorized by the patient, in writing,
514-the medical records in a timely fashion to other health care
515-providers who are treating or serving persons eligible for
516-Medical Assistance under this Article. All dispensers of
517-medical services shall be required to maintain and retain
518-business and professional records sufficient to fully and
519-accurately document the nature, scope, details and receipt of
520-the health care provided to persons eligible for medical
521-assistance under this Code, in accordance with regulations
522-promulgated by the Illinois Department. The rules and
523-regulations shall require that proof of the receipt of
524-prescription drugs, dentures, prosthetic devices and
525-eyeglasses by eligible persons under this Section accompany
526-each claim for reimbursement submitted by the dispenser of
527-such medical services. No such claims for reimbursement shall
528-be approved for payment by the Illinois Department without
529-such proof of receipt, unless the Illinois Department shall
530-have put into effect and shall be operating a system of
531-post-payment audit and review which shall, on a sampling
532-basis, be deemed adequate by the Illinois Department to assure
533-that such drugs, dentures, prosthetic devices and eyeglasses
534-
535-
536-for which payment is being made are actually being received by
537-eligible recipients. Within 90 days after September 16, 1984
538-(the effective date of Public Act 83-1439), the Illinois
539-Department shall establish a current list of acquisition costs
540-for all prosthetic devices and any other items recognized as
541-medical equipment and supplies reimbursable under this Article
542-and shall update such list on a quarterly basis, except that
543-the acquisition costs of all prescription drugs shall be
544-updated no less frequently than every 30 days as required by
545-Section 5-5.12.
546-Notwithstanding any other law to the contrary, the
547-Illinois Department shall, within 365 days after July 22, 2013
548-(the effective date of Public Act 98-104), establish
549-procedures to permit skilled care facilities licensed under
550-the Nursing Home Care Act to submit monthly billing claims for
551-reimbursement purposes. Following development of these
552-procedures, the Department shall, by July 1, 2016, test the
553-viability of the new system and implement any necessary
554-operational or structural changes to its information
555-technology platforms in order to allow for the direct
556-acceptance and payment of nursing home claims.
557-Notwithstanding any other law to the contrary, the
558-Illinois Department shall, within 365 days after August 15,
559-2014 (the effective date of Public Act 98-963), establish
560-procedures to permit ID/DD facilities licensed under the ID/DD
561-Community Care Act and MC/DD facilities licensed under the
562-
563-
564-MC/DD Act to submit monthly billing claims for reimbursement
565-purposes. Following development of these procedures, the
566-Department shall have an additional 365 days to test the
567-viability of the new system and to ensure that any necessary
568-operational or structural changes to its information
569-technology platforms are implemented.
570-The Illinois Department shall require all dispensers of
571-medical services, other than an individual practitioner or
572-group of practitioners, desiring to participate in the Medical
573-Assistance program established under this Article to disclose
574-all financial, beneficial, ownership, equity, surety or other
575-interests in any and all firms, corporations, partnerships,
576-associations, business enterprises, joint ventures, agencies,
577-institutions or other legal entities providing any form of
578-health care services in this State under this Article.
579-The Illinois Department may require that all dispensers of
580-medical services desiring to participate in the medical
581-assistance program established under this Article disclose,
582-under such terms and conditions as the Illinois Department may
583-by rule establish, all inquiries from clients and attorneys
584-regarding medical bills paid by the Illinois Department, which
585-inquiries could indicate potential existence of claims or
586-liens for the Illinois Department.
587-Enrollment of a vendor shall be subject to a provisional
588-period and shall be conditional for one year. During the
589-period of conditional enrollment, the Department may terminate
590-
591-
592-the vendor's eligibility to participate in, or may disenroll
593-the vendor from, the medical assistance program without cause.
594-Unless otherwise specified, such termination of eligibility or
595-disenrollment is not subject to the Department's hearing
596-process. However, a disenrolled vendor may reapply without
597-penalty.
598-The Department has the discretion to limit the conditional
599-enrollment period for vendors based upon the category of risk
600-of the vendor.
601-Prior to enrollment and during the conditional enrollment
602-period in the medical assistance program, all vendors shall be
603-subject to enhanced oversight, screening, and review based on
604-the risk of fraud, waste, and abuse that is posed by the
605-category of risk of the vendor. The Illinois Department shall
606-establish the procedures for oversight, screening, and review,
607-which may include, but need not be limited to: criminal and
608-financial background checks; fingerprinting; license,
609-certification, and authorization verifications; unscheduled or
610-unannounced site visits; database checks; prepayment audit
611-reviews; audits; payment caps; payment suspensions; and other
612-screening as required by federal or State law.
613-The Department shall define or specify the following: (i)
614-by provider notice, the "category of risk of the vendor" for
615-each type of vendor, which shall take into account the level of
616-screening applicable to a particular category of vendor under
617-federal law and regulations; (ii) by rule or provider notice,
618-
619-
620-the maximum length of the conditional enrollment period for
621-each category of risk of the vendor; and (iii) by rule, the
622-hearing rights, if any, afforded to a vendor in each category
623-of risk of the vendor that is terminated or disenrolled during
624-the conditional enrollment period.
625-To be eligible for payment consideration, a vendor's
626-payment claim or bill, either as an initial claim or as a
627-resubmitted claim following prior rejection, must be received
628-by the Illinois Department, or its fiscal intermediary, no
629-later than 180 days after the latest date on the claim on which
630-medical goods or services were provided, with the following
631-exceptions:
632-(1) In the case of a provider whose enrollment is in
633-process by the Illinois Department, the 180-day period
634-shall not begin until the date on the written notice from
635-the Illinois Department that the provider enrollment is
636-complete.
637-(2) In the case of errors attributable to the Illinois
638-Department or any of its claims processing intermediaries
639-which result in an inability to receive, process, or
640-adjudicate a claim, the 180-day period shall not begin
641-until the provider has been notified of the error.
642-(3) In the case of a provider for whom the Illinois
643-Department initiates the monthly billing process.
644-(4) In the case of a provider operated by a unit of
645-local government with a population exceeding 3,000,000
646-
647-
648-when local government funds finance federal participation
649-for claims payments.
650-For claims for services rendered during a period for which
651-a recipient received retroactive eligibility, claims must be
652-filed within 180 days after the Department determines the
653-applicant is eligible. For claims for which the Illinois
654-Department is not the primary payer, claims must be submitted
655-to the Illinois Department within 180 days after the final
656-adjudication by the primary payer.
657-In the case of long term care facilities, within 120
658-calendar days of receipt by the facility of required
659-prescreening information, new admissions with associated
660-admission documents shall be submitted through the Medical
661-Electronic Data Interchange (MEDI) or the Recipient
662-Eligibility Verification (REV) System or shall be submitted
663-directly to the Department of Human Services using required
664-admission forms. Effective September 1, 2014, admission
665-documents, including all prescreening information, must be
666-submitted through MEDI or REV. Confirmation numbers assigned
667-to an accepted transaction shall be retained by a facility to
668-verify timely submittal. Once an admission transaction has
669-been completed, all resubmitted claims following prior
670-rejection are subject to receipt no later than 180 days after
671-the admission transaction has been completed.
672-Claims that are not submitted and received in compliance
673-with the foregoing requirements shall not be eligible for
674-
675-
676-payment under the medical assistance program, and the State
677-shall have no liability for payment of those claims.
678-To the extent consistent with applicable information and
679-privacy, security, and disclosure laws, State and federal
680-agencies and departments shall provide the Illinois Department
681-access to confidential and other information and data
682-necessary to perform eligibility and payment verifications and
683-other Illinois Department functions. This includes, but is not
684-limited to: information pertaining to licensure;
685-certification; earnings; immigration status; citizenship; wage
686-reporting; unearned and earned income; pension income;
687-employment; supplemental security income; social security
688-numbers; National Provider Identifier (NPI) numbers; the
689-National Practitioner Data Bank (NPDB); program and agency
690-exclusions; taxpayer identification numbers; tax delinquency;
691-corporate information; and death records.
692-The Illinois Department shall enter into agreements with
693-State agencies and departments, and is authorized to enter
694-into agreements with federal agencies and departments, under
695-which such agencies and departments shall share data necessary
696-for medical assistance program integrity functions and
697-oversight. The Illinois Department shall develop, in
698-cooperation with other State departments and agencies, and in
699-compliance with applicable federal laws and regulations,
700-appropriate and effective methods to share such data. At a
701-minimum, and to the extent necessary to provide data sharing,
702-
703-
704-the Illinois Department shall enter into agreements with State
705-agencies and departments, and is authorized to enter into
706-agreements with federal agencies and departments, including,
707-but not limited to: the Secretary of State; the Department of
708-Revenue; the Department of Public Health; the Department of
709-Human Services; and the Department of Financial and
710-Professional Regulation.
711-Beginning in fiscal year 2013, the Illinois Department
712-shall set forth a request for information to identify the
713-benefits of a pre-payment, post-adjudication, and post-edit
714-claims system with the goals of streamlining claims processing
715-and provider reimbursement, reducing the number of pending or
716-rejected claims, and helping to ensure a more transparent
717-adjudication process through the utilization of: (i) provider
718-data verification and provider screening technology; and (ii)
719-clinical code editing; and (iii) pre-pay, pre-adjudicated, or
720-post-adjudicated predictive modeling with an integrated case
721-management system with link analysis. Such a request for
722-information shall not be considered as a request for proposal
723-or as an obligation on the part of the Illinois Department to
724-take any action or acquire any products or services.
725-The Illinois Department shall establish policies,
726-procedures, standards and criteria by rule for the
727-acquisition, repair and replacement of orthotic and prosthetic
728-devices and durable medical equipment. Such rules shall
729-provide, but not be limited to, the following services: (1)
730-
731-
732-immediate repair or replacement of such devices by recipients;
733-and (2) rental, lease, purchase or lease-purchase of durable
734-medical equipment in a cost-effective manner, taking into
735-consideration the recipient's medical prognosis, the extent of
736-the recipient's needs, and the requirements and costs for
737-maintaining such equipment. Subject to prior approval, such
738-rules shall enable a recipient to temporarily acquire and use
739-alternative or substitute devices or equipment pending repairs
740-or replacements of any device or equipment previously
741-authorized for such recipient by the Department.
742-Notwithstanding any provision of Section 5-5f to the contrary,
743-the Department may, by rule, exempt certain replacement
744-wheelchair parts from prior approval and, for wheelchairs,
745-wheelchair parts, wheelchair accessories, and related seating
746-and positioning items, determine the wholesale price by
747-methods other than actual acquisition costs.
748-The Department shall require, by rule, all providers of
749-durable medical equipment to be accredited by an accreditation
750-organization approved by the federal Centers for Medicare and
751-Medicaid Services and recognized by the Department in order to
752-bill the Department for providing durable medical equipment to
753-recipients. No later than 15 months after the effective date
754-of the rule adopted pursuant to this paragraph, all providers
755-must meet the accreditation requirement.
756-In order to promote environmental responsibility, meet the
757-needs of recipients and enrollees, and achieve significant
758-
759-
760-cost savings, the Department, or a managed care organization
761-under contract with the Department, may provide recipients or
762-managed care enrollees who have a prescription or Certificate
763-of Medical Necessity access to refurbished durable medical
764-equipment under this Section (excluding prosthetic and
765-orthotic devices as defined in the Orthotics, Prosthetics, and
766-Pedorthics Practice Act and complex rehabilitation technology
767-products and associated services) through the State's
768-assistive technology program's reutilization program, using
769-staff with the Assistive Technology Professional (ATP)
770-Certification if the refurbished durable medical equipment:
771-(i) is available; (ii) is less expensive, including shipping
772-costs, than new durable medical equipment of the same type;
773-(iii) is able to withstand at least 3 years of use; (iv) is
774-cleaned, disinfected, sterilized, and safe in accordance with
775-federal Food and Drug Administration regulations and guidance
776-governing the reprocessing of medical devices in health care
777-settings; and (v) equally meets the needs of the recipient or
778-enrollee. The reutilization program shall confirm that the
779-recipient or enrollee is not already in receipt of the same or
780-similar equipment from another service provider, and that the
781-refurbished durable medical equipment equally meets the needs
782-of the recipient or enrollee. Nothing in this paragraph shall
783-be construed to limit recipient or enrollee choice to obtain
784-new durable medical equipment or place any additional prior
785-authorization conditions on enrollees of managed care
786-
787-
788-organizations.
789-The Department shall execute, relative to the nursing home
790-prescreening project, written inter-agency agreements with the
791-Department of Human Services and the Department on Aging, to
792-effect the following: (i) intake procedures and common
793-eligibility criteria for those persons who are receiving
794-non-institutional services; and (ii) the establishment and
795-development of non-institutional services in areas of the
796-State where they are not currently available or are
797-undeveloped; and (iii) notwithstanding any other provision of
798-law, subject to federal approval, on and after July 1, 2012, an
799-increase in the determination of need (DON) scores from 29 to
800-37 for applicants for institutional and home and
801-community-based long term care; if and only if federal
802-approval is not granted, the Department may, in conjunction
803-with other affected agencies, implement utilization controls
804-or changes in benefit packages to effectuate a similar savings
805-amount for this population; and (iv) no later than July 1,
806-2013, minimum level of care eligibility criteria for
807-institutional and home and community-based long term care; and
808-(v) no later than October 1, 2013, establish procedures to
809-permit long term care providers access to eligibility scores
810-for individuals with an admission date who are seeking or
811-receiving services from the long term care provider. In order
812-to select the minimum level of care eligibility criteria, the
813-Governor shall establish a workgroup that includes affected
814-
815-
816-agency representatives and stakeholders representing the
817-institutional and home and community-based long term care
818-interests. This Section shall not restrict the Department from
819-implementing lower level of care eligibility criteria for
820-community-based services in circumstances where federal
821-approval has been granted.
822-The Illinois Department shall develop and operate, in
823-cooperation with other State Departments and agencies and in
824-compliance with applicable federal laws and regulations,
825-appropriate and effective systems of health care evaluation
826-and programs for monitoring of utilization of health care
827-services and facilities, as it affects persons eligible for
828-medical assistance under this Code.
829-The Illinois Department shall report annually to the
830-General Assembly, no later than the second Friday in April of
831-1979 and each year thereafter, in regard to:
832-(a) actual statistics and trends in utilization of
833-medical services by public aid recipients;
834-(b) actual statistics and trends in the provision of
835-the various medical services by medical vendors;
836-(c) current rate structures and proposed changes in
837-those rate structures for the various medical vendors; and
838-(d) efforts at utilization review and control by the
839-Illinois Department.
840-The period covered by each report shall be the 3 years
841-ending on the June 30 prior to the report. The report shall
842-
843-
844-include suggested legislation for consideration by the General
845-Assembly. The requirement for reporting to the General
846-Assembly shall be satisfied by filing copies of the report as
847-required by Section 3.1 of the General Assembly Organization
848-Act, and filing such additional copies with the State
849-Government Report Distribution Center for the General Assembly
850-as is required under paragraph (t) of Section 7 of the State
851-Library Act.
852-Rulemaking authority to implement Public Act 95-1045, if
853-any, is conditioned on the rules being adopted in accordance
854-with all provisions of the Illinois Administrative Procedure
855-Act and all rules and procedures of the Joint Committee on
856-Administrative Rules; any purported rule not so adopted, for
857-whatever reason, is unauthorized.
858-On and after July 1, 2012, the Department shall reduce any
859-rate of reimbursement for services or other payments or alter
860-any methodologies authorized by this Code to reduce any rate
861-of reimbursement for services or other payments in accordance
862-with Section 5-5e.
863-Because kidney transplantation can be an appropriate,
864-cost-effective alternative to renal dialysis when medically
865-necessary and notwithstanding the provisions of Section 1-11
866-of this Code, beginning October 1, 2014, the Department shall
867-cover kidney transplantation for noncitizens with end-stage
868-renal disease who are not eligible for comprehensive medical
869-benefits, who meet the residency requirements of Section 5-3
870-
871-
872-of this Code, and who would otherwise meet the financial
873-requirements of the appropriate class of eligible persons
874-under Section 5-2 of this Code. To qualify for coverage of
875-kidney transplantation, such person must be receiving
876-emergency renal dialysis services covered by the Department.
877-Providers under this Section shall be prior approved and
878-certified by the Department to perform kidney transplantation
879-and the services under this Section shall be limited to
880-services associated with kidney transplantation.
881-Notwithstanding any other provision of this Code to the
882-contrary, on or after July 1, 2015, all FDA approved forms of
883-medication assisted treatment prescribed for the treatment of
884-alcohol dependence or treatment of opioid dependence shall be
885-covered under both fee-for-service fee for service and managed
886-care medical assistance programs for persons who are otherwise
887-eligible for medical assistance under this Article and shall
888-not be subject to any (1) utilization control, other than
889-those established under the American Society of Addiction
890-Medicine patient placement criteria, (2) prior authorization
891-mandate, or (3) lifetime restriction limit mandate.
892-On or after July 1, 2015, opioid antagonists prescribed
893-for the treatment of an opioid overdose, including the
894-medication product, administration devices, and any pharmacy
895-fees or hospital fees related to the dispensing, distribution,
896-and administration of the opioid antagonist, shall be covered
897-under the medical assistance program for persons who are
898-
899-
900-otherwise eligible for medical assistance under this Article.
901-As used in this Section, "opioid antagonist" means a drug that
902-binds to opioid receptors and blocks or inhibits the effect of
903-opioids acting on those receptors, including, but not limited
904-to, naloxone hydrochloride or any other similarly acting drug
905-approved by the U.S. Food and Drug Administration. The
906-Department shall not impose a copayment on the coverage
907-provided for naloxone hydrochloride under the medical
908-assistance program.
909-Upon federal approval, the Department shall provide
910-coverage and reimbursement for all drugs that are approved for
911-marketing by the federal Food and Drug Administration and that
912-are recommended by the federal Public Health Service or the
913-United States Centers for Disease Control and Prevention for
914-pre-exposure prophylaxis and related pre-exposure prophylaxis
915-services, including, but not limited to, HIV and sexually
916-transmitted infection screening, treatment for sexually
917-transmitted infections, medical monitoring, assorted labs, and
918-counseling to reduce the likelihood of HIV infection among
919-individuals who are not infected with HIV but who are at high
920-risk of HIV infection.
921-A federally qualified health center, as defined in Section
922-1905(l)(2)(B) of the federal Social Security Act, shall be
923-reimbursed by the Department in accordance with the federally
924-qualified health center's encounter rate for services provided
925-to medical assistance recipients that are performed by a
926-
927-
928-dental hygienist, as defined under the Illinois Dental
929-Practice Act, working under the general supervision of a
930-dentist and employed by a federally qualified health center.
931-Within 90 days after October 8, 2021 (the effective date
932-of Public Act 102-665), the Department shall seek federal
933-approval of a State Plan amendment to expand coverage for
934-family planning services that includes presumptive eligibility
935-to individuals whose income is at or below 208% of the federal
936-poverty level. Coverage under this Section shall be effective
937-beginning no later than December 1, 2022.
938-Subject to approval by the federal Centers for Medicare
939-and Medicaid Services of a Title XIX State Plan amendment
940-electing the Program of All-Inclusive Care for the Elderly
941-(PACE) as a State Medicaid option, as provided for by Subtitle
942-I (commencing with Section 4801) of Title IV of the Balanced
943-Budget Act of 1997 (Public Law 105-33) and Part 460
944-(commencing with Section 460.2) of Subchapter E of Title 42 of
945-the Code of Federal Regulations, PACE program services shall
946-become a covered benefit of the medical assistance program,
947-subject to criteria established in accordance with all
948-applicable laws.
949-Notwithstanding any other provision of this Code,
950-community-based pediatric palliative care from a trained
951-interdisciplinary team shall be covered under the medical
952-assistance program as provided in Section 15 of the Pediatric
953-Palliative Care Act.
954-
955-
956-Notwithstanding any other provision of this Code, within
957-12 months after June 2, 2022 (the effective date of Public Act
958-102-1037) and subject to federal approval, acupuncture
959-services performed by an acupuncturist licensed under the
960-Acupuncture Practice Act who is acting within the scope of his
961-or her license shall be covered under the medical assistance
962-program. The Department shall apply for any federal waiver or
963-State Plan amendment, if required, to implement this
964-paragraph. The Department may adopt any rules, including
965-standards and criteria, necessary to implement this paragraph.
966-Notwithstanding any other provision of this Code, the
967-medical assistance program shall, subject to appropriation and
968-federal approval, reimburse hospitals for costs associated
969-with a newborn screening test for the presence of
970-metachromatic leukodystrophy, as required under the Newborn
971-Metabolic Screening Act, at a rate not less than the fee
972-charged by the Department of Public Health. The Department
973-shall seek federal approval before the implementation of the
974-newborn screening test fees by the Department of Public
975-Health.
976-Notwithstanding any other provision of this Code,
977-beginning on January 1, 2024, subject to federal approval,
978-cognitive assessment and care planning services provided to a
979-person who experiences signs or symptoms of cognitive
980-impairment, as defined by the Diagnostic and Statistical
981-Manual of Mental Disorders, Fifth Edition, shall be covered
982-
983-
984-under the medical assistance program for persons who are
985-otherwise eligible for medical assistance under this Article.
986-Notwithstanding any other provision of this Code,
987-medically necessary reconstructive services that are intended
988-to restore physical appearance shall be covered under the
989-medical assistance program for persons who are otherwise
990-eligible for medical assistance under this Article. As used in
991-this paragraph, "reconstructive services" means treatments
992-performed on structures of the body damaged by trauma to
993-restore physical appearance.
994-(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
995-102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
996-55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
997-eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
998-102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
999-5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1000-102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1001-1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
1002-103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1003-1-1-24; revised 12-15-23.)
1004-ARTICLE 10.
1005-Section 10-5. The Illinois Public Aid Code is amended by
1006-adding Section 5-5.05h as follows:
1007-
1008-
1009-(305 ILCS 5/5-5.05h new)
1010-Sec. 5-5.05h. Reimbursement rates for psychiatric
1011-evaluations and medication monitoring. Subject to federal
1012-approval, for dates of service on and after January 1, 2025,
1013-the Department shall make a one-time adjustment to the add-on
1014-rates for services delivered by physicians who are
1015-board-certified in psychiatry and advanced practice registered
1016-nurses who hold a current certification in psychiatric and
1017-mental health nursing. The one-time adjustment shall increase
1018-the add-on rates so that the sum of the Department's base per
1019-service unit rate plus the rate add-on is no less than $264.42
1020-per hour adjusted for time and intensity as determined by the
1021-work relative value units in the 2024 national Medicare
1022-physician fee schedule, indexed to 60 minutes of individual
1023-psychotherapy.
1024-ARTICLE 15.
1025-Section 15-5. The Illinois Public Aid Code is amended by
1026-changing Section 5-5.01a as follows:
1027-(305 ILCS 5/5-5.01a)
1028-Sec. 5-5.01a. Supportive living facilities program.
1029-(a) The Department shall establish and provide oversight
1030-for a program of supportive living facilities that seek to
1031-promote resident independence, dignity, respect, and
1032-
1033-
1034-well-being in the most cost-effective manner.
1035-A supportive living facility is (i) a free-standing
1036-facility or (ii) a distinct physical and operational entity
1037-within a mixed-use building that meets the criteria
1038-established in subsection (d). A supportive living facility
1039-integrates housing with health, personal care, and supportive
1040-services and is a designated setting that offers residents
1041-their own separate, private, and distinct living units.
1042-Sites for the operation of the program shall be selected
1043-by the Department based upon criteria that may include the
1044-need for services in a geographic area, the availability of
1045-funding, and the site's ability to meet the standards.
1046-(b) Beginning July 1, 2014, subject to federal approval,
1047-the Medicaid rates for supportive living facilities shall be
1048-equal to the supportive living facility Medicaid rate
1049-effective on June 30, 2014 increased by 8.85%. Once the
1050-assessment imposed at Article V-G of this Code is determined
1051-to be a permissible tax under Title XIX of the Social Security
1052-Act, the Department shall increase the Medicaid rates for
1053-supportive living facilities effective on July 1, 2014 by
1054-9.09%. The Department shall apply this increase retroactively
1055-to coincide with the imposition of the assessment in Article
1056-V-G of this Code in accordance with the approval for federal
1057-financial participation by the Centers for Medicare and
1058-Medicaid Services.
1059-The Medicaid rates for supportive living facilities
1060-
1061-
1062-effective on July 1, 2017 must be equal to the rates in effect
1063-for supportive living facilities on June 30, 2017 increased by
1064-2.8%.
1065-The Medicaid rates for supportive living facilities
1066-effective on July 1, 2018 must be equal to the rates in effect
1067-for supportive living facilities on June 30, 2018.
1068-Subject to federal approval, the Medicaid rates for
1069-supportive living services on and after July 1, 2019 must be at
1070-least 54.3% of the average total nursing facility services per
1071-diem for the geographic areas defined by the Department while
1072-maintaining the rate differential for dementia care and must
1073-be updated whenever the total nursing facility service per
1074-diems are updated. Beginning July 1, 2022, upon the
1075-implementation of the Patient Driven Payment Model, Medicaid
1076-rates for supportive living services must be at least 54.3% of
1077-the average total nursing services per diem rate for the
1078-geographic areas. For purposes of this provision, the average
1079-total nursing services per diem rate shall include all add-ons
1080-for nursing facilities for the geographic area provided for in
1081-Section 5-5.2. The rate differential for dementia care must be
1082-maintained in these rates and the rates shall be updated
1083-whenever nursing facility per diem rates are updated.
1084-Subject to federal approval, beginning January 1, 2024,
1085-the dementia care rate for supportive living services must be
1086-no less than the non-dementia care supportive living services
1087-rate multiplied by 1.5.
1088-
1089-
1090-(b-5) Subject to federal approval, beginning January 1,
1091-2025, Medicaid rates for supportive living services must be at
1092-least 54.75% of the average total nursing services per diem
1093-rate for the geographic areas defined by the Department and
1094-shall include all add-ons for nursing facilities for the
1095-geographic area provided for in Section 5-5.2.
1096-(c) The Department may adopt rules to implement this
1097-Section. Rules that establish or modify the services,
1098-standards, and conditions for participation in the program
1099-shall be adopted by the Department in consultation with the
1100-Department on Aging, the Department of Rehabilitation
1101-Services, and the Department of Mental Health and
1102-Developmental Disabilities (or their successor agencies).
1103-(d) Subject to federal approval by the Centers for
1104-Medicare and Medicaid Services, the Department shall accept
1105-for consideration of certification under the program any
1106-application for a site or building where distinct parts of the
1107-site or building are designated for purposes other than the
1108-provision of supportive living services, but only if:
1109-(1) those distinct parts of the site or building are
1110-not designated for the purpose of providing assisted
1111-living services as required under the Assisted Living and
1112-Shared Housing Act;
1113-(2) those distinct parts of the site or building are
1114-completely separate from the part of the building used for
1115-the provision of supportive living program services,
1116-
1117-
1118-including separate entrances;
1119-(3) those distinct parts of the site or building do
1120-not share any common spaces with the part of the building
1121-used for the provision of supportive living program
1122-services; and
1123-(4) those distinct parts of the site or building do
1124-not share staffing with the part of the building used for
1125-the provision of supportive living program services.
1126-(e) Facilities or distinct parts of facilities which are
1127-selected as supportive living facilities and are in good
1128-standing with the Department's rules are exempt from the
1129-provisions of the Nursing Home Care Act and the Illinois
1130-Health Facilities Planning Act.
1131-(f) Section 9817 of the American Rescue Plan Act of 2021
1132-(Public Law 117-2) authorizes a 10% enhanced federal medical
1133-assistance percentage for supportive living services for a
1134-12-month period from April 1, 2021 through March 31, 2022.
1135-Subject to federal approval, including the approval of any
1136-necessary waiver amendments or other federally required
1137-documents or assurances, for a 12-month period the Department
1138-must pay a supplemental $26 per diem rate to all supportive
1139-living facilities with the additional federal financial
1140-participation funds that result from the enhanced federal
1141-medical assistance percentage from April 1, 2021 through March
1142-31, 2022. The Department may issue parameters around how the
1143-supplemental payment should be spent, including quality
1144-
1145-
1146-improvement activities. The Department may alter the form,
1147-methods, or timeframes concerning the supplemental per diem
1148-rate to comply with any subsequent changes to federal law,
1149-changes made by guidance issued by the federal Centers for
1150-Medicare and Medicaid Services, or other changes necessary to
1151-receive the enhanced federal medical assistance percentage.
1152-(g) All applications for the expansion of supportive
1153-living dementia care settings involving sites not approved by
1154-the Department on January 1, 2024 (the effective date of
1155-Public Act 103-102) this amendatory Act of the 103rd General
1156-Assembly may allow new elderly non-dementia units in addition
1157-to new dementia care units. The Department may approve such
1158-applications only if the application has: (1) no more than one
1159-non-dementia care unit for each dementia care unit and (2) the
1160-site is not located within 4 miles of an existing supportive
1161-living program site in Cook County (including the City of
1162-Chicago), not located within 12 miles of an existing
1163-supportive living program site in DuPage County, Kane County,
1164-Lake County, McHenry County, or Will County, or not located
1165-within 25 miles of an existing supportive living program site
1166-in any other county.
1167-(h) Beginning January 1, 2025, subject to federal
1168-approval, for a person who is a resident of a supportive living
1169-facility under this Section, the monthly personal needs
1170-allowance shall be $120 per month.
1171-(Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
1172-
1173-
1174-103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
1175-Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)
1176-ARTICLE 20.
1177-Section 20-5. The Birth Center Licensing Act is amended by
1178-changing Section 40 as follows:
1179-(210 ILCS 170/40)
1180-Sec. 40. Reimbursement requirements.
1181-(a) A birth center shall seek certification under Titles
1182-XVIII and XIX of the federal Social Security Act.
1183-(b) Services provided to individuals eligible for medical
1184-assistance shall be covered in accordance with Article V of
1185-the Illinois Public Aid Code and reimbursement rates shall be
1186-set by the Department of Healthcare and Family Services.
1187-Reimbursement rates set by the Department of Healthcare and
1188-Family Services should be based on all types of medically
1189-necessary covered services provided to both the birthing
1190-person and the baby, including:
1191-(1) a professional fee for both the birthing person
1192-and baby;
1193-(2) a facility fee for the birthing person that is no
1194-less than 75% of the statewide average facility payment
1195-rate made to a hospital for an uncomplicated vaginal
1196-birth;
1197-
1198-
1199-(3) a facility fee for the baby that is no less than
1200-75% of the statewide average facility payment rate made to
1201-a hospital for a normal baby; and
1202-(4) additional fees for other services, medications,
1203-laboratory tests, and supplies provided.
1204-(c) A birth center shall provide charitable care
1205-consistent with that provided by comparable health care
1206-providers in the geographic area.
1207-(d) A birth center may not discriminate against any
1208-patient requiring treatment because of the source of payment
1209-for services, including Medicare and Medicaid recipients.
1210-(Source: P.A. 102-518, eff. 8-20-21.)
1211-Section 20-10. The Illinois Public Aid Code is amended by
1212-adding Section 5-18.3 as follows:
1213-(305 ILCS 5/5-18.3 new)
1214-Sec. 5-18.3. Birth center; facility fee.
1215-(a) Reimbursement for services covered under this Article
1216-and provided at a birth center as defined in Section 5 of the
1217-Birth Center Licensing Act shall include:
1218-(1) Beginning January 1, 2025, subject to federal
1219-approval, a facility fee for the birthing person and baby
1220-that is no less than 80% of the statewide average facility
1221-payment rate made to a hospital for an uncomplicated
1222-vaginal birth. The facility fee shall include medications,
1223-
1224-
1225-laboratory tests, and supplies provided.
1226-(2) Beginning January 1, 2025, no less than 80% of the
1227-Department fee schedule rate for professional services for
1228-the birthing person and baby covered under this Article
1229-that are reimbursable separate from the facility fee and
1230-provided within the scope of licensure or certification of
1231-both the practitioner and birth center.
1232-(b) The Department shall submit any necessary application
1233-to the federal Centers for Medicare and Medicaid Services for
1234-a waiver or State Plan amendment to implement the requirements
1235-of this Section.
1236-ARTICLE 30.
1237-Section 30-5. The Illinois Public Aid Code is amended by
1238-changing Sections 5H-1 and 5H-3 as follows:
1239-(305 ILCS 5/5H-1)
1240-Sec. 5H-1. Definitions. As used in this Article:
1241-"Base year" means the 12-month period from January 1, 2023
1242-2018 to December 31, 2023 2018.
1243-"Department" means the Department of Healthcare and Family
1244-Services.
1245-"Federal employee health benefit" means the program of
1246-health benefits plans, as defined in 5 U.S.C. 8901, available
1247-to federal employees under 5 U.S.C. 8901 to 8914.
1248-
1249-
1250-"Fund" means the Healthcare Provider Relief Fund.
1251-"Managed care organization" means an entity operating
1252-under a certificate of authority issued pursuant to the Health
1253-Maintenance Organization Act or as a Managed Care Community
1254-Network pursuant to Section 5-11 of this Code.
1255-"Medicaid managed care organization" means a managed care
1256-organization under contract with the Department to provide
1257-services to recipients of benefits in the medical assistance
1258-program pursuant to Article V of this Code, the Children's
1259-Health Insurance Program Act, or the Covering ALL KIDS Health
1260-Insurance Act. It does not include contracts the same entity
1261-or an affiliated entity has for other business.
1262-"Medicare" means the federal Medicare program established
1263-under Title XVIII of the federal Social Security Act.
1264-"Member months" means the aggregate total number of months
1265-all individuals are enrolled for coverage in a Managed Care
1266-Organization during the base year. Member months are
1267-determined by the Department for Medicaid Managed Care
1268-Organizations based on enrollment data in its Medicaid
1269-Management Information System and by the Department of
1270-Insurance for other Managed Care Organizations based on
1271-required filings with the Department of Insurance. Member
1272-months do not include months individuals are enrolled in a
1273-Limited Health Services Organization, including stand-alone
1274-dental or vision plans, a Medicare Advantage Plan, a Medicare
1275-Supplement Plan, a Medicaid Medicare Alignment Initiate Plan
1276-
1277-
1278-pursuant to a Memorandum of Understanding between the
1279-Department and the Federal Centers for Medicare and Medicaid
1280-Services or a Federal Employee Health Benefits Plan.
1281-(Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.)
1282-(305 ILCS 5/5H-3)
1283-Sec. 5H-3. Managed care assessment.
1284-(a) There is For State Fiscal year 2020 through State
1285-Fiscal Year 2025, there is imposed upon managed care
1286-organization member months an assessment, calculated on base
1287-year data, as set forth below for the appropriate tier:
1288-(1) Tier 1: $78.90 $60.20 per member month.
1289-(2) Tier 2: $1.40 $1.20 per member month.
1290-(3) Tier 3: $2.40 per member month.
1291-(b) The tiers are established as follows:
1292-(1) Tier 1 includes the first 4,195,000 member months
1293-in a Medicaid managed care organization for the base year;
1294-(2) (ii) Tier 2 includes member months over 4,195,000
1295-in a Medicaid managed care organization during the base
1296-year; and
1297-(3) (iv) Tier 3 includes member months during the base
1298-year in a managed care organization that is not a Medicaid
1299-managed care organization.
1300-(c) For State fiscal year 2020, and for each State fiscal
1301-year thereafter, through State fiscal year 2025, the
1302-Department may by rule adjust rates or tier parameters or both
1303-
1304-
1305-in order to maximize the revenue generated by the assessment
1306-consistent with federal regulations and to meet federal
1307-statistical tests necessary for federal financial
1308-participation. Any upward adjustment to the Tier 3 rate shall
1309-be the minimum necessary to meet federal statistical tests.
1310-(Source: P.A. 101-9, eff. 6-5-19.)
1311-ARTICLE 35.
1312-Section 35-5. The Illinois Administrative Procedure Act is
1313-amended by adding Section 5-45.55 as follows:
1314-(5 ILCS 100/5-45.55 new)
1315-Sec. 5-45.55. Emergency rulemaking; Medicaid hospital rate
1316-updates. To provide for the expeditious and timely
1317-implementation of the changes made to Section 14-12.5 of the
1318-Illinois Public Aid Code by this amendatory Act of the 103rd
1319-General Assembly, emergency rules implementing the changes
1320-made by this amendatory Act of the 103rd General Assembly to
1321-Section 14-12.5 of the Illinois Public Aid Code may be adopted
1322-in accordance with Section 5-45 by the Department of
1323-Healthcare and Family Services. The adoption of emergency
1324-rules authorized by Section 5-45 and this Section is deemed to
1325-be necessary for the public interest, safety, and welfare.
1326-This Section is repealed one year after the effective date
1327-of this amendatory Act of the 103rd General Assembly.
1328-
1329-
1330-Section 35-10. The Illinois Public Aid Code is amended by
1331-changing Section 14-12.5 as follows:
1332-(305 ILCS 5/14-12.5)
1333-Sec. 14-12.5. Hospital rate updates.
1334-(a) Notwithstanding any other provision of this Code, the
1335-hospital rates of reimbursement authorized under Sections
1336-5-5.05, 14-12, and 14-13 of this Code shall be adjusted in
1337-accordance with the provisions of this Section.
1338-(b) Notwithstanding any other provision of this Code,
1339-effective for dates of service on and after January 1, 2024,
1340-subject to federal approval, hospital reimbursement rates
1341-shall be revised as follows:
1342-(1) For inpatient general acute care services, the
1343-statewide-standardized amount and the per diem rates for
1344-hospitals exempt from the APR-DRG reimbursement system, in
1345-effect January 1, 2023, shall be increased by 10%.
1346-(2) For inpatient psychiatric services:
1347-(A) For safety-net hospitals, the hospital
1348-specific per diem rate in effect January 1, 2023 and
1349-the minimum per diem rate of $630, authorized in
1350-subsection (b-5) of Section 5-5.05 of this Code, shall
1351-be increased by 10%.
1352-(B) For all general acute care hospitals that are
1353-not safety-net hospitals, the inpatient psychiatric
1354-
1355-
1356-care per diem rates in effect January 1, 2023 shall be
1357-increased by 10%, except that all rates shall be at
1358-least 90% of the minimum inpatient psychiatric care
1359-per diem rate for safety-net hospitals as authorized
1360-in subsection (b-5) of Section 5-5.05 of this Code
1361-including the adjustments authorized in this Section.
1362-The statewide default per diem rate for a hospital
1363-opening a new psychiatric distinct part unit, shall be
1364-set at 90% of the minimum inpatient psychiatric care
1365-per diem rate for safety-net hospitals as authorized
1366-in subsection (b-5) of Section 5-5.05 of this Code,
1367-including the adjustment authorized in this Section.
1368-(C) For all psychiatric specialty hospitals, the
1369-per diem rates in effect January 1, 2023, shall be
1370-increased by 10%, except that all rates shall be at
1371-least 90% of the minimum inpatient per diem rate for
1372-safety-net hospitals as authorized in subsection (b-5)
1373-of Section 5-5.05 of this Code, including the
1374-adjustments authorized in this Section. The statewide
1375-default per diem rate for a new psychiatric specialty
1376-hospital shall be set at 90% of the minimum inpatient
1377-psychiatric care per diem rate for safety-net
1378-hospitals as authorized in subsection (b-5) of Section
1379-5-5.05 of this Code, including the adjustment
1380-authorized in this Section.
1381-(3) For inpatient rehabilitative services, all
1382-
1383-
1384-hospital specific per diem rates in effect January 1,
1385-2023, shall be increased by 10%. The statewide default
1386-inpatient rehabilitative services per diem rates, for
1387-general acute care hospitals and for rehabilitation
1388-specialty hospitals respectively, shall be increased by
1389-10%.
1390-(4) The statewide-standardized amount for outpatient
1391-general acute care services in effect January 1, 2023,
1392-shall be increased by 10%.
1393-(5) The statewide-standardized amount for outpatient
1394-psychiatric care services in effect January 1, 2023, shall
1395-be increased by 10%.
1396-(6) The statewide-standardized amount for outpatient
1397-rehabilitative care services in effect January 1, 2023,
1398-shall be increased by 10%.
1399-(7) The per diem rate in effect January 1, 2023, as
1400-authorized in subsection (a) of Section 14-13 of this
1401-Article shall be increased by 10%.
1402-(8) For services provided Beginning on and after
1403-January 1, 2024 through June 30, 2024, and on and after
1404-January 1, 2027, subject to federal approval, in addition
1405-to the statewide standardized amount, an add-on payment of
1406-at least $210 shall be paid for each inpatient General
1407-Acute and Psychiatric day of care, excluding
1408-Medicare-Medicaid dual eligible crossover days, for all
1409-safety-net hospitals defined in Section 5-5e.1 of this
1410-
1411-
1412-Code.
1413-(A) For Psychiatric days of care, the Department
1414-may implement payment of this add-on by increasing the
1415-hospital specific psychiatric per diem rate, adjusted
1416-in accordance with subparagraph (A) of paragraph (2)
1417-of subsection (b) by $210, or by a separate add-on
1418-payment.
1419-(B) If the add-on adjustment is added to the
1420-hospital specific psychiatric per diem rate to
1421-operationalize payment, the Department shall provide a
1422-rate sheet to each safety-net hospital, which
1423-identifies the hospital psychiatric per diem rate
1424-before and after the adjustment.
1425-(C) The add-on adjustment shall not be considered
1426-when setting the 90% minimum rate identified in
1427-paragraph (2) of subsection (b).
1428-(9) For services provided on and after July 1, 2024,
1429-and on or before December 31, 2026, subject to federal
1430-approval, in addition to the statewide standardized amount
1431-and any other payments authorized under this Code, a
1432-safety-net hospital health care equity add-on payment
1433-shall be paid for each inpatient General Acute and
1434-Psychiatric day of care, excluding Medicare-Medicaid dual
1435-eligible crossover days, for safety-net hospitals defined
1436-in Section 5-5e.1 of this Code, as follows:
1437-(A) if the safety-net hospital's Medicaid
1438-
1439-
1440-inpatient utilization rate, as calculated under
1441-Section 5-5e.1 of this Code, is equal to or greater
1442-than 70%, the add-on payment shall be $425;
1443-(B) if the safety-net hospital's Medicaid
1444-inpatient utilization rate, as calculated under
1445-Section 5-5e.1 of this Code, is equal to or greater
1446-than 50% and less than 70%, the add-on payment shall be
1447-$300;
1448-(C) if the safety-net hospital's Medicaid
1449-inpatient utilization rate, as calculated under
1450-Section 5-5e.1 of this Code, is equal to or greater
1451-than 40% and less than 50%, the add-on payment shall be
1452-$225; and
1453-(D) if the safety-net hospital's Medicaid
1454-inpatient utilization rate, as calculated under
1455-Section 5-5e.1 of this Code, is less than 40%, the
1456-add-on payment shall be $210.
1457-Qualification for the safety-net hospital health care
1458-equity add-on payment shall be updated January 1, 2026,
1459-based on the MIUR determination effective 3 months prior
1460-to the start of the January 1, 2026 calendar year.
1461-Rates described in subparagraphs (A) through (C) shall
1462-be adjusted annually beginning January 1, 2026 by applying
1463-a uniform factor to each rate to spend an approximate
1464-amount of $50,000,000 annually per year using State fiscal
1465-year 2024 days as a basis for calendar year 2026 rates.
1466-
1467-
1468-The add-on adjustment under this paragraph shall not
1469-be considered when setting the 90% minimum rate identified
1470-in subparagraph (B) of paragraph (2).
1471-(10) For services provided on and after July 1, 2024,
1472-and on or before December 31, 2026, subject to federal
1473-approval, in addition to the statewide standardized amount
1474-and any other payments authorized under this Code, a
1475-safety-net hospital low volume add-on payment of $200
1476-shall be paid for each inpatient General Acute and
1477-Psychiatric day of care, excluding Medicare-Medicaid dual
1478-eligible crossover days, for any safety-net hospital as
1479-defined in Section 5-5e.1 that provided less than 11,000
1480-Medicaid inpatient days of care, excluding
1481-Medicare-Medicaid dual eligible crossover days, in the
1482-base period. As used in this paragraph, "base period"
1483-means State fiscal year 2022 admissions received by the
1484-Department prior to October 1, 2023 for the payment period
1485-July 1, 2024 through December 31, 2025, and beginning in
1486-calendar year 2026, the State fiscal year that ends 30
1487-months before the applicable calendar year, such as State
1488-fiscal year 2023 admissions received by the Department
1489-prior to October 1, 2024, for calendar year 2026.
1490-(c) The Department shall take all actions necessary to
1491-ensure the changes authorized in Public Act 103-102 and this
1492-amendatory Act of the 103rd General Assembly are in effect for
1493-dates of service on and after the effective date of the changes
1494-
1495-
1496-made to this Section by this amendatory Act of the 103rd
1497-General Assembly, January 1, 2024, including publishing all
1498-appropriate public notices, applying for federal approval of
1499-amendments to the Illinois Title XIX State Plan, and adopting
1500-administrative rules if necessary.
1501-(d) The Department of Healthcare and Family Services may
1502-adopt rules necessary to implement the changes made by Public
1503-Act 103-102 and this amendatory Act of the 103rd General
1504-Assembly through the use of emergency rulemaking in accordance
1505-with Section 5-45 of the Illinois Administrative Procedure
1506-Act. The 24-month limitation on the adoption of emergency
1507-rules does not apply to rules adopted under this Section. The
1508-General Assembly finds that the adoption of rules to implement
1509-the changes made by Public Act 103-102 and this amendatory Act
1510-of the 103rd General Assembly is deemed an emergency and
1511-necessary for the public interest, safety, and welfare.
1512-(e) The Department shall ensure that all necessary
1513-adjustments to the managed care organization capitation base
1514-rates necessitated by the adjustments in this Section are
1515-completed, published, and applied in accordance with Section
1516-5-30.8 of this Code 90 days prior to the implementation date of
1517-the changes required under Public Act 103-102 and this
1518-amendatory Act of the 103rd General Assembly.
1519-(f) The Department shall publish updated rate sheets or
1520-add-on payment amounts, as applicable, for all hospitals 30
1521-days prior to the effective date of the rate increase, or
1522-
1523-
1524-within 30 days after federal approval by the Centers for
1525-Medicare and Medicaid Services, whichever is later.
1526-(Source: P.A. 103-102, eff. 6-16-23.)
1527-ARTICLE 40.
1528-Section 40-5. The Illinois Public Aid Code is amended by
1529-changing Section 5A-12.7 as follows:
1530-(305 ILCS 5/5A-12.7)
1531-(Section scheduled to be repealed on December 31, 2026)
1532-Sec. 5A-12.7. Continuation of hospital access payments on
1533-and after July 1, 2020.
1534-(a) To preserve and improve access to hospital services,
1535-for hospital services rendered on and after July 1, 2020, the
1536-Department shall, except for hospitals described in subsection
1537-(b) of Section 5A-3, make payments to hospitals or require
1538-capitated managed care organizations to make payments as set
1539-forth in this Section. Payments under this Section are not due
1540-and payable, however, until: (i) the methodologies described
1541-in this Section are approved by the federal government in an
1542-appropriate State Plan amendment or directed payment preprint;
1543-and (ii) the assessment imposed under this Article is
1544-determined to be a permissible tax under Title XIX of the
1545-Social Security Act. In determining the hospital access
1546-payments authorized under subsection (g) of this Section, if a
1547-
1548-
1549-hospital ceases to qualify for payments from the pool, the
1550-payments for all hospitals continuing to qualify for payments
1551-from such pool shall be uniformly adjusted to fully expend the
1552-aggregate net amount of the pool, with such adjustment being
1553-effective on the first day of the second month following the
1554-date the hospital ceases to receive payments from such pool.
1555-(b) Amounts moved into claims-based rates and distributed
1556-in accordance with Section 14-12 shall remain in those
1557-claims-based rates.
1558-(c) Graduate medical education.
1559-(1) The calculation of graduate medical education
1560-payments shall be based on the hospital's Medicare cost
1561-report ending in Calendar Year 2018, as reported in the
1562-Healthcare Cost Report Information System file, release
1563-date September 30, 2019. An Illinois hospital reporting
1564-intern and resident cost on its Medicare cost report shall
1565-be eligible for graduate medical education payments.
1566-(2) Each hospital's annualized Medicaid Intern
1567-Resident Cost is calculated using annualized intern and
1568-resident total costs obtained from Worksheet B Part I,
1569-Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
1570-96-98, and 105-112 multiplied by the percentage that the
1571-hospital's Medicaid days (Worksheet S3 Part I, Column 7,
1572-Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
1573-hospital's total days (Worksheet S3 Part I, Column 8,
1574-Lines 14, 16-18, and 32).
1575-
1576-
1577-(3) An annualized Medicaid indirect medical education
1578-(IME) payment is calculated for each hospital using its
1579-IME payments (Worksheet E Part A, Line 29, Column 1)
1580-multiplied by the percentage that its Medicaid days
1581-(Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
1582-and 32) comprise of its Medicare days (Worksheet S3 Part
1583-I, Column 6, Lines 2, 3, 4, 14, and 16-18).
1584-(4) For each hospital, its annualized Medicaid Intern
1585-Resident Cost and its annualized Medicaid IME payment are
1586-summed, and, except as capped at 120% of the average cost
1587-per intern and resident for all qualifying hospitals as
1588-calculated under this paragraph, is multiplied by the
1589-applicable reimbursement factor as described in this
1590-paragraph, to determine the hospital's final graduate
1591-medical education payment. Each hospital's average cost
1592-per intern and resident shall be calculated by summing its
1593-total annualized Medicaid Intern Resident Cost plus its
1594-annualized Medicaid IME payment and dividing that amount
1595-by the hospital's total Full Time Equivalent Residents and
1596-Interns. If the hospital's average per intern and resident
1597-cost is greater than 120% of the same calculation for all
1598-qualifying hospitals, the hospital's per intern and
1599-resident cost shall be capped at 120% of the average cost
1600-for all qualifying hospitals.
1601-(A) For the period of July 1, 2020 through
1602-December 31, 2022, the applicable reimbursement factor
1603-
1604-
1605-shall be 22.6%.
1606-(B) For the period of January 1, 2023 through
1607-December 31, 2026, the applicable reimbursement factor
1608-shall be 35% for all qualified safety-net hospitals,
1609-as defined in Section 5-5e.1 of this Code, and all
1610-hospitals with 100 or more Full Time Equivalent
1611-Residents and Interns, as reported on the hospital's
1612-Medicare cost report ending in Calendar Year 2018, and
1613-for all other qualified hospitals the applicable
1614-reimbursement factor shall be 30%.
1615-(d) Fee-for-service supplemental payments. For the period
1616-of July 1, 2020 through December 31, 2022, each Illinois
1617-hospital shall receive an annual payment equal to the amounts
1618-below, to be paid in 12 equal installments on or before the
1619-seventh State business day of each month, except that no
1620-payment shall be due within 30 days after the later of the date
1621-of notification of federal approval of the payment
1622-methodologies required under this Section or any waiver
1623-required under 42 CFR 433.68, at which time the sum of amounts
1624-required under this Section prior to the date of notification
1625-is due and payable.
1626-(1) For critical access hospitals, $385 per covered
1627-inpatient day contained in paid fee-for-service claims and
1628-$530 per paid fee-for-service outpatient claim for dates
1629-of service in Calendar Year 2019 in the Department's
1630-Enterprise Data Warehouse as of May 11, 2020.
1631-
1632-
1633-(2) For safety-net hospitals, $960 per covered
1634-inpatient day contained in paid fee-for-service claims and
1635-$625 per paid fee-for-service outpatient claim for dates
1636-of service in Calendar Year 2019 in the Department's
1637-Enterprise Data Warehouse as of May 11, 2020.
1638-(3) For long term acute care hospitals, $295 per
1639-covered inpatient day contained in paid fee-for-service
1640-claims for dates of service in Calendar Year 2019 in the
1641-Department's Enterprise Data Warehouse as of May 11, 2020.
1642-(4) For freestanding psychiatric hospitals, $125 per
1643-covered inpatient day contained in paid fee-for-service
1644-claims and $130 per paid fee-for-service outpatient claim
1645-for dates of service in Calendar Year 2019 in the
1646-Department's Enterprise Data Warehouse as of May 11, 2020.
1647-(5) For freestanding rehabilitation hospitals, $355
1648-per covered inpatient day contained in paid
1649-fee-for-service claims for dates of service in Calendar
1650-Year 2019 in the Department's Enterprise Data Warehouse as
1651-of May 11, 2020.
1652-(6) For all general acute care hospitals and high
1653-Medicaid hospitals as defined in subsection (f), $350 per
1654-covered inpatient day for dates of service in Calendar
1655-Year 2019 contained in paid fee-for-service claims and
1656-$620 per paid fee-for-service outpatient claim in the
1657-Department's Enterprise Data Warehouse as of May 11, 2020.
1658-(7) Alzheimer's treatment access payment. Each
1659-
1660-
1661-Illinois academic medical center or teaching hospital, as
1662-defined in Section 5-5e.2 of this Code, that is identified
1663-as the primary hospital affiliate of one of the Regional
1664-Alzheimer's Disease Assistance Centers, as designated by
1665-the Alzheimer's Disease Assistance Act and identified in
1666-the Department of Public Health's Alzheimer's Disease
1667-State Plan dated December 2016, shall be paid an
1668-Alzheimer's treatment access payment equal to the product
1669-of the qualifying hospital's State Fiscal Year 2018 total
1670-inpatient fee-for-service days multiplied by the
1671-applicable Alzheimer's treatment rate of $226.30 for
1672-hospitals located in Cook County and $116.21 for hospitals
1673-located outside Cook County.
1674-(d-2) Fee-for-service supplemental payments. Beginning
1675-January 1, 2023, each Illinois hospital shall receive an
1676-annual payment equal to the amounts listed below, to be paid in
1677-12 equal installments on or before the seventh State business
1678-day of each month, except that no payment shall be due within
1679-30 days after the later of the date of notification of federal
1680-approval of the payment methodologies required under this
1681-Section or any waiver required under 42 CFR 433.68, at which
1682-time the sum of amounts required under this Section prior to
1683-the date of notification is due and payable. The Department
1684-may adjust the rates in paragraphs (1) through (7) to comply
1685-with the federal upper payment limits, with such adjustments
1686-being determined so that the total estimated spending by
1687-
1688-
1689-hospital class, under such adjusted rates, remains
1690-substantially similar to the total estimated spending under
1691-the original rates set forth in this subsection.
1692-(1) For critical access hospitals, as defined in
1693-subsection (f), $750 per covered inpatient day contained
1694-in paid fee-for-service claims and $750 per paid
1695-fee-for-service outpatient claim for dates of service in
1696-Calendar Year 2019 in the Department's Enterprise Data
1697-Warehouse as of August 6, 2021.
1698-(2) For safety-net hospitals, as described in
1699-subsection (f), $1,350 per inpatient day contained in paid
1700-fee-for-service claims and $1,350 per paid fee-for-service
1701-outpatient claim for dates of service in Calendar Year
1702-2019 in the Department's Enterprise Data Warehouse as of
1703-August 6, 2021.
1704-(3) For long term acute care hospitals, $550 per
1705-covered inpatient day contained in paid fee-for-service
1706-claims for dates of service in Calendar Year 2019 in the
1707-Department's Enterprise Data Warehouse as of August 6,
1708-2021.
1709-(4) For freestanding psychiatric hospitals, $200 per
1710-covered inpatient day contained in paid fee-for-service
1711-claims and $200 per paid fee-for-service outpatient claim
1712-for dates of service in Calendar Year 2019 in the
1713-Department's Enterprise Data Warehouse as of August 6,
1714-2021.
1715-
1716-
1717-(5) For freestanding rehabilitation hospitals, $550
1718-per covered inpatient day contained in paid
1719-fee-for-service claims and $125 per paid fee-for-service
1720-outpatient claim for dates of service in Calendar Year
1721-2019 in the Department's Enterprise Data Warehouse as of
1722-August 6, 2021.
1723-(6) For all general acute care hospitals and high
1724-Medicaid hospitals as defined in subsection (f), $500 per
1725-covered inpatient day for dates of service in Calendar
1726-Year 2019 contained in paid fee-for-service claims and
1727-$500 per paid fee-for-service outpatient claim in the
1728-Department's Enterprise Data Warehouse as of August 6,
1729-2021.
1730-(7) For public hospitals, as defined in subsection
1731-(f), $275 per covered inpatient day contained in paid
1732-fee-for-service claims and $275 per paid fee-for-service
1733-outpatient claim for dates of service in Calendar Year
1734-2019 in the Department's Enterprise Data Warehouse as of
1735-August 6, 2021.
1736-(8) Alzheimer's treatment access payment. Each
1737-Illinois academic medical center or teaching hospital, as
1738-defined in Section 5-5e.2 of this Code, that is identified
1739-as the primary hospital affiliate of one of the Regional
1740-Alzheimer's Disease Assistance Centers, as designated by
1741-the Alzheimer's Disease Assistance Act and identified in
1742-the Department of Public Health's Alzheimer's Disease
1743-
1744-
1745-State Plan dated December 2016, shall be paid an
1746-Alzheimer's treatment access payment equal to the product
1747-of the qualifying hospital's Calendar Year 2019 total
1748-inpatient fee-for-service days, in the Department's
1749-Enterprise Data Warehouse as of August 6, 2021, multiplied
1750-by the applicable Alzheimer's treatment rate of $244.37
1751-for hospitals located in Cook County and $312.03 for
1752-hospitals located outside Cook County.
1753-(e) The Department shall require managed care
1754-organizations (MCOs) to make directed payments and
1755-pass-through payments according to this Section. Each calendar
1756-year, the Department shall require MCOs to pay the maximum
1757-amount out of these funds as allowed as pass-through payments
1758-under federal regulations. The Department shall require MCOs
1759-to make such pass-through payments as specified in this
1760-Section. The Department shall require the MCOs to pay the
1761-remaining amounts as directed Payments as specified in this
1762-Section. The Department shall issue payments to the
1763-Comptroller by the seventh business day of each month for all
1764-MCOs that are sufficient for MCOs to make the directed
1765-payments and pass-through payments according to this Section.
1766-The Department shall require the MCOs to make pass-through
1767-payments and directed payments using electronic funds
1768-transfers (EFT), if the hospital provides the information
1769-necessary to process such EFTs, in accordance with directions
1770-provided monthly by the Department, within 7 business days of
1771-
1772-
1773-the date the funds are paid to the MCOs, as indicated by the
1774-"Paid Date" on the website of the Office of the Comptroller if
1775-the funds are paid by EFT and the MCOs have received directed
1776-payment instructions. If funds are not paid through the
1777-Comptroller by EFT, payment must be made within 7 business
1778-days of the date actually received by the MCO. The MCO will be
1779-considered to have paid the pass-through payments when the
1780-payment remittance number is generated or the date the MCO
1781-sends the check to the hospital, if EFT information is not
1782-supplied. If an MCO is late in paying a pass-through payment or
1783-directed payment as required under this Section (including any
1784-extensions granted by the Department), it shall pay a penalty,
1785-unless waived by the Department for reasonable cause, to the
1786-Department equal to 5% of the amount of the pass-through
1787-payment or directed payment not paid on or before the due date
1788-plus 5% of the portion thereof remaining unpaid on the last day
1789-of each 30-day period thereafter. Payments to MCOs that would
1790-be paid consistent with actuarial certification and enrollment
1791-in the absence of the increased capitation payments under this
1792-Section shall not be reduced as a consequence of payments made
1793-under this subsection. The Department shall publish and
1794-maintain on its website for a period of no less than 8 calendar
1795-quarters, the quarterly calculation of directed payments and
1796-pass-through payments owed to each hospital from each MCO. All
1797-calculations and reports shall be posted no later than the
1798-first day of the quarter for which the payments are to be
1799-
1800-
1801-issued.
1802-(f)(1) For purposes of allocating the funds included in
1803-capitation payments to MCOs, Illinois hospitals shall be
1804-divided into the following classes as defined in
1805-administrative rules:
1806-(A) Beginning July 1, 2020 through December 31, 2022,
1807-critical access hospitals. Beginning January 1, 2023,
1808-"critical access hospital" means a hospital designated by
1809-the Department of Public Health as a critical access
1810-hospital, excluding any hospital meeting the definition of
1811-a public hospital in subparagraph (F).
1812-(B) Safety-net hospitals, except that stand-alone
1813-children's hospitals that are not specialty children's
1814-hospitals and, for calendar years 2025 and 2026 only,
1815-hospitals with over 9,000 Medicaid acute care inpatient
1816-admissions per calendar year, excluding admissions for
1817-Medicare-Medicaid dual eligible patients, will not be
1818-included. For the calendar year beginning January 1, 2023,
1819-and each calendar year thereafter, assignment to the
1820-safety-net class shall be based on the annual safety-net
1821-rate year beginning 15 months before the beginning of the
1822-first Payout Quarter of the calendar year.
1823-(C) Long term acute care hospitals.
1824-(D) Freestanding psychiatric hospitals.
1825-(E) Freestanding rehabilitation hospitals.
1826-(F) Beginning January 1, 2023, "public hospital" means
1827-
1828-
1829-a hospital that is owned or operated by an Illinois
1830-Government body or municipality, excluding a hospital
1831-provider that is a State agency, a State university, or a
1832-county with a population of 3,000,000 or more.
1833-(G) High Medicaid hospitals.
1834-(i) As used in this Section, "high Medicaid
1835-hospital" means a general acute care hospital that:
1836-(I) For the payout periods July 1, 2020
1837-through December 31, 2022, is not a safety-net
1838-hospital or critical access hospital and that has
1839-a Medicaid Inpatient Utilization Rate above 30% or
1840-a hospital that had over 35,000 inpatient Medicaid
1841-days during the applicable period. For the period
1842-July 1, 2020 through December 31, 2020, the
1843-applicable period for the Medicaid Inpatient
1844-Utilization Rate (MIUR) is the rate year 2020 MIUR
1845-and for the number of inpatient days it is State
1846-fiscal year 2018. Beginning in calendar year 2021,
1847-the Department shall use the most recently
1848-determined MIUR, as defined in subsection (h) of
1849-Section 5-5.02, and for the inpatient day
1850-threshold, the State fiscal year ending 18 months
1851-prior to the beginning of the calendar year. For
1852-purposes of calculating MIUR under this Section,
1853-children's hospitals and affiliated general acute
1854-care hospitals shall be considered a single
1855-
1856-
1857-hospital.
1858-(II) For the calendar year beginning January
1859-1, 2023, and each calendar year thereafter, is not
1860-a public hospital, safety-net hospital, or
1861-critical access hospital and that qualifies as a
1862-regional high volume hospital or is a hospital
1863-that has a Medicaid Inpatient Utilization Rate
1864-(MIUR) above 30%. As used in this item, "regional
1865-high volume hospital" means a hospital which ranks
1866-in the top 2 quartiles based on total hospital
1867-services volume, of all eligible general acute
1868-care hospitals, when ranked in descending order
1869-based on total hospital services volume, within
1870-the same Medicaid managed care region, as
1871-designated by the Department, as of January 1,
1872-2022. As used in this item, "total hospital
1873-services volume" means the total of all Medical
1874-Assistance hospital inpatient admissions plus all
1875-Medical Assistance hospital outpatient visits. For
1876-purposes of determining regional high volume
1877-hospital inpatient admissions and outpatient
1878-visits, the Department shall use dates of service
1879-provided during State Fiscal Year 2020 for the
1880-Payout Quarter beginning January 1, 2023. The
1881-Department shall use dates of service from the
1882-State fiscal year ending 18 month before the
1883-
1884-
1885-beginning of the first Payout Quarter of the
1886-subsequent annual determination period.
1887-(ii) For the calendar year beginning January 1,
1888-2023, the Department shall use the Rate Year 2022
1889-Medicaid inpatient utilization rate (MIUR), as defined
1890-in subsection (h) of Section 5-5.02. For each
1891-subsequent annual determination, the Department shall
1892-use the MIUR applicable to the rate year ending
1893-September 30 of the year preceding the beginning of
1894-the calendar year.
1895-(H) General acute care hospitals. As used under this
1896-Section, "general acute care hospitals" means all other
1897-Illinois hospitals not identified in subparagraphs (A)
1898-through (G).
1899-(2) Hospitals' qualification for each class shall be
1900-assessed prior to the beginning of each calendar year and the
1901-new class designation shall be effective January 1 of the next
1902-year. The Department shall publish by rule the process for
1903-establishing class determination.
1904-(3) Beginning January 1, 2024, the Department may reassign
1905-hospitals or entire hospital classes as defined above, if
1906-federal limits on the payments to the class to which the
1907-hospitals are assigned based on the criteria in this
1908-subsection prevent the Department from making payments to the
1909-class that would otherwise be due under this Section. The
1910-Department shall publish the criteria and composition of each
1911-
1912-
1913-new class based on the reassignments, and the projected impact
1914-on payments to each hospital under the new classes on its
1915-website by November 15 of the year before the year in which the
1916-class changes become effective.
1917-(g) Fixed pool directed payments. Beginning July 1, 2020,
1918-the Department shall issue payments to MCOs which shall be
1919-used to issue directed payments to qualified Illinois
1920-safety-net hospitals and critical access hospitals on a
1921-monthly basis in accordance with this subsection. Prior to the
1922-beginning of each Payout Quarter beginning July 1, 2020, the
1923-Department shall use encounter claims data from the
1924-Determination Quarter, accepted by the Department's Medicaid
1925-Management Information System for inpatient and outpatient
1926-services rendered by safety-net hospitals and critical access
1927-hospitals to determine a quarterly uniform per unit add-on for
1928-each hospital class.
1929-(1) Inpatient per unit add-on. A quarterly uniform per
1930-diem add-on shall be derived by dividing the quarterly
1931-Inpatient Directed Payments Pool amount allocated to the
1932-applicable hospital class by the total inpatient days
1933-contained on all encounter claims received during the
1934-Determination Quarter, for all hospitals in the class.
1935-(A) Each hospital in the class shall have a
1936-quarterly inpatient directed payment calculated that
1937-is equal to the product of the number of inpatient days
1938-attributable to the hospital used in the calculation
1939-
1940-
1941-of the quarterly uniform class per diem add-on,
1942-multiplied by the calculated applicable quarterly
1943-uniform class per diem add-on of the hospital class.
1944-(B) Each hospital shall be paid 1/3 of its
1945-quarterly inpatient directed payment in each of the 3
1946-months of the Payout Quarter, in accordance with
1947-directions provided to each MCO by the Department.
1948-(2) Outpatient per unit add-on. A quarterly uniform
1949-per claim add-on shall be derived by dividing the
1950-quarterly Outpatient Directed Payments Pool amount
1951-allocated to the applicable hospital class by the total
1952-outpatient encounter claims received during the
1953-Determination Quarter, for all hospitals in the class.
1954-(A) Each hospital in the class shall have a
1955-quarterly outpatient directed payment calculated that
1956-is equal to the product of the number of outpatient
1957-encounter claims attributable to the hospital used in
1958-the calculation of the quarterly uniform class per
1959-claim add-on, multiplied by the calculated applicable
1960-quarterly uniform class per claim add-on of the
1961-hospital class.
1962-(B) Each hospital shall be paid 1/3 of its
1963-quarterly outpatient directed payment in each of the 3
1964-months of the Payout Quarter, in accordance with
1965-directions provided to each MCO by the Department.
1966-(3) Each MCO shall pay each hospital the Monthly
1967-
1968-
1969-Directed Payment as identified by the Department on its
1970-quarterly determination report.
1971-(4) Definitions. As used in this subsection:
1972-(A) "Payout Quarter" means each 3 month calendar
1973-quarter, beginning July 1, 2020.
1974-(B) "Determination Quarter" means each 3 month
1975-calendar quarter, which ends 3 months prior to the
1976-first day of each Payout Quarter.
1977-(5) For the period July 1, 2020 through December 2020,
1978-the following amounts shall be allocated to the following
1979-hospital class directed payment pools for the quarterly
1980-development of a uniform per unit add-on:
1981-(A) $2,894,500 for hospital inpatient services for
1982-critical access hospitals.
1983-(B) $4,294,374 for hospital outpatient services
1984-for critical access hospitals.
1985-(C) $29,109,330 for hospital inpatient services
1986-for safety-net hospitals.
1987-(D) $35,041,218 for hospital outpatient services
1988-for safety-net hospitals.
1989-(6) For the period January 1, 2023 through December
1990-31, 2023, the Department shall establish the amounts that
1991-shall be allocated to the hospital class directed payment
1992-fixed pools identified in this paragraph for the quarterly
1993-development of a uniform per unit add-on. The Department
1994-shall establish such amounts so that the total amount of
1995-
1996-
1997-payments to each hospital under this Section in calendar
1998-year 2023 is projected to be substantially similar to the
1999-total amount of such payments received by the hospital
2000-under this Section in calendar year 2021, adjusted for
2001-increased funding provided for fixed pool directed
2002-payments under subsection (g) in calendar year 2022,
2003-assuming that the volume and acuity of claims are held
2004-constant. The Department shall publish the directed
2005-payment fixed pool amounts to be established under this
2006-paragraph on its website by November 15, 2022.
2007-(A) Hospital inpatient services for critical
2008-access hospitals.
2009-(B) Hospital outpatient services for critical
2010-access hospitals.
2011-(C) Hospital inpatient services for public
2012-hospitals.
2013-(D) Hospital outpatient services for public
2014-hospitals.
2015-(E) Hospital inpatient services for safety-net
2016-hospitals.
2017-(F) Hospital outpatient services for safety-net
2018-hospitals.
2019-(7) Semi-annual rate maintenance review. The
2020-Department shall ensure that hospitals assigned to the
2021-fixed pools in paragraph (6) are paid no less than 95% of
2022-the annual initial rate for each 6-month period of each
2023-
2024-
2025-annual payout period. For each calendar year, the
2026-Department shall calculate the annual initial rate per day
2027-and per visit for each fixed pool hospital class listed in
2028-paragraph (6), by dividing the total of all applicable
2029-inpatient or outpatient directed payments issued in the
2030-preceding calendar year to the hospitals in each fixed
2031-pool class for the calendar year, plus any increase
2032-resulting from the annual adjustments described in
2033-subsection (i), by the actual applicable total service
2034-units for the preceding calendar year which were the basis
2035-of the total applicable inpatient or outpatient directed
2036-payments issued to the hospitals in each fixed pool class
2037-in the calendar year, except that for calendar year 2023,
2038-the service units from calendar year 2021 shall be used.
2039-(A) The Department shall calculate the effective
2040-rate, per day and per visit, for the payout periods of
2041-January to June and July to December of each year, for
2042-each fixed pool listed in paragraph (6), by dividing
2043-50% of the annual pool by the total applicable
2044-reported service units for the 2 applicable
2045-determination quarters.
2046-(B) If the effective rate calculated in
2047-subparagraph (A) is less than 95% of the annual
2048-initial rate assigned to the class for each pool under
2049-paragraph (6), the Department shall adjust the payment
2050-for each hospital to a level equal to no less than 95%
2051-
2052-
2053-of the annual initial rate, by issuing a retroactive
2054-adjustment payment for the 6-month period under review
2055-as identified in subparagraph (A).
2056-(h) Fixed rate directed payments. Effective July 1, 2020,
2057-the Department shall issue payments to MCOs which shall be
2058-used to issue directed payments to Illinois hospitals not
2059-identified in paragraph (g) on a monthly basis. Prior to the
2060-beginning of each Payout Quarter beginning July 1, 2020, the
2061-Department shall use encounter claims data from the
2062-Determination Quarter, accepted by the Department's Medicaid
2063-Management Information System for inpatient and outpatient
2064-services rendered by hospitals in each hospital class
2065-identified in paragraph (f) and not identified in paragraph
2066-(g). For the period July 1, 2020 through December 2020, the
2067-Department shall direct MCOs to make payments as follows:
2068-(1) For general acute care hospitals an amount equal
2069-to $1,750 multiplied by the hospital's category of service
2070-20 case mix index for the determination quarter multiplied
2071-by the hospital's total number of inpatient admissions for
2072-category of service 20 for the determination quarter.
2073-(2) For general acute care hospitals an amount equal
2074-to $160 multiplied by the hospital's category of service
2075-21 case mix index for the determination quarter multiplied
2076-by the hospital's total number of inpatient admissions for
2077-category of service 21 for the determination quarter.
2078-(3) For general acute care hospitals an amount equal
2079-
2080-
2081-to $80 multiplied by the hospital's category of service 22
2082-case mix index for the determination quarter multiplied by
2083-the hospital's total number of inpatient admissions for
2084-category of service 22 for the determination quarter.
2085-(4) For general acute care hospitals an amount equal
2086-to $375 multiplied by the hospital's category of service
2087-24 case mix index for the determination quarter multiplied
2088-by the hospital's total number of category of service 24
2089-paid EAPG (EAPGs) for the determination quarter.
2090-(5) For general acute care hospitals an amount equal
2091-to $240 multiplied by the hospital's category of service
2092-27 and 28 case mix index for the determination quarter
2093-multiplied by the hospital's total number of category of
2094-service 27 and 28 paid EAPGs for the determination
2095-quarter.
2096-(6) For general acute care hospitals an amount equal
2097-to $290 multiplied by the hospital's category of service
2098-29 case mix index for the determination quarter multiplied
2099-by the hospital's total number of category of service 29
2100-paid EAPGs for the determination quarter.
2101-(7) For high Medicaid hospitals an amount equal to
2102-$1,800 multiplied by the hospital's category of service 20
2103-case mix index for the determination quarter multiplied by
2104-the hospital's total number of inpatient admissions for
2105-category of service 20 for the determination quarter.
2106-(8) For high Medicaid hospitals an amount equal to
2107-
2108-
2109-$160 multiplied by the hospital's category of service 21
2110-case mix index for the determination quarter multiplied by
2111-the hospital's total number of inpatient admissions for
2112-category of service 21 for the determination quarter.
2113-(9) For high Medicaid hospitals an amount equal to $80
2114-multiplied by the hospital's category of service 22 case
2115-mix index for the determination quarter multiplied by the
2116-hospital's total number of inpatient admissions for
2117-category of service 22 for the determination quarter.
2118-(10) For high Medicaid hospitals an amount equal to
2119-$400 multiplied by the hospital's category of service 24
2120-case mix index for the determination quarter multiplied by
2121-the hospital's total number of category of service 24 paid
2122-EAPG outpatient claims for the determination quarter.
2123-(11) For high Medicaid hospitals an amount equal to
2124-$240 multiplied by the hospital's category of service 27
2125-and 28 case mix index for the determination quarter
2126-multiplied by the hospital's total number of category of
2127-service 27 and 28 paid EAPGs for the determination
2128-quarter.
2129-(12) For high Medicaid hospitals an amount equal to
2130-$290 multiplied by the hospital's category of service 29
2131-case mix index for the determination quarter multiplied by
2132-the hospital's total number of category of service 29 paid
2133-EAPGs for the determination quarter.
2134-(13) For long term acute care hospitals the amount of
2135-
2136-
2137-$495 multiplied by the hospital's total number of
2138-inpatient days for the determination quarter.
2139-(14) For psychiatric hospitals the amount of $210
2140-multiplied by the hospital's total number of inpatient
2141-days for category of service 21 for the determination
2142-quarter.
2143-(15) For psychiatric hospitals the amount of $250
2144-multiplied by the hospital's total number of outpatient
2145-claims for category of service 27 and 28 for the
2146-determination quarter.
2147-(16) For rehabilitation hospitals the amount of $410
2148-multiplied by the hospital's total number of inpatient
2149-days for category of service 22 for the determination
2150-quarter.
2151-(17) For rehabilitation hospitals the amount of $100
2152-multiplied by the hospital's total number of outpatient
2153-claims for category of service 29 for the determination
2154-quarter.
2155-(18) Effective for the Payout Quarter beginning
2156-January 1, 2023, for the directed payments to hospitals
2157-required under this subsection, the Department shall
2158-establish the amounts that shall be used to calculate such
2159-directed payments using the methodologies specified in
2160-this paragraph. The Department shall use a single, uniform
2161-rate, adjusted for acuity as specified in paragraphs (1)
2162-through (12), for all categories of inpatient services
2163-
2164-
2165-provided by each class of hospitals and a single uniform
2166-rate, adjusted for acuity as specified in paragraphs (1)
2167-through (12), for all categories of outpatient services
2168-provided by each class of hospitals. The Department shall
2169-establish such amounts so that the total amount of
2170-payments to each hospital under this Section in calendar
2171-year 2023 is projected to be substantially similar to the
2172-total amount of such payments received by the hospital
2173-under this Section in calendar year 2021, adjusted for
2174-increased funding provided for fixed pool directed
2175-payments under subsection (g) in calendar year 2022,
2176-assuming that the volume and acuity of claims are held
2177-constant. The Department shall publish the directed
2178-payment amounts to be established under this subsection on
2179-its website by November 15, 2022.
2180-(19) Each hospital shall be paid 1/3 of their
2181-quarterly inpatient and outpatient directed payment in
2182-each of the 3 months of the Payout Quarter, in accordance
2183-with directions provided to each MCO by the Department.
2184-(20) Each MCO shall pay each hospital the Monthly
2185-Directed Payment amount as identified by the Department on
2186-its quarterly determination report.
2187-Notwithstanding any other provision of this subsection, if
2188-the Department determines that the actual total hospital
2189-utilization data that is used to calculate the fixed rate
2190-directed payments is substantially different than anticipated
2191-
2192-
2193-when the rates in this subsection were initially determined
2194-for unforeseeable circumstances (such as the COVID-19 pandemic
2195-or some other public health emergency), the Department may
2196-adjust the rates specified in this subsection so that the
2197-total directed payments approximate the total spending amount
2198-anticipated when the rates were initially established.
2199-Definitions. As used in this subsection:
2200-(A) "Payout Quarter" means each calendar quarter,
2201-beginning July 1, 2020.
2202-(B) "Determination Quarter" means each calendar
2203-quarter which ends 3 months prior to the first day of
2204-each Payout Quarter.
2205-(C) "Case mix index" means a hospital specific
2206-calculation. For inpatient claims the case mix index
2207-is calculated each quarter by summing the relative
2208-weight of all inpatient Diagnosis-Related Group (DRG)
2209-claims for a category of service in the applicable
2210-Determination Quarter and dividing the sum by the
2211-number of sum total of all inpatient DRG admissions
2212-for the category of service for the associated claims.
2213-The case mix index for outpatient claims is calculated
2214-each quarter by summing the relative weight of all
2215-paid EAPGs in the applicable Determination Quarter and
2216-dividing the sum by the sum total of paid EAPGs for the
2217-associated claims.
2218-(i) Beginning January 1, 2021, the rates for directed
2219-
2220-
2221-payments shall be recalculated in order to spend the
2222-additional funds for directed payments that result from
2223-reduction in the amount of pass-through payments allowed under
2224-federal regulations. The additional funds for directed
2225-payments shall be allocated proportionally to each class of
2226-hospitals based on that class' proportion of services.
2227-(1) Beginning January 1, 2024, the fixed pool directed
2228-payment amounts and the associated annual initial rates
2229-referenced in paragraph (6) of subsection (f) for each
2230-hospital class shall be uniformly increased by a ratio of
2231-not less than, the ratio of the total pass-through
2232-reduction amount pursuant to paragraph (4) of subsection
2233-(j), for the hospitals comprising the hospital fixed pool
2234-directed payment class for the next calendar year, to the
2235-total inpatient and outpatient directed payments for the
2236-hospitals comprising the hospital fixed pool directed
2237-payment class paid during the preceding calendar year.
2238-(2) Beginning January 1, 2024, the fixed rates for the
2239-directed payments referenced in paragraph (18) of
2240-subsection (h) for each hospital class shall be uniformly
2241-increased by a ratio of not less than, the ratio of the
2242-total pass-through reduction amount pursuant to paragraph
2243-(4) of subsection (j), for the hospitals comprising the
2244-hospital directed payment class for the next calendar
2245-year, to the total inpatient and outpatient directed
2246-payments for the hospitals comprising the hospital fixed
2247-
2248-
2249-rate directed payment class paid during the preceding
2250-calendar year.
2251-(j) Pass-through payments.
2252-(1) For the period July 1, 2020 through December 31,
2253-2020, the Department shall assign quarterly pass-through
2254-payments to each class of hospitals equal to one-fourth of
2255-the following annual allocations:
2256-(A) $390,487,095 to safety-net hospitals.
2257-(B) $62,553,886 to critical access hospitals.
2258-(C) $345,021,438 to high Medicaid hospitals.
2259-(D) $551,429,071 to general acute care hospitals.
2260-(E) $27,283,870 to long term acute care hospitals.
2261-(F) $40,825,444 to freestanding psychiatric
2262-hospitals.
2263-(G) $9,652,108 to freestanding rehabilitation
2264-hospitals.
2265-(2) For the period of July 1, 2020 through December
2266-31, 2020, the pass-through payments shall at a minimum
2267-ensure hospitals receive a total amount of monthly
2268-payments under this Section as received in calendar year
2269-2019 in accordance with this Article and paragraph (1) of
2270-subsection (d-5) of Section 14-12, exclusive of amounts
2271-received through payments referenced in subsection (b).
2272-(3) For the calendar year beginning January 1, 2023,
2273-the Department shall establish the annual pass-through
2274-allocation to each class of hospitals and the pass-through
2275-
2276-
2277-payments to each hospital so that the total amount of
2278-payments to each hospital under this Section in calendar
2279-year 2023 is projected to be substantially similar to the
2280-total amount of such payments received by the hospital
2281-under this Section in calendar year 2021, adjusted for
2282-increased funding provided for fixed pool directed
2283-payments under subsection (g) in calendar year 2022,
2284-assuming that the volume and acuity of claims are held
2285-constant. The Department shall publish the pass-through
2286-allocation to each class and the pass-through payments to
2287-each hospital to be established under this subsection on
2288-its website by November 15, 2022.
2289-(4) For the calendar years beginning January 1, 2021
2290-and January 1, 2022, each hospital's pass-through payment
2291-amount shall be reduced proportionally to the reduction of
2292-all pass-through payments required by federal regulations.
2293-Beginning January 1, 2024, the Department shall reduce
2294-total pass-through payments by the minimum amount
2295-necessary to comply with federal regulations. Pass-through
2296-payments to safety-net hospitals, as defined in Section
2297-5-5e.1 of this Code, shall not be reduced until all
2298-pass-through payments to other hospitals have been
2299-eliminated. All other hospitals shall have their
2300-pass-through payments reduced proportionally.
2301-(k) At least 30 days prior to each calendar year, the
2302-Department shall notify each hospital of changes to the
2303-
2304-
2305-payment methodologies in this Section, including, but not
2306-limited to, changes in the fixed rate directed payment rates,
2307-the aggregate pass-through payment amount for all hospitals,
2308-and the hospital's pass-through payment amount for the
2309-upcoming calendar year.
2310-(l) Notwithstanding any other provisions of this Section,
2311-the Department may adopt rules to change the methodology for
2312-directed and pass-through payments as set forth in this
2313-Section, but only to the extent necessary to obtain federal
2314-approval of a necessary State Plan amendment or Directed
2315-Payment Preprint or to otherwise conform to federal law or
2316-federal regulation.
2317-(m) As used in this subsection, "managed care
2318-organization" or "MCO" means an entity which contracts with
2319-the Department to provide services where payment for medical
2320-services is made on a capitated basis, excluding contracted
2321-entities for dual eligible or Department of Children and
2322-Family Services youth populations.
2323-(n) In order to address the escalating infant mortality
2324-rates among minority communities in Illinois, the State shall,
2325-subject to appropriation, create a pool of funding of at least
2326-$50,000,000 annually to be disbursed among safety-net
2327-hospitals that maintain perinatal designation from the
2328-Department of Public Health. The funding shall be used to
2329-preserve or enhance OB/GYN services or other specialty
2330-services at the receiving hospital, with the distribution of
2331-
2332-
2333-funding to be established by rule and with consideration to
2334-perinatal hospitals with safe birthing levels and quality
2335-metrics for healthy mothers and babies.
2336-(o) In order to address the growing challenges of
2337-providing stable access to healthcare in rural Illinois,
2338-including perinatal services, behavioral healthcare including
2339-substance use disorder services (SUDs) and other specialty
2340-services, and to expand access to telehealth services among
2341-rural communities in Illinois, the Department of Healthcare
2342-and Family Services shall administer a program to provide at
2343-least $10,000,000 in financial support annually to critical
2344-access hospitals for delivery of perinatal and OB/GYN
2345-services, behavioral healthcare including SUDS, other
2346-specialty services and telehealth services. The funding shall
2347-be used to preserve or enhance perinatal and OB/GYN services,
2348-behavioral healthcare including SUDS, other specialty
2349-services, as well as the explanation of telehealth services by
2350-the receiving hospital, with the distribution of funding to be
2351-established by rule.
2352-(p) For calendar year 2023, the final amounts, rates, and
2353-payments under subsections (c), (d-2), (g), (h), and (j) shall
2354-be established by the Department, so that the sum of the total
2355-estimated annual payments under subsections (c), (d-2), (g),
2356-(h), and (j) for each hospital class for calendar year 2023, is
2357-no less than:
2358-(1) $858,260,000 to safety-net hospitals.
2359-
2360-
2361-(2) $86,200,000 to critical access hospitals.
2362-(3) $1,765,000,000 to high Medicaid hospitals.
2363-(4) $673,860,000 to general acute care hospitals.
2364-(5) $48,330,000 to long term acute care hospitals.
2365-(6) $89,110,000 to freestanding psychiatric hospitals.
2366-(7) $24,300,000 to freestanding rehabilitation
2367-hospitals.
2368-(8) $32,570,000 to public hospitals.
2369-(q) Hospital Pandemic Recovery Stabilization Payments. The
2370-Department shall disburse a pool of $460,000,000 in stability
2371-payments to hospitals prior to April 1, 2023. The allocation
2372-of the pool shall be based on the hospital directed payment
2373-classes and directed payments issued, during Calendar Year
2374-2022 with added consideration to safety net hospitals, as
2375-defined in subdivision (f)(1)(B) of this Section, and critical
2376-access hospitals.
2377-(Source: P.A. 102-4, eff. 4-27-21; 102-16, eff. 6-17-21;
2378-102-886, eff. 5-17-22; 102-1115, eff. 1-9-23; 103-102, eff.
2379-6-16-23; revised 9-21-23.)
2380-ARTICLE 45.
2381-Section 45-5. The Illinois Public Aid Code is amended by
2382-adding Section 5-5.08a as follows:
2383-(305 ILCS 5/5-5.08a new)
2384-
2385-
2386-Sec. 5-5.08a. Renal dialysis; add-on payments for home
2387-dialysis providers in skilled nursing facilities.
2388-(a) Findings. The General Assembly finds the following:
2389-(1) Home dialysis services provided on-site at skilled
2390-nursing facilities are beneficial to nursing home
2391-residents by permitting more time for other health and
2392-wellness activities, and nullifying burdensome off-site
2393-travel which carries various health care risks and
2394-increased costs.
2395-(2) Home dialysis for nursing home residents provides
2396-an on-site venue for high-acuity residents to receive
2397-dialysis services, effectively creating downstream care
2398-opportunities for hospital patients in need of post-acute
2399-care and dialysis, and reducing the total cost of dialysis
2400-care.
2401-(3) On-site home dialysis in nursing homes is costlier
2402-for the provider than conventional outpatient dialysis, as
2403-labor costs are greater per treatment and such patients
2404-typically have higher acuities, necessitating more
2405-medication and greater staff involvement to promote
2406-patient compliance.
2407-(b) Subject to federal approval, for dates of service
2408-beginning on and after January 1, 2025, for home renal
2409-dialysis provided to residents of skilled nursing facilities,
2410-the Department shall reimburse a per-claim add-on payment to
2411-certified home dialysis providers in accordance with this
2412-
2413-
2414-Section. Certified home dialysis providers providing dialysis
2415-services within a skilled nursing facility shall receive a
2416-per-claim add-on payment of $95 per treatment. As used in this
2417-Section, "certified home dialysis provider" means an end-stage
2418-renal disease facility that (i) provides dialysis treatment or
2419-dialysis training to caregivers or individuals with end-stage
2420-renal disease and (ii) has been approved to provide dialysis
2421-home training support services by the federal Centers for
2422-Medicare and Medicaid Services.
2423-ARTICLE 50.
2424-Section 50-5. The Illinois Public Aid Code is amended by
2425-changing Sections 5-5.07 and 14-13 as follows:
2426-(305 ILCS 5/5-5.07)
2427-Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem
2428-rate. The Department of Children and Family Services shall pay
2429-the DCFS per diem rate for inpatient psychiatric stay at a
2430-free-standing psychiatric hospital or a hospital with a
2431-pediatric or adolescent inpatient psychiatric unit effective
2432-the 3rd day 11th day when a child is in the hospital beyond
2433-medical necessity, and the parent or caregiver has denied the
2434-child access to the home and has refused or failed to make
2435-provisions for another living arrangement for the child or the
2436-child's discharge is being delayed due to a pending inquiry or
2437-
2438-
2439-investigation by the Department of Children and Family
2440-Services. If any portion of a hospital stay is reimbursed
2441-under this Section, the hospital stay shall not be eligible
2442-for payment under the provisions of Section 14-13 of this
2443-Code.
2444-(Source: Reenacted by P.A. 101-15, eff. 6-14-19; reenacted by
2445-P.A. 101-209, eff. 8-5-19; P.A. 101-655, eff. 3-12-21;
2446-102-201, eff. 7-30-21; 102-558, eff. 8-20-21; 102-1037, eff.
2447-6-2-22.)
2448-(305 ILCS 5/14-13)
2449-Sec. 14-13. Reimbursement for inpatient stays extended
2450-beyond medical necessity.
2451-(a) By October 1, 2019, the Department shall by rule
2452-implement a methodology effective for dates of service July 1,
2453-2019 and later to reimburse hospitals for inpatient stays
2454-extended beyond medical necessity due to the inability of the
2455-Department or the managed care organization in which a
2456-recipient is enrolled or the hospital discharge planner to
2457-find an appropriate placement after discharge from the
2458-hospital. The Department shall evaluate the effectiveness of
2459-the current reimbursement rate for inpatient hospital stays
2460-beyond medical necessity.
2461-(b) The methodology shall provide reasonable compensation
2462-for the services provided attributable to the days of the
2463-extended stay for which the prevailing rate methodology
2464-
2465-
2466-provides no reimbursement. The Department may use a day
2467-outlier program to satisfy this requirement. The reimbursement
2468-rate shall be set at a level so as not to act as an incentive
2469-to avoid transfer to the appropriate level of care needed or
2470-placement, after discharge.
2471-(c) The Department shall require managed care
2472-organizations to adopt this methodology or an alternative
2473-methodology that pays at least as much as the Department's
2474-adopted methodology unless otherwise mutually agreed upon
2475-contractual language is developed by the provider and the
2476-managed care organization for a risk-based or innovative
2477-payment methodology.
2478-(d) Days beyond medical necessity shall not be eligible
2479-for per diem add-on payments under the Medicaid High Volume
2480-Adjustment (MHVA) or the Medicaid Percentage Adjustment (MPA)
2481-programs.
2482-(e) For services covered by the fee-for-service program,
2483-reimbursement under this Section shall only be made for days
2484-beyond medical necessity that occur after the hospital has
2485-notified the Department of the need for post-discharge
2486-placement. For services covered by a managed care
2487-organization, hospitals shall notify the appropriate managed
2488-care organization of an admission within 24 hours of
2489-admission. For every 24-hour period beyond the initial 24
2490-hours after admission that the hospital fails to notify the
2491-managed care organization of the admission, reimbursement
2492-
2493-
2494-under this subsection shall be reduced by one day.
2495-(f) The Department of Children and Family Services shall
2496-pay for all inpatient stays beginning on the 3rd day a child is
2497-in the hospital beyond medical necessity, and the parent or
2498-caregiver has denied the child access to the home and has
2499-refused or failed to make provisions for another living
2500-arrangement for the child or the child's discharge is being
2501-delayed due to a pending inquiry or investigation by the
2502-Department of Children and Family Services.
2503-(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.)
2504-ARTICLE 55.
2505-Section 55-5. The Illinois Public Aid Code is amended by
2506-adding Section 5-55 as follows:
2507-(305 ILCS 5/5-55 new)
2508-Sec. 5-55. Reimbursement for music therapy services.
2509-Subject to federal approval, for dates of service beginning on
2510-and after July 1, 2025, the Department shall reimburse music
2511-therapy services provided by licensed professional music
2512-therapists. To be eligible for reimbursement under this
2513-Section, music therapy services must be provided by a licensed
2514-professional music therapist authorized to practice under the
2515-Music Therapy Licensing and Practice Act.
2516-
2517-
2518-ARTICLE 60.
2519-Section 60-5. The Illinois Public Aid Code is amended by
2520-adding Section 5-60 as follows:
2521-(305 ILCS 5/5-60 new)
2522-Sec. 5-60. Optometric services; reimbursement rates.
2523-Notwithstanding any other law or rule to the contrary and
2524-subject to federal approval, for dates of service beginning on
2525-and after January 1, 2025, the reimbursement rates for
2526-optometric and optical services for determining refractive
2527-state, fitting of spectacles, and fitting of bifocal
2528-spectacles shall be increased by 35% above the rates in effect
2529-on January 1, 2024.
2530-ARTICLE 65.
2531-Section 65-5. The Illinois Public Aid Code is amended by
2532-changing Section 5-2.06 as follows:
2533-(305 ILCS 5/5-2.06)
2534-Sec. 5-2.06. Payment rates; Children's Community-Based
2535-Health Care Centers. Beginning January 1, 2025 and subject to
2536-federal approval 2020, the Department shall, for eligible
2537-individuals, reimburse Children's Community-Based Health Care
2538-Centers established in the Alternative Health Care Delivery
2539-
2540-
2541-Act and providing nursing care for the purpose of
2542-transitioning children from a hospital to home placement or
2543-other appropriate setting and reuniting families for a maximum
2544-of up to 120 days on a per diem basis at the lower of the
2545-Children's Community-Based Health Care Center's usual and
2546-customary charge to the public or at the Department rate of
2547-$1,300 $950. Payments at the rate set forth in this Section are
2548-exempt from the 2.7% rate reduction required under Section
2549-5-5e.
2550-(Source: P.A. 101-10, eff. 6-5-19.)
2551-ARTICLE 70.
2552-Section 70-5. The Illinois Public Aid Code is amended by
2553-adding Section 5-5.24a as follows:
2554-(305 ILCS 5/5-5.24a new)
2555-Sec. 5-5.24a. Remote ultrasounds and remote fetal
2556-nonstress tests; reimbursement.
2557-(a) Subject to federal approval, for dates of service
2558-beginning on and after January 1, 2025, the Department shall
2559-reimburse for remote ultrasound procedures and remote fetal
2560-nonstress tests when the patient is in a residence or other
2561-off-site location from the patient's provider and the same
2562-standard of care is met as would be present during an in-person
2563-visit.
2564-
2565-
2566-(b) Remote ultrasounds and remote fetal nonstress tests
2567-are only eligible for reimbursement when the provider uses
2568-digital technology:
2569-(1) to collect medical and other forms of health data
2570-from a patient and to electronically transmit that
2571-information securely to a health care provider in a
2572-different location for interpretation and recommendation;
2573-(2) that is compliant with the federal Health
2574-Insurance Portability and Accountability Act of 1996; and
2575-(3) that is approved by the U.S. Food and Drug
2576-Administration.
2577-(c) A fetal nonstress test is only eligible for
2578-reimbursement with a place of service modifier for at-home
2579-monitoring with remote monitoring solutions that are cleared
2580-by the U.S. Food and Drug Administration for on-label use for
2581-monitoring fetal heart rate, maternal heart rate, and uterine
2582-activity.
2583-(d) The Department shall issue guidance to implement the
2584-provisions of this Section.
2585-ARTICLE 75.
2586-Section 75-5. The Illinois Public Aid Code is amended by
2587-changing Section 5-2b as follows:
2588-(305 ILCS 5/5-2b)
2589-
2590-
2591-Sec. 5-2b. Medically fragile and technology dependent
2592-children eligibility and program; provider reimbursement
2593-rates.
2594-(a) Notwithstanding any other provision of law except as
2595-provided in Section 5-30a, on and after September 1, 2012,
2596-subject to federal approval, medical assistance under this
2597-Article shall be available to children who qualify as persons
2598-with a disability, as defined under the federal Supplemental
2599-Security Income program and who are medically fragile and
2600-technology dependent. The program shall allow eligible
2601-children to receive the medical assistance provided under this
2602-Article in the community and must maximize, to the fullest
2603-extent permissible under federal law, federal reimbursement
2604-and family cost-sharing, including co-pays, premiums, or any
2605-other family contributions, except that the Department shall
2606-be permitted to incentivize the utilization of selected
2607-services through the use of cost-sharing adjustments. The
2608-Department shall establish the policies, procedures,
2609-standards, services, and criteria for this program by rule.
2610-(b) Notwithstanding any other provision of this Code,
2611-subject to federal approval, on and after January 1, 2024, the
2612-reimbursement rates for nursing paid through Nursing and
2613-Personal Care Services for non-waiver customers and to
2614-providers of private duty nursing services for children
2615-eligible for medical assistance under this Section shall be
2616-20% higher than the reimbursement rates in effect for nursing
2617-
2618-
2619-services on December 31, 2023.
2620-(c) Notwithstanding any other provision of this Code,
2621-subject to federal approval, on and after January 1, 2025, the
2622-reimbursement rates for nursing paid through Nursing and
2623-Personal Care Services for non-waiver customers and to
2624-providers of private duty nursing services for children
2625-eligible for medical assistance under this Section shall be 7%
2626-higher than the reimbursement rates in effect for nursing
2627-services on December 31, 2024.
2628-(Source: P.A. 103-102, eff. 1-1-24.)
2629-ARTICLE 80.
2630-Section 80-5. The Illinois Public Aid Code is amended by
2631-adding Section 5-52 as follows:
2632-(305 ILCS 5/5-52 new)
2633-Sec. 5-52. Custom prosthetic and orthotic devices;
2634-reimbursement rates. Subject to federal approval, for dates of
2635-service beginning on and after January 1, 2025, the Department
2636-shall increase the current 2024 Medicaid rate by 7% under the
2637-medical assistance program for custom prosthetic and orthotic
2638-devices.
2639-ARTICLE 85.
2640-
2641-
2642-Section 85-5. The Illinois Public Aid Code is amended by
2643-changing Section 5-4.2 as follows:
2644-(305 ILCS 5/5-4.2)
2645-Sec. 5-4.2. Ambulance services payments.
2646-(a) For ambulance services provided to a recipient of aid
2647-under this Article on or after January 1, 1993, the Illinois
2648-Department shall reimburse ambulance service providers at
2649-rates calculated in accordance with this Section. It is the
2650-intent of the General Assembly to provide adequate
2651-reimbursement for ambulance services so as to ensure adequate
2652-access to services for recipients of aid under this Article
2653-and to provide appropriate incentives to ambulance service
2654-providers to provide services in an efficient and
2655-cost-effective manner. Thus, it is the intent of the General
2656-Assembly that the Illinois Department implement a
2657-reimbursement system for ambulance services that, to the
2658-extent practicable and subject to the availability of funds
2659-appropriated by the General Assembly for this purpose, is
2660-consistent with the payment principles of Medicare. To ensure
2661-uniformity between the payment principles of Medicare and
2662-Medicaid, the Illinois Department shall follow, to the extent
2663-necessary and practicable and subject to the availability of
2664-funds appropriated by the General Assembly for this purpose,
2665-the statutes, laws, regulations, policies, procedures,
2666-principles, definitions, guidelines, and manuals used to
2667-
2668-
2669-determine the amounts paid to ambulance service providers
2670-under Title XVIII of the Social Security Act (Medicare).
2671-(b) For ambulance services provided to a recipient of aid
2672-under this Article on or after January 1, 1996, the Illinois
2673-Department shall reimburse ambulance service providers based
2674-upon the actual distance traveled if a natural disaster,
2675-weather conditions, road repairs, or traffic congestion
2676-necessitates the use of a route other than the most direct
2677-route.
2678-(c) For purposes of this Section, "ambulance services"
2679-includes medical transportation services provided by means of
2680-an ambulance, air ambulance, medi-car, service car, or taxi.
2681-(c-1) For purposes of this Section, "ground ambulance
2682-service" means medical transportation services that are
2683-described as ground ambulance services by the Centers for
2684-Medicare and Medicaid Services and provided in a vehicle that
2685-is licensed as an ambulance by the Illinois Department of
2686-Public Health pursuant to the Emergency Medical Services (EMS)
2687-Systems Act.
2688-(c-2) For purposes of this Section, "ground ambulance
2689-service provider" means a vehicle service provider as
2690-described in the Emergency Medical Services (EMS) Systems Act
2691-that operates licensed ambulances for the purpose of providing
2692-emergency ambulance services, or non-emergency ambulance
2693-services, or both. For purposes of this Section, this includes
2694-both ambulance providers and ambulance suppliers as described
2695-
2696-
2697-by the Centers for Medicare and Medicaid Services.
2698-(c-3) For purposes of this Section, "medi-car" means
2699-transportation services provided to a patient who is confined
2700-to a wheelchair and requires the use of a hydraulic or electric
2701-lift or ramp and wheelchair lockdown when the patient's
2702-condition does not require medical observation, medical
2703-supervision, medical equipment, the administration of
2704-medications, or the administration of oxygen.
2705-(c-4) For purposes of this Section, "service car" means
2706-transportation services provided to a patient by a passenger
2707-vehicle where that patient does not require the specialized
2708-modes described in subsection (c-1) or (c-3).
2709-(c-5) For purposes of this Section, "air ambulance
2710-service" means medical transport by helicopter or airplane for
2711-patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
2712-that is described as an air ambulance service by the federal
2713-Centers for Medicare and Medicaid Services.
2714-(d) This Section does not prohibit separate billing by
2715-ambulance service providers for oxygen furnished while
2716-providing advanced life support services.
2717-(e) Beginning with services rendered on or after July 1,
2718-2008, all providers of non-emergency medi-car and service car
2719-transportation must certify that the driver and employee
2720-attendant, as applicable, have completed a safety program
2721-approved by the Department to protect both the patient and the
2722-driver, prior to transporting a patient. The provider must
2723-
2724-
2725-maintain this certification in its records. The provider shall
2726-produce such documentation upon demand by the Department or
2727-its representative. Failure to produce documentation of such
2728-training shall result in recovery of any payments made by the
2729-Department for services rendered by a non-certified driver or
2730-employee attendant. Medi-car and service car providers must
2731-maintain legible documentation in their records of the driver
2732-and, as applicable, employee attendant that actually
2733-transported the patient. Providers must recertify all drivers
2734-and employee attendants every 3 years. If they meet the
2735-established training components set forth by the Department,
2736-providers of non-emergency medi-car and service car
2737-transportation that are either directly or through an
2738-affiliated company licensed by the Department of Public Health
2739-shall be approved by the Department to have in-house safety
2740-programs for training their own staff.
2741-Notwithstanding the requirements above, any public
2742-transportation provider of medi-car and service car
2743-transportation that receives federal funding under 49 U.S.C.
2744-5307 and 5311 need not certify its drivers and employee
2745-attendants under this Section, since safety training is
2746-already federally mandated.
2747-(f) With respect to any policy or program administered by
2748-the Department or its agent regarding approval of
2749-non-emergency medical transportation by ground ambulance
2750-service providers, including, but not limited to, the
2751-
2752-
2753-Non-Emergency Transportation Services Prior Approval Program
2754-(NETSPAP), the Department shall establish by rule a process by
2755-which ground ambulance service providers of non-emergency
2756-medical transportation may appeal any decision by the
2757-Department or its agent for which no denial was received prior
2758-to the time of transport that either (i) denies a request for
2759-approval for payment of non-emergency transportation by means
2760-of ground ambulance service or (ii) grants a request for
2761-approval of non-emergency transportation by means of ground
2762-ambulance service at a level of service that entitles the
2763-ground ambulance service provider to a lower level of
2764-compensation from the Department than the ground ambulance
2765-service provider would have received as compensation for the
2766-level of service requested. The rule shall be filed by
2767-December 15, 2012 and shall provide that, for any decision
2768-rendered by the Department or its agent on or after the date
2769-the rule takes effect, the ground ambulance service provider
2770-shall have 60 days from the date the decision is received to
2771-file an appeal. The rule established by the Department shall
2772-be, insofar as is practical, consistent with the Illinois
2773-Administrative Procedure Act. The Director's decision on an
2774-appeal under this Section shall be a final administrative
2775-decision subject to review under the Administrative Review
2776-Law.
2777-(f-5) Beginning 90 days after July 20, 2012 (the effective
2778-date of Public Act 97-842), (i) no denial of a request for
2779-
2780-
2781-approval for payment of non-emergency transportation by means
2782-of ground ambulance service, and (ii) no approval of
2783-non-emergency transportation by means of ground ambulance
2784-service at a level of service that entitles the ground
2785-ambulance service provider to a lower level of compensation
2786-from the Department than would have been received at the level
2787-of service submitted by the ground ambulance service provider,
2788-may be issued by the Department or its agent unless the
2789-Department has submitted the criteria for determining the
2790-appropriateness of the transport for first notice publication
2791-in the Illinois Register pursuant to Section 5-40 of the
2792-Illinois Administrative Procedure Act.
2793-(f-6) Within 90 days after June 2, 2022 (the effective
2794-date of Public Act 102-1037) this amendatory Act of the 102nd
2795-General Assembly and subject to federal approval, the
2796-Department shall file rules to allow for the approval of
2797-ground ambulance services when the sole purpose of the
2798-transport is for the navigation of stairs or the assisting or
2799-lifting of a patient at a medical facility or during a medical
2800-appointment in instances where the Department or a contracted
2801-Medicaid managed care organization or their transportation
2802-broker is unable to secure transportation through any other
2803-transportation provider.
2804-(f-7) For non-emergency ground ambulance claims properly
2805-denied under Department policy at the time the claim is filed
2806-due to failure to submit a valid Medical Certification for
2807-
2808-
2809-Non-Emergency Ambulance on and after December 15, 2012 and
2810-prior to January 1, 2021, the Department shall allot
2811-$2,000,000 to a pool to reimburse such claims if the provider
2812-proves medical necessity for the service by other means.
2813-Providers must submit any such denied claims for which they
2814-seek compensation to the Department no later than December 31,
2815-2021 along with documentation of medical necessity. No later
2816-than May 31, 2022, the Department shall determine for which
2817-claims medical necessity was established. Such claims for
2818-which medical necessity was established shall be paid at the
2819-rate in effect at the time of the service, provided the
2820-$2,000,000 is sufficient to pay at those rates. If the pool is
2821-not sufficient, claims shall be paid at a uniform percentage
2822-of the applicable rate such that the pool of $2,000,000 is
2823-exhausted. The appeal process described in subsection (f)
2824-shall not be applicable to the Department's determinations
2825-made in accordance with this subsection.
2826-(g) Whenever a patient covered by a medical assistance
2827-program under this Code or by another medical program
2828-administered by the Department, including a patient covered
2829-under the State's Medicaid managed care program, is being
2830-transported from a facility and requires non-emergency
2831-transportation including ground ambulance, medi-car, or
2832-service car transportation, a Physician Certification
2833-Statement as described in this Section shall be required for
2834-each patient. Facilities shall develop procedures for a
2835-
2836-
2837-licensed medical professional to provide a written and signed
2838-Physician Certification Statement. The Physician Certification
2839-Statement shall specify the level of transportation services
2840-needed and complete a medical certification establishing the
2841-criteria for approval of non-emergency ambulance
2842-transportation, as published by the Department of Healthcare
2843-and Family Services, that is met by the patient. This
2844-certification shall be completed prior to ordering the
2845-transportation service and prior to patient discharge. The
2846-Physician Certification Statement is not required prior to
2847-transport if a delay in transport can be expected to
2848-negatively affect the patient outcome. If the ground ambulance
2849-provider, medi-car provider, or service car provider is unable
2850-to obtain the required Physician Certification Statement
2851-within 10 calendar days following the date of the service, the
2852-ground ambulance provider, medi-car provider, or service car
2853-provider must document its attempt to obtain the requested
2854-certification and may then submit the claim for payment.
2855-Acceptable documentation includes a signed return receipt from
2856-the U.S. Postal Service, facsimile receipt, email receipt, or
2857-other similar service that evidences that the ground ambulance
2858-provider, medi-car provider, or service car provider attempted
2859-to obtain the required Physician Certification Statement.
2860-The medical certification specifying the level and type of
2861-non-emergency transportation needed shall be in the form of
2862-the Physician Certification Statement on a standardized form
2863-
2864-
2865-prescribed by the Department of Healthcare and Family
2866-Services. Within 75 days after July 27, 2018 (the effective
2867-date of Public Act 100-646), the Department of Healthcare and
2868-Family Services shall develop a standardized form of the
2869-Physician Certification Statement specifying the level and
2870-type of transportation services needed in consultation with
2871-the Department of Public Health, Medicaid managed care
2872-organizations, a statewide association representing ambulance
2873-providers, a statewide association representing hospitals, 3
2874-statewide associations representing nursing homes, and other
2875-stakeholders. The Physician Certification Statement shall
2876-include, but is not limited to, the criteria necessary to
2877-demonstrate medical necessity for the level of transport
2878-needed as required by (i) the Department of Healthcare and
2879-Family Services and (ii) the federal Centers for Medicare and
2880-Medicaid Services as outlined in the Centers for Medicare and
2881-Medicaid Services' Medicare Benefit Policy Manual, Pub.
2882-100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
2883-Certification Statement shall satisfy the obligations of
2884-hospitals under Section 6.22 of the Hospital Licensing Act and
2885-nursing homes under Section 2-217 of the Nursing Home Care
2886-Act. Implementation and acceptance of the Physician
2887-Certification Statement shall take place no later than 90 days
2888-after the issuance of the Physician Certification Statement by
2889-the Department of Healthcare and Family Services.
2890-Pursuant to subsection (E) of Section 12-4.25 of this
2891-
2892-
2893-Code, the Department is entitled to recover overpayments paid
2894-to a provider or vendor, including, but not limited to, from
2895-the discharging physician, the discharging facility, and the
2896-ground ambulance service provider, in instances where a
2897-non-emergency ground ambulance service is rendered as the
2898-result of improper or false certification.
2899-Beginning October 1, 2018, the Department of Healthcare
2900-and Family Services shall collect data from Medicaid managed
2901-care organizations and transportation brokers, including the
2902-Department's NETSPAP broker, regarding denials and appeals
2903-related to the missing or incomplete Physician Certification
2904-Statement forms and overall compliance with this subsection.
2905-The Department of Healthcare and Family Services shall publish
2906-quarterly results on its website within 15 days following the
2907-end of each quarter.
2908-(h) On and after July 1, 2012, the Department shall reduce
2909-any rate of reimbursement for services or other payments or
2910-alter any methodologies authorized by this Code to reduce any
2911-rate of reimbursement for services or other payments in
2912-accordance with Section 5-5e.
2913-(i) Subject to federal approval, on and after January 1,
2914-2024 through June 30, 2026, the Department shall increase the
2915-base rate of reimbursement for both base charges and mileage
2916-charges for ground ambulance service providers not
2917-participating in the Ground Emergency Medical Transportation
2918-(GEMT) Program for medical transportation services provided by
2919-
2920-
2921-means of a ground ambulance to a level not lower than 140% of
2922-the base rate in effect as of January 1, 2023.
2923-(j) For the purpose of understanding ground ambulance
2924-transportation services cost structures and their impact on
2925-the Medical Assistance Program, the Department shall engage
2926-stakeholders, including, but not limited to, a statewide
2927-association representing private ground ambulance service
2928-providers in Illinois, to develop recommendations for a plan
2929-for the regular collection of cost data for all ground
2930-ambulance transportation providers reimbursed under the
2931-Illinois Title XIX State Plan. Cost data obtained through this
2932-process shall be used to inform on and to ensure the
2933-effectiveness and efficiency of Illinois Medicaid rates. The
2934-Department shall establish a process to limit public
2935-availability of portions of the cost report data determined to
2936-be proprietary. This process shall be concluded and
2937-recommendations shall be provided no later than December 31,
2938-2025 April 1, 2024.
2939-(k) (j) Subject to federal approval, beginning on January
2940-1, 2024, the Department shall increase the base rate of
2941-reimbursement for both base charges and mileage charges for
2942-medical transportation services provided by means of an air
2943-ambulance to a level not lower than 50% of the Medicare
2944-ambulance fee schedule rates, by designated Medicare locality,
2945-in effect on January 1, 2023.
2946-(Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21;
2947-
2948-
2949-102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article
2950-70, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section
2951-80-5, eff. 1-1-24; revised 12-15-23.)
2952-ARTICLE 90.
2953-Section 90-5. The Illinois Public Aid Code is amended by
2954-changing Section 5-5 as follows:
2955-(305 ILCS 5/5-5)
2956-Sec. 5-5. Medical services. The Illinois Department, by
2957-rule, shall determine the quantity and quality of and the rate
2958-of reimbursement for the medical assistance for which payment
2959-will be authorized, and the medical services to be provided,
2960-which may include all or part of the following: (1) inpatient
2961-hospital services; (2) outpatient hospital services; (3) other
2962-laboratory and X-ray services; (4) skilled nursing home
2963-services; (5) physicians' services whether furnished in the
2964-office, the patient's home, a hospital, a skilled nursing
2965-home, or elsewhere; (6) medical care, or any other type of
2966-remedial care furnished by licensed practitioners; (7) home
2967-health care services; (8) private duty nursing service; (9)
2968-clinic services; (10) dental services, including prevention
2969-and treatment of periodontal disease and dental caries disease
2970-for pregnant individuals, provided by an individual licensed
2971-to practice dentistry or dental surgery; for purposes of this
2972-
2973-
2974-item (10), "dental services" means diagnostic, preventive, or
2975-corrective procedures provided by or under the supervision of
2976-a dentist in the practice of his or her profession; (11)
2977-physical therapy and related services; (12) prescribed drugs,
2978-dentures, and prosthetic devices; and eyeglasses prescribed by
2979-a physician skilled in the diseases of the eye, or by an
2980-optometrist, whichever the person may select; (13) other
2981-diagnostic, screening, preventive, and rehabilitative
2982-services, including to ensure that the individual's need for
2983-intervention or treatment of mental disorders or substance use
2984-disorders or co-occurring mental health and substance use
2985-disorders is determined using a uniform screening, assessment,
2986-and evaluation process inclusive of criteria, for children and
2987-adults; for purposes of this item (13), a uniform screening,
2988-assessment, and evaluation process refers to a process that
2989-includes an appropriate evaluation and, as warranted, a
2990-referral; "uniform" does not mean the use of a singular
2991-instrument, tool, or process that all must utilize; (14)
2992-transportation and such other expenses as may be necessary;
2993-(15) medical treatment of sexual assault survivors, as defined
2994-in Section 1a of the Sexual Assault Survivors Emergency
2995-Treatment Act, for injuries sustained as a result of the
2996-sexual assault, including examinations and laboratory tests to
2997-discover evidence which may be used in criminal proceedings
2998-arising from the sexual assault; (16) the diagnosis and
2999-treatment of sickle cell anemia; (16.5) services performed by
3000-
3001-
3002-a chiropractic physician licensed under the Medical Practice
3003-Act of 1987 and acting within the scope of his or her license,
3004-including, but not limited to, chiropractic manipulative
3005-treatment; and (17) any other medical care, and any other type
3006-of remedial care recognized under the laws of this State. The
3007-term "any other type of remedial care" shall include nursing
3008-care and nursing home service for persons who rely on
3009-treatment by spiritual means alone through prayer for healing.
3010-Notwithstanding any other provision of this Section, a
3011-comprehensive tobacco use cessation program that includes
3012-purchasing prescription drugs or prescription medical devices
3013-approved by the Food and Drug Administration shall be covered
3014-under the medical assistance program under this Article for
3015-persons who are otherwise eligible for assistance under this
3016-Article.
3017-Notwithstanding any other provision of this Code,
3018-reproductive health care that is otherwise legal in Illinois
3019-shall be covered under the medical assistance program for
3020-persons who are otherwise eligible for medical assistance
3021-under this Article.
3022-Notwithstanding any other provision of this Section, all
3023-tobacco cessation medications approved by the United States
3024-Food and Drug Administration and all individual and group
3025-tobacco cessation counseling services and telephone-based
3026-counseling services and tobacco cessation medications provided
3027-through the Illinois Tobacco Quitline shall be covered under
3028-
3029-
3030-the medical assistance program for persons who are otherwise
3031-eligible for assistance under this Article. The Department
3032-shall comply with all federal requirements necessary to obtain
3033-federal financial participation, as specified in 42 CFR
3034-433.15(b)(7), for telephone-based counseling services provided
3035-through the Illinois Tobacco Quitline, including, but not
3036-limited to: (i) entering into a memorandum of understanding or
3037-interagency agreement with the Department of Public Health, as
3038-administrator of the Illinois Tobacco Quitline; and (ii)
3039-developing a cost allocation plan for Medicaid-allowable
3040-Illinois Tobacco Quitline services in accordance with 45 CFR
3041-95.507. The Department shall submit the memorandum of
3042-understanding or interagency agreement, the cost allocation
3043-plan, and all other necessary documentation to the Centers for
3044-Medicare and Medicaid Services for review and approval.
3045-Coverage under this paragraph shall be contingent upon federal
3046-approval.
3047-Notwithstanding any other provision of this Code, the
3048-Illinois Department may not require, as a condition of payment
3049-for any laboratory test authorized under this Article, that a
3050-physician's handwritten signature appear on the laboratory
3051-test order form. The Illinois Department may, however, impose
3052-other appropriate requirements regarding laboratory test order
3053-documentation.
3054-Upon receipt of federal approval of an amendment to the
3055-Illinois Title XIX State Plan for this purpose, the Department
3056-
3057-
3058-shall authorize the Chicago Public Schools (CPS) to procure a
3059-vendor or vendors to manufacture eyeglasses for individuals
3060-enrolled in a school within the CPS system. CPS shall ensure
3061-that its vendor or vendors are enrolled as providers in the
3062-medical assistance program and in any capitated Medicaid
3063-managed care entity (MCE) serving individuals enrolled in a
3064-school within the CPS system. Under any contract procured
3065-under this provision, the vendor or vendors must serve only
3066-individuals enrolled in a school within the CPS system. Claims
3067-for services provided by CPS's vendor or vendors to recipients
3068-of benefits in the medical assistance program under this Code,
3069-the Children's Health Insurance Program, or the Covering ALL
3070-KIDS Health Insurance Program shall be submitted to the
3071-Department or the MCE in which the individual is enrolled for
3072-payment and shall be reimbursed at the Department's or the
3073-MCE's established rates or rate methodologies for eyeglasses.
3074-On and after July 1, 2012, the Department of Healthcare
3075-and Family Services may provide the following services to
3076-persons eligible for assistance under this Article who are
3077-participating in education, training or employment programs
3078-operated by the Department of Human Services as successor to
3079-the Department of Public Aid:
3080-(1) dental services provided by or under the
3081-supervision of a dentist; and
3082-(2) eyeglasses prescribed by a physician skilled in
3083-the diseases of the eye, or by an optometrist, whichever
3084-
3085-
3086-the person may select.
3087-On and after July 1, 2018, the Department of Healthcare
3088-and Family Services shall provide dental services to any adult
3089-who is otherwise eligible for assistance under the medical
3090-assistance program. As used in this paragraph, "dental
3091-services" means diagnostic, preventative, restorative, or
3092-corrective procedures, including procedures and services for
3093-the prevention and treatment of periodontal disease and dental
3094-caries disease, provided by an individual who is licensed to
3095-practice dentistry or dental surgery or who is under the
3096-supervision of a dentist in the practice of his or her
3097-profession.
3098-On and after July 1, 2018, targeted dental services, as
3099-set forth in Exhibit D of the Consent Decree entered by the
3100-United States District Court for the Northern District of
3101-Illinois, Eastern Division, in the matter of Memisovski v.
3102-Maram, Case No. 92 C 1982, that are provided to adults under
3103-the medical assistance program shall be established at no less
3104-than the rates set forth in the "New Rate" column in Exhibit D
3105-of the Consent Decree for targeted dental services that are
3106-provided to persons under the age of 18 under the medical
3107-assistance program.
3108-Notwithstanding any other provision of this Code and
3109-subject to federal approval, the Department may adopt rules to
3110-allow a dentist who is volunteering his or her service at no
3111-cost to render dental services through an enrolled
3112-
3113-
3114-not-for-profit health clinic without the dentist personally
3115-enrolling as a participating provider in the medical
3116-assistance program. A not-for-profit health clinic shall
3117-include a public health clinic or Federally Qualified Health
3118-Center or other enrolled provider, as determined by the
3119-Department, through which dental services covered under this
3120-Section are performed. The Department shall establish a
3121-process for payment of claims for reimbursement for covered
3122-dental services rendered under this provision.
3123-Subject to appropriation and to federal approval, the
3124-Department shall file administrative rules updating the
3125-Handicapping Labio-Lingual Deviation orthodontic scoring tool
3126-by January 1, 2025, or as soon as practicable.
3127-On and after January 1, 2022, the Department of Healthcare
3128-and Family Services shall administer and regulate a
3129-school-based dental program that allows for the out-of-office
3130-delivery of preventative dental services in a school setting
3131-to children under 19 years of age. The Department shall
3132-establish, by rule, guidelines for participation by providers
3133-and set requirements for follow-up referral care based on the
3134-requirements established in the Dental Office Reference Manual
3135-published by the Department that establishes the requirements
3136-for dentists participating in the All Kids Dental School
3137-Program. Every effort shall be made by the Department when
3138-developing the program requirements to consider the different
3139-geographic differences of both urban and rural areas of the
3140-
3141-
3142-State for initial treatment and necessary follow-up care. No
3143-provider shall be charged a fee by any unit of local government
3144-to participate in the school-based dental program administered
3145-by the Department. Nothing in this paragraph shall be
3146-construed to limit or preempt a home rule unit's or school
3147-district's authority to establish, change, or administer a
3148-school-based dental program in addition to, or independent of,
3149-the school-based dental program administered by the
3150-Department.
3151-The Illinois Department, by rule, may distinguish and
3152-classify the medical services to be provided only in
3153-accordance with the classes of persons designated in Section
3154-5-2.
3155-The Department of Healthcare and Family Services must
3156-provide coverage and reimbursement for amino acid-based
3157-elemental formulas, regardless of delivery method, for the
3158-diagnosis and treatment of (i) eosinophilic disorders and (ii)
3159-short bowel syndrome when the prescribing physician has issued
3160-a written order stating that the amino acid-based elemental
3161-formula is medically necessary.
3162-The Illinois Department shall authorize the provision of,
3163-and shall authorize payment for, screening by low-dose
3164-mammography for the presence of occult breast cancer for
3165-individuals 35 years of age or older who are eligible for
3166-medical assistance under this Article, as follows:
3167-(A) A baseline mammogram for individuals 35 to 39
3168-
3169-
3170-years of age.
3171-(B) An annual mammogram for individuals 40 years of
3172-age or older.
3173-(C) A mammogram at the age and intervals considered
3174-medically necessary by the individual's health care
3175-provider for individuals under 40 years of age and having
3176-a family history of breast cancer, prior personal history
3177-of breast cancer, positive genetic testing, or other risk
3178-factors.
3179-(D) A comprehensive ultrasound screening and MRI of an
3180-entire breast or breasts if a mammogram demonstrates
3181-heterogeneous or dense breast tissue or when medically
3182-necessary as determined by a physician licensed to
3183-practice medicine in all of its branches.
3184-(E) A screening MRI when medically necessary, as
3185-determined by a physician licensed to practice medicine in
3186-all of its branches.
3187-(F) A diagnostic mammogram when medically necessary,
3188-as determined by a physician licensed to practice medicine
3189-in all its branches, advanced practice registered nurse,
3190-or physician assistant.
3191-The Department shall not impose a deductible, coinsurance,
3192-copayment, or any other cost-sharing requirement on the
3193-coverage provided under this paragraph; except that this
3194-sentence does not apply to coverage of diagnostic mammograms
3195-to the extent such coverage would disqualify a high-deductible
3196-
3197-
3198-health plan from eligibility for a health savings account
3199-pursuant to Section 223 of the Internal Revenue Code (26
3200-U.S.C. 223).
3201-All screenings shall include a physical breast exam,
3202-instruction on self-examination and information regarding the
3203-frequency of self-examination and its value as a preventative
3204-tool.
3205-For purposes of this Section:
3206-"Diagnostic mammogram" means a mammogram obtained using
3207-diagnostic mammography.
3208-"Diagnostic mammography" means a method of screening that
3209-is designed to evaluate an abnormality in a breast, including
3210-an abnormality seen or suspected on a screening mammogram or a
3211-subjective or objective abnormality otherwise detected in the
3212-breast.
3213-"Low-dose mammography" means the x-ray examination of the
3214-breast using equipment dedicated specifically for mammography,
3215-including the x-ray tube, filter, compression device, and
3216-image receptor, with an average radiation exposure delivery of
3217-less than one rad per breast for 2 views of an average size
3218-breast. The term also includes digital mammography and
3219-includes breast tomosynthesis.
3220-"Breast tomosynthesis" means a radiologic procedure that
3221-involves the acquisition of projection images over the
3222-stationary breast to produce cross-sectional digital
3223-three-dimensional images of the breast.
3224-
3225-
3226-If, at any time, the Secretary of the United States
3227-Department of Health and Human Services, or its successor
3228-agency, promulgates rules or regulations to be published in
3229-the Federal Register or publishes a comment in the Federal
3230-Register or issues an opinion, guidance, or other action that
3231-would require the State, pursuant to any provision of the
3232-Patient Protection and Affordable Care Act (Public Law
3233-111-148), including, but not limited to, 42 U.S.C.
3234-18031(d)(3)(B) or any successor provision, to defray the cost
3235-of any coverage for breast tomosynthesis outlined in this
3236-paragraph, then the requirement that an insurer cover breast
3237-tomosynthesis is inoperative other than any such coverage
3238-authorized under Section 1902 of the Social Security Act, 42
3239-U.S.C. 1396a, and the State shall not assume any obligation
3240-for the cost of coverage for breast tomosynthesis set forth in
3241-this paragraph.
3242-On and after January 1, 2016, the Department shall ensure
3243-that all networks of care for adult clients of the Department
3244-include access to at least one breast imaging Center of
3245-Imaging Excellence as certified by the American College of
3246-Radiology.
3247-On and after January 1, 2012, providers participating in a
3248-quality improvement program approved by the Department shall
3249-be reimbursed for screening and diagnostic mammography at the
3250-same rate as the Medicare program's rates, including the
3251-increased reimbursement for digital mammography and, after
3252-
3253-
3254-January 1, 2023 (the effective date of Public Act 102-1018),
3255-breast tomosynthesis.
3256-The Department shall convene an expert panel including
3257-representatives of hospitals, free-standing mammography
3258-facilities, and doctors, including radiologists, to establish
3259-quality standards for mammography.
3260-On and after January 1, 2017, providers participating in a
3261-breast cancer treatment quality improvement program approved
3262-by the Department shall be reimbursed for breast cancer
3263-treatment at a rate that is no lower than 95% of the Medicare
3264-program's rates for the data elements included in the breast
3265-cancer treatment quality program.
3266-The Department shall convene an expert panel, including
3267-representatives of hospitals, free-standing breast cancer
3268-treatment centers, breast cancer quality organizations, and
3269-doctors, including breast surgeons, reconstructive breast
3270-surgeons, oncologists, and primary care providers to establish
3271-quality standards for breast cancer treatment.
3272-Subject to federal approval, the Department shall
3273-establish a rate methodology for mammography at federally
3274-qualified health centers and other encounter-rate clinics.
3275-These clinics or centers may also collaborate with other
3276-hospital-based mammography facilities. By January 1, 2016, the
3277-Department shall report to the General Assembly on the status
3278-of the provision set forth in this paragraph.
3279-The Department shall establish a methodology to remind
3280-
3281-
3282-individuals who are age-appropriate for screening mammography,
3283-but who have not received a mammogram within the previous 18
3284-months, of the importance and benefit of screening
3285-mammography. The Department shall work with experts in breast
3286-cancer outreach and patient navigation to optimize these
3287-reminders and shall establish a methodology for evaluating
3288-their effectiveness and modifying the methodology based on the
3289-evaluation.
3290-The Department shall establish a performance goal for
3291-primary care providers with respect to their female patients
3292-over age 40 receiving an annual mammogram. This performance
3293-goal shall be used to provide additional reimbursement in the
3294-form of a quality performance bonus to primary care providers
3295-who meet that goal.
3296-The Department shall devise a means of case-managing or
3297-patient navigation for beneficiaries diagnosed with breast
3298-cancer. This program shall initially operate as a pilot
3299-program in areas of the State with the highest incidence of
3300-mortality related to breast cancer. At least one pilot program
3301-site shall be in the metropolitan Chicago area and at least one
3302-site shall be outside the metropolitan Chicago area. On or
3303-after July 1, 2016, the pilot program shall be expanded to
3304-include one site in western Illinois, one site in southern
3305-Illinois, one site in central Illinois, and 4 sites within
3306-metropolitan Chicago. An evaluation of the pilot program shall
3307-be carried out measuring health outcomes and cost of care for
3308-
3309-
3310-those served by the pilot program compared to similarly
3311-situated patients who are not served by the pilot program.
3312-The Department shall require all networks of care to
3313-develop a means either internally or by contract with experts
3314-in navigation and community outreach to navigate cancer
3315-patients to comprehensive care in a timely fashion. The
3316-Department shall require all networks of care to include
3317-access for patients diagnosed with cancer to at least one
3318-academic commission on cancer-accredited cancer program as an
3319-in-network covered benefit.
3320-The Department shall provide coverage and reimbursement
3321-for a human papillomavirus (HPV) vaccine that is approved for
3322-marketing by the federal Food and Drug Administration for all
3323-persons between the ages of 9 and 45. Subject to federal
3324-approval, the Department shall provide coverage and
3325-reimbursement for a human papillomavirus (HPV) vaccine for
3326-persons of the age of 46 and above who have been diagnosed with
3327-cervical dysplasia with a high risk of recurrence or
3328-progression. The Department shall disallow any
3329-preauthorization requirements for the administration of the
3330-human papillomavirus (HPV) vaccine.
3331-On or after July 1, 2022, individuals who are otherwise
3332-eligible for medical assistance under this Article shall
3333-receive coverage for perinatal depression screenings for the
3334-12-month period beginning on the last day of their pregnancy.
3335-Medical assistance coverage under this paragraph shall be
3336-
3337-
3338-conditioned on the use of a screening instrument approved by
3339-the Department.
3340-Any medical or health care provider shall immediately
3341-recommend, to any pregnant individual who is being provided
3342-prenatal services and is suspected of having a substance use
3343-disorder as defined in the Substance Use Disorder Act,
3344-referral to a local substance use disorder treatment program
3345-licensed by the Department of Human Services or to a licensed
3346-hospital which provides substance abuse treatment services.
3347-The Department of Healthcare and Family Services shall assure
3348-coverage for the cost of treatment of the drug abuse or
3349-addiction for pregnant recipients in accordance with the
3350-Illinois Medicaid Program in conjunction with the Department
3351-of Human Services.
3352-All medical providers providing medical assistance to
3353-pregnant individuals under this Code shall receive information
3354-from the Department on the availability of services under any
3355-program providing case management services for addicted
3356-individuals, including information on appropriate referrals
3357-for other social services that may be needed by addicted
3358-individuals in addition to treatment for addiction.
3359-The Illinois Department, in cooperation with the
3360-Departments of Human Services (as successor to the Department
3361-of Alcoholism and Substance Abuse) and Public Health, through
3362-a public awareness campaign, may provide information
3363-concerning treatment for alcoholism and drug abuse and
3364-
3365-
3366-addiction, prenatal health care, and other pertinent programs
3367-directed at reducing the number of drug-affected infants born
3368-to recipients of medical assistance.
3369-Neither the Department of Healthcare and Family Services
3370-nor the Department of Human Services shall sanction the
3371-recipient solely on the basis of the recipient's substance
3372-abuse.
3373-The Illinois Department shall establish such regulations
3374-governing the dispensing of health services under this Article
3375-as it shall deem appropriate. The Department should seek the
3376-advice of formal professional advisory committees appointed by
3377-the Director of the Illinois Department for the purpose of
3378-providing regular advice on policy and administrative matters,
3379-information dissemination and educational activities for
3380-medical and health care providers, and consistency in
3381-procedures to the Illinois Department.
3382-The Illinois Department may develop and contract with
3383-Partnerships of medical providers to arrange medical services
3384-for persons eligible under Section 5-2 of this Code.
3385-Implementation of this Section may be by demonstration
3386-projects in certain geographic areas. The Partnership shall be
3387-represented by a sponsor organization. The Department, by
3388-rule, shall develop qualifications for sponsors of
3389-Partnerships. Nothing in this Section shall be construed to
3390-require that the sponsor organization be a medical
3391-organization.
3392-
3393-
3394-The sponsor must negotiate formal written contracts with
3395-medical providers for physician services, inpatient and
3396-outpatient hospital care, home health services, treatment for
3397-alcoholism and substance abuse, and other services determined
3398-necessary by the Illinois Department by rule for delivery by
3399-Partnerships. Physician services must include prenatal and
3400-obstetrical care. The Illinois Department shall reimburse
3401-medical services delivered by Partnership providers to clients
3402-in target areas according to provisions of this Article and
3403-the Illinois Health Finance Reform Act, except that:
3404-(1) Physicians participating in a Partnership and
3405-providing certain services, which shall be determined by
3406-the Illinois Department, to persons in areas covered by
3407-the Partnership may receive an additional surcharge for
3408-such services.
3409-(2) The Department may elect to consider and negotiate
3410-financial incentives to encourage the development of
3411-Partnerships and the efficient delivery of medical care.
3412-(3) Persons receiving medical services through
3413-Partnerships may receive medical and case management
3414-services above the level usually offered through the
3415-medical assistance program.
3416-Medical providers shall be required to meet certain
3417-qualifications to participate in Partnerships to ensure the
3418-delivery of high quality medical services. These
3419-qualifications shall be determined by rule of the Illinois
3420-
3421-
3422-Department and may be higher than qualifications for
3423-participation in the medical assistance program. Partnership
3424-sponsors may prescribe reasonable additional qualifications
3425-for participation by medical providers, only with the prior
3426-written approval of the Illinois Department.
3427-Nothing in this Section shall limit the free choice of
3428-practitioners, hospitals, and other providers of medical
3429-services by clients. In order to ensure patient freedom of
3430-choice, the Illinois Department shall immediately promulgate
3431-all rules and take all other necessary actions so that
3432-provided services may be accessed from therapeutically
3433-certified optometrists to the full extent of the Illinois
3434-Optometric Practice Act of 1987 without discriminating between
3435-service providers.
3436-The Department shall apply for a waiver from the United
3437-States Health Care Financing Administration to allow for the
3438-implementation of Partnerships under this Section.
3439-The Illinois Department shall require health care
3440-providers to maintain records that document the medical care
3441-and services provided to recipients of Medical Assistance
3442-under this Article. Such records must be retained for a period
3443-of not less than 6 years from the date of service or as
3444-provided by applicable State law, whichever period is longer,
3445-except that if an audit is initiated within the required
3446-retention period then the records must be retained until the
3447-audit is completed and every exception is resolved. The
3448-
3449-
3450-Illinois Department shall require health care providers to
3451-make available, when authorized by the patient, in writing,
3452-the medical records in a timely fashion to other health care
3453-providers who are treating or serving persons eligible for
3454-Medical Assistance under this Article. All dispensers of
3455-medical services shall be required to maintain and retain
3456-business and professional records sufficient to fully and
3457-accurately document the nature, scope, details and receipt of
3458-the health care provided to persons eligible for medical
3459-assistance under this Code, in accordance with regulations
3460-promulgated by the Illinois Department. The rules and
3461-regulations shall require that proof of the receipt of
3462-prescription drugs, dentures, prosthetic devices and
3463-eyeglasses by eligible persons under this Section accompany
3464-each claim for reimbursement submitted by the dispenser of
3465-such medical services. No such claims for reimbursement shall
3466-be approved for payment by the Illinois Department without
3467-such proof of receipt, unless the Illinois Department shall
3468-have put into effect and shall be operating a system of
3469-post-payment audit and review which shall, on a sampling
3470-basis, be deemed adequate by the Illinois Department to assure
3471-that such drugs, dentures, prosthetic devices and eyeglasses
3472-for which payment is being made are actually being received by
3473-eligible recipients. Within 90 days after September 16, 1984
3474-(the effective date of Public Act 83-1439), the Illinois
3475-Department shall establish a current list of acquisition costs
3476-
3477-
3478-for all prosthetic devices and any other items recognized as
3479-medical equipment and supplies reimbursable under this Article
3480-and shall update such list on a quarterly basis, except that
3481-the acquisition costs of all prescription drugs shall be
3482-updated no less frequently than every 30 days as required by
3483-Section 5-5.12.
3484-Notwithstanding any other law to the contrary, the
3485-Illinois Department shall, within 365 days after July 22, 2013
3486-(the effective date of Public Act 98-104), establish
3487-procedures to permit skilled care facilities licensed under
3488-the Nursing Home Care Act to submit monthly billing claims for
3489-reimbursement purposes. Following development of these
3490-procedures, the Department shall, by July 1, 2016, test the
3491-viability of the new system and implement any necessary
3492-operational or structural changes to its information
3493-technology platforms in order to allow for the direct
3494-acceptance and payment of nursing home claims.
3495-Notwithstanding any other law to the contrary, the
3496-Illinois Department shall, within 365 days after August 15,
3497-2014 (the effective date of Public Act 98-963), establish
3498-procedures to permit ID/DD facilities licensed under the ID/DD
3499-Community Care Act and MC/DD facilities licensed under the
3500-MC/DD Act to submit monthly billing claims for reimbursement
3501-purposes. Following development of these procedures, the
3502-Department shall have an additional 365 days to test the
3503-viability of the new system and to ensure that any necessary
3504-
3505-
3506-operational or structural changes to its information
3507-technology platforms are implemented.
3508-The Illinois Department shall require all dispensers of
3509-medical services, other than an individual practitioner or
3510-group of practitioners, desiring to participate in the Medical
3511-Assistance program established under this Article to disclose
3512-all financial, beneficial, ownership, equity, surety or other
3513-interests in any and all firms, corporations, partnerships,
3514-associations, business enterprises, joint ventures, agencies,
3515-institutions or other legal entities providing any form of
3516-health care services in this State under this Article.
3517-The Illinois Department may require that all dispensers of
3518-medical services desiring to participate in the medical
3519-assistance program established under this Article disclose,
3520-under such terms and conditions as the Illinois Department may
3521-by rule establish, all inquiries from clients and attorneys
3522-regarding medical bills paid by the Illinois Department, which
3523-inquiries could indicate potential existence of claims or
3524-liens for the Illinois Department.
3525-Enrollment of a vendor shall be subject to a provisional
3526-period and shall be conditional for one year. During the
3527-period of conditional enrollment, the Department may terminate
3528-the vendor's eligibility to participate in, or may disenroll
3529-the vendor from, the medical assistance program without cause.
3530-Unless otherwise specified, such termination of eligibility or
3531-disenrollment is not subject to the Department's hearing
3532-
3533-
3534-process. However, a disenrolled vendor may reapply without
3535-penalty.
3536-The Department has the discretion to limit the conditional
3537-enrollment period for vendors based upon the category of risk
3538-of the vendor.
3539-Prior to enrollment and during the conditional enrollment
3540-period in the medical assistance program, all vendors shall be
3541-subject to enhanced oversight, screening, and review based on
3542-the risk of fraud, waste, and abuse that is posed by the
3543-category of risk of the vendor. The Illinois Department shall
3544-establish the procedures for oversight, screening, and review,
3545-which may include, but need not be limited to: criminal and
3546-financial background checks; fingerprinting; license,
3547-certification, and authorization verifications; unscheduled or
3548-unannounced site visits; database checks; prepayment audit
3549-reviews; audits; payment caps; payment suspensions; and other
3550-screening as required by federal or State law.
3551-The Department shall define or specify the following: (i)
3552-by provider notice, the "category of risk of the vendor" for
3553-each type of vendor, which shall take into account the level of
3554-screening applicable to a particular category of vendor under
3555-federal law and regulations; (ii) by rule or provider notice,
3556-the maximum length of the conditional enrollment period for
3557-each category of risk of the vendor; and (iii) by rule, the
3558-hearing rights, if any, afforded to a vendor in each category
3559-of risk of the vendor that is terminated or disenrolled during
3560-
3561-
3562-the conditional enrollment period.
3563-To be eligible for payment consideration, a vendor's
3564-payment claim or bill, either as an initial claim or as a
3565-resubmitted claim following prior rejection, must be received
3566-by the Illinois Department, or its fiscal intermediary, no
3567-later than 180 days after the latest date on the claim on which
3568-medical goods or services were provided, with the following
3569-exceptions:
3570-(1) In the case of a provider whose enrollment is in
3571-process by the Illinois Department, the 180-day period
3572-shall not begin until the date on the written notice from
3573-the Illinois Department that the provider enrollment is
3574-complete.
3575-(2) In the case of errors attributable to the Illinois
3576-Department or any of its claims processing intermediaries
3577-which result in an inability to receive, process, or
3578-adjudicate a claim, the 180-day period shall not begin
3579-until the provider has been notified of the error.
3580-(3) In the case of a provider for whom the Illinois
3581-Department initiates the monthly billing process.
3582-(4) In the case of a provider operated by a unit of
3583-local government with a population exceeding 3,000,000
3584-when local government funds finance federal participation
3585-for claims payments.
3586-For claims for services rendered during a period for which
3587-a recipient received retroactive eligibility, claims must be
3588-
3589-
3590-filed within 180 days after the Department determines the
3591-applicant is eligible. For claims for which the Illinois
3592-Department is not the primary payer, claims must be submitted
3593-to the Illinois Department within 180 days after the final
3594-adjudication by the primary payer.
3595-In the case of long term care facilities, within 120
3596-calendar days of receipt by the facility of required
3597-prescreening information, new admissions with associated
3598-admission documents shall be submitted through the Medical
3599-Electronic Data Interchange (MEDI) or the Recipient
3600-Eligibility Verification (REV) System or shall be submitted
3601-directly to the Department of Human Services using required
3602-admission forms. Effective September 1, 2014, admission
3603-documents, including all prescreening information, must be
3604-submitted through MEDI or REV. Confirmation numbers assigned
3605-to an accepted transaction shall be retained by a facility to
3606-verify timely submittal. Once an admission transaction has
3607-been completed, all resubmitted claims following prior
3608-rejection are subject to receipt no later than 180 days after
3609-the admission transaction has been completed.
3610-Claims that are not submitted and received in compliance
3611-with the foregoing requirements shall not be eligible for
3612-payment under the medical assistance program, and the State
3613-shall have no liability for payment of those claims.
3614-To the extent consistent with applicable information and
3615-privacy, security, and disclosure laws, State and federal
3616-
3617-
3618-agencies and departments shall provide the Illinois Department
3619-access to confidential and other information and data
3620-necessary to perform eligibility and payment verifications and
3621-other Illinois Department functions. This includes, but is not
3622-limited to: information pertaining to licensure;
3623-certification; earnings; immigration status; citizenship; wage
3624-reporting; unearned and earned income; pension income;
3625-employment; supplemental security income; social security
3626-numbers; National Provider Identifier (NPI) numbers; the
3627-National Practitioner Data Bank (NPDB); program and agency
3628-exclusions; taxpayer identification numbers; tax delinquency;
3629-corporate information; and death records.
3630-The Illinois Department shall enter into agreements with
3631-State agencies and departments, and is authorized to enter
3632-into agreements with federal agencies and departments, under
3633-which such agencies and departments shall share data necessary
3634-for medical assistance program integrity functions and
3635-oversight. The Illinois Department shall develop, in
3636-cooperation with other State departments and agencies, and in
3637-compliance with applicable federal laws and regulations,
3638-appropriate and effective methods to share such data. At a
3639-minimum, and to the extent necessary to provide data sharing,
3640-the Illinois Department shall enter into agreements with State
3641-agencies and departments, and is authorized to enter into
3642-agreements with federal agencies and departments, including,
3643-but not limited to: the Secretary of State; the Department of
3644-
3645-
3646-Revenue; the Department of Public Health; the Department of
3647-Human Services; and the Department of Financial and
3648-Professional Regulation.
3649-Beginning in fiscal year 2013, the Illinois Department
3650-shall set forth a request for information to identify the
3651-benefits of a pre-payment, post-adjudication, and post-edit
3652-claims system with the goals of streamlining claims processing
3653-and provider reimbursement, reducing the number of pending or
3654-rejected claims, and helping to ensure a more transparent
3655-adjudication process through the utilization of: (i) provider
3656-data verification and provider screening technology; and (ii)
3657-clinical code editing; and (iii) pre-pay, pre-adjudicated, or
3658-post-adjudicated predictive modeling with an integrated case
3659-management system with link analysis. Such a request for
3660-information shall not be considered as a request for proposal
3661-or as an obligation on the part of the Illinois Department to
3662-take any action or acquire any products or services.
3663-The Illinois Department shall establish policies,
3664-procedures, standards and criteria by rule for the
3665-acquisition, repair and replacement of orthotic and prosthetic
3666-devices and durable medical equipment. Such rules shall
3667-provide, but not be limited to, the following services: (1)
3668-immediate repair or replacement of such devices by recipients;
3669-and (2) rental, lease, purchase or lease-purchase of durable
3670-medical equipment in a cost-effective manner, taking into
3671-consideration the recipient's medical prognosis, the extent of
3672-
3673-
3674-the recipient's needs, and the requirements and costs for
3675-maintaining such equipment. Subject to prior approval, such
3676-rules shall enable a recipient to temporarily acquire and use
3677-alternative or substitute devices or equipment pending repairs
3678-or replacements of any device or equipment previously
3679-authorized for such recipient by the Department.
3680-Notwithstanding any provision of Section 5-5f to the contrary,
3681-the Department may, by rule, exempt certain replacement
3682-wheelchair parts from prior approval and, for wheelchairs,
3683-wheelchair parts, wheelchair accessories, and related seating
3684-and positioning items, determine the wholesale price by
3685-methods other than actual acquisition costs.
3686-The Department shall require, by rule, all providers of
3687-durable medical equipment to be accredited by an accreditation
3688-organization approved by the federal Centers for Medicare and
3689-Medicaid Services and recognized by the Department in order to
3690-bill the Department for providing durable medical equipment to
3691-recipients. No later than 15 months after the effective date
3692-of the rule adopted pursuant to this paragraph, all providers
3693-must meet the accreditation requirement.
3694-In order to promote environmental responsibility, meet the
3695-needs of recipients and enrollees, and achieve significant
3696-cost savings, the Department, or a managed care organization
3697-under contract with the Department, may provide recipients or
3698-managed care enrollees who have a prescription or Certificate
3699-of Medical Necessity access to refurbished durable medical
3700-
3701-
3702-equipment under this Section (excluding prosthetic and
3703-orthotic devices as defined in the Orthotics, Prosthetics, and
3704-Pedorthics Practice Act and complex rehabilitation technology
3705-products and associated services) through the State's
3706-assistive technology program's reutilization program, using
3707-staff with the Assistive Technology Professional (ATP)
3708-Certification if the refurbished durable medical equipment:
3709-(i) is available; (ii) is less expensive, including shipping
3710-costs, than new durable medical equipment of the same type;
3711-(iii) is able to withstand at least 3 years of use; (iv) is
3712-cleaned, disinfected, sterilized, and safe in accordance with
3713-federal Food and Drug Administration regulations and guidance
3714-governing the reprocessing of medical devices in health care
3715-settings; and (v) equally meets the needs of the recipient or
3716-enrollee. The reutilization program shall confirm that the
3717-recipient or enrollee is not already in receipt of the same or
3718-similar equipment from another service provider, and that the
3719-refurbished durable medical equipment equally meets the needs
3720-of the recipient or enrollee. Nothing in this paragraph shall
3721-be construed to limit recipient or enrollee choice to obtain
3722-new durable medical equipment or place any additional prior
3723-authorization conditions on enrollees of managed care
3724-organizations.
3725-The Department shall execute, relative to the nursing home
3726-prescreening project, written inter-agency agreements with the
3727-Department of Human Services and the Department on Aging, to
3728-
3729-
3730-effect the following: (i) intake procedures and common
3731-eligibility criteria for those persons who are receiving
3732-non-institutional services; and (ii) the establishment and
3733-development of non-institutional services in areas of the
3734-State where they are not currently available or are
3735-undeveloped; and (iii) notwithstanding any other provision of
3736-law, subject to federal approval, on and after July 1, 2012, an
3737-increase in the determination of need (DON) scores from 29 to
3738-37 for applicants for institutional and home and
3739-community-based long term care; if and only if federal
3740-approval is not granted, the Department may, in conjunction
3741-with other affected agencies, implement utilization controls
3742-or changes in benefit packages to effectuate a similar savings
3743-amount for this population; and (iv) no later than July 1,
3744-2013, minimum level of care eligibility criteria for
3745-institutional and home and community-based long term care; and
3746-(v) no later than October 1, 2013, establish procedures to
3747-permit long term care providers access to eligibility scores
3748-for individuals with an admission date who are seeking or
3749-receiving services from the long term care provider. In order
3750-to select the minimum level of care eligibility criteria, the
3751-Governor shall establish a workgroup that includes affected
3752-agency representatives and stakeholders representing the
3753-institutional and home and community-based long term care
3754-interests. This Section shall not restrict the Department from
3755-implementing lower level of care eligibility criteria for
3756-
3757-
3758-community-based services in circumstances where federal
3759-approval has been granted.
3760-The Illinois Department shall develop and operate, in
3761-cooperation with other State Departments and agencies and in
3762-compliance with applicable federal laws and regulations,
3763-appropriate and effective systems of health care evaluation
3764-and programs for monitoring of utilization of health care
3765-services and facilities, as it affects persons eligible for
3766-medical assistance under this Code.
3767-The Illinois Department shall report annually to the
3768-General Assembly, no later than the second Friday in April of
3769-1979 and each year thereafter, in regard to:
3770-(a) actual statistics and trends in utilization of
3771-medical services by public aid recipients;
3772-(b) actual statistics and trends in the provision of
3773-the various medical services by medical vendors;
3774-(c) current rate structures and proposed changes in
3775-those rate structures for the various medical vendors; and
3776-(d) efforts at utilization review and control by the
3777-Illinois Department.
3778-The period covered by each report shall be the 3 years
3779-ending on the June 30 prior to the report. The report shall
3780-include suggested legislation for consideration by the General
3781-Assembly. The requirement for reporting to the General
3782-Assembly shall be satisfied by filing copies of the report as
3783-required by Section 3.1 of the General Assembly Organization
3784-
3785-
3786-Act, and filing such additional copies with the State
3787-Government Report Distribution Center for the General Assembly
3788-as is required under paragraph (t) of Section 7 of the State
3789-Library Act.
3790-Rulemaking authority to implement Public Act 95-1045, if
3791-any, is conditioned on the rules being adopted in accordance
3792-with all provisions of the Illinois Administrative Procedure
3793-Act and all rules and procedures of the Joint Committee on
3794-Administrative Rules; any purported rule not so adopted, for
3795-whatever reason, is unauthorized.
3796-On and after July 1, 2012, the Department shall reduce any
3797-rate of reimbursement for services or other payments or alter
3798-any methodologies authorized by this Code to reduce any rate
3799-of reimbursement for services or other payments in accordance
3800-with Section 5-5e.
3801-Because kidney transplantation can be an appropriate,
3802-cost-effective alternative to renal dialysis when medically
3803-necessary and notwithstanding the provisions of Section 1-11
3804-of this Code, beginning October 1, 2014, the Department shall
3805-cover kidney transplantation for noncitizens with end-stage
3806-renal disease who are not eligible for comprehensive medical
3807-benefits, who meet the residency requirements of Section 5-3
3808-of this Code, and who would otherwise meet the financial
3809-requirements of the appropriate class of eligible persons
3810-under Section 5-2 of this Code. To qualify for coverage of
3811-kidney transplantation, such person must be receiving
3812-
3813-
3814-emergency renal dialysis services covered by the Department.
3815-Providers under this Section shall be prior approved and
3816-certified by the Department to perform kidney transplantation
3817-and the services under this Section shall be limited to
3818-services associated with kidney transplantation.
3819-Notwithstanding any other provision of this Code to the
3820-contrary, on or after July 1, 2015, all FDA approved forms of
3821-medication assisted treatment prescribed for the treatment of
3822-alcohol dependence or treatment of opioid dependence shall be
3823-covered under both fee-for-service fee for service and managed
3824-care medical assistance programs for persons who are otherwise
3825-eligible for medical assistance under this Article and shall
3826-not be subject to any (1) utilization control, other than
3827-those established under the American Society of Addiction
3828-Medicine patient placement criteria, (2) prior authorization
3829-mandate, or (3) lifetime restriction limit mandate.
3830-On or after July 1, 2015, opioid antagonists prescribed
3831-for the treatment of an opioid overdose, including the
3832-medication product, administration devices, and any pharmacy
3833-fees or hospital fees related to the dispensing, distribution,
3834-and administration of the opioid antagonist, shall be covered
3835-under the medical assistance program for persons who are
3836-otherwise eligible for medical assistance under this Article.
3837-As used in this Section, "opioid antagonist" means a drug that
3838-binds to opioid receptors and blocks or inhibits the effect of
3839-opioids acting on those receptors, including, but not limited
3840-
3841-
3842-to, naloxone hydrochloride or any other similarly acting drug
3843-approved by the U.S. Food and Drug Administration. The
3844-Department shall not impose a copayment on the coverage
3845-provided for naloxone hydrochloride under the medical
3846-assistance program.
3847-Upon federal approval, the Department shall provide
3848-coverage and reimbursement for all drugs that are approved for
3849-marketing by the federal Food and Drug Administration and that
3850-are recommended by the federal Public Health Service or the
3851-United States Centers for Disease Control and Prevention for
3852-pre-exposure prophylaxis and related pre-exposure prophylaxis
3853-services, including, but not limited to, HIV and sexually
3854-transmitted infection screening, treatment for sexually
3855-transmitted infections, medical monitoring, assorted labs, and
3856-counseling to reduce the likelihood of HIV infection among
3857-individuals who are not infected with HIV but who are at high
3858-risk of HIV infection.
3859-A federally qualified health center, as defined in Section
3860-1905(l)(2)(B) of the federal Social Security Act, shall be
3861-reimbursed by the Department in accordance with the federally
3862-qualified health center's encounter rate for services provided
3863-to medical assistance recipients that are performed by a
3864-dental hygienist, as defined under the Illinois Dental
3865-Practice Act, working under the general supervision of a
3866-dentist and employed by a federally qualified health center.
3867-Within 90 days after October 8, 2021 (the effective date
3868-
3869-
3870-of Public Act 102-665), the Department shall seek federal
3871-approval of a State Plan amendment to expand coverage for
3872-family planning services that includes presumptive eligibility
3873-to individuals whose income is at or below 208% of the federal
3874-poverty level. Coverage under this Section shall be effective
3875-beginning no later than December 1, 2022.
3876-Subject to approval by the federal Centers for Medicare
3877-and Medicaid Services of a Title XIX State Plan amendment
3878-electing the Program of All-Inclusive Care for the Elderly
3879-(PACE) as a State Medicaid option, as provided for by Subtitle
3880-I (commencing with Section 4801) of Title IV of the Balanced
3881-Budget Act of 1997 (Public Law 105-33) and Part 460
3882-(commencing with Section 460.2) of Subchapter E of Title 42 of
3883-the Code of Federal Regulations, PACE program services shall
3884-become a covered benefit of the medical assistance program,
3885-subject to criteria established in accordance with all
3886-applicable laws.
3887-Notwithstanding any other provision of this Code,
3888-community-based pediatric palliative care from a trained
3889-interdisciplinary team shall be covered under the medical
3890-assistance program as provided in Section 15 of the Pediatric
3891-Palliative Care Act.
3892-Notwithstanding any other provision of this Code, within
3893-12 months after June 2, 2022 (the effective date of Public Act
3894-102-1037) and subject to federal approval, acupuncture
3895-services performed by an acupuncturist licensed under the
3896-
3897-
3898-Acupuncture Practice Act who is acting within the scope of his
3899-or her license shall be covered under the medical assistance
3900-program. The Department shall apply for any federal waiver or
3901-State Plan amendment, if required, to implement this
3902-paragraph. The Department may adopt any rules, including
3903-standards and criteria, necessary to implement this paragraph.
3904-Notwithstanding any other provision of this Code, the
3905-medical assistance program shall, subject to appropriation and
3906-federal approval, reimburse hospitals for costs associated
3907-with a newborn screening test for the presence of
3908-metachromatic leukodystrophy, as required under the Newborn
3909-Metabolic Screening Act, at a rate not less than the fee
3910-charged by the Department of Public Health. The Department
3911-shall seek federal approval before the implementation of the
3912-newborn screening test fees by the Department of Public
3913-Health.
3914-Notwithstanding any other provision of this Code,
3915-beginning on January 1, 2024, subject to federal approval,
3916-cognitive assessment and care planning services provided to a
3917-person who experiences signs or symptoms of cognitive
3918-impairment, as defined by the Diagnostic and Statistical
3919-Manual of Mental Disorders, Fifth Edition, shall be covered
3920-under the medical assistance program for persons who are
3921-otherwise eligible for medical assistance under this Article.
3922-Notwithstanding any other provision of this Code,
3923-medically necessary reconstructive services that are intended
3924-
3925-
3926-to restore physical appearance shall be covered under the
3927-medical assistance program for persons who are otherwise
3928-eligible for medical assistance under this Article. As used in
3929-this paragraph, "reconstructive services" means treatments
3930-performed on structures of the body damaged by trauma to
3931-restore physical appearance.
3932-(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
3933-102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
3934-55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
3935-eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
3936-102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
3937-5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
3938-102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
3939-1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
3940-103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
3941-1-1-24; revised 12-15-23.)
3942-ARTICLE 95.
3943-Section 95-5. The Specialized Mental Health Rehabilitation
3944-Act of 2013 is amended by changing Section 5-107 as follows:
3945-(210 ILCS 49/5-107)
3946-Sec. 5-107. Quality of life enhancement. Beginning on July
3947-1, 2019, for improving the quality of life and the quality of
3948-care, an additional payment shall be awarded to a facility for
3949-
3950-
3951-their single occupancy rooms. This payment shall be in
3952-addition to the rate for recovery and rehabilitation. The
3953-additional rate for single room occupancy shall be no less
3954-than $10 per day, per single room occupancy. The Department of
3955-Healthcare and Family Services shall adjust payment to
3956-Medicaid managed care entities to cover these costs. Beginning
3957-July 1, 2022, for improving the quality of life and the quality
3958-of care, a payment of no less than $5 per day, per single room
3959-occupancy shall be added to the existing $10 additional per
3960-day, per single room occupancy rate for a total of at least $15
3961-per day, per single room occupancy. For improving the quality
3962-of life and the quality of care, on January 1, 2024, a payment
3963-of no less than $10.50 per day, per single room occupancy shall
3964-be added to the existing $15 additional per day, per single
3965-room occupancy rate for a total of at least $25.50 per day, per
3966-single room occupancy. For improving the quality of life and
3967-the quality of care, beginning on January 1, 2025, a payment of
3968-no less than $10 per day, per single room occupancy shall be
3969-added to the existing $25.50 additional per day, per single
3970-room occupancy rate for a total of at least $35.50 per day, per
3971-single room occupancy. Beginning July 1, 2022, for improving
3972-the quality of life and the quality of care, an additional
3973-payment shall be awarded to a facility for its dual-occupancy
3974-rooms. This payment shall be in addition to the rate for
3975-recovery and rehabilitation. The additional rate for
3976-dual-occupancy rooms shall be no less than $10 per day, per
3977-
3978-
3979-Medicaid-occupied bed, in each dual-occupancy room. Beginning
3980-January 1, 2024, for improving the quality of life and the
3981-quality of care, a payment of no less than $4.50 per day, per
3982-dual-occupancy room shall be added to the existing $10
3983-additional per day, per dual-occupancy room rate for a total
3984-of at least $14.50, per Medicaid-occupied bed, in each
3985-dual-occupancy room. Beginning January 1, 2025, for improving
3986-the quality of life and the quality of care, a payment of no
3987-less than $8.75 per day, per dual-occupancy room shall be
3988-added to the existing $14.50 additional per day, per
3989-dual-occupancy room rate for a total of at least $23.25, per
3990-Medicaid-occupied bed, in each dual-occupancy room. The
3991-Department of Healthcare and Family Services shall adjust
3992-payment to Medicaid managed care entities to cover these
3993-costs. As used in this Section, "dual-occupancy room" means a
3994-room that contains 2 resident beds.
3995-(Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24.)
3996-ARTICLE 100.
3997-Section 100-5. The Illinois Public Aid Code is amended by
3998-changing Section 5-5.01a as follows:
3999-(305 ILCS 5/5-5.01a)
4000-Sec. 5-5.01a. Supportive living facilities program.
4001-(a) The Department shall establish and provide oversight
4002-
4003-
4004-for a program of supportive living facilities that seek to
4005-promote resident independence, dignity, respect, and
4006-well-being in the most cost-effective manner.
4007-A supportive living facility is (i) a free-standing
4008-facility or (ii) a distinct physical and operational entity
4009-within a mixed-use building that meets the criteria
4010-established in subsection (d). A supportive living facility
4011-integrates housing with health, personal care, and supportive
4012-services and is a designated setting that offers residents
4013-their own separate, private, and distinct living units.
4014-Sites for the operation of the program shall be selected
4015-by the Department based upon criteria that may include the
4016-need for services in a geographic area, the availability of
4017-funding, and the site's ability to meet the standards.
4018-(b) Beginning July 1, 2014, subject to federal approval,
4019-the Medicaid rates for supportive living facilities shall be
4020-equal to the supportive living facility Medicaid rate
4021-effective on June 30, 2014 increased by 8.85%. Once the
4022-assessment imposed at Article V-G of this Code is determined
4023-to be a permissible tax under Title XIX of the Social Security
4024-Act, the Department shall increase the Medicaid rates for
4025-supportive living facilities effective on July 1, 2014 by
4026-9.09%. The Department shall apply this increase retroactively
4027-to coincide with the imposition of the assessment in Article
4028-V-G of this Code in accordance with the approval for federal
4029-financial participation by the Centers for Medicare and
4030-
4031-
4032-Medicaid Services.
4033-The Medicaid rates for supportive living facilities
4034-effective on July 1, 2017 must be equal to the rates in effect
4035-for supportive living facilities on June 30, 2017 increased by
4036-2.8%.
4037-The Medicaid rates for supportive living facilities
4038-effective on July 1, 2018 must be equal to the rates in effect
4039-for supportive living facilities on June 30, 2018.
4040-Subject to federal approval, the Medicaid rates for
4041-supportive living services on and after July 1, 2019 must be at
4042-least 54.3% of the average total nursing facility services per
4043-diem for the geographic areas defined by the Department while
4044-maintaining the rate differential for dementia care and must
4045-be updated whenever the total nursing facility service per
4046-diems are updated. Beginning July 1, 2022, upon the
4047-implementation of the Patient Driven Payment Model, Medicaid
4048-rates for supportive living services must be at least 54.3% of
4049-the average total nursing services per diem rate for the
4050-geographic areas. For purposes of this provision, the average
4051-total nursing services per diem rate shall include all add-ons
4052-for nursing facilities for the geographic area provided for in
4053-Section 5-5.2. The rate differential for dementia care must be
4054-maintained in these rates and the rates shall be updated
4055-whenever nursing facility per diem rates are updated.
4056-Subject to federal approval, beginning January 1, 2024,
4057-the dementia care rate for supportive living services must be
4058-
4059-
4060-no less than the non-dementia care supportive living services
4061-rate multiplied by 1.5.
4062-(c) The Department may adopt rules to implement this
4063-Section. Rules that establish or modify the services,
4064-standards, and conditions for participation in the program
4065-shall be adopted by the Department in consultation with the
4066-Department on Aging, the Department of Rehabilitation
4067-Services, and the Department of Mental Health and
4068-Developmental Disabilities (or their successor agencies).
4069-(d) Subject to federal approval by the Centers for
4070-Medicare and Medicaid Services, the Department shall accept
4071-for consideration of certification under the program any
4072-application for a site or building where distinct parts of the
4073-site or building are designated for purposes other than the
4074-provision of supportive living services, but only if:
4075-(1) those distinct parts of the site or building are
4076-not designated for the purpose of providing assisted
4077-living services as required under the Assisted Living and
4078-Shared Housing Act;
4079-(2) those distinct parts of the site or building are
4080-completely separate from the part of the building used for
4081-the provision of supportive living program services,
4082-including separate entrances;
4083-(3) those distinct parts of the site or building do
4084-not share any common spaces with the part of the building
4085-used for the provision of supportive living program
4086-
4087-
4088-services; and
4089-(4) those distinct parts of the site or building do
4090-not share staffing with the part of the building used for
4091-the provision of supportive living program services.
4092-(e) Facilities or distinct parts of facilities which are
4093-selected as supportive living facilities and are in good
4094-standing with the Department's rules are exempt from the
4095-provisions of the Nursing Home Care Act and the Illinois
4096-Health Facilities Planning Act.
4097-(f) Section 9817 of the American Rescue Plan Act of 2021
4098-(Public Law 117-2) authorizes a 10% enhanced federal medical
4099-assistance percentage for supportive living services for a
4100-12-month period from April 1, 2021 through March 31, 2022.
4101-Subject to federal approval, including the approval of any
4102-necessary waiver amendments or other federally required
4103-documents or assurances, for a 12-month period the Department
4104-must pay a supplemental $26 per diem rate to all supportive
4105-living facilities with the additional federal financial
4106-participation funds that result from the enhanced federal
4107-medical assistance percentage from April 1, 2021 through March
4108-31, 2022. The Department may issue parameters around how the
4109-supplemental payment should be spent, including quality
4110-improvement activities. The Department may alter the form,
4111-methods, or timeframes concerning the supplemental per diem
4112-rate to comply with any subsequent changes to federal law,
4113-changes made by guidance issued by the federal Centers for
4114-
4115-
4116-Medicare and Medicaid Services, or other changes necessary to
4117-receive the enhanced federal medical assistance percentage.
4118-(g) All applications for the expansion of supportive
4119-living dementia care settings involving sites not approved by
4120-the Department by January 1, 2024 on the effective date of this
4121-amendatory Act of the 103rd General Assembly may allow new
4122-elderly non-dementia units in addition to new dementia care
4123-units. The Department may approve such applications only if
4124-the application has: (1) no more than one non-dementia care
4125-unit for each dementia care unit and (2) the site is not
4126-located within 4 miles of an existing supportive living
4127-program site in Cook County (including the City of Chicago),
4128-not located within 12 miles of an existing supportive living
4129-program site in Alexander, Bond, Boone, Calhoun, Champaign,
4130-Clinton, DeKalb, DuPage Fulton, Grundy, Henry, Jackson,
4131-Jersey, Johnson, Kane, Kankakee, Kendall, Lake, Macon,
4132-Macoupin, Madison, Marshall, McHenry, McLean, Menard, Mercer,
4133-Monroe, Peoria, Piatt, Rock Island, Sangamon, Stark, St.
4134-Clair, Tazewell, Vermilion, Will, Williamson, Winnebago, or
4135-Woodford counties County, Kane County, Lake County, McHenry
4136-County, or Will County, or not located within 25 miles of an
4137-existing supportive living program site in any other county.
4138-(Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
4139-103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
4140-Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)
4141-
4142-
4143-ARTICLE 105.
4144-Section 105-5. The Illinois Public Aid Code is amended by
4145-changing Section 5-36 as follows:
4146-(305 ILCS 5/5-36)
4147-Sec. 5-36. Pharmacy benefits.
4148-(a)(1) The Department may enter into a contract with a
4149-third party on a fee-for-service reimbursement model for the
4150-purpose of administering pharmacy benefits as provided in this
4151-Section for members not enrolled in a Medicaid managed care
4152-organization; however, these services shall be approved by the
4153-Department. The Department shall ensure coordination of care
4154-between the third-party administrator and managed care
4155-organizations as a consideration in any contracts established
4156-in accordance with this Section. Any managed care techniques,
4157-principles, or administration of benefits utilized in
4158-accordance with this subsection shall comply with State law.
4159-(2) The following shall apply to contracts between
4160-entities contracting relating to the Department's third-party
4161-administrators and pharmacies:
4162-(A) the Department shall approve any contract between
4163-a third-party administrator and a pharmacy;
4164-(B) the Department's third-party administrator shall
4165-not change the terms of a contract between a third-party
4166-administrator and a pharmacy without written approval by
4167-
4168-
4169-the Department; and
4170-(C) the Department's third-party administrator shall
4171-not create, modify, implement, or indirectly establish any
4172-fee on a pharmacy, pharmacist, or a recipient of medical
4173-assistance without written approval by the Department.
4174-(b) The provisions of this Section shall not apply to
4175-outpatient pharmacy services provided by a health care
4176-facility registered as a covered entity pursuant to 42 U.S.C.
4177-256b or any pharmacy owned by or contracted with the covered
4178-entity. A Medicaid managed care organization shall, either
4179-directly or through a pharmacy benefit manager, administer and
4180-reimburse outpatient pharmacy claims submitted by a health
4181-care facility registered as a covered entity pursuant to 42
4182-U.S.C. 256b, its owned pharmacies, and contracted pharmacies
4183-in accordance with the contractual agreements the Medicaid
4184-managed care organization or its pharmacy benefit manager has
4185-with such facilities and pharmacies and in accordance with
4186-subsection (h-5).
4187-(b-5) Any pharmacy benefit manager that contracts with a
4188-Medicaid managed care organization to administer and reimburse
4189-pharmacy claims as provided in this Section must be registered
4190-with the Director of Insurance in accordance with Section
4191-513b2 of the Illinois Insurance Code.
4192-(c) On at least an annual basis, the Director of the
4193-Department of Healthcare and Family Services shall submit a
4194-report beginning no later than one year after January 1, 2020
4195-
4196-
4197-(the effective date of Public Act 101-452) that provides an
4198-update on any contract, contract issues, formulary, dispensing
4199-fees, and maximum allowable cost concerns regarding a
4200-third-party administrator and managed care. The requirement
4201-for reporting to the General Assembly shall be satisfied by
4202-filing copies of the report with the Speaker, the Minority
4203-Leader, and the Clerk of the House of Representatives and with
4204-the President, the Minority Leader, and the Secretary of the
4205-Senate. The Department shall take care that no proprietary
4206-information is included in the report required under this
4207-Section.
4208-(d) A pharmacy benefit manager shall notify the Department
4209-in writing of any activity, policy, or practice of the
4210-pharmacy benefit manager that directly or indirectly presents
4211-a conflict of interest that interferes with the discharge of
4212-the pharmacy benefit manager's duty to a managed care
4213-organization to exercise its contractual duties. "Conflict of
4214-interest" shall be defined by rule by the Department.
4215-(e) A pharmacy benefit manager shall, upon request,
4216-disclose to the Department the following information:
4217-(1) whether the pharmacy benefit manager has a
4218-contract, agreement, or other arrangement with a
4219-pharmaceutical manufacturer to exclusively dispense or
4220-provide a drug to a managed care organization's enrollees,
4221-and the aggregate amounts of consideration of economic
4222-benefits collected or received pursuant to that
4223-
4224-
4225-arrangement;
4226-(2) the percentage of claims payments made by the
4227-pharmacy benefit manager to pharmacies owned, managed, or
4228-controlled by the pharmacy benefit manager or any of the
4229-pharmacy benefit manager's management companies, parent
4230-companies, subsidiary companies, or jointly held
4231-companies;
4232-(3) the aggregate amount of the fees or assessments
4233-imposed on, or collected from, pharmacy providers; and
4234-(4) the average annualized percentage of revenue
4235-collected by the pharmacy benefit manager as a result of
4236-each contract it has executed with a managed care
4237-organization contracted by the Department to provide
4238-medical assistance benefits which is not paid by the
4239-pharmacy benefit manager to pharmacy providers and
4240-pharmaceutical manufacturers or labelers or in order to
4241-perform administrative functions pursuant to its contracts
4242-with managed care organizations; .
4243-(5) the total number of prescriptions dispensed under
4244-each contract the pharmacy benefit manager has with a
4245-managed care organization (MCO) contracted by the
4246-Department to provide medical assistance benefits;
4247-(6) the aggregate wholesale acquisition cost for drugs
4248-that were dispensed to enrollees in each MCO with which
4249-the pharmacy benefit manager has a contract by any
4250-pharmacy owned, managed, or controlled by the pharmacy
4251-
4252-
4253-benefit manager or any of the pharmacy benefit manager's
4254-management companies, parent companies, subsidiary
4255-companies, or jointly-held companies;
4256-(7) the aggregate amount of administrative fees that
4257-the pharmacy benefit manager received from all
4258-pharmaceutical manufacturers for prescriptions dispensed
4259-to MCO enrollees;
4260-(8) for each MCO with which the pharmacy benefit
4261-manager has a contract, the aggregate amount of payments
4262-received by the pharmacy benefit manager from the MCO;
4263-(9) for each MCO with which the pharmacy benefit
4264-manager has a contract, the aggregate amount of
4265-reimbursements the pharmacy benefit manager paid to
4266-contracting pharmacies; and
4267-(10) any other information considered necessary by the
4268-Department.
4269-(f) The information disclosed under subsection (e) shall
4270-include all retail, mail order, specialty, and compounded
4271-prescription products. All information made available to the
4272-Department under subsection (e) is confidential and not
4273-subject to disclosure under the Freedom of Information Act.
4274-All information made available to the Department under
4275-subsection (e) shall not be reported or distributed in any way
4276-that compromises its competitive, proprietary, or financial
4277-value. The information shall only be used by the Department to
4278-assess the contract, agreement, or other arrangements made
4279-
4280-
4281-between a pharmacy benefit manager and a pharmacy provider,
4282-pharmaceutical manufacturer or labeler, managed care
4283-organization, or other entity, as applicable.
4284-(g) A pharmacy benefit manager shall disclose directly in
4285-writing to a pharmacy provider or pharmacy services
4286-administrative organization contracting with the pharmacy
4287-benefit manager of any material change to a contract provision
4288-that affects the terms of the reimbursement, the process for
4289-verifying benefits and eligibility, dispute resolution,
4290-procedures for verifying drugs included on the formulary, and
4291-contract termination at least 30 days prior to the date of the
4292-change to the provision. The terms of this subsection shall be
4293-deemed met if the pharmacy benefit manager posts the
4294-information on a website, viewable by the public. A pharmacy
4295-service administration organization shall notify all contract
4296-pharmacies of any material change, as described in this
4297-subsection, within 2 days of notification. As used in this
4298-Section, "pharmacy services administrative organization" means
4299-an entity operating within the State that contracts with
4300-independent pharmacies to conduct business on their behalf
4301-with third-party payers. A pharmacy services administrative
4302-organization may provide administrative services to pharmacies
4303-and negotiate and enter into contracts with third-party payers
4304-or pharmacy benefit managers on behalf of pharmacies.
4305-(h) A pharmacy benefit manager shall not include the
4306-following in a contract with a pharmacy provider:
4307-
4308-
4309-(1) a provision prohibiting the provider from
4310-informing a patient of a less costly alternative to a
4311-prescribed medication; or
4312-(2) a provision that prohibits the provider from
4313-dispensing a particular amount of a prescribed medication,
4314-if the pharmacy benefit manager allows that amount to be
4315-dispensed through a pharmacy owned or controlled by the
4316-pharmacy benefit manager, unless the prescription drug is
4317-subject to restricted distribution by the United States
4318-Food and Drug Administration or requires special handling,
4319-provider coordination, or patient education that cannot be
4320-provided by a retail pharmacy.
4321-(h-5) Unless required by law, a Medicaid managed care
4322-organization or pharmacy benefit manager administering or
4323-managing benefits on behalf of a Medicaid managed care
4324-organization shall not refuse to contract with a 340B entity
4325-or 340B pharmacy for refusing to accept less favorable payment
4326-terms or reimbursement methodologies when compared to
4327-similarly situated non-340B entities and shall not include in
4328-a contract with a 340B entity or 340B pharmacy a provision
4329-that:
4330-(1) imposes any fee, chargeback, or rate adjustment
4331-that is not similarly imposed on similarly situated
4332-pharmacies that are not 340B entities or 340B pharmacies;
4333-(2) imposes any fee, chargeback, or rate adjustment
4334-that exceeds the fee, chargeback, or rate adjustment that
4335-
4336-
4337-is not similarly imposed on similarly situated pharmacies
4338-that are not 340B entities or 340B pharmacies;
4339-(3) prevents or interferes with an individual's choice
4340-to receive a prescription drug from a 340B entity or 340B
4341-pharmacy through any legally permissible means;
4342-(4) excludes a 340B entity or 340B pharmacy from a
4343-pharmacy network on the basis of whether the 340B entity
4344-or 340B pharmacy participates in the 340B drug discount
4345-program;
4346-(5) prevents a 340B entity or 340B pharmacy from using
4347-a drug purchased under the 340B drug discount program so
4348-long as the drug recipient is a patient of the 340B entity;
4349-nothing in this Section exempts a 340B pharmacy from
4350-following the Department's preferred drug list or from any
4351-prior approval requirements of the Department or the
4352-Medicaid managed care organization that are imposed on the
4353-drug for all pharmacies; or
4354-(6) any other provision that discriminates against a
4355-340B entity or 340B pharmacy by treating a 340B entity or
4356-340B pharmacy differently than non-340B entities or
4357-non-340B pharmacies for any reason relating to the
4358-entity's participation in the 340B drug discount program.
4359-A provision that violates this subsection in any contract
4360-between a Medicaid managed care organization or its pharmacy
4361-benefit manager and a 340B entity entered into, amended, or
4362-renewed after July 1, 2022 shall be void and unenforceable.
4363-
4364-
4365-In this subsection (h-5):
4366-"340B entity" means a covered entity as defined in 42
4367-U.S.C. 256b(a)(4) authorized to participate in the 340B drug
4368-discount program.
4369-"340B pharmacy" means any pharmacy used to dispense 340B
4370-drugs for a covered entity, whether entity-owned or external.
4371-(i) Nothing in this Section shall be construed to prohibit
4372-a pharmacy benefit manager from requiring the same
4373-reimbursement and terms and conditions for a pharmacy provider
4374-as for a pharmacy owned, controlled, or otherwise associated
4375-with the pharmacy benefit manager.
4376-(j) A pharmacy benefit manager shall establish and
4377-implement a process for the resolution of disputes arising out
4378-of this Section, which shall be approved by the Department.
4379-(k) The Department shall adopt rules establishing
4380-reasonable dispensing fees for fee-for-service payments in
4381-accordance with guidance or guidelines from the federal
4382-Centers for Medicare and Medicaid Services.
4383-(Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21;
4384-102-778, eff. 7-1-22.)
4385-ARTICLE 110.
4386-Section 110-5. The Specialized Mental Health
4387-Rehabilitation Act of 2013 is amended by adding Section 5-113
4388-as follows:
4389-
4390-
4391-(210 ILCS 49/5-113 new)
4392-Sec. 5-113. Specialized mental health rehabilitation
4393-facility; one payment. Notwithstanding any other provision of
4394-this Act to the contrary, beginning January 1, 2025, there
4395-shall be a separate per diem add-on paid solely and
4396-exclusively to facilities licensed under this Act that are
4397-licensed for only single occupancy rooms and have reduced
4398-their licensed capacity. No facility licensed under this Act
4399-shall be eligible for these payments if the facility contains
4400-any rooms that house more than a single occupant and have
4401-failed to reduce the facilities' licensed capacity.
4402-The payment shall be a per diem add-on payment. For
4403-facilities with less than 100 licensed beds, the add-on
4404-payment shall result in a rate not less than $240 per day. For
4405-facilities with 100 licensed beds to 130 licensed beds, the
4406-add-on payment shall result in a rate not less than $230 per
4407-day. For facilities with more than 130 licensed beds, the
4408-add-on payment shall result in a rate of not less than $220 per
4409-day. All add-on rates shall be based upon the new licensed
4410-capacity.
4411-Any additional payments in effect after January 1, 2025
4412-under Section 5-107 shall be paid in addition to the amounts
4413-listed in this Section. Facilities receiving payments under
4414-this Section shall receive payment as prescribed under Section
4415-5-101.
4416-
4417-
4418-ARTICLE 115.
4419-Section 115-5. The Illinois Public Aid Code is amended by
4420-adding Section 5-53 as follows:
4421-(305 ILCS 5/5-53 new)
4422-Sec. 5-53. Coverage for self-measure blood pressure
4423-monitoring services. Subject to federal approval and
4424-notwithstanding any other provision of this Code, for services
4425-on and after January 1, 2025, the following self-measure blood
4426-pressure monitoring services shall be covered and reimbursed
4427-under the medical assistance program for persons who are
4428-otherwise eligible for medical assistance under this Article:
4429-(1) patient education and training services on the
4430-set-up and use of a self-measure blood pressure
4431-measurement device validated for clinical accuracy and
4432-device calibration; and
4433-(2) separate self-measurement readings and the
4434-collection of data reports by the patient or caregiver to
4435-the health care provider in order to communicate blood
4436-pressure readings and create or modify treatment plans.
4437-ARTICLE 120.
4438-(305 ILCS 5/15-6 rep.)
4439-
4440-
4441-Section 120-5. The Illinois Public Aid Code is amended by
4442-repealing Section 15-6.
4443-Article 125.
4444-Section 125-5. The State Finance Act is amended by
4445-changing Section 5.797 as follows:
4446-(30 ILCS 105/5.797)
4447-Sec. 5.797. The Electronic Health Record Incentive Fund.
4448-This Section is repealed on January 1, 2025.
4449-(Source: P.A. 97-169, eff. 7-22-11; 97-813, eff. 7-13-12.)
4450-Section 125-10. The Illinois Public Aid Code is amended by
4451-changing Section 12-10.6a as follows:
4452-(305 ILCS 5/12-10.6a)
4453-Sec. 12-10.6a. The Electronic Health Record Incentive
4454-Fund.
4455-(a) The Electronic Health Record Incentive Fund is a
4456-special fund created in the State treasury. All federal moneys
4457-received by the Department of Healthcare and Family Services
4458-for payments to qualifying health care providers to encourage
4459-the adoption and use of certified electronic health records
4460-technology pursuant to paragraph 1903(t)(1) of the Social
4461-Security Act, shall be deposited into the Fund.
4462-
4463-
4464-(b) Disbursements from the Fund shall be made at the
4465-direction of the Director of Healthcare and Family Services to
4466-qualifying health care providers, in amounts established under
4467-applicable federal regulation (42 CFR 495 et seq.), in order
4468-to encourage the adoption and use of certified electronic
4469-health records technology.
4470-(c) On January 1, 2025, or as soon thereafter as
4471-practical, the State Comptroller shall direct and the State
4472-Treasurer shall transfer the remaining balance from the
4473-Electronic Health Record Incentive Fund into the Public Aid
4474-Recoveries Trust Fund. Upon completion of the transfer, the
4475-Electronic Health Record Incentive Fund is dissolved, and any
4476-future deposits due to that Fund and any outstanding
4477-obligations or liabilities of that Fund shall pass to the
4478-Public Aid Recoveries Trust Fund.
4479-(Source: P.A. 97-169, eff. 7-22-11.)
4480-Article 130.
4481-(30 ILCS 105/5.836 rep.)
4482-Section 130-5. The State Finance Act is amended by
4483-repealing Section 5.836.
4484-(305 ILCS 5/5-31 rep.)
4485-(305 ILCS 5/5-32 rep.)
4486-Section 130-10. The Illinois Public Aid Code is amended by
4487-
4488-
4489-repealing Sections 5-31 and 5-32.
4490-Article 135.
4491-Section 135-5. The State Finance Act is amended by
4492-changing Section 5.481 as follows:
4493-(30 ILCS 105/5.481)
4494-Sec. 5.481. The Juvenile Rehabilitation Services Medicaid
4495-Matching Fund. This Section is repealed on January 1, 2026.
4496-(Source: P.A. 90-587, eff. 7-1-98.)
4497-Section 135-10. The Illinois Public Aid Code is amended by
4498-changing Sections 12-9 and 12-10.4 as follows:
4499-(305 ILCS 5/12-9) (from Ch. 23, par. 12-9)
4500-Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
4501-Public Aid Recoveries Trust Fund shall consist of (1)
4502-recoveries by the Department of Healthcare and Family Services
4503-(formerly Illinois Department of Public Aid) authorized by
4504-this Code in respect to applicants or recipients under
4505-Articles III, IV, V, and VI, including recoveries made by the
4506-Department of Healthcare and Family Services (formerly
4507-Illinois Department of Public Aid) from the estates of
4508-deceased recipients, (2) recoveries made by the Department of
4509-Healthcare and Family Services (formerly Illinois Department
4510-
4511-
4512-of Public Aid) in respect to applicants and recipients under
4513-the Children's Health Insurance Program Act, and the Covering
4514-ALL KIDS Health Insurance Act, (2.5) recoveries made by the
4515-Department of Healthcare and Family Services in connection
4516-with the imposition of an administrative penalty as provided
4517-under Section 12-4.45, (3) federal funds received on behalf of
4518-and earned by State universities, other State agencies or
4519-departments, and local governmental entities for services
4520-provided to applicants or recipients covered under this Code,
4521-the Children's Health Insurance Program Act, and the Covering
4522-ALL KIDS Health Insurance Act, (3.5) federal financial
4523-participation revenue related to eligible disbursements made
4524-by the Department of Healthcare and Family Services from
4525-appropriations required by this Section, and (4) all other
4526-moneys received to the Fund, including interest thereon. The
4527-Fund shall be held as a special fund in the State Treasury.
4528-Disbursements from this Fund shall be only (1) for the
4529-reimbursement of claims collected by the Department of
4530-Healthcare and Family Services (formerly Illinois Department
4531-of Public Aid) through error or mistake, (2) for payment to
4532-persons or agencies designated as payees or co-payees on any
4533-instrument, whether or not negotiable, delivered to the
4534-Department of Healthcare and Family Services (formerly
4535-Illinois Department of Public Aid) as a recovery under this
4536-Section, such payment to be in proportion to the respective
4537-interests of the payees in the amount so collected, (3) for
4538-
4539-
4540-payments to the Department of Human Services for collections
4541-made by the Department of Healthcare and Family Services
4542-(formerly Illinois Department of Public Aid) on behalf of the
4543-Department of Human Services under this Code, the Children's
4544-Health Insurance Program Act, and the Covering ALL KIDS Health
4545-Insurance Act, (4) for payment of administrative expenses
4546-incurred in performing the activities authorized under this
4547-Code, the Children's Health Insurance Program Act, and the
4548-Covering ALL KIDS Health Insurance Act, (5) for payment of
4549-fees to persons or agencies in the performance of activities
4550-pursuant to the collection of monies owed the State that are
4551-collected under this Code, the Children's Health Insurance
4552-Program Act, and the Covering ALL KIDS Health Insurance Act,
4553-(6) for payments of any amounts which are reimbursable to the
4554-federal government which are required to be paid by State
4555-warrant by either the State or federal government, and (7) for
4556-payments to State universities, other State agencies or
4557-departments, and local governmental entities of federal funds
4558-for services provided to applicants or recipients covered
4559-under this Code, the Children's Health Insurance Program Act,
4560-and the Covering ALL KIDS Health Insurance Act. Disbursements
4561-from this Fund for purposes of items (4) and (5) of this
4562-paragraph shall be subject to appropriations from the Fund to
4563-the Department of Healthcare and Family Services (formerly
4564-Illinois Department of Public Aid).
4565-The balance in this Fund after payment therefrom of any
4566-
4567-
4568-amounts reimbursable to the federal government, and minus the
4569-amount reasonably anticipated to be needed to make the
4570-disbursements authorized by this Section during the current
4571-and following 3 calendar months, shall be certified by the
4572-Director of Healthcare and Family Services and transferred by
4573-the State Comptroller to the Drug Rebate Fund or the
4574-Healthcare Provider Relief Fund in the State Treasury, as
4575-appropriate, on at least an annual basis by June 30th of each
4576-fiscal year. The Director of Healthcare and Family Services
4577-may certify and the State Comptroller shall transfer to the
4578-Drug Rebate Fund or the Healthcare Provider Relief Fund
4579-amounts on a more frequent basis.
4580-On July 1, 1999, the State Comptroller shall transfer the
4581-sum of $5,000,000 from the Public Aid Recoveries Trust Fund
4582-(formerly the Public Assistance Recoveries Trust Fund) into
4583-the DHS Recoveries Trust Fund.
4584-(Source: P.A. 97-647, eff. 1-1-12; 97-689, eff. 6-14-12;
4585-98-130, eff. 8-2-13; 98-651, eff. 6-16-14.)
4586-(305 ILCS 5/12-10.4)
4587-Sec. 12-10.4. Juvenile Rehabilitation Services Medicaid
4588-Matching Fund. There is created in the State Treasury the
4589-Juvenile Rehabilitation Services Medicaid Matching Fund.
4590-Deposits to this Fund shall consist of all moneys received
4591-from the federal government for behavioral health services
4592-secured by counties pursuant to an agreement with the
4593-
4594-
4595-Department of Healthcare and Family Services with respect to
4596-Title XIX of the Social Security Act or under the Children's
4597-Health Insurance Program pursuant to the Children's Health
4598-Insurance Program Act and Title XXI of the Social Security Act
4599-for minors who are committed to mental health facilities by
4600-the Illinois court system and for residential placements
4601-secured by the Department of Juvenile Justice for minors as a
4602-condition of their aftercare release.
4603-Disbursements from the Fund shall be made, subject to
4604-appropriation, by the Department of Healthcare and Family
4605-Services for grants to the Department of Juvenile Justice and
4606-those counties which secure behavioral health services ordered
4607-by the courts and which have an interagency agreement with the
4608-Department and submit detailed bills according to standards
4609-determined by the Department.
4610-On January 1, 2026, or as soon thereafter as practical,
4611-the State Comptroller shall direct and the State Treasurer
4612-shall transfer the remaining balance from the Juvenile
4613-Rehabilitation Services Medicaid Matching Fund into the Public
4614-Aid Recoveries Trust Fund. Upon completion of the transfer,
4615-the Juvenile Rehabilitation Services Medicaid Matching Fund is
4616-dissolved, and any future deposits due to that Fund and any
4617-outstanding obligations or liabilities of that Fund shall pass
4618-to the Public Aid Recoveries Trust Fund.
4619-(Source: P.A. 98-558, eff. 1-1-14.)
4620-
4621-
4622-Article 140.
4623-(30 ILCS 105/5.856 rep.)
4624-Section 140-5. The State Finance Act is amended by
4625-repealing Section 5.856.
4626-(305 ILCS 5/Art. V-G rep.)
4627-Section 140-10. The Illinois Public Aid Code is amended by
4628-repealing Article V-G.
4629-Article 145.
4630-Section 145-5. The State Finance Act is amended by
4631-changing Sections 5.409 and 6z-40 as follows:
4632-(30 ILCS 105/5.409)
4633-Sec. 5.409. The Provider Inquiry Trust Fund. This Section
4634-is repealed on January 1, 2025.
4635-(Source: P.A. 89-21, eff. 7-1-95.)
4636-(30 ILCS 105/6z-40)
4637-Sec. 6z-40. Provider Inquiry Trust Fund. The Provider
4638-Inquiry Trust Fund is created as a special fund in the State
4639-treasury. Payments into the fund shall consist of fees or
4640-other moneys owed by providers of services or their agents,
4641-including other State agencies, for access to and utilization
4642-
4643-
4644-of Illinois Department of Healthcare and Family Services
4645-Public Aid eligibility files to verify eligibility of clients,
4646-bills for services, or other similar, related uses.
4647-Disbursements from the fund shall consist of payments to the
4648-Department of Innovation and Technology Central Management
4649-Services for communication and statistical services and for
4650-payments for administrative expenses incurred by the Illinois
4651-Department of Healthcare and Family Services Public Aid in the
4652-operation of the fund.
4653-On January 1, 2025, or as soon thereafter as practical,
4654-the State Comptroller shall direct and the State Treasurer
4655-shall transfer the remaining balance from the Provider Inquiry
4656-Trust Fund into the Healthcare Provider Relief Fund. Upon
4657-completion of the transfer, the Provider Inquiry Trust Fund is
4658-dissolved, and any future deposits due to that Fund and any
4659-outstanding obligations or liabilities of that Fund shall pass
4660-to the Healthcare Provider Relief Fund.
4661-(Source: P.A. 94-91, eff. 7-1-05.)
4662-ARTICLE 150.
4663-Section 150-5. The Illinois Public Aid Code is amended by
4664-changing Section 5-30.1 and by adding Section 5-30.18 as
4665-follows:
4666-(305 ILCS 5/5-30.1)
4667-
4668-
4669-Sec. 5-30.1. Managed care protections.
4670-(a) As used in this Section:
4671-"Managed care organization" or "MCO" means any entity
4672-which contracts with the Department to provide services where
4673-payment for medical services is made on a capitated basis.
4674-"Emergency services" means health care items and services,
4675-including inpatient and outpatient hospital services,
4676-furnished or required to evaluate and stabilize an emergency
4677-medical condition. "Emergency services" include inpatient
4678-stabilization services furnished during the inpatient
4679-stabilization period. "Emergency services" do not include
4680-post-stabilization medical services. include:
4681-(1) emergency services, as defined by Section 10 of
4682-the Managed Care Reform and Patient Rights Act;
4683-(2) emergency medical screening examinations, as
4684-defined by Section 10 of the Managed Care Reform and
4685-Patient Rights Act;
4686-(3) post-stabilization medical services, as defined by
4687-Section 10 of the Managed Care Reform and Patient Rights
4688-Act; and
4689-(4) emergency medical conditions, as defined by
4690-Section 10 of the Managed Care Reform and Patient Rights
4691-Act.
4692-"Emergency medical condition" means a medical condition
4693-manifesting itself by acute symptoms of sufficient severity,
4694-regardless of the final diagnosis given, such that a prudent
4695-
4696-
4697-layperson, who possesses an average knowledge of health and
4698-medicine, could reasonably expect the absence of immediate
4699-medical attention to result in:
4700-(1) placing the health of the individual (or, with
4701-respect to a pregnant woman, the health of the woman or her
4702-unborn child) in serious jeopardy;
4703-(2) serious impairment to bodily functions;
4704-(3) serious dysfunction of any bodily organ or part;
4705-(4) inadequately controlled pain; or
4706-(5) with respect to a pregnant woman who is having
4707-contractions:
4708-(A) inadequate time to complete a safe transfer to
4709-another hospital before delivery; or
4710-(B) a transfer to another hospital may pose a
4711-threat to the health or safety of the woman or unborn
4712-child.
4713-"Emergency medical screening examination" means a medical
4714-screening examination and evaluation by a physician licensed
4715-to practice medicine in all its branches or, to the extent
4716-permitted by applicable laws, by other appropriately licensed
4717-personnel under the supervision of or in collaboration with a
4718-physician licensed to practice medicine in all its branches to
4719-determine whether the need for emergency services exists.
4720-"Health care services" mean any medical or behavioral
4721-health services covered under the medical assistance program
4722-that are subject to review under a service authorization
4723-
4724-
4725-program.
4726-"Inpatient stabilization period" means the initial 72
4727-hours of inpatient stabilization services, beginning from the
4728-date and time of the order for inpatient admission to the
4729-hospital.
4730-"Inpatient stabilization services" mean emergency services
4731-furnished in the inpatient setting at a hospital pursuant to
4732-an order for inpatient admission by a physician or other
4733-qualified practitioner who has admitting privileges at the
4734-hospital, as permitted by State law, to stabilize an emergency
4735-medical condition following an emergency medical screening
4736-examination.
4737-"Post-stabilization medical services" means health care
4738-services provided to an enrollee that are furnished in a
4739-hospital by a provider that is qualified to furnish such
4740-services and determined to be medically necessary by the
4741-provider and directly related to the emergency medical
4742-condition following stabilization.
4743-"Provider" means a facility or individual who is actively
4744-enrolled in the medical assistance program and licensed or
4745-otherwise authorized to order, prescribe, refer, or render
4746-health care services in this State.
4747-"Service authorization determination" means a decision
4748-made by a service authorization program in advance of,
4749-concurrent to, or after the provision of a health care service
4750-to approve, change the level of care, partially deny, deny, or
4751-
4752-
4753-otherwise limit coverage and reimbursement for a health care
4754-service upon review of a service authorization request.
4755-"Service authorization program" means any utilization
4756-review, utilization management, peer review, quality review,
4757-or other medical management activity conducted by an MCO, or
4758-its contracted utilization review organization, including, but
4759-not limited to, prior authorization, prior approval,
4760-pre-certification, concurrent review, retrospective review, or
4761-certification of admission, of health care services provided
4762-in the inpatient or outpatient hospital setting.
4763-"Service authorization request" means a request by a
4764-provider to a service authorization program to determine
4765-whether a health care service meets the reimbursement
4766-eligibility requirements for medically necessary, clinically
4767-appropriate care, resulting in the issuance of a service
4768-authorization determination.
4769-"Utilization review organization" or "URO" means an MCO's
4770-utilization review department or a peer review organization or
4771-quality improvement organization that contracts with an MCO to
4772-administer a service authorization program and make service
4773-authorization determinations.
4774-(b) As provided by Section 5-16.12, managed care
4775-organizations are subject to the provisions of the Managed
4776-Care Reform and Patient Rights Act.
4777-(c) An MCO shall pay any provider of emergency services,
4778-including for inpatient stabilization services provided during
4779-
4780-
4781-the inpatient stabilization period, that does not have in
4782-effect a contract with the contracted Medicaid MCO. The
4783-default rate of reimbursement shall be the rate paid under
4784-Illinois Medicaid fee-for-service program methodology,
4785-including all policy adjusters, including but not limited to
4786-Medicaid High Volume Adjustments, Medicaid Percentage
4787-Adjustments, Outpatient High Volume Adjustments, and all
4788-outlier add-on adjustments to the extent such adjustments are
4789-incorporated in the development of the applicable MCO
4790-capitated rates.
4791-(d) (Blank). An MCO shall pay for all post-stabilization
4792-services as a covered service in any of the following
4793-situations:
4794-(1) the MCO authorized such services;
4795-(2) such services were administered to maintain the
4796-enrollee's stabilized condition within one hour after a
4797-request to the MCO for authorization of further
4798-post-stabilization services;
4799-(3) the MCO did not respond to a request to authorize
4800-such services within one hour;
4801-(4) the MCO could not be contacted; or
4802-(5) the MCO and the treating provider, if the treating
4803-provider is a non-affiliated provider, could not reach an
4804-agreement concerning the enrollee's care and an affiliated
4805-provider was unavailable for a consultation, in which case
4806-the MCO must pay for such services rendered by the
4807-
4808-
4809-treating non-affiliated provider until an affiliated
4810-provider was reached and either concurred with the
4811-treating non-affiliated provider's plan of care or assumed
4812-responsibility for the enrollee's care. Such payment shall
4813-be made at the default rate of reimbursement paid under
4814-Illinois Medicaid fee-for-service program methodology,
4815-including all policy adjusters, including but not limited
4816-to Medicaid High Volume Adjustments, Medicaid Percentage
4817-Adjustments, Outpatient High Volume Adjustments and all
4818-outlier add-on adjustments to the extent that such
4819-adjustments are incorporated in the development of the
4820-applicable MCO capitated rates.
4821-(e) Notwithstanding any other provision of law, the The
4822-following requirements apply to MCOs in determining payment
4823-for all emergency services, including inpatient stabilization
4824-services provided during the inpatient stabilization period:
4825-(1) The MCO MCOs shall not impose any service
4826-authorization program requirements for prior approval of
4827-emergency services, including, but not limited to, prior
4828-authorization, prior approval, pre-certification,
4829-certification of admission, concurrent review, or
4830-retrospective review.
4831-(A) Notification period: Hospitals shall notify
4832-the enrollee's Medicaid MCO within 48 hours of the
4833-date and time the order for inpatient admission is
4834-written. Notification shall be limited to advising the
4835-
4836-
4837-MCO that the patient has been admitted to a hospital
4838-inpatient level of care.
4839-(B) If the admitting hospital complies with the
4840-notification provisions of subparagraph (A), the
4841-Medicaid MCO may not initiate concurrent review before
4842-the end of the inpatient stabilization period. If the
4843-admitting hospital does not comply with the
4844-notification requirements in subparagraph (A), the
4845-Medicaid MCO may initiate concurrent review for the
4846-continuation of the stay beginning at the end of the
4847-48-hour notification period.
4848-(C) Coverage for services provided during the
4849-48-hour notification period may not be retrospectively
4850-denied.
4851-(2) The MCO shall cover emergency services provided to
4852-enrollees who are temporarily away from their residence
4853-and outside the contracting area to the extent that the
4854-enrollees would be entitled to the emergency services if
4855-they still were within the contracting area.
4856-(3) The MCO shall have no obligation to cover
4857-emergency medical services provided on an emergency basis
4858-that are not covered services under the contract between
4859-the MCO and the Department.
4860-(4) The MCO shall not condition coverage for emergency
4861-services on the treating provider notifying the MCO of the
4862-enrollee's emergency medical screening examination and
4863-
4864-
4865-treatment within 10 days after presentation for emergency
4866-services.
4867-(5) The determination of the attending emergency
4868-physician, or the practitioner responsible for the
4869-enrollee's care at the hospital the provider actually
4870-treating the enrollee, of whether an enrollee requires
4871-inpatient stabilization services, can be stabilized in the
4872-outpatient setting, or is sufficiently stabilized for
4873-discharge or transfer to another setting facility, shall
4874-be binding on the MCO. The MCO shall cover and reimburse
4875-providers for emergency services as billed by the provider
4876-for all enrollees whether the emergency services are
4877-provided by an affiliated or non-affiliated provider,
4878-except in cases of fraud. The MCO shall reimburse
4879-inpatient stabilization services provided during the
4880-inpatient stabilization period and billed as inpatient
4881-level of care based on the appropriate inpatient
4882-reimbursement methodology.
4883-(6) The MCO's financial responsibility for
4884-post-stabilization medical care services it has not
4885-pre-approved ends when:
4886-(A) a plan physician with privileges at the
4887-treating hospital assumes responsibility for the
4888-enrollee's care;
4889-(B) a plan physician assumes responsibility for
4890-the enrollee's care through transfer;
4891-
4892-
4893-(C) a contracting entity representative and the
4894-treating physician reach an agreement concerning the
4895-enrollee's care; or
4896-(D) the enrollee is discharged.
4897-(e-5) An MCO shall pay for all post-stabilization medical
4898-services as a covered service in any of the following
4899-situations:
4900-(1) the MCO or its URO authorized such services;
4901-(2) such services were administered to maintain the
4902-enrollee's stabilized condition within one hour after a
4903-request to the MCO for authorization of further
4904-post-stabilization services;
4905-(3) the MCO or its URO did not respond to a request to
4906-authorize such services within one hour;
4907-(4) the MCO or its URO could not be contacted; or
4908-(5) the MCO or its URO and the treating provider, if
4909-the treating provider is a non-affiliated provider, could
4910-not reach an agreement concerning the enrollee's care and
4911-an affiliated provider was unavailable for a consultation,
4912-in which case the MCO must pay for such services rendered
4913-by the treating non-affiliated provider until an
4914-affiliated provider was reached and either concurred with
4915-the treating non-affiliated provider's plan of care or
4916-assumed responsibility for the enrollee's care. Such
4917-payment shall be made at the default rate of reimbursement
4918-paid under the State's Medicaid fee-for-service program
4919-
4920-
4921-methodology, including all policy adjusters, including,
4922-but not limited to, Medicaid High Volume Adjustments,
4923-Medicaid Percentage Adjustments, Outpatient High Volume
4924-Adjustments, and all outlier add-on adjustments to the
4925-extent that such adjustments are incorporated in the
4926-development of the applicable MCO capitated rates.
4927-(f) Network adequacy and transparency.
4928-(1) The Department shall:
4929-(A) ensure that an adequate provider network is in
4930-place, taking into consideration health professional
4931-shortage areas and medically underserved areas;
4932-(B) publicly release an explanation of its process
4933-for analyzing network adequacy;
4934-(C) periodically ensure that an MCO continues to
4935-have an adequate network in place;
4936-(D) require MCOs, including Medicaid Managed Care
4937-Entities as defined in Section 5-30.2, to meet
4938-provider directory requirements under Section 5-30.3;
4939-(E) require MCOs to ensure that any
4940-Medicaid-certified provider under contract with an MCO
4941-and previously submitted on a roster on the date of
4942-service is paid for any medically necessary,
4943-Medicaid-covered, and authorized service rendered to
4944-any of the MCO's enrollees, regardless of inclusion on
4945-the MCO's published and publicly available directory
4946-of available providers; and
4947-
4948-
4949-(F) require MCOs, including Medicaid Managed Care
4950-Entities as defined in Section 5-30.2, to meet each of
4951-the requirements under subsection (d-5) of Section 10
4952-of the Network Adequacy and Transparency Act; with
4953-necessary exceptions to the MCO's network to ensure
4954-that admission and treatment with a provider or at a
4955-treatment facility in accordance with the network
4956-adequacy standards in paragraph (3) of subsection
4957-(d-5) of Section 10 of the Network Adequacy and
4958-Transparency Act is limited to providers or facilities
4959-that are Medicaid certified.
4960-(2) Each MCO shall confirm its receipt of information
4961-submitted specific to physician or dentist additions or
4962-physician or dentist deletions from the MCO's provider
4963-network within 3 days after receiving all required
4964-information from contracted physicians or dentists, and
4965-electronic physician and dental directories must be
4966-updated consistent with current rules as published by the
4967-Centers for Medicare and Medicaid Services or its
4968-successor agency.
4969-(g) Timely payment of claims.
4970-(1) The MCO shall pay a claim within 30 days of
4971-receiving a claim that contains all the essential
4972-information needed to adjudicate the claim.
4973-(2) The MCO shall notify the billing party of its
4974-inability to adjudicate a claim within 30 days of
4975-
4976-
4977-receiving that claim.
4978-(3) The MCO shall pay a penalty that is at least equal
4979-to the timely payment interest penalty imposed under
4980-Section 368a of the Illinois Insurance Code for any claims
4981-not timely paid.
4982-(A) When an MCO is required to pay a timely payment
4983-interest penalty to a provider, the MCO must calculate
4984-and pay the timely payment interest penalty that is
4985-due to the provider within 30 days after the payment of
4986-the claim. In no event shall a provider be required to
4987-request or apply for payment of any owed timely
4988-payment interest penalties.
4989-(B) Such payments shall be reported separately
4990-from the claim payment for services rendered to the
4991-MCO's enrollee and clearly identified as interest
4992-payments.
4993-(4)(A) The Department shall require MCOs to expedite
4994-payments to providers identified on the Department's
4995-expedited provider list, determined in accordance with 89
4996-Ill. Adm. Code 140.71(b), on a schedule at least as
4997-frequently as the providers are paid under the
4998-Department's fee-for-service expedited provider schedule.
4999-(B) Compliance with the expedited provider requirement
5000-may be satisfied by an MCO through the use of a Periodic
5001-Interim Payment (PIP) program that has been mutually
5002-agreed to and documented between the MCO and the provider,
5003-
5004-
5005-if the PIP program ensures that any expedited provider
5006-receives regular and periodic payments based on prior
5007-period payment experience from that MCO. Total payments
5008-under the PIP program may be reconciled against future PIP
5009-payments on a schedule mutually agreed to between the MCO
5010-and the provider.
5011-(C) The Department shall share at least monthly its
5012-expedited provider list and the frequency with which it
5013-pays providers on the expedited list.
5014-(g-5) Recognizing that the rapid transformation of the
5015-Illinois Medicaid program may have unintended operational
5016-challenges for both payers and providers:
5017-(1) in no instance shall a medically necessary covered
5018-service rendered in good faith, based upon eligibility
5019-information documented by the provider, be denied coverage
5020-or diminished in payment amount if the eligibility or
5021-coverage information available at the time the service was
5022-rendered is later found to be inaccurate in the assignment
5023-of coverage responsibility between MCOs or the
5024-fee-for-service system, except for instances when an
5025-individual is deemed to have not been eligible for
5026-coverage under the Illinois Medicaid program; and
5027-(2) the Department shall, by December 31, 2016, adopt
5028-rules establishing policies that shall be included in the
5029-Medicaid managed care policy and procedures manual
5030-addressing payment resolutions in situations in which a
5031-
5032-
5033-provider renders services based upon information obtained
5034-after verifying a patient's eligibility and coverage plan
5035-through either the Department's current enrollment system
5036-or a system operated by the coverage plan identified by
5037-the patient presenting for services:
5038-(A) such medically necessary covered services
5039-shall be considered rendered in good faith;
5040-(B) such policies and procedures shall be
5041-developed in consultation with industry
5042-representatives of the Medicaid managed care health
5043-plans and representatives of provider associations
5044-representing the majority of providers within the
5045-identified provider industry; and
5046-(C) such rules shall be published for a review and
5047-comment period of no less than 30 days on the
5048-Department's website with final rules remaining
5049-available on the Department's website.
5050-The rules on payment resolutions shall include, but
5051-not be limited to:
5052-(A) the extension of the timely filing period;
5053-(B) retroactive prior authorizations; and
5054-(C) guaranteed minimum payment rate of no less
5055-than the current, as of the date of service,
5056-fee-for-service rate, plus all applicable add-ons,
5057-when the resulting service relationship is out of
5058-network.
5059-
5060-
5061-The rules shall be applicable for both MCO coverage
5062-and fee-for-service coverage.
5063-If the fee-for-service system is ultimately determined to
5064-have been responsible for coverage on the date of service, the
5065-Department shall provide for an extended period for claims
5066-submission outside the standard timely filing requirements.
5067-(g-6) MCO Performance Metrics Report.
5068-(1) The Department shall publish, on at least a
5069-quarterly basis, each MCO's operational performance,
5070-including, but not limited to, the following categories of
5071-metrics:
5072-(A) claims payment, including timeliness and
5073-accuracy;
5074-(B) prior authorizations;
5075-(C) grievance and appeals;
5076-(D) utilization statistics;
5077-(E) provider disputes;
5078-(F) provider credentialing; and
5079-(G) member and provider customer service.
5080-(2) The Department shall ensure that the metrics
5081-report is accessible to providers online by January 1,
5082-2017.
5083-(3) The metrics shall be developed in consultation
5084-with industry representatives of the Medicaid managed care
5085-health plans and representatives of associations
5086-representing the majority of providers within the
5087-
5088-
5089-identified industry.
5090-(4) Metrics shall be defined and incorporated into the
5091-applicable Managed Care Policy Manual issued by the
5092-Department.
5093-(g-7) MCO claims processing and performance analysis. In
5094-order to monitor MCO payments to hospital providers, pursuant
5095-to Public Act 100-580, the Department shall post an analysis
5096-of MCO claims processing and payment performance on its
5097-website every 6 months. Such analysis shall include a review
5098-and evaluation of a representative sample of hospital claims
5099-that are rejected and denied for clean and unclean claims and
5100-the top 5 reasons for such actions and timeliness of claims
5101-adjudication, which identifies the percentage of claims
5102-adjudicated within 30, 60, 90, and over 90 days, and the dollar
5103-amounts associated with those claims.
5104-(g-8) Dispute resolution process. The Department shall
5105-maintain a provider complaint portal through which a provider
5106-can submit to the Department unresolved disputes with an MCO.
5107-An unresolved dispute means an MCO's decision that denies in
5108-whole or in part a claim for reimbursement to a provider for
5109-health care services rendered by the provider to an enrollee
5110-of the MCO with which the provider disagrees. Disputes shall
5111-not be submitted to the portal until the provider has availed
5112-itself of the MCO's internal dispute resolution process.
5113-Disputes that are submitted to the MCO internal dispute
5114-resolution process may be submitted to the Department of
5115-
5116-
5117-Healthcare and Family Services' complaint portal no sooner
5118-than 30 days after submitting to the MCO's internal process
5119-and not later than 30 days after the unsatisfactory resolution
5120-of the internal MCO process or 60 days after submitting the
5121-dispute to the MCO internal process. Multiple claim disputes
5122-involving the same MCO may be submitted in one complaint,
5123-regardless of whether the claims are for different enrollees,
5124-when the specific reason for non-payment of the claims
5125-involves a common question of fact or policy. Within 10
5126-business days of receipt of a complaint, the Department shall
5127-present such disputes to the appropriate MCO, which shall then
5128-have 30 days to issue its written proposal to resolve the
5129-dispute. The Department may grant one 30-day extension of this
5130-time frame to one of the parties to resolve the dispute. If the
5131-dispute remains unresolved at the end of this time frame or the
5132-provider is not satisfied with the MCO's written proposal to
5133-resolve the dispute, the provider may, within 30 days, request
5134-the Department to review the dispute and make a final
5135-determination. Within 30 days of the request for Department
5136-review of the dispute, both the provider and the MCO shall
5137-present all relevant information to the Department for
5138-resolution and make individuals with knowledge of the issues
5139-available to the Department for further inquiry if needed.
5140-Within 30 days of receiving the relevant information on the
5141-dispute, or the lapse of the period for submitting such
5142-information, the Department shall issue a written decision on
5143-
5144-
5145-the dispute based on contractual terms between the provider
5146-and the MCO, contractual terms between the MCO and the
5147-Department of Healthcare and Family Services and applicable
5148-Medicaid policy. The decision of the Department shall be
5149-final. By January 1, 2020, the Department shall establish by
5150-rule further details of this dispute resolution process.
5151-Disputes between MCOs and providers presented to the
5152-Department for resolution are not contested cases, as defined
5153-in Section 1-30 of the Illinois Administrative Procedure Act,
5154-conferring any right to an administrative hearing.
5155-(g-9)(1) The Department shall publish annually on its
5156-website a report on the calculation of each managed care
5157-organization's medical loss ratio showing the following:
5158-(A) Premium revenue, with appropriate adjustments.
5159-(B) Benefit expense, setting forth the aggregate
5160-amount spent for the following:
5161-(i) Direct paid claims.
5162-(ii) Subcapitation payments.
5163-(iii) Other claim payments.
5164-(iv) Direct reserves.
5165-(v) Gross recoveries.
5166-(vi) Expenses for activities that improve health
5167-care quality as allowed by the Department.
5168-(2) The medical loss ratio shall be calculated consistent
5169-with federal law and regulation following a claims runout
5170-period determined by the Department.
5171-
5172-
5173-(g-10)(1) "Liability effective date" means the date on
5174-which an MCO becomes responsible for payment for medically
5175-necessary and covered services rendered by a provider to one
5176-of its enrollees in accordance with the contract terms between
5177-the MCO and the provider. The liability effective date shall
5178-be the later of:
5179-(A) The execution date of a network participation
5180-contract agreement.
5181-(B) The date the provider or its representative
5182-submits to the MCO the complete and accurate standardized
5183-roster form for the provider in the format approved by the
5184-Department.
5185-(C) The provider effective date contained within the
5186-Department's provider enrollment subsystem within the
5187-Illinois Medicaid Program Advanced Cloud Technology
5188-(IMPACT) System.
5189-(2) The standardized roster form may be submitted to the
5190-MCO at the same time that the provider submits an enrollment
5191-application to the Department through IMPACT.
5192-(3) By October 1, 2019, the Department shall require all
5193-MCOs to update their provider directory with information for
5194-new practitioners of existing contracted providers within 30
5195-days of receipt of a complete and accurate standardized roster
5196-template in the format approved by the Department provided
5197-that the provider is effective in the Department's provider
5198-enrollment subsystem within the IMPACT system. Such provider
5199-
5200-
5201-directory shall be readily accessible for purposes of
5202-selecting an approved health care provider and comply with all
5203-other federal and State requirements.
5204-(g-11) The Department shall work with relevant
5205-stakeholders on the development of operational guidelines to
5206-enhance and improve operational performance of Illinois'
5207-Medicaid managed care program, including, but not limited to,
5208-improving provider billing practices, reducing claim
5209-rejections and inappropriate payment denials, and
5210-standardizing processes, procedures, definitions, and response
5211-timelines, with the goal of reducing provider and MCO
5212-administrative burdens and conflict. The Department shall
5213-include a report on the progress of these program improvements
5214-and other topics in its Fiscal Year 2020 annual report to the
5215-General Assembly.
5216-(g-12) Notwithstanding any other provision of law, if the
5217-Department or an MCO requires submission of a claim for
5218-payment in a non-electronic format, a provider shall always be
5219-afforded a period of no less than 90 business days, as a
5220-correction period, following any notification of rejection by
5221-either the Department or the MCO to correct errors or
5222-omissions in the original submission.
5223-Under no circumstances, either by an MCO or under the
5224-State's fee-for-service system, shall a provider be denied
5225-payment for failure to comply with any timely submission
5226-requirements under this Code or under any existing contract,
5227-
5228-
5229-unless the non-electronic format claim submission occurs after
5230-the initial 180 days following the latest date of service on
5231-the claim, or after the 90 business days correction period
5232-following notification to the provider of rejection or denial
5233-of payment.
5234-(g-13) Utilization Review Standardization and
5235-Transparency.
5236-(1) To ensure greater standardization and transparency
5237-related to service authorization determinations, for all
5238-individuals covered under the medical assistance program,
5239-including both the fee-for-service and managed care
5240-programs, the Department shall, in consultation with the
5241-MCOs, a statewide association representing the MCOs, a
5242-statewide association representing the majority of
5243-Illinois hospitals, a statewide association representing
5244-physicians, or any other interested parties deemed
5245-appropriate by the Department, adopt administrative rules
5246-consistent with this subsection, in accordance with the
5247-Illinois Administrative Procedure Act.
5248-(2) Prior to July 1, 2025, the Department shall in
5249-accordance with the Illinois Administrative Procedure Act
5250-adopt rules which govern MCO practices for dates of
5251-services on and after July 1, 2025, as follows:
5252-(A) guidelines related to the publication of MCO
5253-authorization policies;
5254-(B) procedures that, due to medical complexity,
5255-
5256-
5257-must be reimbursed under the applicable inpatient
5258-methodology, when provided in the inpatient setting
5259-and billed as an inpatient service;
5260-(C) standardization of administrative forms used
5261-in the member appeal process;
5262-(D) limitations on second or subsequent medical
5263-necessity review of a health care service already
5264-authorized by the MCO or URO under a service
5265-authorization program;
5266-(E) standardization of peer-to-peer processes and
5267-timelines;
5268-(F) defined criteria for urgent and standard
5269-post-acute care service authorization requests; and
5270-(G) standardized criteria for service
5271-authorization programs for authorization of admission
5272-to a long-term acute care hospital.
5273-(3) The Department shall expand the scope of the
5274-quality and compliance audits conducted by its contracted
5275-external quality review organization to include, but not
5276-be limited to:
5277-(A) an analysis of the Medicaid MCO's compliance
5278-with nationally recognized clinical decision
5279-guidelines;
5280-(B) an analysis that compares and contrasts the
5281-Medicaid MCO's service authorization determination
5282-outcomes to the outcomes of each other MCO plan and the
5283-
5284-
5285-State's fee-for-service program model to evaluate
5286-whether service authorization determinations are being
5287-made consistently by all Medicaid MCOs to ensure that
5288-all individuals are being treated in accordance with
5289-equitable standards of care;
5290-(C) an analysis, for each Medicaid MCO, of the
5291-number of service authorization requests, including
5292-requests for concurrent review and certification of
5293-admissions, received, initially denied, overturned
5294-through any post-denial process including, but not
5295-limited to, enrollee or provider appeal, peer-to-peer
5296-review, or the provider dispute resolution process,
5297-denied but approved for a lower or different level of
5298-care, and the number denied on final determination;
5299-and
5300-(D) provide a written report to the General
5301-Assembly, detailing the items listed in this
5302-subsection and any other metrics deemed necessary by
5303-the Department, by the second April, following the
5304-effective date of this amendatory Act of the 103rd
5305-General Assembly, and each April thereafter. The
5306-Department shall make this report available within 30
5307-days of delivery to the General Assembly, on its
5308-public facing website.
5309-(h) The Department shall not expand mandatory MCO
5310-enrollment into new counties beyond those counties already
5311-
5312-
5313-designated by the Department as of June 1, 2014 for the
5314-individuals whose eligibility for medical assistance is not
5315-the seniors or people with disabilities population until the
5316-Department provides an opportunity for accountable care
5317-entities and MCOs to participate in such newly designated
5318-counties.
5319-(h-5) Leading indicator data sharing. By January 1, 2024,
5320-the Department shall obtain input from the Department of Human
5321-Services, the Department of Juvenile Justice, the Department
5322-of Children and Family Services, the State Board of Education,
5323-managed care organizations, providers, and clinical experts to
5324-identify and analyze key indicators from assessments and data
5325-sets available to the Department that can be shared with
5326-managed care organizations and similar care coordination
5327-entities contracted with the Department as leading indicators
5328-for elevated behavioral health crisis risk for children. To
5329-the extent permitted by State and federal law, the identified
5330-leading indicators shall be shared with managed care
5331-organizations and similar care coordination entities
5332-contracted with the Department within 6 months of
5333-identification for the purpose of improving care coordination
5334-with the early detection of elevated risk. Leading indicators
5335-shall be reassessed annually with stakeholder input.
5336-(i) The requirements of this Section apply to contracts
5337-with accountable care entities and MCOs entered into, amended,
5338-or renewed after June 16, 2014 (the effective date of Public
5339-
5340-
5341-Act 98-651).
5342-(j) Health care information released to managed care
5343-organizations. A health care provider shall release to a
5344-Medicaid managed care organization, upon request, and subject
5345-to the Health Insurance Portability and Accountability Act of
5346-1996 and any other law applicable to the release of health
5347-information, the health care information of the MCO's
5348-enrollee, if the enrollee has completed and signed a general
5349-release form that grants to the health care provider
5350-permission to release the recipient's health care information
5351-to the recipient's insurance carrier.
5352-(k) The Department of Healthcare and Family Services,
5353-managed care organizations, a statewide organization
5354-representing hospitals, and a statewide organization
5355-representing safety-net hospitals shall explore ways to
5356-support billing departments in safety-net hospitals.
5357-(l) The requirements of this Section added by Public Act
5358-102-4 shall apply to services provided on or after the first
5359-day of the month that begins 60 days after April 27, 2021 (the
5360-effective date of Public Act 102-4).
5361-(m) Except where otherwise expressly specified, the
5362-requirements of this Section added by this amendatory Act of
5363-the 103rd General Assembly shall apply to services provided on
5364-or after July 1, 2025.
5365-(Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21;
5366-102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff.
5367-
5368-
5369-5-13-22; 103-546, eff. 8-11-23.)
5370-(305 ILCS 5/5-30.18 new)
5371-Sec. 5-30.18. Service authorization program performance.
5372-(a) Definitions. As used in this Section:
5373-"Gold Card provider" means a provider identified by each
5374-Medicaid Managed Care Organization (MCO) as qualified under
5375-the guidelines outlined by the Department in accordance with
5376-subsection (c) and thereby granted a service authorization
5377-exemption when ordering a health care service.
5378-"Health care service" means any medical or behavioral
5379-health service covered under the medical assistance program
5380-that is rendered in the inpatient or outpatient hospital
5381-setting, including hospital-based clinics, and subject to
5382-review under a service authorization program.
5383-"Provider" means an individual actively enrolled in the
5384-medical assistance program and licensed or otherwise
5385-authorized to order, prescribe, refer, or render health care
5386-services in this State, and, as determined by the Department,
5387-may also include hospitals that submit service authorization
5388-requests.
5389-"Service authorization exemption" means an exception
5390-granted by a Medicaid MCO to a provider under which all service
5391-authorization requests for covered health care services,
5392-excluding pharmacy services and durable medical equipment, are
5393-automatically deemed to be medically necessary, clinically
5394-
5395-
5396-appropriate, and approved for reimbursement as ordered.
5397-"Service authorization program" means any utilization
5398-review, utilization management, peer review, quality review,
5399-or other medical management activity conducted in advance of,
5400-concurrent to, or after the provision of a health care service
5401-by a Medicaid MCO, either directly or through a contracted
5402-utilization review organization (URO), including, but not
5403-limited to, prior authorization, pre-certification,
5404-certification of admission, concurrent review, and
5405-retrospective review of health care services.
5406-"Service authorization request" means a request by a
5407-provider to a service authorization program to determine
5408-whether a health care service that is otherwise covered under
5409-the medical assistance program meets the reimbursement
5410-requirements established by the Medicaid MCO, or its
5411-contracted URO, for medically necessary, clinically
5412-appropriate care and to issue a service authorization
5413-determination.
5414-"Utilization review organization" or "URO" means a managed
5415-care organization or other entity that has established or
5416-administers one or more service authorization programs.
5417-(b) In consultation with the Medicaid MCOs, a statewide
5418-association representing managed care organizations, a
5419-statewide association representing the majority of Illinois
5420-hospitals, and a statewide association representing
5421-physicians, the Department shall in accordance with the
5422-
5423-
5424-Illinois Administrative Procedure Act, adopt administrative
5425-rules, consistent with this Section, to require each Medicaid
5426-MCO to identify Gold Card providers with such identification
5427-initially being effective for health care services provided on
5428-and after July 1, 2025.
5429-(c) The Department shall adopt rules, in accordance with
5430-the Illinois Administrative Procedure Act, to implement this
5431-Section that include, but are not limited to, the following
5432-provisions:
5433-(1) Require each Medicaid MCO to provide a service
5434-authorization exemption to a provider if the provider has
5435-submitted at least 50 service authorization requests to
5436-its service authorization program in the preceding
5437-calendar year and the service authorization program
5438-approved at least 90% of all service authorization
5439-requests, regardless of the type of health care services
5440-requested.
5441-(2) Require that service authorization exemptions be
5442-limited to services provided in an inpatient or outpatient
5443-hospital setting inclusive of hospital-based clinics.
5444-Service authorization exemptions under this Section shall
5445-not pertain to pharmacy services and durable medical
5446-equipment and supplies.
5447-(3) The service authorization exemption shall be valid
5448-for at least one year, shall be made by each Medicaid MCO
5449-or its URO, and shall be binding on the Medicaid MCO and
5450-
5451-
5452-its URO.
5453-(4) The provider shall be required to continue to
5454-document medically necessary, clinically appropriate care
5455-and submit such documentation to the Medicaid MCO for the
5456-purpose of continuous performance monitoring. If a
5457-provider fails to maintain the 90% service authorization
5458-standard, as determined on no more frequent a basis than
5459-bi-annually, the provider's service authorization
5460-exemption is subject to temporary or permanent suspension.
5461-(5) Require that each Medicaid MCO publish on its
5462-provider portal a list of all providers that have
5463-qualified for a service authorization exemption or
5464-indicate that a provider has qualified for a service
5465-authorization exemption on its provider-facing provider
5466-roster.
5467-(6) Require that no later than December 1 of each
5468-calendar year, each Medicaid MCO shall provide written
5469-notification to all providers who qualify for a service
5470-authorization exemption, for the subsequent calendar year.
5471-(7) Require that each Medicaid MCO or its URO use the
5472-policies and guidelines published by the Department to
5473-evaluate whether a provider meets the criteria to qualify
5474-for a service authorization exemption and the conditions
5475-under which a service authorization exemption may be
5476-rescinded, including review of the provider's service
5477-authorization determinations during the preceding calendar
5478-
5479-
5480-year.
5481-(8) Require each Medicaid MCO to provide the
5482-Department a list of all providers who were denied a
5483-service authorization exemption or had a previously
5484-granted service authorization exemption suspended, with
5485-such denials being subject to an annual audit conducted by
5486-an independent third-party URO to ensure their
5487-appropriateness.
5488-(A) The independent third-party URO shall issue a
5489-written report consistent with this paragraph.
5490-(B) The independent third-party URO shall not be
5491-owned by, affiliated with, or employed by any Medicaid
5492-MCO or its contracted URO, nor shall it have any
5493-financial interest in the Medicaid MCO's service
5494-authorization exemption program.
5495-(d) Each Medicaid MCO must have a standard method to
5496-accept and process professional claims and facility claims, as
5497-billed by the provider, for a health care service that is
5498-rendered, prescribed, or ordered by a provider granted a
5499-service authorization exemption, except in cases of fraud.
5500-(e) A service authorization program shall not deny,
5501-partially deny, reduce the level of care, or otherwise limit
5502-reimbursement to the rendering or supervising provider,
5503-including the rendering facility, for health care services
5504-ordered by a provider who qualifies for a service
5505-authorization exemption, except in cases of fraud.
5506-
5507-
5508-(f) This Section is repealed on December 31, 2030.
5509-ARTICLE 155.
5510-Section 155-5. The Community-Integrated Living
5511-Arrangements Licensure and Certification Act is amended by
5512-adding Section 13.3 as follows:
5513-(210 ILCS 135/13.3 new)
5514-Sec. 13.3. Community-integrated living arrangement per
5515-diem reimbursement. As used in this Section, "medical absence"
5516-means a situation in which a resident is temporarily absent
5517-from a community-integrated living arrangement to receive
5518-medical treatment or for other reasons that have been
5519-recommended by third-party medical personnel, including, but
5520-not limited to, hospitalizations, placements in short-term
5521-stabilization homes or State-operated facilities, stays in
5522-nursing facilities, rehabilitation in long-term care
5523-facilities, or other absences for legitimate medical reasons.
5524-Beginning January 1, 2025, the Department's Division of
5525-Developmental Disabilities shall provide 100% of the per diem
5526-reimbursement to a 24-hour community-integrated living
5527-arrangement provider for up to 20 days for any resident
5528-requiring a medical absence. During the medical absence, the
5529-provider shall hold the bed for the resident. After the
5530-medical absence, the resident shall return to the
5531-
5532-
5533-community-integrated living arrangement when the resident is
5534-medically able to return in order for the provider to receive
5535-the full per diem reimbursement for the absent days. The per
5536-diem reimbursement shall be in addition to the existing
5537-occupancy factor policy set by the Division of Developmental
5538-Disabilities.
5539-ARTICLE 160.
5540-Section 160-5. The Illinois Public Aid Code is amended by
5541-adding Section 5-5.12f as follows:
5542-(305 ILCS 5/5-5.12f new)
5543-Sec. 5-5.12f. Prescription drugs for mental illness; no
5544-utilization or prior approval mandates.
5545-(a) Notwithstanding any other provision of this Code to
5546-the contrary, except as otherwise provided in subsection (b),
5547-for the purpose of removing barriers to the timely treatment
5548-of serious mental illnesses, prior authorization mandates and
5549-utilization management controls shall not be imposed under the
5550-fee-for-service and managed care medical assistance programs
5551-on any FDA-approved prescription drug that is recognized by a
5552-generally accepted standard medical reference as effective in
5553-the treatment of conditions specified in the most recent
5554-Diagnostic and Statistical Manual of Mental Disorders
5555-published by the American Psychiatric Association if a
5556-
5557-
5558-preferred or non-preferred drug is prescribed to an adult
5559-patient to treat serious mental illness and one of the
5560-following applies:
5561-(1) the patient has changed providers, including, but
5562-not limited to, a change from an inpatient to an
5563-outpatient provider, and is stable on the drug that has
5564-been previously prescribed, and received prior
5565-authorization, if required;
5566-(2) the patient has changed insurance coverage and is
5567-stable on the drug that has been previously prescribed and
5568-received prior authorization under the previous source of
5569-coverage; or
5570-(3) subject to federal law on maximum dosage limits
5571-and safety edits adopted by the Department's Drug and
5572-Therapeutics Board, including those safety edits and
5573-limits needed to comply with federal requirements
5574-contained in 42 CFR 456.703, the patient has previously
5575-been prescribed and obtained prior authorization for the
5576-drug and the prescription modifies the dosage, dosage
5577-frequency, or both, of the drug as part of the same
5578-treatment for which the drug was previously prescribed.
5579-(b) The following safety edits shall be permitted for
5580-prescription drugs covered under this Section:
5581-(1) clinically appropriate drug utilization review
5582-(DUR) edits, including, but not limited to, drug-to-drug,
5583-drug-age, and drug-dose;
5584-
5585-
5586-(2) generic drug substitution if a generic drug is
5587-available for the prescribed medication in the same dosage
5588-and formulation; and
5589-(3) any utilization management control that is
5590-necessary for the Department to comply with any current
5591-consent decrees or federal waivers.
5592-(c) As used in this Section, "serious mental illness"
5593-means any one or more of the following diagnoses and
5594-International Classification of Diseases, Tenth Revision,
5595-Clinical Modification (ICD-10-CM) codes listed by the
5596-Department of Human Services' Division of Mental Health, as
5597-amended, on its official website:
5598-(1) Delusional Disorder (F22)
5599-(2) Brief Psychotic Disorder (F23)
5600-(3) Schizophreniform Disorder (F20.81)
5601-(4) Schizophrenia (F20.9)
5602-(5) Schizoaffective Disorder (F25.x)
5603-(6) Catatonia Associated with Another Mental Disorder
5604-(Catatonia Specifier) (F06.1)
5605-(7) Other Specified Schizophrenia Spectrum and Other
5606-Psychotic Disorder (F28)
5607-(8) Unspecified Schizophrenia Spectrum and Other
5608-Psychotic Disorder (F29)
5609-(9) Bipolar I Disorder (F31.xx)
5610-(10) Bipolar II Disorder (F31.81)
5611-(11) Cyclothymic Disorder (F34.0)
5612-
5613-
5614-(12) Unspecified Bipolar and Related Disorder (F31.9)
5615-(13) Disruptive Mood Dysregulation Disorder (F34.8)
5616-(14) Major Depressive Disorder Single episode (F32.xx)
5617-(15) Major Depressive Disorder, Recurrent episode
5618-(F33.xx)
5619-(16) Obsessive-Compulsive Disorder (F42)
5620-(17) Posttraumatic Stress Disorder (F43.10)
5621-(18) Anorexia Nervosa (F50.0x)
5622-(19) Bulimia Nervosa (F50.2)
5623-(20) Postpartum Depression (F53.0)
5624-(21) Puerperal Psychosis (F53.1)
5625-(22) Factitious Disorder Imposed on Another (F68.A)
5626-(d) Notwithstanding any other provision of law, nothing in
5627-this Section shall not be construed to conflict with Section
5628-1927(a)(1) and (b)(1)(A) of the federal Social Security Act
5629-and any implementing regulations and agreements.
5630-ARTICLE 165.
5631-Section 165-5. The Illinois Public Aid Code is amended by
5632-changing Section 5-5.01a as follows:
5633-(305 ILCS 5/5-5.01a)
5634-Sec. 5-5.01a. Supportive living facilities program.
5635-(a) The Department shall establish and provide oversight
5636-for a program of supportive living facilities that seek to
5637-
5638-
5639-promote resident independence, dignity, respect, and
5640-well-being in the most cost-effective manner.
5641-A supportive living facility is (i) a free-standing
5642-facility or (ii) a distinct physical and operational entity
5643-within a mixed-use building that meets the criteria
5644-established in subsection (d). A supportive living facility
5645-integrates housing with health, personal care, and supportive
5646-services and is a designated setting that offers residents
5647-their own separate, private, and distinct living units.
5648-Sites for the operation of the program shall be selected
5649-by the Department based upon criteria that may include the
5650-need for services in a geographic area, the availability of
5651-funding, and the site's ability to meet the standards.
5652-(b) Beginning July 1, 2014, subject to federal approval,
5653-the Medicaid rates for supportive living facilities shall be
5654-equal to the supportive living facility Medicaid rate
5655-effective on June 30, 2014 increased by 8.85%. Once the
5656-assessment imposed at Article V-G of this Code is determined
5657-to be a permissible tax under Title XIX of the Social Security
5658-Act, the Department shall increase the Medicaid rates for
5659-supportive living facilities effective on July 1, 2014 by
5660-9.09%. The Department shall apply this increase retroactively
5661-to coincide with the imposition of the assessment in Article
5662-V-G of this Code in accordance with the approval for federal
5663-financial participation by the Centers for Medicare and
5664-Medicaid Services.
5665-
5666-
5667-The Medicaid rates for supportive living facilities
5668-effective on July 1, 2017 must be equal to the rates in effect
5669-for supportive living facilities on June 30, 2017 increased by
5670-2.8%.
5671-The Medicaid rates for supportive living facilities
5672-effective on July 1, 2018 must be equal to the rates in effect
5673-for supportive living facilities on June 30, 2018.
5674-Subject to federal approval, the Medicaid rates for
5675-supportive living services on and after July 1, 2019 must be at
5676-least 54.3% of the average total nursing facility services per
5677-diem for the geographic areas defined by the Department while
5678-maintaining the rate differential for dementia care and must
5679-be updated whenever the total nursing facility service per
5680-diems are updated. Beginning July 1, 2022, upon the
5681-implementation of the Patient Driven Payment Model, Medicaid
5682-rates for supportive living services must be at least 54.3% of
5683-the average total nursing services per diem rate for the
5684-geographic areas. For purposes of this provision, the average
5685-total nursing services per diem rate shall include all add-ons
5686-for nursing facilities for the geographic area provided for in
5687-Section 5-5.2. The rate differential for dementia care must be
5688-maintained in these rates and the rates shall be updated
5689-whenever nursing facility per diem rates are updated.
5690-Subject to federal approval, beginning January 1, 2024,
5691-the dementia care rate for supportive living services must be
5692-no less than the non-dementia care supportive living services
5693-
5694-
5695-rate multiplied by 1.5.
5696-(c) The Department may adopt rules to implement this
5697-Section. Rules that establish or modify the services,
5698-standards, and conditions for participation in the program
5699-shall be adopted by the Department in consultation with the
5700-Department on Aging, the Department of Rehabilitation
5701-Services, and the Department of Mental Health and
5702-Developmental Disabilities (or their successor agencies).
5703-(d) Subject to federal approval by the Centers for
5704-Medicare and Medicaid Services, the Department shall accept
5705-for consideration of certification under the program any
5706-application for a site or building where distinct parts of the
5707-site or building are designated for purposes other than the
5708-provision of supportive living services, but only if:
5709-(1) those distinct parts of the site or building are
5710-not designated for the purpose of providing assisted
5711-living services as required under the Assisted Living and
5712-Shared Housing Act;
5713-(2) those distinct parts of the site or building are
5714-completely separate from the part of the building used for
5715-the provision of supportive living program services,
5716-including separate entrances;
5717-(3) those distinct parts of the site or building do
5718-not share any common spaces with the part of the building
5719-used for the provision of supportive living program
5720-services; and
5721-
5722-
5723-(4) those distinct parts of the site or building do
5724-not share staffing with the part of the building used for
5725-the provision of supportive living program services.
5726-(e) Facilities or distinct parts of facilities which are
5727-selected as supportive living facilities and are in good
5728-standing with the Department's rules are exempt from the
5729-provisions of the Nursing Home Care Act and the Illinois
5730-Health Facilities Planning Act.
5731-(f) Section 9817 of the American Rescue Plan Act of 2021
5732-(Public Law 117-2) authorizes a 10% enhanced federal medical
5733-assistance percentage for supportive living services for a
5734-12-month period from April 1, 2021 through March 31, 2022.
5735-Subject to federal approval, including the approval of any
5736-necessary waiver amendments or other federally required
5737-documents or assurances, for a 12-month period the Department
5738-must pay a supplemental $26 per diem rate to all supportive
5739-living facilities with the additional federal financial
5740-participation funds that result from the enhanced federal
5741-medical assistance percentage from April 1, 2021 through March
5742-31, 2022. The Department may issue parameters around how the
5743-supplemental payment should be spent, including quality
5744-improvement activities. The Department may alter the form,
5745-methods, or timeframes concerning the supplemental per diem
5746-rate to comply with any subsequent changes to federal law,
5747-changes made by guidance issued by the federal Centers for
5748-Medicare and Medicaid Services, or other changes necessary to
5749-
5750-
5751-receive the enhanced federal medical assistance percentage.
5752-(g) All applications for the expansion of supportive
5753-living dementia care settings involving sites not approved by
5754-the Department on January 1, 2024 (the effective date of
5755-Public Act 103-102) this amendatory Act of the 103rd General
5756-Assembly may allow new elderly non-dementia units in addition
5757-to new dementia care units. The Department may approve such
5758-applications only if the application has: (1) no more than one
5759-non-dementia care unit for each dementia care unit and (2) the
5760-site is not located within 4 miles of an existing supportive
5761-living program site in Cook County (including the City of
5762-Chicago), not located within 12 miles of an existing
5763-supportive living program site in DuPage County, Kane County,
5764-Lake County, McHenry County, or Will County, or not located
5765-within 25 miles of an existing supportive living program site
5766-in any other county.
5767-(h) As stated in the supportive living program home and
5768-community-based service waiver approved by the federal Centers
5769-for Medicare and Medicaid Services, and beginning July 1,
5770-2025, the Department must maintain the rate add-on implemented
5771-on January 1, 2023 for the provision of 2 meals per day at no
5772-less than $6.15 per day.
5773-(Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
5774-103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
5775-Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)
5776-
5777-
5778-ARTICLE 170.
5779-Section 170-5. The Illinois Public Aid Code is amended by
5780-adding Section 5-2.06a as follows:
5781-(305 ILCS 5/5-2.06a new)
5782-Sec. 5-2.06a. Medically fragile children; reimbursement
5783-for legally responsible family caregivers. By January 1, 2025,
5784-the Department of Healthcare and Family Services shall apply
5785-for a Home and Community-Based Services State Plan amendment
5786-and any federal waiver necessary to reimburse legally
5787-responsible family caregivers as providers of personal care or
5788-home health aide services under the Illinois Title XIX State
5789-Plan Home and Community-Based Services benefit and the home
5790-and community-based services waiver program authorized under
5791-Section 1915(c) of the Social Security Act for persons who are
5792-medically fragile and technology dependent. To be eligible for
5793-reimbursement under this Section, a legally responsible family
5794-caregiver must be a certified nursing assistant or certified
5795-nurse aide and must provide services to a medically fragile
5796-relative who is receiving in-home shift nursing services
5797-coordinated by the University of Illinois at Chicago, Division
5798-of Specialized Care for Children. Upon federal approval of the
5799-State Plan amendment and waiver, the Department shall
5800-promulgate rules that define who qualifies for reimbursement
5801-as a legally responsible family caregiver, specify which
5802-
5803-
5804-personal care and home health aide services are eligible for
5805-reimbursement if the provider is a legally responsible family
5806-caregiver, establish oversight policies to ensure legally
5807-responsible family caregivers meet and comply with licensing
5808-and program requirements, and adopt any other policies or
5809-procedures necessary to implement this Section.
5810-ARTICLE 175.
5811-Section 175-5. The Illinois Public Aid Code is amended by
5812-changing Section 5-5.5 as follows:
5813-(305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5)
5814-Sec. 5-5.5. Elements of Payment Rate.
5815-(a) The Department of Healthcare and Family Services shall
5816-develop a prospective method for determining payment rates for
5817-nursing facility and ICF/DD services in nursing facilities
5818-composed of the following cost elements:
5819-(1) Standard Services, with the cost of this component
5820-being determined by taking into account the actual costs
5821-to the facilities of these services subject to cost
5822-ceilings to be defined in the Department's rules.
5823-(2) Resident Services, with the cost of this component
5824-being determined by taking into account the actual costs,
5825-needs and utilization of these services, as derived from
5826-an assessment of the resident needs in the nursing
5827-
5828-
5829-facilities.
5830-(3) Ancillary Services, with the payment rate being
5831-developed for each individual type of service. Payment
5832-shall be made only when authorized under procedures
5833-developed by the Department of Healthcare and Family
5834-Services.
5835-(4) Nurse's Aide Training, with the cost of this
5836-component being determined by taking into account the
5837-actual cost to the facilities of such training.
5838-(5) Real Estate Taxes, with the cost of this component
5839-being determined by taking into account the figures
5840-contained in the most currently available cost reports
5841-(with no imposition of maximums) updated to the midpoint
5842-of the current rate year for long term care services
5843-rendered between July 1, 1984 and June 30, 1985, and with
5844-the cost of this component being determined by taking into
5845-account the actual 1983 taxes for which the nursing homes
5846-were assessed (with no imposition of maximums) updated to
5847-the midpoint of the current rate year for long term care
5848-services rendered between July 1, 1985 and June 30, 1986.
5849-(b) In developing a prospective method for determining
5850-payment rates for nursing facility and ICF/DD services in
5851-nursing facilities and ICF/DDs, the Department of Healthcare
5852-and Family Services shall consider the following cost
5853-elements:
5854-(1) Reasonable capital cost determined by utilizing
5855-
5856-
5857-incurred interest rate and the current value of the
5858-investment, including land, utilizing composite rates, or
5859-by utilizing such other reasonable cost related methods
5860-determined by the Department. However, beginning with the
5861-rate reimbursement period effective July 1, 1987, the
5862-Department shall be prohibited from establishing,
5863-including, and implementing any depreciation factor in
5864-calculating the capital cost element.
5865-(2) Profit, with the actual amount being produced and
5866-accruing to the providers in the form of a return on their
5867-total investment, on the basis of their ability to
5868-economically and efficiently deliver a type of service.
5869-The method of payment may assure the opportunity for a
5870-profit, but shall not guarantee or establish a specific
5871-amount as a cost.
5872-(c) The Illinois Department may implement the amendatory
5873-changes to this Section made by this amendatory Act of 1991
5874-through the use of emergency rules in accordance with the
5875-provisions of Section 5.02 of the Illinois Administrative
5876-Procedure Act. For purposes of the Illinois Administrative
5877-Procedure Act, the adoption of rules to implement the
5878-amendatory changes to this Section made by this amendatory Act
5879-of 1991 shall be deemed an emergency and necessary for the
5880-public interest, safety and welfare.
5881-(d) No later than January 1, 2001, the Department of
5882-Public Aid shall file with the Joint Committee on
5883-
5884-
5885-Administrative Rules, pursuant to the Illinois Administrative
5886-Procedure Act, a proposed rule, or a proposed amendment to an
5887-existing rule, regarding payment for appropriate services,
5888-including assessment, care planning, discharge planning, and
5889-treatment provided by nursing facilities to residents who have
5890-a serious mental illness.
5891-(e) On and after July 1, 2012, the Department shall reduce
5892-any rate of reimbursement for services or other payments or
5893-alter any methodologies authorized by this Code to reduce any
5894-rate of reimbursement for services or other payments in
5895-accordance with Section 5-5e.
5896-(f) Beginning January 1, 2025, the real estate tax
5897-component of the payment rate shall be updated using the most
5898-recent property tax bill on file with the Department for
5899-facilities licensed under the Nursing Home Care Act and
5900-facilities licensed under the Specialized Mental Health
5901-Rehabilitation Act of 2013. The per diem rate shall be
5902-computed by dividing the real estate tax costs reported in the
5903-cost report inflated to the midpoint of the rate year by the
5904-total number of patient days reported in the same cost report.
5905-Computation of the real estate tax component shall be based on
5906-capital days.
5907-(Source: P.A. 96-1123, eff. 1-1-11; 96-1530, eff. 2-16-11;
5908-97-689, eff. 6-14-12.)
5909-ARTICLE 180.
5910-
5911-
5912-Section 180-5. The Illinois Public Aid Code is amended by
5913-changing Section 5-5.2 as follows:
5914-(305 ILCS 5/5-5.2)
5915-Sec. 5-5.2. Payment.
5916-(a) All nursing facilities that are grouped pursuant to
5917-Section 5-5.1 of this Act shall receive the same rate of
5918-payment for similar services.
5919-(b) It shall be a matter of State policy that the Illinois
5920-Department shall utilize a uniform billing cycle throughout
5921-the State for the long-term care providers.
5922-(c) (Blank).
5923-(c-1) Notwithstanding any other provisions of this Code,
5924-the methodologies for reimbursement of nursing services as
5925-provided under this Article shall no longer be applicable for
5926-bills payable for nursing services rendered on or after a new
5927-reimbursement system based on the Patient Driven Payment Model
5928-(PDPM) has been fully operationalized, which shall take effect
5929-for services provided on or after the implementation of the
5930-PDPM reimbursement system begins. For the purposes of Public
5931-Act 102-1035 this amendatory Act of the 102nd General
5932-Assembly, the implementation date of the PDPM reimbursement
5933-system and all related provisions shall be July 1, 2022 if the
5934-following conditions are met: (i) the Centers for Medicare and
5935-Medicaid Services has approved corresponding changes in the
5936-
5937-
5938-reimbursement system and bed assessment; and (ii) the
5939-Department has filed rules to implement these changes no later
5940-than June 1, 2022. Failure of the Department to file rules to
5941-implement the changes provided in Public Act 102-1035 this
5942-amendatory Act of the 102nd General Assembly no later than
5943-June 1, 2022 shall result in the implementation date being
5944-delayed to October 1, 2022.
5945-(d) The new nursing services reimbursement methodology
5946-utilizing the Patient Driven Payment Model, which shall be
5947-referred to as the PDPM reimbursement system, taking effect
5948-July 1, 2022, upon federal approval by the Centers for
5949-Medicare and Medicaid Services, shall be based on the
5950-following:
5951-(1) The methodology shall be resident-centered,
5952-facility-specific, cost-based, and based on guidance from
5953-the Centers for Medicare and Medicaid Services.
5954-(2) Costs shall be annually rebased and case mix index
5955-quarterly updated. The nursing services methodology will
5956-be assigned to the Medicaid enrolled residents on record
5957-as of 30 days prior to the beginning of the rate period in
5958-the Department's Medicaid Management Information System
5959-(MMIS) as present on the last day of the second quarter
5960-preceding the rate period based upon the Assessment
5961-Reference Date of the Minimum Data Set (MDS).
5962-(3) Regional wage adjustors based on the Health
5963-Service Areas (HSA) groupings and adjusters in effect on
5964-
5965-
5966-April 30, 2012 shall be included, except no adjuster shall
5967-be lower than 1.06.
5968-(4) PDPM nursing case mix indices in effect on March
5969-1, 2022 shall be assigned to each resident class at no less
5970-than 0.7858 of the Centers for Medicare and Medicaid
5971-Services PDPM unadjusted case mix values, in effect on
5972-March 1, 2022.
5973-(5) The pool of funds available for distribution by
5974-case mix and the base facility rate shall be determined
5975-using the formula contained in subsection (d-1).
5976-(6) The Department shall establish a variable per diem
5977-staffing add-on in accordance with the most recent
5978-available federal staffing report, currently the Payroll
5979-Based Journal, for the same period of time, and if
5980-applicable adjusted for acuity using the same quarter's
5981-MDS. The Department shall rely on Payroll Based Journals
5982-provided to the Department of Public Health to make a
5983-determination of non-submission. If the Department is
5984-notified by a facility of missing or inaccurate Payroll
5985-Based Journal data or an incorrect calculation of
5986-staffing, the Department must make a correction as soon as
5987-the error is verified for the applicable quarter.
5988-Beginning October 1, 2024, the staffing percentage
5989-used in the calculation of the per diem staffing add-on
5990-shall be its PDPM STRIVE Staffing Ratio which equals: its
5991-Reported Total Nurse Staffing Hours Per Resident Per Day
5992-
5993-
5994-as published in the most recent federal staffing report
5995-(the Provider Information File), divided by the facility's
5996-PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
5997-Staffing Target is equal to .82 times the facility's
5998-Illinois Adjusted Facility Case-Mix Hours Per Resident Per
5999-Day. A facility's Illinois Adjusted Facility Case Mix
6000-Hours Per Resident Per Day is equal to its Case-Mix Total
6001-Nurse Staffing Hours Per Resident Per Day (as published in
6002-the most recent federal staffing report) times 3.662
6003-(which reflects the national resident days-weighted mean
6004-Reported Total Nurse Staffing Hours Per Resident Per Day
6005-as calculated using the January 2024 federal Provider
6006-Information Files), divided by the national resident
6007-days-weighted mean Reported Total Nurse Staffing Hours Per
6008-Resident Per Day calculated using the most recent federal
6009-Provider Information File.
6010-(6.5) Beginning July 1, 2024, the paid per diem
6011-staffing add-on shall be the paid per diem staffing add-on
6012-in effect April 1, 2024. For dates beginning October 1,
6013-2024 and through September 30, 2025, the denominator for
6014-the staffing percentage shall be the lesser of the
6015-facility's PDPM STRIVE Staffing Target and:
6016-(A) For the quarter beginning October 1, 2024, the
6017-sum of 20% of the facility's PDPM STRIVE Staffing
6018-Target and 80% of the facility's Case-Mix Total Nurse
6019-Staffing Hours Per Resident Per Day (as published in
6020-
6021-
6022-the January 2024 federal staffing report).
6023-(B) For the quarter beginning January 1, 2025, the
6024-sum of 40% of the facility's PDPM STRIVE Staffing
6025-Target and 60% of the facility's Case-Mix Total Nurse
6026-Staffing Hours Per Resident Per Day (as published in
6027-the January 2024 federal staffing report).
6028-(C) For the quarter beginning March 1, 2025, the
6029-sum of 60% of the facility's PDPM STRIVE Staffing
6030-Target and 40% of the facility's Case-Mix Total Nurse
6031-Staffing Hours Per Resident Per Day (as published in
6032-the January 2024 federal staffing report).
6033-(D) For the quarter beginning July 1, 2025, the
6034-sum of 80% of the facility's PDPM STRIVE Staffing
6035-Target and 20% of the facility's Case-Mix Total Nurse
6036-Staffing Hours Per Resident Per Day (as published in
6037-the January 2024 federal staffing report).
6038-Facilities with at least 70% of the staffing
6039-indicated by the STRIVE study shall be paid a per diem
6040-add-on of $9, increasing by equivalent steps for each
6041-whole percentage point until the facilities reach a per
6042-diem of $16.52 $14.88. Facilities with at least 80% of the
6043-staffing indicated by the STRIVE study shall be paid a per
6044-diem add-on of $16.52 $14.88, increasing by equivalent
6045-steps for each whole percentage point until the facilities
6046-reach a per diem add-on of $25.77 $23.80. Facilities with
6047-at least 92% of the staffing indicated by the STRIVE study
6048-
6049-
6050-shall be paid a per diem add-on of $25.77 $23.80,
6051-increasing by equivalent steps for each whole percentage
6052-point until the facilities reach a per diem add-on of
6053-$30.98 $29.75. Facilities with at least 100% of the
6054-staffing indicated by the STRIVE study shall be paid a per
6055-diem add-on of $30.98 $29.75, increasing by equivalent
6056-steps for each whole percentage point until the facilities
6057-reach a per diem add-on of $36.44 $35.70. Facilities with
6058-at least 110% of the staffing indicated by the STRIVE
6059-study shall be paid a per diem add-on of $36.44 $35.70,
6060-increasing by equivalent steps for each whole percentage
6061-point until the facilities reach a per diem add-on of
6062-$38.68. Facilities with at least 125% or higher of the
6063-staffing indicated by the STRIVE study shall be paid a per
6064-diem add-on of $38.68. No Beginning April 1, 2023, no
6065-nursing facility's variable staffing per diem add-on shall
6066-be reduced by more than 5% in 2 consecutive quarters. For
6067-the quarters beginning July 1, 2022 and October 1, 2022,
6068-no facility's variable per diem staffing add-on shall be
6069-calculated at a rate lower than 85% of the staffing
6070-indicated by the STRIVE study. No facility below 70% of
6071-the staffing indicated by the STRIVE study shall receive a
6072-variable per diem staffing add-on after December 31, 2022.
6073-(7) For dates of services beginning July 1, 2022, the
6074-PDPM nursing component per diem for each nursing facility
6075-shall be the product of the facility's (i) statewide PDPM
6076-
6077-
6078-nursing base per diem rate, $92.25, adjusted for the
6079-facility average PDPM case mix index calculated quarterly
6080-and (ii) the regional wage adjuster, and then add the
6081-Medicaid access adjustment as defined in (e-3) of this
6082-Section. Transition rates for services provided between
6083-July 1, 2022 and October 1, 2023 shall be the greater of
6084-the PDPM nursing component per diem or:
6085-(A) for the quarter beginning July 1, 2022, the
6086-RUG-IV nursing component per diem;
6087-(B) for the quarter beginning October 1, 2022, the
6088-sum of the RUG-IV nursing component per diem
6089-multiplied by 0.80 and the PDPM nursing component per
6090-diem multiplied by 0.20;
6091-(C) for the quarter beginning January 1, 2023, the
6092-sum of the RUG-IV nursing component per diem
6093-multiplied by 0.60 and the PDPM nursing component per
6094-diem multiplied by 0.40;
6095-(D) for the quarter beginning April 1, 2023, the
6096-sum of the RUG-IV nursing component per diem
6097-multiplied by 0.40 and the PDPM nursing component per
6098-diem multiplied by 0.60;
6099-(E) for the quarter beginning July 1, 2023, the
6100-sum of the RUG-IV nursing component per diem
6101-multiplied by 0.20 and the PDPM nursing component per
6102-diem multiplied by 0.80; or
6103-(F) for the quarter beginning October 1, 2023 and
6104-
6105-
6106-each subsequent quarter, the transition rate shall end
6107-and a nursing facility shall be paid 100% of the PDPM
6108-nursing component per diem.
6109-(d-1) Calculation of base year Statewide RUG-IV nursing
6110-base per diem rate.
6111-(1) Base rate spending pool shall be:
6112-(A) The base year resident days which are
6113-calculated by multiplying the number of Medicaid
6114-residents in each nursing home as indicated in the MDS
6115-data defined in paragraph (4) by 365.
6116-(B) Each facility's nursing component per diem in
6117-effect on July 1, 2012 shall be multiplied by
6118-subsection (A).
6119-(C) Thirteen million is added to the product of
6120-subparagraph (A) and subparagraph (B) to adjust for
6121-the exclusion of nursing homes defined in paragraph
6122-(5).
6123-(2) For each nursing home with Medicaid residents as
6124-indicated by the MDS data defined in paragraph (4),
6125-weighted days adjusted for case mix and regional wage
6126-adjustment shall be calculated. For each home this
6127-calculation is the product of:
6128-(A) Base year resident days as calculated in
6129-subparagraph (A) of paragraph (1).
6130-(B) The nursing home's regional wage adjustor
6131-based on the Health Service Areas (HSA) groupings and
6132-
6133-
6134-adjustors in effect on April 30, 2012.
6135-(C) Facility weighted case mix which is the number
6136-of Medicaid residents as indicated by the MDS data
6137-defined in paragraph (4) multiplied by the associated
6138-case weight for the RUG-IV 48 grouper model using
6139-standard RUG-IV procedures for index maximization.
6140-(D) The sum of the products calculated for each
6141-nursing home in subparagraphs (A) through (C) above
6142-shall be the base year case mix, rate adjusted
6143-weighted days.
6144-(3) The Statewide RUG-IV nursing base per diem rate:
6145-(A) on January 1, 2014 shall be the quotient of the
6146-paragraph (1) divided by the sum calculated under
6147-subparagraph (D) of paragraph (2);
6148-(B) on and after July 1, 2014 and until July 1,
6149-2022, shall be the amount calculated under
6150-subparagraph (A) of this paragraph (3) plus $1.76; and
6151-(C) beginning July 1, 2022 and thereafter, $7
6152-shall be added to the amount calculated under
6153-subparagraph (B) of this paragraph (3) of this
6154-Section.
6155-(4) Minimum Data Set (MDS) comprehensive assessments
6156-for Medicaid residents on the last day of the quarter used
6157-to establish the base rate.
6158-(5) Nursing facilities designated as of July 1, 2012
6159-by the Department as "Institutions for Mental Disease"
6160-
6161-
6162-shall be excluded from all calculations under this
6163-subsection. The data from these facilities shall not be
6164-used in the computations described in paragraphs (1)
6165-through (4) above to establish the base rate.
6166-(e) Beginning July 1, 2014, the Department shall allocate
6167-funding in the amount up to $10,000,000 for per diem add-ons to
6168-the RUGS methodology for dates of service on and after July 1,
6169-2014:
6170-(1) $0.63 for each resident who scores in I4200
6171-Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
6172-(2) $2.67 for each resident who scores either a "1" or
6173-"2" in any items S1200A through S1200I and also scores in
6174-RUG groups PA1, PA2, BA1, or BA2.
6175-(e-1) (Blank).
6176-(e-2) For dates of services beginning January 1, 2014 and
6177-ending September 30, 2023, the RUG-IV nursing component per
6178-diem for a nursing home shall be the product of the statewide
6179-RUG-IV nursing base per diem rate, the facility average case
6180-mix index, and the regional wage adjustor. For dates of
6181-service beginning July 1, 2022 and ending September 30, 2023,
6182-the Medicaid access adjustment described in subsection (e-3)
6183-shall be added to the product.
6184-(e-3) A Medicaid Access Adjustment of $4 adjusted for the
6185-facility average PDPM case mix index calculated quarterly
6186-shall be added to the statewide PDPM nursing per diem for all
6187-facilities with annual Medicaid bed days of at least 70% of all
6188-
6189-
6190-occupied bed days adjusted quarterly. For each new calendar
6191-year and for the 6-month period beginning July 1, 2022, the
6192-percentage of a facility's occupied bed days comprised of
6193-Medicaid bed days shall be determined by the Department
6194-quarterly. For dates of service beginning January 1, 2023, the
6195-Medicaid Access Adjustment shall be increased to $4.75. This
6196-subsection shall be inoperative on and after January 1, 2028.
6197-(e-4) Subject to federal approval, on and after January 1,
6198-2024, the Department shall increase the rate add-on at
6199-paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
6200-for ventilator services from $208 per day to $481 per day.
6201-Payment is subject to the criteria and requirements under 89
6202-Ill. Adm. Code 147.335.
6203-(f) (Blank).
6204-(g) Notwithstanding any other provision of this Code, on
6205-and after July 1, 2012, for facilities not designated by the
6206-Department of Healthcare and Family Services as "Institutions
6207-for Mental Disease", rates effective May 1, 2011 shall be
6208-adjusted as follows:
6209-(1) (Blank);
6210-(2) (Blank);
6211-(3) Facility rates for the capital and support
6212-components shall be reduced by 1.7%.
6213-(h) Notwithstanding any other provision of this Code, on
6214-and after July 1, 2012, nursing facilities designated by the
6215-Department of Healthcare and Family Services as "Institutions
6216-
6217-
6218-for Mental Disease" and "Institutions for Mental Disease" that
6219-are facilities licensed under the Specialized Mental Health
6220-Rehabilitation Act of 2013 shall have the nursing,
6221-socio-developmental, capital, and support components of their
6222-reimbursement rate effective May 1, 2011 reduced in total by
6223-2.7%.
6224-(i) On and after July 1, 2014, the reimbursement rates for
6225-the support component of the nursing facility rate for
6226-facilities licensed under the Nursing Home Care Act as skilled
6227-or intermediate care facilities shall be the rate in effect on
6228-June 30, 2014 increased by 8.17%.
6229-(i-1) Subject to federal approval, on and after January 1,
6230-2024, the reimbursement rates for the support component of the
6231-nursing facility rate for facilities licensed under the
6232-Nursing Home Care Act as skilled or intermediate care
6233-facilities shall be the rate in effect on June 30, 2023
6234-increased by 12%.
6235-(j) Notwithstanding any other provision of law, subject to
6236-federal approval, effective July 1, 2019, sufficient funds
6237-shall be allocated for changes to rates for facilities
6238-licensed under the Nursing Home Care Act as skilled nursing
6239-facilities or intermediate care facilities for dates of
6240-services on and after July 1, 2019: (i) to establish, through
6241-June 30, 2022 a per diem add-on to the direct care per diem
6242-rate not to exceed $70,000,000 annually in the aggregate
6243-taking into account federal matching funds for the purpose of
6244-
6245-
6246-addressing the facility's unique staffing needs, adjusted
6247-quarterly and distributed by a weighted formula based on
6248-Medicaid bed days on the last day of the second quarter
6249-preceding the quarter for which the rate is being adjusted.
6250-Beginning July 1, 2022, the annual $70,000,000 described in
6251-the preceding sentence shall be dedicated to the variable per
6252-diem add-on for staffing under paragraph (6) of subsection
6253-(d); and (ii) in an amount not to exceed $170,000,000 annually
6254-in the aggregate taking into account federal matching funds to
6255-permit the support component of the nursing facility rate to
6256-be updated as follows:
6257-(1) 80%, or $136,000,000, of the funds shall be used
6258-to update each facility's rate in effect on June 30, 2019
6259-using the most recent cost reports on file, which have had
6260-a limited review conducted by the Department of Healthcare
6261-and Family Services and will not hold up enacting the rate
6262-increase, with the Department of Healthcare and Family
6263-Services.
6264-(2) After completing the calculation in paragraph (1),
6265-any facility whose rate is less than the rate in effect on
6266-June 30, 2019 shall have its rate restored to the rate in
6267-effect on June 30, 2019 from the 20% of the funds set
6268-aside.
6269-(3) The remainder of the 20%, or $34,000,000, shall be
6270-used to increase each facility's rate by an equal
6271-percentage.
6272-
6273-
6274-(k) During the first quarter of State Fiscal Year 2020,
6275-the Department of Healthcare of Family Services must convene a
6276-technical advisory group consisting of members of all trade
6277-associations representing Illinois skilled nursing providers
6278-to discuss changes necessary with federal implementation of
6279-Medicare's Patient-Driven Payment Model. Implementation of
6280-Medicare's Patient-Driven Payment Model shall, by September 1,
6281-2020, end the collection of the MDS data that is necessary to
6282-maintain the current RUG-IV Medicaid payment methodology. The
6283-technical advisory group must consider a revised reimbursement
6284-methodology that takes into account transparency,
6285-accountability, actual staffing as reported under the
6286-federally required Payroll Based Journal system, changes to
6287-the minimum wage, adequacy in coverage of the cost of care, and
6288-a quality component that rewards quality improvements.
6289-(l) The Department shall establish per diem add-on
6290-payments to improve the quality of care delivered by
6291-facilities, including:
6292-(1) Incentive payments determined by facility
6293-performance on specified quality measures in an initial
6294-amount of $70,000,000. Nothing in this subsection shall be
6295-construed to limit the quality of care payments in the
6296-aggregate statewide to $70,000,000, and, if quality of
6297-care has improved across nursing facilities, the
6298-Department shall adjust those add-on payments accordingly.
6299-The quality payment methodology described in this
6300-
6301-
6302-subsection must be used for at least State Fiscal Year
6303-2023. Beginning with the quarter starting July 1, 2023,
6304-the Department may add, remove, or change quality metrics
6305-and make associated changes to the quality payment
6306-methodology as outlined in subparagraph (E). Facilities
6307-designated by the Centers for Medicare and Medicaid
6308-Services as a special focus facility or a hospital-based
6309-nursing home do not qualify for quality payments.
6310-(A) Each quality pool must be distributed by
6311-assigning a quality weighted score for each nursing
6312-home which is calculated by multiplying the nursing
6313-home's quality base period Medicaid days by the
6314-nursing home's star rating weight in that period.
6315-(B) Star rating weights are assigned based on the
6316-nursing home's star rating for the LTS quality star
6317-rating. As used in this subparagraph, "LTS quality
6318-star rating" means the long-term stay quality rating
6319-for each nursing facility, as assigned by the Centers
6320-for Medicare and Medicaid Services under the Five-Star
6321-Quality Rating System. The rating is a number ranging
6322-from 0 (lowest) to 5 (highest).
6323-(i) Zero-star or one-star rating has a weight
6324-of 0.
6325-(ii) Two-star rating has a weight of 0.75.
6326-(iii) Three-star rating has a weight of 1.5.
6327-(iv) Four-star rating has a weight of 2.5.
6328-
6329-
6330-(v) Five-star rating has a weight of 3.5.
6331-(C) Each nursing home's quality weight score is
6332-divided by the sum of all quality weight scores for
6333-qualifying nursing homes to determine the proportion
6334-of the quality pool to be paid to the nursing home.
6335-(D) The quality pool is no less than $70,000,000
6336-annually or $17,500,000 per quarter. The Department
6337-shall publish on its website the estimated payments
6338-and the associated weights for each facility 45 days
6339-prior to when the initial payments for the quarter are
6340-to be paid. The Department shall assign each facility
6341-the most recent and applicable quarter's STAR value
6342-unless the facility notifies the Department within 15
6343-days of an issue and the facility provides reasonable
6344-evidence demonstrating its timely compliance with
6345-federal data submission requirements for the quarter
6346-of record. If such evidence cannot be provided to the
6347-Department, the STAR rating assigned to the facility
6348-shall be reduced by one from the prior quarter.
6349-(E) The Department shall review quality metrics
6350-used for payment of the quality pool and make
6351-recommendations for any associated changes to the
6352-methodology for distributing quality pool payments in
6353-consultation with associations representing long-term
6354-care providers, consumer advocates, organizations
6355-representing workers of long-term care facilities, and
6356-
6357-
6358-payors. The Department may establish, by rule, changes
6359-to the methodology for distributing quality pool
6360-payments.
6361-(F) The Department shall disburse quality pool
6362-payments from the Long-Term Care Provider Fund on a
6363-monthly basis in amounts proportional to the total
6364-quality pool payment determined for the quarter.
6365-(G) The Department shall publish any changes in
6366-the methodology for distributing quality pool payments
6367-prior to the beginning of the measurement period or
6368-quality base period for any metric added to the
6369-distribution's methodology.
6370-(2) Payments based on CNA tenure, promotion, and CNA
6371-training for the purpose of increasing CNA compensation.
6372-It is the intent of this subsection that payments made in
6373-accordance with this paragraph be directly incorporated
6374-into increased compensation for CNAs. As used in this
6375-paragraph, "CNA" means a certified nursing assistant as
6376-that term is described in Section 3-206 of the Nursing
6377-Home Care Act, Section 3-206 of the ID/DD Community Care
6378-Act, and Section 3-206 of the MC/DD Act. The Department
6379-shall establish, by rule, payments to nursing facilities
6380-equal to Medicaid's share of the tenure wage increments
6381-specified in this paragraph for all reported CNA employee
6382-hours compensated according to a posted schedule
6383-consisting of increments at least as large as those
6384-
6385-
6386-specified in this paragraph. The increments are as
6387-follows: an additional $1.50 per hour for CNAs with at
6388-least one and less than 2 years' experience plus another
6389-$1 per hour for each additional year of experience up to a
6390-maximum of $6.50 for CNAs with at least 6 years of
6391-experience. For purposes of this paragraph, Medicaid's
6392-share shall be the ratio determined by paid Medicaid bed
6393-days divided by total bed days for the applicable time
6394-period used in the calculation. In addition, and additive
6395-to any tenure increments paid as specified in this
6396-paragraph, the Department shall establish, by rule,
6397-payments supporting Medicaid's share of the
6398-promotion-based wage increments for CNA employee hours
6399-compensated for that promotion with at least a $1.50
6400-hourly increase. Medicaid's share shall be established as
6401-it is for the tenure increments described in this
6402-paragraph. Qualifying promotions shall be defined by the
6403-Department in rules for an expected 10-15% subset of CNAs
6404-assigned intermediate, specialized, or added roles such as
6405-CNA trainers, CNA scheduling "captains", and CNA
6406-specialists for resident conditions like dementia or
6407-memory care or behavioral health.
6408-(m) The Department shall work with nursing facility
6409-industry representatives to design policies and procedures to
6410-permit facilities to address the integrity of data from
6411-federal reporting sites used by the Department in setting
6412-
6413-
6414-facility rates.
6415-(Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
6416-102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
6417-Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
6418-Section 50-5, eff. 1-1-24; revised 12-15-23.)
6419-ARTICLE 185.
6420-Section 185-5. The Illinois Public Aid Code is amended by
6421-changing Section 5-5a.1 as follows:
6422-(305 ILCS 5/5-5a.1)
6423-Sec. 5-5a.1. Telehealth services for persons with
6424-intellectual and developmental disabilities. The Department
6425-shall file an amendment to the Home and Community-Based
6426-Services Waiver Program for Adults with Developmental
6427-Disabilities authorized under Section 1915(c) of the Social
6428-Security Act to incorporate telehealth services administered
6429-by a provider of telehealth services that demonstrates
6430-knowledge and experience in providing medical and emergency
6431-services for persons with intellectual and developmental
6432-disabilities. For dates of service on and after January 1,
6433-2025, the Department shall pay negotiated, agreed upon
6434-administrative fees associated with implementing telehealth
6435-services for persons with intellectual and developmental
6436-disabilities who are receiving Community Integrated Living
6437-
6438-
6439-Arrangement residential services under the Home and
6440-Community-Based Services Waiver Program for Adults with
6441-Developmental Disabilities. The implementation of telehealth
6442-services shall not impede the choice of any individual
6443-receiving waiver-funded services through the Home and
6444-Community-Based Services Waiver Program for Adults with
6445-Developmental Disabilities to receive in-person health care
6446-services at any time. The Department shall ensure individuals
6447-enrolled in the waiver, or their guardians, request to opt-in
6448-to these services. For individuals who opt in, this service
6449-shall be included in the individual's person-centered plan.
6450-The use of telehealth services shall not be used for the
6451-convenience of staff at any time nor shall it replace primary
6452-care physician services. The Department shall pay
6453-administrative fees associated with implementing telehealth
6454-services for all persons with intellectual and developmental
6455-disabilities who are receiving services under the Home and
6456-Community-Based Services Waiver Program for Adults with
6457-Developmental Disabilities.
6458-(Source: P.A. 103-102, eff. 7-1-23.)
6459-ARTICLE 190.
6460-Section 190-5. The Pharmacy Practice Act is amended by
6461-changing Sections 3 and 9.6 as follows:
6462-
6463-
6464-(225 ILCS 85/3)
6465-(Section scheduled to be repealed on January 1, 2028)
6466-Sec. 3. Definitions. For the purpose of this Act, except
6467-where otherwise limited therein:
6468-(a) "Pharmacy" or "drugstore" means and includes every
6469-store, shop, pharmacy department, or other place where
6470-pharmacist care is provided by a pharmacist (1) where drugs,
6471-medicines, or poisons are dispensed, sold or offered for sale
6472-at retail, or displayed for sale at retail; or (2) where
6473-prescriptions of physicians, dentists, advanced practice
6474-registered nurses, physician assistants, veterinarians,
6475-podiatric physicians, or optometrists, within the limits of
6476-their licenses, are compounded, filled, or dispensed; or (3)
6477-which has upon it or displayed within it, or affixed to or used
6478-in connection with it, a sign bearing the word or words
6479-"Pharmacist", "Druggist", "Pharmacy", "Pharmaceutical Care",
6480-"Apothecary", "Drugstore", "Medicine Store", "Prescriptions",
6481-"Drugs", "Dispensary", "Medicines", or any word or words of
6482-similar or like import, either in the English language or any
6483-other language; or (4) where the characteristic prescription
6484-sign (Rx) or similar design is exhibited; or (5) any store, or
6485-shop, or other place with respect to which any of the above
6486-words, objects, signs or designs are used in any
6487-advertisement.
6488-(b) "Drugs" means and includes (1) articles recognized in
6489-the official United States Pharmacopoeia/National Formulary
6490-
6491-
6492-(USP/NF), or any supplement thereto and being intended for and
6493-having for their main use the diagnosis, cure, mitigation,
6494-treatment or prevention of disease in man or other animals, as
6495-approved by the United States Food and Drug Administration,
6496-but does not include devices or their components, parts, or
6497-accessories; and (2) all other articles intended for and
6498-having for their main use the diagnosis, cure, mitigation,
6499-treatment or prevention of disease in man or other animals, as
6500-approved by the United States Food and Drug Administration,
6501-but does not include devices or their components, parts, or
6502-accessories; and (3) articles (other than food) having for
6503-their main use and intended to affect the structure or any
6504-function of the body of man or other animals; and (4) articles
6505-having for their main use and intended for use as a component
6506-or any articles specified in clause (1), (2) or (3); but does
6507-not include devices or their components, parts or accessories.
6508-(c) "Medicines" means and includes all drugs intended for
6509-human or veterinary use approved by the United States Food and
6510-Drug Administration.
6511-(d) "Practice of pharmacy" means:
6512-(1) the interpretation and the provision of assistance
6513-in the monitoring, evaluation, and implementation of
6514-prescription drug orders;
6515-(2) the dispensing of prescription drug orders;
6516-(3) participation in drug and device selection;
6517-(4) drug administration limited to the administration
6518-
6519-
6520-of oral, topical, injectable, and inhalation as follows:
6521-(A) in the context of patient education on the
6522-proper use or delivery of medications;
6523-(B) vaccination of patients 7 years of age and
6524-older pursuant to a valid prescription or standing
6525-order, by a physician licensed to practice medicine in
6526-all its branches, except for vaccinations covered by
6527-paragraph (15), upon completion of appropriate
6528-training, including how to address contraindications
6529-and adverse reactions set forth by rule, with
6530-notification to the patient's physician and
6531-appropriate record retention, or pursuant to hospital
6532-pharmacy and therapeutics committee policies and
6533-procedures. Eligible vaccines are those listed on the
6534-U.S. Centers for Disease Control and Prevention (CDC)
6535-Recommended Immunization Schedule, the CDC's Health
6536-Information for International Travel, or the U.S. Food
6537-and Drug Administration's Vaccines Licensed and
6538-Authorized for Use in the United States. As applicable
6539-to the State's Medicaid program and other payers,
6540-vaccines ordered and administered in accordance with
6541-this subsection shall be covered and reimbursed at no
6542-less than the rate that the vaccine is reimbursed when
6543-ordered and administered by a physician;
6544-(B-5) following the initial administration of
6545-long-acting or extended-release form opioid
6546-
6547-
6548-antagonists by a physician licensed to practice
6549-medicine in all its branches, administration of
6550-injections of long-acting or extended-release form
6551-opioid antagonists for the treatment of substance use
6552-disorder, pursuant to a valid prescription by a
6553-physician licensed to practice medicine in all its
6554-branches, upon completion of appropriate training,
6555-including how to address contraindications and adverse
6556-reactions, including, but not limited to, respiratory
6557-depression and the performance of cardiopulmonary
6558-resuscitation, set forth by rule, with notification to
6559-the patient's physician and appropriate record
6560-retention, or pursuant to hospital pharmacy and
6561-therapeutics committee policies and procedures;
6562-(C) administration of injections of
6563-alpha-hydroxyprogesterone caproate, pursuant to a
6564-valid prescription, by a physician licensed to
6565-practice medicine in all its branches, upon completion
6566-of appropriate training, including how to address
6567-contraindications and adverse reactions set forth by
6568-rule, with notification to the patient's physician and
6569-appropriate record retention, or pursuant to hospital
6570-pharmacy and therapeutics committee policies and
6571-procedures; and
6572-(D) administration of injections of long-term
6573-antipsychotic medications pursuant to a valid
6574-
6575-
6576-prescription by a physician licensed to practice
6577-medicine in all its branches, upon completion of
6578-appropriate training conducted by an Accreditation
6579-Council of Pharmaceutical Education accredited
6580-provider, including how to address contraindications
6581-and adverse reactions set forth by rule, with
6582-notification to the patient's physician and
6583-appropriate record retention, or pursuant to hospital
6584-pharmacy and therapeutics committee policies and
6585-procedures.
6586-(5) (blank);
6587-(6) drug regimen review;
6588-(7) drug or drug-related research;
6589-(8) the provision of patient counseling;
6590-(9) the practice of telepharmacy;
6591-(10) the provision of those acts or services necessary
6592-to provide pharmacist care;
6593-(11) medication therapy management;
6594-(12) the responsibility for compounding and labeling
6595-of drugs and devices (except labeling by a manufacturer,
6596-repackager, or distributor of non-prescription drugs and
6597-commercially packaged legend drugs and devices), proper
6598-and safe storage of drugs and devices, and maintenance of
6599-required records;
6600-(13) the assessment and consultation of patients and
6601-dispensing of hormonal contraceptives;
6602-
6603-
6604-(14) the initiation, dispensing, or administration of
6605-drugs, laboratory tests, assessments, referrals, and
6606-consultations for human immunodeficiency virus
6607-pre-exposure prophylaxis and human immunodeficiency virus
6608-post-exposure prophylaxis under Section 43.5;
6609-(15) vaccination of patients 7 years of age and older
6610-for COVID-19 or influenza subcutaneously, intramuscularly,
6611-or orally as authorized, approved, or licensed by the
6612-United States Food and Drug Administration, pursuant to
6613-the following conditions:
6614-(A) the vaccine must be authorized or licensed by
6615-the United States Food and Drug Administration;
6616-(B) the vaccine must be ordered and administered
6617-according to the Advisory Committee on Immunization
6618-Practices standard immunization schedule;
6619-(C) the pharmacist must complete a course of
6620-training accredited by the Accreditation Council on
6621-Pharmacy Education or a similar health authority or
6622-professional body approved by the Division of
6623-Professional Regulation;
6624-(D) the pharmacist must have a current certificate
6625-in basic cardiopulmonary resuscitation;
6626-(E) the pharmacist must complete, during each
6627-State licensing period, a minimum of 2 hours of
6628-immunization-related continuing pharmacy education
6629-approved by the Accreditation Council on Pharmacy
6630-
6631-
6632-Education;
6633-(F) the pharmacist must comply with recordkeeping
6634-and reporting requirements of the jurisdiction in
6635-which the pharmacist administers vaccines, including
6636-informing the patient's primary-care provider, when
6637-available, and complying with requirements whereby the
6638-person administering a vaccine must review the vaccine
6639-registry or other vaccination records prior to
6640-administering the vaccine; and
6641-(G) the pharmacist must inform the pharmacist's
6642-patients who are less than 18 years old, as well as the
6643-adult caregiver accompanying the child, of the
6644-importance of a well-child visit with a pediatrician
6645-or other licensed primary-care provider and must refer
6646-patients as appropriate;
6647-(16) the ordering and administration of COVID-19
6648-therapeutics subcutaneously, intramuscularly, or orally
6649-with notification to the patient's physician and
6650-appropriate record retention or pursuant to hospital
6651-pharmacy and therapeutics committee policies and
6652-procedures. Eligible therapeutics are those approved,
6653-authorized, or licensed by the United States Food and Drug
6654-Administration and must be administered subcutaneously,
6655-intramuscularly, or orally in accordance with that
6656-approval, authorization, or licensing; and
6657-(17) the ordering and administration of point of care
6658-
6659-
6660-tests, and screenings, and treatments for (i) influenza,
6661-(ii) SARS-CoV-2 SARS-COV 2, (iii) Group A Streptococcus,
6662-(iv) respiratory syncytial virus, (v) adult-stage head
6663-louse, and (vi) (iii) health conditions identified by a
6664-statewide public health emergency, as defined in the
6665-Illinois Emergency Management Agency Act, with
6666-notification to the patient's physician, if any, and
6667-appropriate record retention or pursuant to hospital
6668-pharmacy and therapeutics committee policies and
6669-procedures. Eligible tests and screenings are those
6670-approved, authorized, or licensed by the United States
6671-Food and Drug Administration and must be administered in
6672-accordance with that approval, authorization, or
6673-licensing.
6674-A pharmacist who orders or administers tests or
6675-screenings for health conditions described in this
6676-paragraph may use a test that may guide clinical
6677-decision-making for the health condition that is waived
6678-under the federal Clinical Laboratory Improvement
6679-Amendments of 1988 and regulations promulgated thereunder
6680-or any established screening procedure that is established
6681-under a statewide protocol.
6682-A pharmacist may delegate the administrative and
6683-technical tasks of performing a test for the health
6684-conditions described in this paragraph to a registered
6685-pharmacy technician or student pharmacist acting under the
6686-
6687-
6688-supervision of the pharmacist.
6689-The testing, screening, and treatment ordered under
6690-this paragraph by a pharmacist shall not be denied
6691-reimbursement under health benefit plans that are within
6692-the scope of the pharmacist's license and shall be covered
6693-as if the services or procedures were performed by a
6694-physician, an advanced practice registered nurse, or a
6695-physician assistant.
6696-A pharmacy benefit manager, health carrier, health
6697-benefit plan, or third-party payor shall not discriminate
6698-against a pharmacy or a pharmacist with respect to
6699-participation referral, reimbursement of a covered
6700-service, or indemnification if a pharmacist is acting
6701-within the scope of the pharmacist's license and the
6702-pharmacy is operating in compliance with all applicable
6703-laws and rules.
6704-A pharmacist who performs any of the acts defined as the
6705-practice of pharmacy in this State must be actively licensed
6706-as a pharmacist under this Act.
6707-(e) "Prescription" means and includes any written, oral,
6708-facsimile, or electronically transmitted order for drugs or
6709-medical devices, issued by a physician licensed to practice
6710-medicine in all its branches, dentist, veterinarian, podiatric
6711-physician, or optometrist, within the limits of his or her
6712-license, by a physician assistant in accordance with
6713-subsection (f) of Section 4, or by an advanced practice
6714-
6715-
6716-registered nurse in accordance with subsection (g) of Section
6717-4, containing the following: (1) name of the patient; (2) date
6718-when prescription was issued; (3) name and strength of drug or
6719-description of the medical device prescribed; and (4)
6720-quantity; (5) directions for use; (6) prescriber's name,
6721-address, and signature; and (7) DEA registration number where
6722-required, for controlled substances. The prescription may, but
6723-is not required to, list the illness, disease, or condition
6724-for which the drug or device is being prescribed. DEA
6725-registration numbers shall not be required on inpatient drug
6726-orders. A prescription for medication other than controlled
6727-substances shall be valid for up to 15 months from the date
6728-issued for the purpose of refills, unless the prescription
6729-states otherwise.
6730-(f) "Person" means and includes a natural person,
6731-partnership, association, corporation, government entity, or
6732-any other legal entity.
6733-(g) "Department" means the Department of Financial and
6734-Professional Regulation.
6735-(h) "Board of Pharmacy" or "Board" means the State Board
6736-of Pharmacy of the Department of Financial and Professional
6737-Regulation.
6738-(i) "Secretary" means the Secretary of Financial and
6739-Professional Regulation.
6740-(j) "Drug product selection" means the interchange for a
6741-prescribed pharmaceutical product in accordance with Section
6742-
6743-
6744-25 of this Act and Section 3.14 of the Illinois Food, Drug and
6745-Cosmetic Act.
6746-(k) "Inpatient drug order" means an order issued by an
6747-authorized prescriber for a resident or patient of a facility
6748-licensed under the Nursing Home Care Act, the ID/DD Community
6749-Care Act, the MC/DD Act, the Specialized Mental Health
6750-Rehabilitation Act of 2013, the Hospital Licensing Act, or the
6751-University of Illinois Hospital Act, or a facility which is
6752-operated by the Department of Human Services (as successor to
6753-the Department of Mental Health and Developmental
6754-Disabilities) or the Department of Corrections.
6755-(k-5) "Pharmacist" means an individual health care
6756-professional and provider currently licensed by this State to
6757-engage in the practice of pharmacy.
6758-(l) "Pharmacist in charge" means the licensed pharmacist
6759-whose name appears on a pharmacy license and who is
6760-responsible for all aspects of the operation related to the
6761-practice of pharmacy.
6762-(m) "Dispense" or "dispensing" means the interpretation,
6763-evaluation, and implementation of a prescription drug order,
6764-including the preparation and delivery of a drug or device to a
6765-patient or patient's agent in a suitable container
6766-appropriately labeled for subsequent administration to or use
6767-by a patient in accordance with applicable State and federal
6768-laws and regulations. "Dispense" or "dispensing" does not mean
6769-the physical delivery to a patient or a patient's
6770-
6771-
6772-representative in a home or institution by a designee of a
6773-pharmacist or by common carrier. "Dispense" or "dispensing"
6774-also does not mean the physical delivery of a drug or medical
6775-device to a patient or patient's representative by a
6776-pharmacist's designee within a pharmacy or drugstore while the
6777-pharmacist is on duty and the pharmacy is open.
6778-(n) "Nonresident pharmacy" means a pharmacy that is
6779-located in a state, commonwealth, or territory of the United
6780-States, other than Illinois, that delivers, dispenses, or
6781-distributes, through the United States Postal Service,
6782-commercially acceptable parcel delivery service, or other
6783-common carrier, to Illinois residents, any substance which
6784-requires a prescription.
6785-(o) "Compounding" means the preparation and mixing of
6786-components, excluding flavorings, (1) as the result of a
6787-prescriber's prescription drug order or initiative based on
6788-the prescriber-patient-pharmacist relationship in the course
6789-of professional practice or (2) for the purpose of, or
6790-incident to, research, teaching, or chemical analysis and not
6791-for sale or dispensing. "Compounding" includes the preparation
6792-of drugs or devices in anticipation of receiving prescription
6793-drug orders based on routine, regularly observed dispensing
6794-patterns. Commercially available products may be compounded
6795-for dispensing to individual patients only if all of the
6796-following conditions are met: (i) the commercial product is
6797-not reasonably available from normal distribution channels in
6798-
6799-
6800-a timely manner to meet the patient's needs and (ii) the
6801-prescribing practitioner has requested that the drug be
6802-compounded.
6803-(p) (Blank).
6804-(q) (Blank).
6805-(r) "Patient counseling" means the communication between a
6806-pharmacist or a student pharmacist under the supervision of a
6807-pharmacist and a patient or the patient's representative about
6808-the patient's medication or device for the purpose of
6809-optimizing proper use of prescription medications or devices.
6810-"Patient counseling" may include without limitation (1)
6811-obtaining a medication history; (2) acquiring a patient's
6812-allergies and health conditions; (3) facilitation of the
6813-patient's understanding of the intended use of the medication;
6814-(4) proper directions for use; (5) significant potential
6815-adverse events; (6) potential food-drug interactions; and (7)
6816-the need to be compliant with the medication therapy. A
6817-pharmacy technician may only participate in the following
6818-aspects of patient counseling under the supervision of a
6819-pharmacist: (1) obtaining medication history; (2) providing
6820-the offer for counseling by a pharmacist or student
6821-pharmacist; and (3) acquiring a patient's allergies and health
6822-conditions.
6823-(s) "Patient profiles" or "patient drug therapy record"
6824-means the obtaining, recording, and maintenance of patient
6825-prescription information, including prescriptions for
6826-
6827-
6828-controlled substances, and personal information.
6829-(t) (Blank).
6830-(u) "Medical device" or "device" means an instrument,
6831-apparatus, implement, machine, contrivance, implant, in vitro
6832-reagent, or other similar or related article, including any
6833-component part or accessory, required under federal law to
6834-bear the label "Caution: Federal law requires dispensing by or
6835-on the order of a physician". A seller of goods and services
6836-who, only for the purpose of retail sales, compounds, sells,
6837-rents, or leases medical devices shall not, by reasons
6838-thereof, be required to be a licensed pharmacy.
6839-(v) "Unique identifier" means an electronic signature,
6840-handwritten signature or initials, thumb print, or other
6841-acceptable biometric or electronic identification process as
6842-approved by the Department.
6843-(w) "Current usual and customary retail price" means the
6844-price that a pharmacy charges to a non-third-party payor.
6845-(x) "Automated pharmacy system" means a mechanical system
6846-located within the confines of the pharmacy or remote location
6847-that performs operations or activities, other than compounding
6848-or administration, relative to storage, packaging, dispensing,
6849-or distribution of medication, and which collects, controls,
6850-and maintains all transaction information.
6851-(y) "Drug regimen review" means and includes the
6852-evaluation of prescription drug orders and patient records for
6853-(1) known allergies; (2) drug or potential therapy
6854-
6855-
6856-contraindications; (3) reasonable dose, duration of use, and
6857-route of administration, taking into consideration factors
6858-such as age, gender, and contraindications; (4) reasonable
6859-directions for use; (5) potential or actual adverse drug
6860-reactions; (6) drug-drug interactions; (7) drug-food
6861-interactions; (8) drug-disease contraindications; (9)
6862-therapeutic duplication; (10) patient laboratory values when
6863-authorized and available; (11) proper utilization (including
6864-over or under utilization) and optimum therapeutic outcomes;
6865-and (12) abuse and misuse.
6866-(z) "Electronically transmitted prescription" means a
6867-prescription that is created, recorded, or stored by
6868-electronic means; issued and validated with an electronic
6869-signature; and transmitted by electronic means directly from
6870-the prescriber to a pharmacy. An electronic prescription is
6871-not an image of a physical prescription that is transferred by
6872-electronic means from computer to computer, facsimile to
6873-facsimile, or facsimile to computer.
6874-(aa) "Medication therapy management services" means a
6875-distinct service or group of services offered by licensed
6876-pharmacists, physicians licensed to practice medicine in all
6877-its branches, advanced practice registered nurses authorized
6878-in a written agreement with a physician licensed to practice
6879-medicine in all its branches, or physician assistants
6880-authorized in guidelines by a supervising physician that
6881-optimize therapeutic outcomes for individual patients through
6882-
6883-
6884-improved medication use. In a retail or other non-hospital
6885-pharmacy, medication therapy management services shall consist
6886-of the evaluation of prescription drug orders and patient
6887-medication records to resolve conflicts with the following:
6888-(1) known allergies;
6889-(2) drug or potential therapy contraindications;
6890-(3) reasonable dose, duration of use, and route of
6891-administration, taking into consideration factors such as
6892-age, gender, and contraindications;
6893-(4) reasonable directions for use;
6894-(5) potential or actual adverse drug reactions;
6895-(6) drug-drug interactions;
6896-(7) drug-food interactions;
6897-(8) drug-disease contraindications;
6898-(9) identification of therapeutic duplication;
6899-(10) patient laboratory values when authorized and
6900-available;
6901-(11) proper utilization (including over or under
6902-utilization) and optimum therapeutic outcomes; and
6903-(12) drug abuse and misuse.
6904-"Medication therapy management services" includes the
6905-following:
6906-(1) documenting the services delivered and
6907-communicating the information provided to patients'
6908-prescribers within an appropriate time frame, not to
6909-exceed 48 hours;
6910-
6911-
6912-(2) providing patient counseling designed to enhance a
6913-patient's understanding and the appropriate use of his or
6914-her medications; and
6915-(3) providing information, support services, and
6916-resources designed to enhance a patient's adherence with
6917-his or her prescribed therapeutic regimens.
6918-"Medication therapy management services" may also include
6919-patient care functions authorized by a physician licensed to
6920-practice medicine in all its branches for his or her
6921-identified patient or groups of patients under specified
6922-conditions or limitations in a standing order from the
6923-physician.
6924-"Medication therapy management services" in a licensed
6925-hospital may also include the following:
6926-(1) reviewing assessments of the patient's health
6927-status; and
6928-(2) following protocols of a hospital pharmacy and
6929-therapeutics committee with respect to the fulfillment of
6930-medication orders.
6931-(bb) "Pharmacist care" means the provision by a pharmacist
6932-of medication therapy management services, with or without the
6933-dispensing of drugs or devices, intended to achieve outcomes
6934-that improve patient health, quality of life, and comfort and
6935-enhance patient safety.
6936-(cc) "Protected health information" means individually
6937-identifiable health information that, except as otherwise
6938-
6939-
6940-provided, is:
6941-(1) transmitted by electronic media;
6942-(2) maintained in any medium set forth in the
6943-definition of "electronic media" in the federal Health
6944-Insurance Portability and Accountability Act; or
6945-(3) transmitted or maintained in any other form or
6946-medium.
6947-"Protected health information" does not include
6948-individually identifiable health information found in:
6949-(1) education records covered by the federal Family
6950-Educational Right and Privacy Act; or
6951-(2) employment records held by a licensee in its role
6952-as an employer.
6953-(dd) "Standing order" means a specific order for a patient
6954-or group of patients issued by a physician licensed to
6955-practice medicine in all its branches in Illinois.
6956-(ee) "Address of record" means the designated address
6957-recorded by the Department in the applicant's application file
6958-or licensee's license file maintained by the Department's
6959-licensure maintenance unit.
6960-(ff) "Home pharmacy" means the location of a pharmacy's
6961-primary operations.
6962-(gg) "Email address of record" means the designated email
6963-address recorded by the Department in the applicant's
6964-application file or the licensee's license file, as maintained
6965-by the Department's licensure maintenance unit.
6966-
6967-
6968-(Source: P.A. 102-16, eff. 6-17-21; 102-103, eff. 1-1-22;
6969-102-558, eff. 8-20-21; 102-813, eff. 5-13-22; 102-1051, eff.
6970-1-1-23; 103-1, eff. 4-27-23.)
6971-(225 ILCS 85/9.6)
6972-Sec. 9.6. Administration of vaccines and therapeutics by
6973-registered pharmacy technicians and student pharmacists.
6974-(a) Under the supervision of an appropriately trained
6975-pharmacist, a registered pharmacy technician or student
6976-pharmacist may administer COVID-19, SARS-CoV-2, respiratory
6977-syncytial virus, and influenza vaccines subcutaneously,
6978-intramuscularly, or orally as authorized, approved, or
6979-licensed by the United States Food and Drug Administration,
6980-subject to the following conditions:
6981-(1) the vaccination must be ordered by the supervising
6982-pharmacist;
6983-(2) the supervising pharmacist must be readily and
6984-immediately available to the immunizing pharmacy
6985-technician or student pharmacist;
6986-(3) the pharmacy technician or student pharmacist must
6987-complete a practical training program that is approved by
6988-the Accreditation Council for Pharmacy Education and that
6989-includes hands-on injection technique training and
6990-training in the recognition and treatment of emergency
6991-reactions to vaccines;
6992-(4) the pharmacy technician or student pharmacist must
6993-
6994-
6995-have a current certificate in basic cardiopulmonary
6996-resuscitation;
6997-(5) the pharmacy technician or student pharmacist must
6998-complete, during the relevant licensing period, a minimum
6999-of 2 hours of immunization-related continuing pharmacy
7000-education that is approved by the Accreditation Council
7001-for Pharmacy Education;
7002-(6) the supervising pharmacist must comply with all
7003-relevant recordkeeping and reporting requirements;
7004-(7) the supervising pharmacist must be responsible for
7005-complying with requirements related to reporting adverse
7006-events;
7007-(8) the supervising pharmacist must review the vaccine
7008-registry or other vaccination records prior to ordering
7009-the vaccination to be administered by the pharmacy
7010-technician or student pharmacist;
7011-(9) the pharmacy technician or student pharmacist
7012-must, if the patient is 18 years of age or younger, inform
7013-the patient and the adult caregiver accompanying the
7014-patient of the importance of a well-child visit with a
7015-pediatrician or other licensed primary-care provider and
7016-must refer patients as appropriate;
7017-(10) in the case of a COVID-19 vaccine, the
7018-vaccination must be ordered and administered according to
7019-the Advisory Committee on Immunization Practices' COVID-19
7020-vaccine recommendations;
7021-
7022-
7023-(11) in the case of a COVID-19 vaccine, the
7024-supervising pharmacist must comply with any applicable
7025-requirements or conditions of use as set forth in the
7026-Centers for Disease Control and Prevention COVID-19
7027-vaccination provider agreement and any other federal
7028-requirements that apply to the administration of COVID-19
7029-vaccines being administered; and
7030-(12) the registered pharmacy technician or student
7031-pharmacist and the supervising pharmacist must comply with
7032-all other requirements of this Act and the rules adopted
7033-thereunder pertaining to the administration of drugs.
7034-(b) Under the supervision of an appropriately trained
7035-pharmacist, a registered pharmacy technician or student
7036-pharmacist may administer COVID-19 therapeutics
7037-subcutaneously, intramuscularly, or orally as authorized,
7038-approved, or licensed by the United States Food and Drug
7039-Administration, subject to the following conditions:
7040-(1) the COVID-19 therapeutic must be authorized,
7041-approved or licensed by the United States Food and Drug
7042-Administration;
7043-(2) the COVID-19 therapeutic must be administered
7044-subcutaneously, intramuscularly, or orally in accordance
7045-with the United States Food and Drug Administration
7046-approval, authorization, or licensing;
7047-(3) a pharmacy technician or student pharmacist
7048-practicing pursuant to this Section must complete a
7049-
7050-
7051-practical training program that is approved by the
7052-Accreditation Council for Pharmacy Education and that
7053-includes hands-on injection technique training, clinical
7054-evaluation of indications and contraindications of
7055-COVID-19 therapeutics training, training in the
7056-recognition and treatment of emergency reactions to
7057-COVID-19 therapeutics, and any additional training
7058-required in the United States Food and Drug Administration
7059-approval, authorization, or licensing;
7060-(4) the pharmacy technician or student pharmacist must
7061-have a current certificate in basic cardiopulmonary
7062-resuscitation;
7063-(5) the pharmacy technician or student pharmacist must
7064-comply with any applicable requirements or conditions of
7065-use that apply to the administration of COVID-19
7066-therapeutics;
7067-(6) the supervising pharmacist must comply with all
7068-relevant recordkeeping and reporting requirements;
7069-(7) the supervising pharmacist must be readily and
7070-immediately available to the pharmacy technician or
7071-student pharmacist; and
7072-(8) the registered pharmacy technician or student
7073-pharmacist and the supervising pharmacist must comply with
7074-all other requirements of this Act and the rules adopted
7075-thereunder pertaining to the administration of drugs.
7076-(Source: P.A. 103-1, eff. 4-27-23.)
7077-
7078-
7079-ARTICLE 999.
31+SB3268 Enrolled- 2 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 2 - LRB103 39338 KTG 69500 b
32+ SB3268 Enrolled - 2 - LRB103 39338 KTG 69500 b
33+1 to practice dentistry or dental surgery; for purposes of this
34+2 item (10), "dental services" means diagnostic, preventive, or
35+3 corrective procedures provided by or under the supervision of
36+4 a dentist in the practice of his or her profession; (11)
37+5 physical therapy and related services; (12) prescribed drugs,
38+6 dentures, and prosthetic devices; and eyeglasses prescribed by
39+7 a physician skilled in the diseases of the eye, or by an
40+8 optometrist, whichever the person may select; (13) other
41+9 diagnostic, screening, preventive, and rehabilitative
42+10 services, including to ensure that the individual's need for
43+11 intervention or treatment of mental disorders or substance use
44+12 disorders or co-occurring mental health and substance use
45+13 disorders is determined using a uniform screening, assessment,
46+14 and evaluation process inclusive of criteria, for children and
47+15 adults; for purposes of this item (13), a uniform screening,
48+16 assessment, and evaluation process refers to a process that
49+17 includes an appropriate evaluation and, as warranted, a
50+18 referral; "uniform" does not mean the use of a singular
51+19 instrument, tool, or process that all must utilize; (14)
52+20 transportation and such other expenses as may be necessary;
53+21 (15) medical treatment of sexual assault survivors, as defined
54+22 in Section 1a of the Sexual Assault Survivors Emergency
55+23 Treatment Act, for injuries sustained as a result of the
56+24 sexual assault, including examinations and laboratory tests to
57+25 discover evidence which may be used in criminal proceedings
58+26 arising from the sexual assault; (16) the diagnosis and
59+
60+
61+
62+
63+
64+ SB3268 Enrolled - 2 - LRB103 39338 KTG 69500 b
65+
66+
67+SB3268 Enrolled- 3 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 3 - LRB103 39338 KTG 69500 b
68+ SB3268 Enrolled - 3 - LRB103 39338 KTG 69500 b
69+1 treatment of sickle cell anemia; (16.5) services performed by
70+2 a chiropractic physician licensed under the Medical Practice
71+3 Act of 1987 and acting within the scope of his or her license,
72+4 including, but not limited to, chiropractic manipulative
73+5 treatment; and (17) any other medical care, and any other type
74+6 of remedial care recognized under the laws of this State. The
75+7 term "any other type of remedial care" shall include nursing
76+8 care and nursing home service for persons who rely on
77+9 treatment by spiritual means alone through prayer for healing.
78+10 Notwithstanding any other provision of this Section, a
79+11 comprehensive tobacco use cessation program that includes
80+12 purchasing prescription drugs or prescription medical devices
81+13 approved by the Food and Drug Administration shall be covered
82+14 under the medical assistance program under this Article for
83+15 persons who are otherwise eligible for assistance under this
84+16 Article.
85+17 Notwithstanding any other provision of this Code,
86+18 reproductive health care that is otherwise legal in Illinois
87+19 shall be covered under the medical assistance program for
88+20 persons who are otherwise eligible for medical assistance
89+21 under this Article.
90+22 Notwithstanding any other provision of this Section, all
91+23 tobacco cessation medications approved by the United States
92+24 Food and Drug Administration and all individual and group
93+25 tobacco cessation counseling services and telephone-based
94+26 counseling services and tobacco cessation medications provided
95+
96+
97+
98+
99+
100+ SB3268 Enrolled - 3 - LRB103 39338 KTG 69500 b
101+
102+
103+SB3268 Enrolled- 4 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 4 - LRB103 39338 KTG 69500 b
104+ SB3268 Enrolled - 4 - LRB103 39338 KTG 69500 b
105+1 through the Illinois Tobacco Quitline shall be covered under
106+2 the medical assistance program for persons who are otherwise
107+3 eligible for assistance under this Article. The Department
108+4 shall comply with all federal requirements necessary to obtain
109+5 federal financial participation, as specified in 42 CFR
110+6 433.15(b)(7), for telephone-based counseling services provided
111+7 through the Illinois Tobacco Quitline, including, but not
112+8 limited to: (i) entering into a memorandum of understanding or
113+9 interagency agreement with the Department of Public Health, as
114+10 administrator of the Illinois Tobacco Quitline; and (ii)
115+11 developing a cost allocation plan for Medicaid-allowable
116+12 Illinois Tobacco Quitline services in accordance with 45 CFR
117+13 95.507. The Department shall submit the memorandum of
118+14 understanding or interagency agreement, the cost allocation
119+15 plan, and all other necessary documentation to the Centers for
120+16 Medicare and Medicaid Services for review and approval.
121+17 Coverage under this paragraph shall be contingent upon federal
122+18 approval.
123+19 Notwithstanding any other provision of this Code, the
124+20 Illinois Department may not require, as a condition of payment
125+21 for any laboratory test authorized under this Article, that a
126+22 physician's handwritten signature appear on the laboratory
127+23 test order form. The Illinois Department may, however, impose
128+24 other appropriate requirements regarding laboratory test order
129+25 documentation.
130+26 Upon receipt of federal approval of an amendment to the
131+
132+
133+
134+
135+
136+ SB3268 Enrolled - 4 - LRB103 39338 KTG 69500 b
137+
138+
139+SB3268 Enrolled- 5 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 5 - LRB103 39338 KTG 69500 b
140+ SB3268 Enrolled - 5 - LRB103 39338 KTG 69500 b
141+1 Illinois Title XIX State Plan for this purpose, the Department
142+2 shall authorize the Chicago Public Schools (CPS) to procure a
143+3 vendor or vendors to manufacture eyeglasses for individuals
144+4 enrolled in a school within the CPS system. CPS shall ensure
145+5 that its vendor or vendors are enrolled as providers in the
146+6 medical assistance program and in any capitated Medicaid
147+7 managed care entity (MCE) serving individuals enrolled in a
148+8 school within the CPS system. Under any contract procured
149+9 under this provision, the vendor or vendors must serve only
150+10 individuals enrolled in a school within the CPS system. Claims
151+11 for services provided by CPS's vendor or vendors to recipients
152+12 of benefits in the medical assistance program under this Code,
153+13 the Children's Health Insurance Program, or the Covering ALL
154+14 KIDS Health Insurance Program shall be submitted to the
155+15 Department or the MCE in which the individual is enrolled for
156+16 payment and shall be reimbursed at the Department's or the
157+17 MCE's established rates or rate methodologies for eyeglasses.
158+18 On and after July 1, 2012, the Department of Healthcare
159+19 and Family Services may provide the following services to
160+20 persons eligible for assistance under this Article who are
161+21 participating in education, training or employment programs
162+22 operated by the Department of Human Services as successor to
163+23 the Department of Public Aid:
164+24 (1) dental services provided by or under the
165+25 supervision of a dentist; and
166+26 (2) eyeglasses prescribed by a physician skilled in
167+
168+
169+
170+
171+
172+ SB3268 Enrolled - 5 - LRB103 39338 KTG 69500 b
173+
174+
175+SB3268 Enrolled- 6 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 6 - LRB103 39338 KTG 69500 b
176+ SB3268 Enrolled - 6 - LRB103 39338 KTG 69500 b
177+1 the diseases of the eye, or by an optometrist, whichever
178+2 the person may select.
179+3 On and after July 1, 2018, the Department of Healthcare
180+4 and Family Services shall provide dental services to any adult
181+5 who is otherwise eligible for assistance under the medical
182+6 assistance program. As used in this paragraph, "dental
183+7 services" means diagnostic, preventative, restorative, or
184+8 corrective procedures, including procedures and services for
185+9 the prevention and treatment of periodontal disease and dental
186+10 caries disease, provided by an individual who is licensed to
187+11 practice dentistry or dental surgery or who is under the
188+12 supervision of a dentist in the practice of his or her
189+13 profession.
190+14 On and after July 1, 2018, targeted dental services, as
191+15 set forth in Exhibit D of the Consent Decree entered by the
192+16 United States District Court for the Northern District of
193+17 Illinois, Eastern Division, in the matter of Memisovski v.
194+18 Maram, Case No. 92 C 1982, that are provided to adults under
195+19 the medical assistance program shall be established at no less
196+20 than the rates set forth in the "New Rate" column in Exhibit D
197+21 of the Consent Decree for targeted dental services that are
198+22 provided to persons under the age of 18 under the medical
199+23 assistance program.
200+24 Subject to federal approval, on and after January 1, 2025,
201+25 the rates paid for sedation evaluation and the provision of
202+26 deep sedation and intravenous sedation for the purpose of
203+
204+
205+
206+
207+
208+ SB3268 Enrolled - 6 - LRB103 39338 KTG 69500 b
209+
210+
211+SB3268 Enrolled- 7 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 7 - LRB103 39338 KTG 69500 b
212+ SB3268 Enrolled - 7 - LRB103 39338 KTG 69500 b
213+1 dental services shall be increased by 33% above the rates in
214+2 effect on December 31, 2024. The rates paid for nitrous oxide
215+3 sedation shall not be impacted by this paragraph and shall
216+4 remain the same as the rates in effect on December 31, 2024.
217+5 Notwithstanding any other provision of this Code and
218+6 subject to federal approval, the Department may adopt rules to
219+7 allow a dentist who is volunteering his or her service at no
220+8 cost to render dental services through an enrolled
221+9 not-for-profit health clinic without the dentist personally
222+10 enrolling as a participating provider in the medical
223+11 assistance program. A not-for-profit health clinic shall
224+12 include a public health clinic or Federally Qualified Health
225+13 Center or other enrolled provider, as determined by the
226+14 Department, through which dental services covered under this
227+15 Section are performed. The Department shall establish a
228+16 process for payment of claims for reimbursement for covered
229+17 dental services rendered under this provision.
230+18 On and after January 1, 2022, the Department of Healthcare
231+19 and Family Services shall administer and regulate a
232+20 school-based dental program that allows for the out-of-office
233+21 delivery of preventative dental services in a school setting
234+22 to children under 19 years of age. The Department shall
235+23 establish, by rule, guidelines for participation by providers
236+24 and set requirements for follow-up referral care based on the
237+25 requirements established in the Dental Office Reference Manual
238+26 published by the Department that establishes the requirements
239+
240+
241+
242+
243+
244+ SB3268 Enrolled - 7 - LRB103 39338 KTG 69500 b
245+
246+
247+SB3268 Enrolled- 8 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 8 - LRB103 39338 KTG 69500 b
248+ SB3268 Enrolled - 8 - LRB103 39338 KTG 69500 b
249+1 for dentists participating in the All Kids Dental School
250+2 Program. Every effort shall be made by the Department when
251+3 developing the program requirements to consider the different
252+4 geographic differences of both urban and rural areas of the
253+5 State for initial treatment and necessary follow-up care. No
254+6 provider shall be charged a fee by any unit of local government
255+7 to participate in the school-based dental program administered
256+8 by the Department. Nothing in this paragraph shall be
257+9 construed to limit or preempt a home rule unit's or school
258+10 district's authority to establish, change, or administer a
259+11 school-based dental program in addition to, or independent of,
260+12 the school-based dental program administered by the
261+13 Department.
262+14 The Illinois Department, by rule, may distinguish and
263+15 classify the medical services to be provided only in
264+16 accordance with the classes of persons designated in Section
265+17 5-2.
266+18 The Department of Healthcare and Family Services must
267+19 provide coverage and reimbursement for amino acid-based
268+20 elemental formulas, regardless of delivery method, for the
269+21 diagnosis and treatment of (i) eosinophilic disorders and (ii)
270+22 short bowel syndrome when the prescribing physician has issued
271+23 a written order stating that the amino acid-based elemental
272+24 formula is medically necessary.
273+25 The Illinois Department shall authorize the provision of,
274+26 and shall authorize payment for, screening by low-dose
275+
276+
277+
278+
279+
280+ SB3268 Enrolled - 8 - LRB103 39338 KTG 69500 b
281+
282+
283+SB3268 Enrolled- 9 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 9 - LRB103 39338 KTG 69500 b
284+ SB3268 Enrolled - 9 - LRB103 39338 KTG 69500 b
285+1 mammography for the presence of occult breast cancer for
286+2 individuals 35 years of age or older who are eligible for
287+3 medical assistance under this Article, as follows:
288+4 (A) A baseline mammogram for individuals 35 to 39
289+5 years of age.
290+6 (B) An annual mammogram for individuals 40 years of
291+7 age or older.
292+8 (C) A mammogram at the age and intervals considered
293+9 medically necessary by the individual's health care
294+10 provider for individuals under 40 years of age and having
295+11 a family history of breast cancer, prior personal history
296+12 of breast cancer, positive genetic testing, or other risk
297+13 factors.
298+14 (D) A comprehensive ultrasound screening and MRI of an
299+15 entire breast or breasts if a mammogram demonstrates
300+16 heterogeneous or dense breast tissue or when medically
301+17 necessary as determined by a physician licensed to
302+18 practice medicine in all of its branches.
303+19 (E) A screening MRI when medically necessary, as
304+20 determined by a physician licensed to practice medicine in
305+21 all of its branches.
306+22 (F) A diagnostic mammogram when medically necessary,
307+23 as determined by a physician licensed to practice medicine
308+24 in all its branches, advanced practice registered nurse,
309+25 or physician assistant.
310+26 The Department shall not impose a deductible, coinsurance,
311+
312+
313+
314+
315+
316+ SB3268 Enrolled - 9 - LRB103 39338 KTG 69500 b
317+
318+
319+SB3268 Enrolled- 10 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 10 - LRB103 39338 KTG 69500 b
320+ SB3268 Enrolled - 10 - LRB103 39338 KTG 69500 b
321+1 copayment, or any other cost-sharing requirement on the
322+2 coverage provided under this paragraph; except that this
323+3 sentence does not apply to coverage of diagnostic mammograms
324+4 to the extent such coverage would disqualify a high-deductible
325+5 health plan from eligibility for a health savings account
326+6 pursuant to Section 223 of the Internal Revenue Code (26
327+7 U.S.C. 223).
328+8 All screenings shall include a physical breast exam,
329+9 instruction on self-examination and information regarding the
330+10 frequency of self-examination and its value as a preventative
331+11 tool.
332+12 For purposes of this Section:
333+13 "Diagnostic mammogram" means a mammogram obtained using
334+14 diagnostic mammography.
335+15 "Diagnostic mammography" means a method of screening that
336+16 is designed to evaluate an abnormality in a breast, including
337+17 an abnormality seen or suspected on a screening mammogram or a
338+18 subjective or objective abnormality otherwise detected in the
339+19 breast.
340+20 "Low-dose mammography" means the x-ray examination of the
341+21 breast using equipment dedicated specifically for mammography,
342+22 including the x-ray tube, filter, compression device, and
343+23 image receptor, with an average radiation exposure delivery of
344+24 less than one rad per breast for 2 views of an average size
345+25 breast. The term also includes digital mammography and
346+26 includes breast tomosynthesis.
347+
348+
349+
350+
351+
352+ SB3268 Enrolled - 10 - LRB103 39338 KTG 69500 b
353+
354+
355+SB3268 Enrolled- 11 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 11 - LRB103 39338 KTG 69500 b
356+ SB3268 Enrolled - 11 - LRB103 39338 KTG 69500 b
357+1 "Breast tomosynthesis" means a radiologic procedure that
358+2 involves the acquisition of projection images over the
359+3 stationary breast to produce cross-sectional digital
360+4 three-dimensional images of the breast.
361+5 If, at any time, the Secretary of the United States
362+6 Department of Health and Human Services, or its successor
363+7 agency, promulgates rules or regulations to be published in
364+8 the Federal Register or publishes a comment in the Federal
365+9 Register or issues an opinion, guidance, or other action that
366+10 would require the State, pursuant to any provision of the
367+11 Patient Protection and Affordable Care Act (Public Law
368+12 111-148), including, but not limited to, 42 U.S.C.
369+13 18031(d)(3)(B) or any successor provision, to defray the cost
370+14 of any coverage for breast tomosynthesis outlined in this
371+15 paragraph, then the requirement that an insurer cover breast
372+16 tomosynthesis is inoperative other than any such coverage
373+17 authorized under Section 1902 of the Social Security Act, 42
374+18 U.S.C. 1396a, and the State shall not assume any obligation
375+19 for the cost of coverage for breast tomosynthesis set forth in
376+20 this paragraph.
377+21 On and after January 1, 2016, the Department shall ensure
378+22 that all networks of care for adult clients of the Department
379+23 include access to at least one breast imaging Center of
380+24 Imaging Excellence as certified by the American College of
381+25 Radiology.
382+26 On and after January 1, 2012, providers participating in a
383+
384+
385+
386+
387+
388+ SB3268 Enrolled - 11 - LRB103 39338 KTG 69500 b
389+
390+
391+SB3268 Enrolled- 12 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 12 - LRB103 39338 KTG 69500 b
392+ SB3268 Enrolled - 12 - LRB103 39338 KTG 69500 b
393+1 quality improvement program approved by the Department shall
394+2 be reimbursed for screening and diagnostic mammography at the
395+3 same rate as the Medicare program's rates, including the
396+4 increased reimbursement for digital mammography and, after
397+5 January 1, 2023 (the effective date of Public Act 102-1018),
398+6 breast tomosynthesis.
399+7 The Department shall convene an expert panel including
400+8 representatives of hospitals, free-standing mammography
401+9 facilities, and doctors, including radiologists, to establish
402+10 quality standards for mammography.
403+11 On and after January 1, 2017, providers participating in a
404+12 breast cancer treatment quality improvement program approved
405+13 by the Department shall be reimbursed for breast cancer
406+14 treatment at a rate that is no lower than 95% of the Medicare
407+15 program's rates for the data elements included in the breast
408+16 cancer treatment quality program.
409+17 The Department shall convene an expert panel, including
410+18 representatives of hospitals, free-standing breast cancer
411+19 treatment centers, breast cancer quality organizations, and
412+20 doctors, including breast surgeons, reconstructive breast
413+21 surgeons, oncologists, and primary care providers to establish
414+22 quality standards for breast cancer treatment.
415+23 Subject to federal approval, the Department shall
416+24 establish a rate methodology for mammography at federally
417+25 qualified health centers and other encounter-rate clinics.
418+26 These clinics or centers may also collaborate with other
419+
420+
421+
422+
423+
424+ SB3268 Enrolled - 12 - LRB103 39338 KTG 69500 b
425+
426+
427+SB3268 Enrolled- 13 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 13 - LRB103 39338 KTG 69500 b
428+ SB3268 Enrolled - 13 - LRB103 39338 KTG 69500 b
429+1 hospital-based mammography facilities. By January 1, 2016, the
430+2 Department shall report to the General Assembly on the status
431+3 of the provision set forth in this paragraph.
432+4 The Department shall establish a methodology to remind
433+5 individuals who are age-appropriate for screening mammography,
434+6 but who have not received a mammogram within the previous 18
435+7 months, of the importance and benefit of screening
436+8 mammography. The Department shall work with experts in breast
437+9 cancer outreach and patient navigation to optimize these
438+10 reminders and shall establish a methodology for evaluating
439+11 their effectiveness and modifying the methodology based on the
440+12 evaluation.
441+13 The Department shall establish a performance goal for
442+14 primary care providers with respect to their female patients
443+15 over age 40 receiving an annual mammogram. This performance
444+16 goal shall be used to provide additional reimbursement in the
445+17 form of a quality performance bonus to primary care providers
446+18 who meet that goal.
447+19 The Department shall devise a means of case-managing or
448+20 patient navigation for beneficiaries diagnosed with breast
449+21 cancer. This program shall initially operate as a pilot
450+22 program in areas of the State with the highest incidence of
451+23 mortality related to breast cancer. At least one pilot program
452+24 site shall be in the metropolitan Chicago area and at least one
453+25 site shall be outside the metropolitan Chicago area. On or
454+26 after July 1, 2016, the pilot program shall be expanded to
455+
456+
457+
458+
459+
460+ SB3268 Enrolled - 13 - LRB103 39338 KTG 69500 b
461+
462+
463+SB3268 Enrolled- 14 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 14 - LRB103 39338 KTG 69500 b
464+ SB3268 Enrolled - 14 - LRB103 39338 KTG 69500 b
465+1 include one site in western Illinois, one site in southern
466+2 Illinois, one site in central Illinois, and 4 sites within
467+3 metropolitan Chicago. An evaluation of the pilot program shall
468+4 be carried out measuring health outcomes and cost of care for
469+5 those served by the pilot program compared to similarly
470+6 situated patients who are not served by the pilot program.
471+7 The Department shall require all networks of care to
472+8 develop a means either internally or by contract with experts
473+9 in navigation and community outreach to navigate cancer
474+10 patients to comprehensive care in a timely fashion. The
475+11 Department shall require all networks of care to include
476+12 access for patients diagnosed with cancer to at least one
477+13 academic commission on cancer-accredited cancer program as an
478+14 in-network covered benefit.
479+15 The Department shall provide coverage and reimbursement
480+16 for a human papillomavirus (HPV) vaccine that is approved for
481+17 marketing by the federal Food and Drug Administration for all
482+18 persons between the ages of 9 and 45. Subject to federal
483+19 approval, the Department shall provide coverage and
484+20 reimbursement for a human papillomavirus (HPV) vaccine for
485+21 persons of the age of 46 and above who have been diagnosed with
486+22 cervical dysplasia with a high risk of recurrence or
487+23 progression. The Department shall disallow any
488+24 preauthorization requirements for the administration of the
489+25 human papillomavirus (HPV) vaccine.
490+26 On or after July 1, 2022, individuals who are otherwise
491+
492+
493+
494+
495+
496+ SB3268 Enrolled - 14 - LRB103 39338 KTG 69500 b
497+
498+
499+SB3268 Enrolled- 15 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 15 - LRB103 39338 KTG 69500 b
500+ SB3268 Enrolled - 15 - LRB103 39338 KTG 69500 b
501+1 eligible for medical assistance under this Article shall
502+2 receive coverage for perinatal depression screenings for the
503+3 12-month period beginning on the last day of their pregnancy.
504+4 Medical assistance coverage under this paragraph shall be
505+5 conditioned on the use of a screening instrument approved by
506+6 the Department.
507+7 Any medical or health care provider shall immediately
508+8 recommend, to any pregnant individual who is being provided
509+9 prenatal services and is suspected of having a substance use
510+10 disorder as defined in the Substance Use Disorder Act,
511+11 referral to a local substance use disorder treatment program
512+12 licensed by the Department of Human Services or to a licensed
513+13 hospital which provides substance abuse treatment services.
514+14 The Department of Healthcare and Family Services shall assure
515+15 coverage for the cost of treatment of the drug abuse or
516+16 addiction for pregnant recipients in accordance with the
517+17 Illinois Medicaid Program in conjunction with the Department
518+18 of Human Services.
519+19 All medical providers providing medical assistance to
520+20 pregnant individuals under this Code shall receive information
521+21 from the Department on the availability of services under any
522+22 program providing case management services for addicted
523+23 individuals, including information on appropriate referrals
524+24 for other social services that may be needed by addicted
525+25 individuals in addition to treatment for addiction.
526+26 The Illinois Department, in cooperation with the
527+
528+
529+
530+
531+
532+ SB3268 Enrolled - 15 - LRB103 39338 KTG 69500 b
533+
534+
535+SB3268 Enrolled- 16 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 16 - LRB103 39338 KTG 69500 b
536+ SB3268 Enrolled - 16 - LRB103 39338 KTG 69500 b
537+1 Departments of Human Services (as successor to the Department
538+2 of Alcoholism and Substance Abuse) and Public Health, through
539+3 a public awareness campaign, may provide information
540+4 concerning treatment for alcoholism and drug abuse and
541+5 addiction, prenatal health care, and other pertinent programs
542+6 directed at reducing the number of drug-affected infants born
543+7 to recipients of medical assistance.
544+8 Neither the Department of Healthcare and Family Services
545+9 nor the Department of Human Services shall sanction the
546+10 recipient solely on the basis of the recipient's substance
547+11 abuse.
548+12 The Illinois Department shall establish such regulations
549+13 governing the dispensing of health services under this Article
550+14 as it shall deem appropriate. The Department should seek the
551+15 advice of formal professional advisory committees appointed by
552+16 the Director of the Illinois Department for the purpose of
553+17 providing regular advice on policy and administrative matters,
554+18 information dissemination and educational activities for
555+19 medical and health care providers, and consistency in
556+20 procedures to the Illinois Department.
557+21 The Illinois Department may develop and contract with
558+22 Partnerships of medical providers to arrange medical services
559+23 for persons eligible under Section 5-2 of this Code.
560+24 Implementation of this Section may be by demonstration
561+25 projects in certain geographic areas. The Partnership shall be
562+26 represented by a sponsor organization. The Department, by
563+
564+
565+
566+
567+
568+ SB3268 Enrolled - 16 - LRB103 39338 KTG 69500 b
569+
570+
571+SB3268 Enrolled- 17 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 17 - LRB103 39338 KTG 69500 b
572+ SB3268 Enrolled - 17 - LRB103 39338 KTG 69500 b
573+1 rule, shall develop qualifications for sponsors of
574+2 Partnerships. Nothing in this Section shall be construed to
575+3 require that the sponsor organization be a medical
576+4 organization.
577+5 The sponsor must negotiate formal written contracts with
578+6 medical providers for physician services, inpatient and
579+7 outpatient hospital care, home health services, treatment for
580+8 alcoholism and substance abuse, and other services determined
581+9 necessary by the Illinois Department by rule for delivery by
582+10 Partnerships. Physician services must include prenatal and
583+11 obstetrical care. The Illinois Department shall reimburse
584+12 medical services delivered by Partnership providers to clients
585+13 in target areas according to provisions of this Article and
586+14 the Illinois Health Finance Reform Act, except that:
587+15 (1) Physicians participating in a Partnership and
588+16 providing certain services, which shall be determined by
589+17 the Illinois Department, to persons in areas covered by
590+18 the Partnership may receive an additional surcharge for
591+19 such services.
592+20 (2) The Department may elect to consider and negotiate
593+21 financial incentives to encourage the development of
594+22 Partnerships and the efficient delivery of medical care.
595+23 (3) Persons receiving medical services through
596+24 Partnerships may receive medical and case management
597+25 services above the level usually offered through the
598+26 medical assistance program.
599+
600+
601+
602+
603+
604+ SB3268 Enrolled - 17 - LRB103 39338 KTG 69500 b
605+
606+
607+SB3268 Enrolled- 18 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 18 - LRB103 39338 KTG 69500 b
608+ SB3268 Enrolled - 18 - LRB103 39338 KTG 69500 b
609+1 Medical providers shall be required to meet certain
610+2 qualifications to participate in Partnerships to ensure the
611+3 delivery of high quality medical services. These
612+4 qualifications shall be determined by rule of the Illinois
613+5 Department and may be higher than qualifications for
614+6 participation in the medical assistance program. Partnership
615+7 sponsors may prescribe reasonable additional qualifications
616+8 for participation by medical providers, only with the prior
617+9 written approval of the Illinois Department.
618+10 Nothing in this Section shall limit the free choice of
619+11 practitioners, hospitals, and other providers of medical
620+12 services by clients. In order to ensure patient freedom of
621+13 choice, the Illinois Department shall immediately promulgate
622+14 all rules and take all other necessary actions so that
623+15 provided services may be accessed from therapeutically
624+16 certified optometrists to the full extent of the Illinois
625+17 Optometric Practice Act of 1987 without discriminating between
626+18 service providers.
627+19 The Department shall apply for a waiver from the United
628+20 States Health Care Financing Administration to allow for the
629+21 implementation of Partnerships under this Section.
630+22 The Illinois Department shall require health care
631+23 providers to maintain records that document the medical care
632+24 and services provided to recipients of Medical Assistance
633+25 under this Article. Such records must be retained for a period
634+26 of not less than 6 years from the date of service or as
635+
636+
637+
638+
639+
640+ SB3268 Enrolled - 18 - LRB103 39338 KTG 69500 b
641+
642+
643+SB3268 Enrolled- 19 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 19 - LRB103 39338 KTG 69500 b
644+ SB3268 Enrolled - 19 - LRB103 39338 KTG 69500 b
645+1 provided by applicable State law, whichever period is longer,
646+2 except that if an audit is initiated within the required
647+3 retention period then the records must be retained until the
648+4 audit is completed and every exception is resolved. The
649+5 Illinois Department shall require health care providers to
650+6 make available, when authorized by the patient, in writing,
651+7 the medical records in a timely fashion to other health care
652+8 providers who are treating or serving persons eligible for
653+9 Medical Assistance under this Article. All dispensers of
654+10 medical services shall be required to maintain and retain
655+11 business and professional records sufficient to fully and
656+12 accurately document the nature, scope, details and receipt of
657+13 the health care provided to persons eligible for medical
658+14 assistance under this Code, in accordance with regulations
659+15 promulgated by the Illinois Department. The rules and
660+16 regulations shall require that proof of the receipt of
661+17 prescription drugs, dentures, prosthetic devices and
662+18 eyeglasses by eligible persons under this Section accompany
663+19 each claim for reimbursement submitted by the dispenser of
664+20 such medical services. No such claims for reimbursement shall
665+21 be approved for payment by the Illinois Department without
666+22 such proof of receipt, unless the Illinois Department shall
667+23 have put into effect and shall be operating a system of
668+24 post-payment audit and review which shall, on a sampling
669+25 basis, be deemed adequate by the Illinois Department to assure
670+26 that such drugs, dentures, prosthetic devices and eyeglasses
671+
672+
673+
674+
675+
676+ SB3268 Enrolled - 19 - LRB103 39338 KTG 69500 b
677+
678+
679+SB3268 Enrolled- 20 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 20 - LRB103 39338 KTG 69500 b
680+ SB3268 Enrolled - 20 - LRB103 39338 KTG 69500 b
681+1 for which payment is being made are actually being received by
682+2 eligible recipients. Within 90 days after September 16, 1984
683+3 (the effective date of Public Act 83-1439), the Illinois
684+4 Department shall establish a current list of acquisition costs
685+5 for all prosthetic devices and any other items recognized as
686+6 medical equipment and supplies reimbursable under this Article
687+7 and shall update such list on a quarterly basis, except that
688+8 the acquisition costs of all prescription drugs shall be
689+9 updated no less frequently than every 30 days as required by
690+10 Section 5-5.12.
691+11 Notwithstanding any other law to the contrary, the
692+12 Illinois Department shall, within 365 days after July 22, 2013
693+13 (the effective date of Public Act 98-104), establish
694+14 procedures to permit skilled care facilities licensed under
695+15 the Nursing Home Care Act to submit monthly billing claims for
696+16 reimbursement purposes. Following development of these
697+17 procedures, the Department shall, by July 1, 2016, test the
698+18 viability of the new system and implement any necessary
699+19 operational or structural changes to its information
700+20 technology platforms in order to allow for the direct
701+21 acceptance and payment of nursing home claims.
702+22 Notwithstanding any other law to the contrary, the
703+23 Illinois Department shall, within 365 days after August 15,
704+24 2014 (the effective date of Public Act 98-963), establish
705+25 procedures to permit ID/DD facilities licensed under the ID/DD
706+26 Community Care Act and MC/DD facilities licensed under the
707+
708+
709+
710+
711+
712+ SB3268 Enrolled - 20 - LRB103 39338 KTG 69500 b
713+
714+
715+SB3268 Enrolled- 21 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 21 - LRB103 39338 KTG 69500 b
716+ SB3268 Enrolled - 21 - LRB103 39338 KTG 69500 b
717+1 MC/DD Act to submit monthly billing claims for reimbursement
718+2 purposes. Following development of these procedures, the
719+3 Department shall have an additional 365 days to test the
720+4 viability of the new system and to ensure that any necessary
721+5 operational or structural changes to its information
722+6 technology platforms are implemented.
723+7 The Illinois Department shall require all dispensers of
724+8 medical services, other than an individual practitioner or
725+9 group of practitioners, desiring to participate in the Medical
726+10 Assistance program established under this Article to disclose
727+11 all financial, beneficial, ownership, equity, surety or other
728+12 interests in any and all firms, corporations, partnerships,
729+13 associations, business enterprises, joint ventures, agencies,
730+14 institutions or other legal entities providing any form of
731+15 health care services in this State under this Article.
732+16 The Illinois Department may require that all dispensers of
733+17 medical services desiring to participate in the medical
734+18 assistance program established under this Article disclose,
735+19 under such terms and conditions as the Illinois Department may
736+20 by rule establish, all inquiries from clients and attorneys
737+21 regarding medical bills paid by the Illinois Department, which
738+22 inquiries could indicate potential existence of claims or
739+23 liens for the Illinois Department.
740+24 Enrollment of a vendor shall be subject to a provisional
741+25 period and shall be conditional for one year. During the
742+26 period of conditional enrollment, the Department may terminate
743+
744+
745+
746+
747+
748+ SB3268 Enrolled - 21 - LRB103 39338 KTG 69500 b
749+
750+
751+SB3268 Enrolled- 22 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 22 - LRB103 39338 KTG 69500 b
752+ SB3268 Enrolled - 22 - LRB103 39338 KTG 69500 b
753+1 the vendor's eligibility to participate in, or may disenroll
754+2 the vendor from, the medical assistance program without cause.
755+3 Unless otherwise specified, such termination of eligibility or
756+4 disenrollment is not subject to the Department's hearing
757+5 process. However, a disenrolled vendor may reapply without
758+6 penalty.
759+7 The Department has the discretion to limit the conditional
760+8 enrollment period for vendors based upon the category of risk
761+9 of the vendor.
762+10 Prior to enrollment and during the conditional enrollment
763+11 period in the medical assistance program, all vendors shall be
764+12 subject to enhanced oversight, screening, and review based on
765+13 the risk of fraud, waste, and abuse that is posed by the
766+14 category of risk of the vendor. The Illinois Department shall
767+15 establish the procedures for oversight, screening, and review,
768+16 which may include, but need not be limited to: criminal and
769+17 financial background checks; fingerprinting; license,
770+18 certification, and authorization verifications; unscheduled or
771+19 unannounced site visits; database checks; prepayment audit
772+20 reviews; audits; payment caps; payment suspensions; and other
773+21 screening as required by federal or State law.
774+22 The Department shall define or specify the following: (i)
775+23 by provider notice, the "category of risk of the vendor" for
776+24 each type of vendor, which shall take into account the level of
777+25 screening applicable to a particular category of vendor under
778+26 federal law and regulations; (ii) by rule or provider notice,
779+
780+
781+
782+
783+
784+ SB3268 Enrolled - 22 - LRB103 39338 KTG 69500 b
785+
786+
787+SB3268 Enrolled- 23 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 23 - LRB103 39338 KTG 69500 b
788+ SB3268 Enrolled - 23 - LRB103 39338 KTG 69500 b
789+1 the maximum length of the conditional enrollment period for
790+2 each category of risk of the vendor; and (iii) by rule, the
791+3 hearing rights, if any, afforded to a vendor in each category
792+4 of risk of the vendor that is terminated or disenrolled during
793+5 the conditional enrollment period.
794+6 To be eligible for payment consideration, a vendor's
795+7 payment claim or bill, either as an initial claim or as a
796+8 resubmitted claim following prior rejection, must be received
797+9 by the Illinois Department, or its fiscal intermediary, no
798+10 later than 180 days after the latest date on the claim on which
799+11 medical goods or services were provided, with the following
800+12 exceptions:
801+13 (1) In the case of a provider whose enrollment is in
802+14 process by the Illinois Department, the 180-day period
803+15 shall not begin until the date on the written notice from
804+16 the Illinois Department that the provider enrollment is
805+17 complete.
806+18 (2) In the case of errors attributable to the Illinois
807+19 Department or any of its claims processing intermediaries
808+20 which result in an inability to receive, process, or
809+21 adjudicate a claim, the 180-day period shall not begin
810+22 until the provider has been notified of the error.
811+23 (3) In the case of a provider for whom the Illinois
812+24 Department initiates the monthly billing process.
813+25 (4) In the case of a provider operated by a unit of
814+26 local government with a population exceeding 3,000,000
815+
816+
817+
818+
819+
820+ SB3268 Enrolled - 23 - LRB103 39338 KTG 69500 b
821+
822+
823+SB3268 Enrolled- 24 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 24 - LRB103 39338 KTG 69500 b
824+ SB3268 Enrolled - 24 - LRB103 39338 KTG 69500 b
825+1 when local government funds finance federal participation
826+2 for claims payments.
827+3 For claims for services rendered during a period for which
828+4 a recipient received retroactive eligibility, claims must be
829+5 filed within 180 days after the Department determines the
830+6 applicant is eligible. For claims for which the Illinois
831+7 Department is not the primary payer, claims must be submitted
832+8 to the Illinois Department within 180 days after the final
833+9 adjudication by the primary payer.
834+10 In the case of long term care facilities, within 120
835+11 calendar days of receipt by the facility of required
836+12 prescreening information, new admissions with associated
837+13 admission documents shall be submitted through the Medical
838+14 Electronic Data Interchange (MEDI) or the Recipient
839+15 Eligibility Verification (REV) System or shall be submitted
840+16 directly to the Department of Human Services using required
841+17 admission forms. Effective September 1, 2014, admission
842+18 documents, including all prescreening information, must be
843+19 submitted through MEDI or REV. Confirmation numbers assigned
844+20 to an accepted transaction shall be retained by a facility to
845+21 verify timely submittal. Once an admission transaction has
846+22 been completed, all resubmitted claims following prior
847+23 rejection are subject to receipt no later than 180 days after
848+24 the admission transaction has been completed.
849+25 Claims that are not submitted and received in compliance
850+26 with the foregoing requirements shall not be eligible for
851+
852+
853+
854+
855+
856+ SB3268 Enrolled - 24 - LRB103 39338 KTG 69500 b
857+
858+
859+SB3268 Enrolled- 25 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 25 - LRB103 39338 KTG 69500 b
860+ SB3268 Enrolled - 25 - LRB103 39338 KTG 69500 b
861+1 payment under the medical assistance program, and the State
862+2 shall have no liability for payment of those claims.
863+3 To the extent consistent with applicable information and
864+4 privacy, security, and disclosure laws, State and federal
865+5 agencies and departments shall provide the Illinois Department
866+6 access to confidential and other information and data
867+7 necessary to perform eligibility and payment verifications and
868+8 other Illinois Department functions. This includes, but is not
869+9 limited to: information pertaining to licensure;
870+10 certification; earnings; immigration status; citizenship; wage
871+11 reporting; unearned and earned income; pension income;
872+12 employment; supplemental security income; social security
873+13 numbers; National Provider Identifier (NPI) numbers; the
874+14 National Practitioner Data Bank (NPDB); program and agency
875+15 exclusions; taxpayer identification numbers; tax delinquency;
876+16 corporate information; and death records.
877+17 The Illinois Department shall enter into agreements with
878+18 State agencies and departments, and is authorized to enter
879+19 into agreements with federal agencies and departments, under
880+20 which such agencies and departments shall share data necessary
881+21 for medical assistance program integrity functions and
882+22 oversight. The Illinois Department shall develop, in
883+23 cooperation with other State departments and agencies, and in
884+24 compliance with applicable federal laws and regulations,
885+25 appropriate and effective methods to share such data. At a
886+26 minimum, and to the extent necessary to provide data sharing,
887+
888+
889+
890+
891+
892+ SB3268 Enrolled - 25 - LRB103 39338 KTG 69500 b
893+
894+
895+SB3268 Enrolled- 26 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 26 - LRB103 39338 KTG 69500 b
896+ SB3268 Enrolled - 26 - LRB103 39338 KTG 69500 b
897+1 the Illinois Department shall enter into agreements with State
898+2 agencies and departments, and is authorized to enter into
899+3 agreements with federal agencies and departments, including,
900+4 but not limited to: the Secretary of State; the Department of
901+5 Revenue; the Department of Public Health; the Department of
902+6 Human Services; and the Department of Financial and
903+7 Professional Regulation.
904+8 Beginning in fiscal year 2013, the Illinois Department
905+9 shall set forth a request for information to identify the
906+10 benefits of a pre-payment, post-adjudication, and post-edit
907+11 claims system with the goals of streamlining claims processing
908+12 and provider reimbursement, reducing the number of pending or
909+13 rejected claims, and helping to ensure a more transparent
910+14 adjudication process through the utilization of: (i) provider
911+15 data verification and provider screening technology; and (ii)
912+16 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
913+17 post-adjudicated predictive modeling with an integrated case
914+18 management system with link analysis. Such a request for
915+19 information shall not be considered as a request for proposal
916+20 or as an obligation on the part of the Illinois Department to
917+21 take any action or acquire any products or services.
918+22 The Illinois Department shall establish policies,
919+23 procedures, standards and criteria by rule for the
920+24 acquisition, repair and replacement of orthotic and prosthetic
921+25 devices and durable medical equipment. Such rules shall
922+26 provide, but not be limited to, the following services: (1)
923+
924+
925+
926+
927+
928+ SB3268 Enrolled - 26 - LRB103 39338 KTG 69500 b
929+
930+
931+SB3268 Enrolled- 27 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 27 - LRB103 39338 KTG 69500 b
932+ SB3268 Enrolled - 27 - LRB103 39338 KTG 69500 b
933+1 immediate repair or replacement of such devices by recipients;
934+2 and (2) rental, lease, purchase or lease-purchase of durable
935+3 medical equipment in a cost-effective manner, taking into
936+4 consideration the recipient's medical prognosis, the extent of
937+5 the recipient's needs, and the requirements and costs for
938+6 maintaining such equipment. Subject to prior approval, such
939+7 rules shall enable a recipient to temporarily acquire and use
940+8 alternative or substitute devices or equipment pending repairs
941+9 or replacements of any device or equipment previously
942+10 authorized for such recipient by the Department.
943+11 Notwithstanding any provision of Section 5-5f to the contrary,
944+12 the Department may, by rule, exempt certain replacement
945+13 wheelchair parts from prior approval and, for wheelchairs,
946+14 wheelchair parts, wheelchair accessories, and related seating
947+15 and positioning items, determine the wholesale price by
948+16 methods other than actual acquisition costs.
949+17 The Department shall require, by rule, all providers of
950+18 durable medical equipment to be accredited by an accreditation
951+19 organization approved by the federal Centers for Medicare and
952+20 Medicaid Services and recognized by the Department in order to
953+21 bill the Department for providing durable medical equipment to
954+22 recipients. No later than 15 months after the effective date
955+23 of the rule adopted pursuant to this paragraph, all providers
956+24 must meet the accreditation requirement.
957+25 In order to promote environmental responsibility, meet the
958+26 needs of recipients and enrollees, and achieve significant
959+
960+
961+
962+
963+
964+ SB3268 Enrolled - 27 - LRB103 39338 KTG 69500 b
965+
966+
967+SB3268 Enrolled- 28 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 28 - LRB103 39338 KTG 69500 b
968+ SB3268 Enrolled - 28 - LRB103 39338 KTG 69500 b
969+1 cost savings, the Department, or a managed care organization
970+2 under contract with the Department, may provide recipients or
971+3 managed care enrollees who have a prescription or Certificate
972+4 of Medical Necessity access to refurbished durable medical
973+5 equipment under this Section (excluding prosthetic and
974+6 orthotic devices as defined in the Orthotics, Prosthetics, and
975+7 Pedorthics Practice Act and complex rehabilitation technology
976+8 products and associated services) through the State's
977+9 assistive technology program's reutilization program, using
978+10 staff with the Assistive Technology Professional (ATP)
979+11 Certification if the refurbished durable medical equipment:
980+12 (i) is available; (ii) is less expensive, including shipping
981+13 costs, than new durable medical equipment of the same type;
982+14 (iii) is able to withstand at least 3 years of use; (iv) is
983+15 cleaned, disinfected, sterilized, and safe in accordance with
984+16 federal Food and Drug Administration regulations and guidance
985+17 governing the reprocessing of medical devices in health care
986+18 settings; and (v) equally meets the needs of the recipient or
987+19 enrollee. The reutilization program shall confirm that the
988+20 recipient or enrollee is not already in receipt of the same or
989+21 similar equipment from another service provider, and that the
990+22 refurbished durable medical equipment equally meets the needs
991+23 of the recipient or enrollee. Nothing in this paragraph shall
992+24 be construed to limit recipient or enrollee choice to obtain
993+25 new durable medical equipment or place any additional prior
994+26 authorization conditions on enrollees of managed care
995+
996+
997+
998+
999+
1000+ SB3268 Enrolled - 28 - LRB103 39338 KTG 69500 b
1001+
1002+
1003+SB3268 Enrolled- 29 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 29 - LRB103 39338 KTG 69500 b
1004+ SB3268 Enrolled - 29 - LRB103 39338 KTG 69500 b
1005+1 organizations.
1006+2 The Department shall execute, relative to the nursing home
1007+3 prescreening project, written inter-agency agreements with the
1008+4 Department of Human Services and the Department on Aging, to
1009+5 effect the following: (i) intake procedures and common
1010+6 eligibility criteria for those persons who are receiving
1011+7 non-institutional services; and (ii) the establishment and
1012+8 development of non-institutional services in areas of the
1013+9 State where they are not currently available or are
1014+10 undeveloped; and (iii) notwithstanding any other provision of
1015+11 law, subject to federal approval, on and after July 1, 2012, an
1016+12 increase in the determination of need (DON) scores from 29 to
1017+13 37 for applicants for institutional and home and
1018+14 community-based long term care; if and only if federal
1019+15 approval is not granted, the Department may, in conjunction
1020+16 with other affected agencies, implement utilization controls
1021+17 or changes in benefit packages to effectuate a similar savings
1022+18 amount for this population; and (iv) no later than July 1,
1023+19 2013, minimum level of care eligibility criteria for
1024+20 institutional and home and community-based long term care; and
1025+21 (v) no later than October 1, 2013, establish procedures to
1026+22 permit long term care providers access to eligibility scores
1027+23 for individuals with an admission date who are seeking or
1028+24 receiving services from the long term care provider. In order
1029+25 to select the minimum level of care eligibility criteria, the
1030+26 Governor shall establish a workgroup that includes affected
1031+
1032+
1033+
1034+
1035+
1036+ SB3268 Enrolled - 29 - LRB103 39338 KTG 69500 b
1037+
1038+
1039+SB3268 Enrolled- 30 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 30 - LRB103 39338 KTG 69500 b
1040+ SB3268 Enrolled - 30 - LRB103 39338 KTG 69500 b
1041+1 agency representatives and stakeholders representing the
1042+2 institutional and home and community-based long term care
1043+3 interests. This Section shall not restrict the Department from
1044+4 implementing lower level of care eligibility criteria for
1045+5 community-based services in circumstances where federal
1046+6 approval has been granted.
1047+7 The Illinois Department shall develop and operate, in
1048+8 cooperation with other State Departments and agencies and in
1049+9 compliance with applicable federal laws and regulations,
1050+10 appropriate and effective systems of health care evaluation
1051+11 and programs for monitoring of utilization of health care
1052+12 services and facilities, as it affects persons eligible for
1053+13 medical assistance under this Code.
1054+14 The Illinois Department shall report annually to the
1055+15 General Assembly, no later than the second Friday in April of
1056+16 1979 and each year thereafter, in regard to:
1057+17 (a) actual statistics and trends in utilization of
1058+18 medical services by public aid recipients;
1059+19 (b) actual statistics and trends in the provision of
1060+20 the various medical services by medical vendors;
1061+21 (c) current rate structures and proposed changes in
1062+22 those rate structures for the various medical vendors; and
1063+23 (d) efforts at utilization review and control by the
1064+24 Illinois Department.
1065+25 The period covered by each report shall be the 3 years
1066+26 ending on the June 30 prior to the report. The report shall
1067+
1068+
1069+
1070+
1071+
1072+ SB3268 Enrolled - 30 - LRB103 39338 KTG 69500 b
1073+
1074+
1075+SB3268 Enrolled- 31 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 31 - LRB103 39338 KTG 69500 b
1076+ SB3268 Enrolled - 31 - LRB103 39338 KTG 69500 b
1077+1 include suggested legislation for consideration by the General
1078+2 Assembly. The requirement for reporting to the General
1079+3 Assembly shall be satisfied by filing copies of the report as
1080+4 required by Section 3.1 of the General Assembly Organization
1081+5 Act, and filing such additional copies with the State
1082+6 Government Report Distribution Center for the General Assembly
1083+7 as is required under paragraph (t) of Section 7 of the State
1084+8 Library Act.
1085+9 Rulemaking authority to implement Public Act 95-1045, if
1086+10 any, is conditioned on the rules being adopted in accordance
1087+11 with all provisions of the Illinois Administrative Procedure
1088+12 Act and all rules and procedures of the Joint Committee on
1089+13 Administrative Rules; any purported rule not so adopted, for
1090+14 whatever reason, is unauthorized.
1091+15 On and after July 1, 2012, the Department shall reduce any
1092+16 rate of reimbursement for services or other payments or alter
1093+17 any methodologies authorized by this Code to reduce any rate
1094+18 of reimbursement for services or other payments in accordance
1095+19 with Section 5-5e.
1096+20 Because kidney transplantation can be an appropriate,
1097+21 cost-effective alternative to renal dialysis when medically
1098+22 necessary and notwithstanding the provisions of Section 1-11
1099+23 of this Code, beginning October 1, 2014, the Department shall
1100+24 cover kidney transplantation for noncitizens with end-stage
1101+25 renal disease who are not eligible for comprehensive medical
1102+26 benefits, who meet the residency requirements of Section 5-3
1103+
1104+
1105+
1106+
1107+
1108+ SB3268 Enrolled - 31 - LRB103 39338 KTG 69500 b
1109+
1110+
1111+SB3268 Enrolled- 32 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 32 - LRB103 39338 KTG 69500 b
1112+ SB3268 Enrolled - 32 - LRB103 39338 KTG 69500 b
1113+1 of this Code, and who would otherwise meet the financial
1114+2 requirements of the appropriate class of eligible persons
1115+3 under Section 5-2 of this Code. To qualify for coverage of
1116+4 kidney transplantation, such person must be receiving
1117+5 emergency renal dialysis services covered by the Department.
1118+6 Providers under this Section shall be prior approved and
1119+7 certified by the Department to perform kidney transplantation
1120+8 and the services under this Section shall be limited to
1121+9 services associated with kidney transplantation.
1122+10 Notwithstanding any other provision of this Code to the
1123+11 contrary, on or after July 1, 2015, all FDA approved forms of
1124+12 medication assisted treatment prescribed for the treatment of
1125+13 alcohol dependence or treatment of opioid dependence shall be
1126+14 covered under both fee-for-service fee for service and managed
1127+15 care medical assistance programs for persons who are otherwise
1128+16 eligible for medical assistance under this Article and shall
1129+17 not be subject to any (1) utilization control, other than
1130+18 those established under the American Society of Addiction
1131+19 Medicine patient placement criteria, (2) prior authorization
1132+20 mandate, or (3) lifetime restriction limit mandate.
1133+21 On or after July 1, 2015, opioid antagonists prescribed
1134+22 for the treatment of an opioid overdose, including the
1135+23 medication product, administration devices, and any pharmacy
1136+24 fees or hospital fees related to the dispensing, distribution,
1137+25 and administration of the opioid antagonist, shall be covered
1138+26 under the medical assistance program for persons who are
1139+
1140+
1141+
1142+
1143+
1144+ SB3268 Enrolled - 32 - LRB103 39338 KTG 69500 b
1145+
1146+
1147+SB3268 Enrolled- 33 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 33 - LRB103 39338 KTG 69500 b
1148+ SB3268 Enrolled - 33 - LRB103 39338 KTG 69500 b
1149+1 otherwise eligible for medical assistance under this Article.
1150+2 As used in this Section, "opioid antagonist" means a drug that
1151+3 binds to opioid receptors and blocks or inhibits the effect of
1152+4 opioids acting on those receptors, including, but not limited
1153+5 to, naloxone hydrochloride or any other similarly acting drug
1154+6 approved by the U.S. Food and Drug Administration. The
1155+7 Department shall not impose a copayment on the coverage
1156+8 provided for naloxone hydrochloride under the medical
1157+9 assistance program.
1158+10 Upon federal approval, the Department shall provide
1159+11 coverage and reimbursement for all drugs that are approved for
1160+12 marketing by the federal Food and Drug Administration and that
1161+13 are recommended by the federal Public Health Service or the
1162+14 United States Centers for Disease Control and Prevention for
1163+15 pre-exposure prophylaxis and related pre-exposure prophylaxis
1164+16 services, including, but not limited to, HIV and sexually
1165+17 transmitted infection screening, treatment for sexually
1166+18 transmitted infections, medical monitoring, assorted labs, and
1167+19 counseling to reduce the likelihood of HIV infection among
1168+20 individuals who are not infected with HIV but who are at high
1169+21 risk of HIV infection.
1170+22 A federally qualified health center, as defined in Section
1171+23 1905(l)(2)(B) of the federal Social Security Act, shall be
1172+24 reimbursed by the Department in accordance with the federally
1173+25 qualified health center's encounter rate for services provided
1174+26 to medical assistance recipients that are performed by a
1175+
1176+
1177+
1178+
1179+
1180+ SB3268 Enrolled - 33 - LRB103 39338 KTG 69500 b
1181+
1182+
1183+SB3268 Enrolled- 34 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 34 - LRB103 39338 KTG 69500 b
1184+ SB3268 Enrolled - 34 - LRB103 39338 KTG 69500 b
1185+1 dental hygienist, as defined under the Illinois Dental
1186+2 Practice Act, working under the general supervision of a
1187+3 dentist and employed by a federally qualified health center.
1188+4 Within 90 days after October 8, 2021 (the effective date
1189+5 of Public Act 102-665), the Department shall seek federal
1190+6 approval of a State Plan amendment to expand coverage for
1191+7 family planning services that includes presumptive eligibility
1192+8 to individuals whose income is at or below 208% of the federal
1193+9 poverty level. Coverage under this Section shall be effective
1194+10 beginning no later than December 1, 2022.
1195+11 Subject to approval by the federal Centers for Medicare
1196+12 and Medicaid Services of a Title XIX State Plan amendment
1197+13 electing the Program of All-Inclusive Care for the Elderly
1198+14 (PACE) as a State Medicaid option, as provided for by Subtitle
1199+15 I (commencing with Section 4801) of Title IV of the Balanced
1200+16 Budget Act of 1997 (Public Law 105-33) and Part 460
1201+17 (commencing with Section 460.2) of Subchapter E of Title 42 of
1202+18 the Code of Federal Regulations, PACE program services shall
1203+19 become a covered benefit of the medical assistance program,
1204+20 subject to criteria established in accordance with all
1205+21 applicable laws.
1206+22 Notwithstanding any other provision of this Code,
1207+23 community-based pediatric palliative care from a trained
1208+24 interdisciplinary team shall be covered under the medical
1209+25 assistance program as provided in Section 15 of the Pediatric
1210+26 Palliative Care Act.
1211+
1212+
1213+
1214+
1215+
1216+ SB3268 Enrolled - 34 - LRB103 39338 KTG 69500 b
1217+
1218+
1219+SB3268 Enrolled- 35 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 35 - LRB103 39338 KTG 69500 b
1220+ SB3268 Enrolled - 35 - LRB103 39338 KTG 69500 b
1221+1 Notwithstanding any other provision of this Code, within
1222+2 12 months after June 2, 2022 (the effective date of Public Act
1223+3 102-1037) and subject to federal approval, acupuncture
1224+4 services performed by an acupuncturist licensed under the
1225+5 Acupuncture Practice Act who is acting within the scope of his
1226+6 or her license shall be covered under the medical assistance
1227+7 program. The Department shall apply for any federal waiver or
1228+8 State Plan amendment, if required, to implement this
1229+9 paragraph. The Department may adopt any rules, including
1230+10 standards and criteria, necessary to implement this paragraph.
1231+11 Notwithstanding any other provision of this Code, the
1232+12 medical assistance program shall, subject to appropriation and
1233+13 federal approval, reimburse hospitals for costs associated
1234+14 with a newborn screening test for the presence of
1235+15 metachromatic leukodystrophy, as required under the Newborn
1236+16 Metabolic Screening Act, at a rate not less than the fee
1237+17 charged by the Department of Public Health. The Department
1238+18 shall seek federal approval before the implementation of the
1239+19 newborn screening test fees by the Department of Public
1240+20 Health.
1241+21 Notwithstanding any other provision of this Code,
1242+22 beginning on January 1, 2024, subject to federal approval,
1243+23 cognitive assessment and care planning services provided to a
1244+24 person who experiences signs or symptoms of cognitive
1245+25 impairment, as defined by the Diagnostic and Statistical
1246+26 Manual of Mental Disorders, Fifth Edition, shall be covered
1247+
1248+
1249+
1250+
1251+
1252+ SB3268 Enrolled - 35 - LRB103 39338 KTG 69500 b
1253+
1254+
1255+SB3268 Enrolled- 36 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 36 - LRB103 39338 KTG 69500 b
1256+ SB3268 Enrolled - 36 - LRB103 39338 KTG 69500 b
1257+1 under the medical assistance program for persons who are
1258+2 otherwise eligible for medical assistance under this Article.
1259+3 Notwithstanding any other provision of this Code,
1260+4 medically necessary reconstructive services that are intended
1261+5 to restore physical appearance shall be covered under the
1262+6 medical assistance program for persons who are otherwise
1263+7 eligible for medical assistance under this Article. As used in
1264+8 this paragraph, "reconstructive services" means treatments
1265+9 performed on structures of the body damaged by trauma to
1266+10 restore physical appearance.
1267+11 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
1268+12 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
1269+13 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
1270+14 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
1271+15 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
1272+16 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
1273+17 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1274+18 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
1275+19 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1276+20 1-1-24; revised 12-15-23.)
1277+21 ARTICLE 10.
1278+22 Section 10-5. The Illinois Public Aid Code is amended by
1279+23 adding Section 5-5.05h as follows:
1280+
1281+
1282+
1283+
1284+
1285+ SB3268 Enrolled - 36 - LRB103 39338 KTG 69500 b
1286+
1287+
1288+SB3268 Enrolled- 37 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 37 - LRB103 39338 KTG 69500 b
1289+ SB3268 Enrolled - 37 - LRB103 39338 KTG 69500 b
1290+1 (305 ILCS 5/5-5.05h new)
1291+2 Sec. 5-5.05h. Reimbursement rates for psychiatric
1292+3 evaluations and medication monitoring. Subject to federal
1293+4 approval, for dates of service on and after January 1, 2025,
1294+5 the Department shall make a one-time adjustment to the add-on
1295+6 rates for services delivered by physicians who are
1296+7 board-certified in psychiatry and advanced practice registered
1297+8 nurses who hold a current certification in psychiatric and
1298+9 mental health nursing. The one-time adjustment shall increase
1299+10 the add-on rates so that the sum of the Department's base per
1300+11 service unit rate plus the rate add-on is no less than $264.42
1301+12 per hour adjusted for time and intensity as determined by the
1302+13 work relative value units in the 2024 national Medicare
1303+14 physician fee schedule, indexed to 60 minutes of individual
1304+15 psychotherapy.
1305+16 ARTICLE 15.
1306+17 Section 15-5. The Illinois Public Aid Code is amended by
1307+18 changing Section 5-5.01a as follows:
1308+19 (305 ILCS 5/5-5.01a)
1309+20 Sec. 5-5.01a. Supportive living facilities program.
1310+21 (a) The Department shall establish and provide oversight
1311+22 for a program of supportive living facilities that seek to
1312+23 promote resident independence, dignity, respect, and
1313+
1314+
1315+
1316+
1317+
1318+ SB3268 Enrolled - 37 - LRB103 39338 KTG 69500 b
1319+
1320+
1321+SB3268 Enrolled- 38 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 38 - LRB103 39338 KTG 69500 b
1322+ SB3268 Enrolled - 38 - LRB103 39338 KTG 69500 b
1323+1 well-being in the most cost-effective manner.
1324+2 A supportive living facility is (i) a free-standing
1325+3 facility or (ii) a distinct physical and operational entity
1326+4 within a mixed-use building that meets the criteria
1327+5 established in subsection (d). A supportive living facility
1328+6 integrates housing with health, personal care, and supportive
1329+7 services and is a designated setting that offers residents
1330+8 their own separate, private, and distinct living units.
1331+9 Sites for the operation of the program shall be selected
1332+10 by the Department based upon criteria that may include the
1333+11 need for services in a geographic area, the availability of
1334+12 funding, and the site's ability to meet the standards.
1335+13 (b) Beginning July 1, 2014, subject to federal approval,
1336+14 the Medicaid rates for supportive living facilities shall be
1337+15 equal to the supportive living facility Medicaid rate
1338+16 effective on June 30, 2014 increased by 8.85%. Once the
1339+17 assessment imposed at Article V-G of this Code is determined
1340+18 to be a permissible tax under Title XIX of the Social Security
1341+19 Act, the Department shall increase the Medicaid rates for
1342+20 supportive living facilities effective on July 1, 2014 by
1343+21 9.09%. The Department shall apply this increase retroactively
1344+22 to coincide with the imposition of the assessment in Article
1345+23 V-G of this Code in accordance with the approval for federal
1346+24 financial participation by the Centers for Medicare and
1347+25 Medicaid Services.
1348+26 The Medicaid rates for supportive living facilities
1349+
1350+
1351+
1352+
1353+
1354+ SB3268 Enrolled - 38 - LRB103 39338 KTG 69500 b
1355+
1356+
1357+SB3268 Enrolled- 39 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 39 - LRB103 39338 KTG 69500 b
1358+ SB3268 Enrolled - 39 - LRB103 39338 KTG 69500 b
1359+1 effective on July 1, 2017 must be equal to the rates in effect
1360+2 for supportive living facilities on June 30, 2017 increased by
1361+3 2.8%.
1362+4 The Medicaid rates for supportive living facilities
1363+5 effective on July 1, 2018 must be equal to the rates in effect
1364+6 for supportive living facilities on June 30, 2018.
1365+7 Subject to federal approval, the Medicaid rates for
1366+8 supportive living services on and after July 1, 2019 must be at
1367+9 least 54.3% of the average total nursing facility services per
1368+10 diem for the geographic areas defined by the Department while
1369+11 maintaining the rate differential for dementia care and must
1370+12 be updated whenever the total nursing facility service per
1371+13 diems are updated. Beginning July 1, 2022, upon the
1372+14 implementation of the Patient Driven Payment Model, Medicaid
1373+15 rates for supportive living services must be at least 54.3% of
1374+16 the average total nursing services per diem rate for the
1375+17 geographic areas. For purposes of this provision, the average
1376+18 total nursing services per diem rate shall include all add-ons
1377+19 for nursing facilities for the geographic area provided for in
1378+20 Section 5-5.2. The rate differential for dementia care must be
1379+21 maintained in these rates and the rates shall be updated
1380+22 whenever nursing facility per diem rates are updated.
1381+23 Subject to federal approval, beginning January 1, 2024,
1382+24 the dementia care rate for supportive living services must be
1383+25 no less than the non-dementia care supportive living services
1384+26 rate multiplied by 1.5.
1385+
1386+
1387+
1388+
1389+
1390+ SB3268 Enrolled - 39 - LRB103 39338 KTG 69500 b
1391+
1392+
1393+SB3268 Enrolled- 40 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 40 - LRB103 39338 KTG 69500 b
1394+ SB3268 Enrolled - 40 - LRB103 39338 KTG 69500 b
1395+1 (b-5) Subject to federal approval, beginning January 1,
1396+2 2025, Medicaid rates for supportive living services must be at
1397+3 least 54.75% of the average total nursing services per diem
1398+4 rate for the geographic areas defined by the Department and
1399+5 shall include all add-ons for nursing facilities for the
1400+6 geographic area provided for in Section 5-5.2.
1401+7 (c) The Department may adopt rules to implement this
1402+8 Section. Rules that establish or modify the services,
1403+9 standards, and conditions for participation in the program
1404+10 shall be adopted by the Department in consultation with the
1405+11 Department on Aging, the Department of Rehabilitation
1406+12 Services, and the Department of Mental Health and
1407+13 Developmental Disabilities (or their successor agencies).
1408+14 (d) Subject to federal approval by the Centers for
1409+15 Medicare and Medicaid Services, the Department shall accept
1410+16 for consideration of certification under the program any
1411+17 application for a site or building where distinct parts of the
1412+18 site or building are designated for purposes other than the
1413+19 provision of supportive living services, but only if:
1414+20 (1) those distinct parts of the site or building are
1415+21 not designated for the purpose of providing assisted
1416+22 living services as required under the Assisted Living and
1417+23 Shared Housing Act;
1418+24 (2) those distinct parts of the site or building are
1419+25 completely separate from the part of the building used for
1420+26 the provision of supportive living program services,
1421+
1422+
1423+
1424+
1425+
1426+ SB3268 Enrolled - 40 - LRB103 39338 KTG 69500 b
1427+
1428+
1429+SB3268 Enrolled- 41 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 41 - LRB103 39338 KTG 69500 b
1430+ SB3268 Enrolled - 41 - LRB103 39338 KTG 69500 b
1431+1 including separate entrances;
1432+2 (3) those distinct parts of the site or building do
1433+3 not share any common spaces with the part of the building
1434+4 used for the provision of supportive living program
1435+5 services; and
1436+6 (4) those distinct parts of the site or building do
1437+7 not share staffing with the part of the building used for
1438+8 the provision of supportive living program services.
1439+9 (e) Facilities or distinct parts of facilities which are
1440+10 selected as supportive living facilities and are in good
1441+11 standing with the Department's rules are exempt from the
1442+12 provisions of the Nursing Home Care Act and the Illinois
1443+13 Health Facilities Planning Act.
1444+14 (f) Section 9817 of the American Rescue Plan Act of 2021
1445+15 (Public Law 117-2) authorizes a 10% enhanced federal medical
1446+16 assistance percentage for supportive living services for a
1447+17 12-month period from April 1, 2021 through March 31, 2022.
1448+18 Subject to federal approval, including the approval of any
1449+19 necessary waiver amendments or other federally required
1450+20 documents or assurances, for a 12-month period the Department
1451+21 must pay a supplemental $26 per diem rate to all supportive
1452+22 living facilities with the additional federal financial
1453+23 participation funds that result from the enhanced federal
1454+24 medical assistance percentage from April 1, 2021 through March
1455+25 31, 2022. The Department may issue parameters around how the
1456+26 supplemental payment should be spent, including quality
1457+
1458+
1459+
1460+
1461+
1462+ SB3268 Enrolled - 41 - LRB103 39338 KTG 69500 b
1463+
1464+
1465+SB3268 Enrolled- 42 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 42 - LRB103 39338 KTG 69500 b
1466+ SB3268 Enrolled - 42 - LRB103 39338 KTG 69500 b
1467+1 improvement activities. The Department may alter the form,
1468+2 methods, or timeframes concerning the supplemental per diem
1469+3 rate to comply with any subsequent changes to federal law,
1470+4 changes made by guidance issued by the federal Centers for
1471+5 Medicare and Medicaid Services, or other changes necessary to
1472+6 receive the enhanced federal medical assistance percentage.
1473+7 (g) All applications for the expansion of supportive
1474+8 living dementia care settings involving sites not approved by
1475+9 the Department on January 1, 2024 (the effective date of
1476+10 Public Act 103-102) this amendatory Act of the 103rd General
1477+11 Assembly may allow new elderly non-dementia units in addition
1478+12 to new dementia care units. The Department may approve such
1479+13 applications only if the application has: (1) no more than one
1480+14 non-dementia care unit for each dementia care unit and (2) the
1481+15 site is not located within 4 miles of an existing supportive
1482+16 living program site in Cook County (including the City of
1483+17 Chicago), not located within 12 miles of an existing
1484+18 supportive living program site in DuPage County, Kane County,
1485+19 Lake County, McHenry County, or Will County, or not located
1486+20 within 25 miles of an existing supportive living program site
1487+21 in any other county.
1488+22 (h) Beginning January 1, 2025, subject to federal
1489+23 approval, for a person who is a resident of a supportive living
1490+24 facility under this Section, the monthly personal needs
1491+25 allowance shall be $120 per month.
1492+26 (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
1493+
1494+
1495+
1496+
1497+
1498+ SB3268 Enrolled - 42 - LRB103 39338 KTG 69500 b
1499+
1500+
1501+SB3268 Enrolled- 43 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 43 - LRB103 39338 KTG 69500 b
1502+ SB3268 Enrolled - 43 - LRB103 39338 KTG 69500 b
1503+1 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
1504+2 Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)
1505+3 ARTICLE 20.
1506+4 Section 20-5. The Birth Center Licensing Act is amended by
1507+5 changing Section 40 as follows:
1508+6 (210 ILCS 170/40)
1509+7 Sec. 40. Reimbursement requirements.
1510+8 (a) A birth center shall seek certification under Titles
1511+9 XVIII and XIX of the federal Social Security Act.
1512+10 (b) Services provided to individuals eligible for medical
1513+11 assistance shall be covered in accordance with Article V of
1514+12 the Illinois Public Aid Code and reimbursement rates shall be
1515+13 set by the Department of Healthcare and Family Services.
1516+14 Reimbursement rates set by the Department of Healthcare and
1517+15 Family Services should be based on all types of medically
1518+16 necessary covered services provided to both the birthing
1519+17 person and the baby, including:
1520+18 (1) a professional fee for both the birthing person
1521+19 and baby;
1522+20 (2) a facility fee for the birthing person that is no
1523+21 less than 75% of the statewide average facility payment
1524+22 rate made to a hospital for an uncomplicated vaginal
1525+23 birth;
1526+
1527+
1528+
1529+
1530+
1531+ SB3268 Enrolled - 43 - LRB103 39338 KTG 69500 b
1532+
1533+
1534+SB3268 Enrolled- 44 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 44 - LRB103 39338 KTG 69500 b
1535+ SB3268 Enrolled - 44 - LRB103 39338 KTG 69500 b
1536+1 (3) a facility fee for the baby that is no less than
1537+2 75% of the statewide average facility payment rate made to
1538+3 a hospital for a normal baby; and
1539+4 (4) additional fees for other services, medications,
1540+5 laboratory tests, and supplies provided.
1541+6 (c) A birth center shall provide charitable care
1542+7 consistent with that provided by comparable health care
1543+8 providers in the geographic area.
1544+9 (d) A birth center may not discriminate against any
1545+10 patient requiring treatment because of the source of payment
1546+11 for services, including Medicare and Medicaid recipients.
1547+12 (Source: P.A. 102-518, eff. 8-20-21.)
1548+13 Section 20-10. The Illinois Public Aid Code is amended by
1549+14 adding Section 5-18.3 as follows:
1550+15 (305 ILCS 5/5-18.3 new)
1551+16 Sec. 5-18.3. Birth center; facility fee.
1552+17 (a) Reimbursement for services covered under this Article
1553+18 and provided at a birth center as defined in Section 5 of the
1554+19 Birth Center Licensing Act shall include:
1555+20 (1) Beginning January 1, 2025, subject to federal
1556+21 approval, a facility fee for the birthing person and baby
1557+22 that is no less than 80% of the statewide average facility
1558+23 payment rate made to a hospital for an uncomplicated
1559+24 vaginal birth. The facility fee shall include medications,
1560+
1561+
1562+
1563+
1564+
1565+ SB3268 Enrolled - 44 - LRB103 39338 KTG 69500 b
1566+
1567+
1568+SB3268 Enrolled- 45 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 45 - LRB103 39338 KTG 69500 b
1569+ SB3268 Enrolled - 45 - LRB103 39338 KTG 69500 b
1570+1 laboratory tests, and supplies provided.
1571+2 (2) Beginning January 1, 2025, no less than 80% of the
1572+3 Department fee schedule rate for professional services for
1573+4 the birthing person and baby covered under this Article
1574+5 that are reimbursable separate from the facility fee and
1575+6 provided within the scope of licensure or certification of
1576+7 both the practitioner and birth center.
1577+8 (b) The Department shall submit any necessary application
1578+9 to the federal Centers for Medicare and Medicaid Services for
1579+10 a waiver or State Plan amendment to implement the requirements
1580+11 of this Section.
1581+12 ARTICLE 30.
1582+13 Section 30-5. The Illinois Public Aid Code is amended by
1583+14 changing Sections 5H-1 and 5H-3 as follows:
1584+15 (305 ILCS 5/5H-1)
1585+16 Sec. 5H-1. Definitions. As used in this Article:
1586+17 "Base year" means the 12-month period from January 1, 2023
1587+18 2018 to December 31, 2023 2018.
1588+19 "Department" means the Department of Healthcare and Family
1589+20 Services.
1590+21 "Federal employee health benefit" means the program of
1591+22 health benefits plans, as defined in 5 U.S.C. 8901, available
1592+23 to federal employees under 5 U.S.C. 8901 to 8914.
1593+
1594+
1595+
1596+
1597+
1598+ SB3268 Enrolled - 45 - LRB103 39338 KTG 69500 b
1599+
1600+
1601+SB3268 Enrolled- 46 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 46 - LRB103 39338 KTG 69500 b
1602+ SB3268 Enrolled - 46 - LRB103 39338 KTG 69500 b
1603+1 "Fund" means the Healthcare Provider Relief Fund.
1604+2 "Managed care organization" means an entity operating
1605+3 under a certificate of authority issued pursuant to the Health
1606+4 Maintenance Organization Act or as a Managed Care Community
1607+5 Network pursuant to Section 5-11 of this Code.
1608+6 "Medicaid managed care organization" means a managed care
1609+7 organization under contract with the Department to provide
1610+8 services to recipients of benefits in the medical assistance
1611+9 program pursuant to Article V of this Code, the Children's
1612+10 Health Insurance Program Act, or the Covering ALL KIDS Health
1613+11 Insurance Act. It does not include contracts the same entity
1614+12 or an affiliated entity has for other business.
1615+13 "Medicare" means the federal Medicare program established
1616+14 under Title XVIII of the federal Social Security Act.
1617+15 "Member months" means the aggregate total number of months
1618+16 all individuals are enrolled for coverage in a Managed Care
1619+17 Organization during the base year. Member months are
1620+18 determined by the Department for Medicaid Managed Care
1621+19 Organizations based on enrollment data in its Medicaid
1622+20 Management Information System and by the Department of
1623+21 Insurance for other Managed Care Organizations based on
1624+22 required filings with the Department of Insurance. Member
1625+23 months do not include months individuals are enrolled in a
1626+24 Limited Health Services Organization, including stand-alone
1627+25 dental or vision plans, a Medicare Advantage Plan, a Medicare
1628+26 Supplement Plan, a Medicaid Medicare Alignment Initiate Plan
1629+
1630+
1631+
1632+
1633+
1634+ SB3268 Enrolled - 46 - LRB103 39338 KTG 69500 b
1635+
1636+
1637+SB3268 Enrolled- 47 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 47 - LRB103 39338 KTG 69500 b
1638+ SB3268 Enrolled - 47 - LRB103 39338 KTG 69500 b
1639+1 pursuant to a Memorandum of Understanding between the
1640+2 Department and the Federal Centers for Medicare and Medicaid
1641+3 Services or a Federal Employee Health Benefits Plan.
1642+4 (Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.)
1643+5 (305 ILCS 5/5H-3)
1644+6 Sec. 5H-3. Managed care assessment.
1645+7 (a) There is For State Fiscal year 2020 through State
1646+8 Fiscal Year 2025, there is imposed upon managed care
1647+9 organization member months an assessment, calculated on base
1648+10 year data, as set forth below for the appropriate tier:
1649+11 (1) Tier 1: $78.90 $60.20 per member month.
1650+12 (2) Tier 2: $1.40 $1.20 per member month.
1651+13 (3) Tier 3: $2.40 per member month.
1652+14 (b) The tiers are established as follows:
1653+15 (1) Tier 1 includes the first 4,195,000 member months
1654+16 in a Medicaid managed care organization for the base year;
1655+17 (2) (ii) Tier 2 includes member months over 4,195,000
1656+18 in a Medicaid managed care organization during the base
1657+19 year; and
1658+20 (3) (iv) Tier 3 includes member months during the base
1659+21 year in a managed care organization that is not a Medicaid
1660+22 managed care organization.
1661+23 (c) For State fiscal year 2020, and for each State fiscal
1662+24 year thereafter, through State fiscal year 2025, the
1663+25 Department may by rule adjust rates or tier parameters or both
1664+
1665+
1666+
1667+
1668+
1669+ SB3268 Enrolled - 47 - LRB103 39338 KTG 69500 b
1670+
1671+
1672+SB3268 Enrolled- 48 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 48 - LRB103 39338 KTG 69500 b
1673+ SB3268 Enrolled - 48 - LRB103 39338 KTG 69500 b
1674+1 in order to maximize the revenue generated by the assessment
1675+2 consistent with federal regulations and to meet federal
1676+3 statistical tests necessary for federal financial
1677+4 participation. Any upward adjustment to the Tier 3 rate shall
1678+5 be the minimum necessary to meet federal statistical tests.
1679+6 (Source: P.A. 101-9, eff. 6-5-19.)
1680+7 ARTICLE 35.
1681+8 Section 35-5. The Illinois Administrative Procedure Act is
1682+9 amended by adding Section 5-45.55 as follows:
1683+10 (5 ILCS 100/5-45.55 new)
1684+11 Sec. 5-45.55. Emergency rulemaking; Medicaid hospital rate
1685+12 updates. To provide for the expeditious and timely
1686+13 implementation of the changes made to Section 14-12.5 of the
1687+14 Illinois Public Aid Code by this amendatory Act of the 103rd
1688+15 General Assembly, emergency rules implementing the changes
1689+16 made by this amendatory Act of the 103rd General Assembly to
1690+17 Section 14-12.5 of the Illinois Public Aid Code may be adopted
1691+18 in accordance with Section 5-45 by the Department of
1692+19 Healthcare and Family Services. The adoption of emergency
1693+20 rules authorized by Section 5-45 and this Section is deemed to
1694+21 be necessary for the public interest, safety, and welfare.
1695+22 This Section is repealed one year after the effective date
1696+23 of this amendatory Act of the 103rd General Assembly.
1697+
1698+
1699+
1700+
1701+
1702+ SB3268 Enrolled - 48 - LRB103 39338 KTG 69500 b
1703+
1704+
1705+SB3268 Enrolled- 49 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 49 - LRB103 39338 KTG 69500 b
1706+ SB3268 Enrolled - 49 - LRB103 39338 KTG 69500 b
1707+1 Section 35-10. The Illinois Public Aid Code is amended by
1708+2 changing Section 14-12.5 as follows:
1709+3 (305 ILCS 5/14-12.5)
1710+4 Sec. 14-12.5. Hospital rate updates.
1711+5 (a) Notwithstanding any other provision of this Code, the
1712+6 hospital rates of reimbursement authorized under Sections
1713+7 5-5.05, 14-12, and 14-13 of this Code shall be adjusted in
1714+8 accordance with the provisions of this Section.
1715+9 (b) Notwithstanding any other provision of this Code,
1716+10 effective for dates of service on and after January 1, 2024,
1717+11 subject to federal approval, hospital reimbursement rates
1718+12 shall be revised as follows:
1719+13 (1) For inpatient general acute care services, the
1720+14 statewide-standardized amount and the per diem rates for
1721+15 hospitals exempt from the APR-DRG reimbursement system, in
1722+16 effect January 1, 2023, shall be increased by 10%.
1723+17 (2) For inpatient psychiatric services:
1724+18 (A) For safety-net hospitals, the hospital
1725+19 specific per diem rate in effect January 1, 2023 and
1726+20 the minimum per diem rate of $630, authorized in
1727+21 subsection (b-5) of Section 5-5.05 of this Code, shall
1728+22 be increased by 10%.
1729+23 (B) For all general acute care hospitals that are
1730+24 not safety-net hospitals, the inpatient psychiatric
1731+
1732+
1733+
1734+
1735+
1736+ SB3268 Enrolled - 49 - LRB103 39338 KTG 69500 b
1737+
1738+
1739+SB3268 Enrolled- 50 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 50 - LRB103 39338 KTG 69500 b
1740+ SB3268 Enrolled - 50 - LRB103 39338 KTG 69500 b
1741+1 care per diem rates in effect January 1, 2023 shall be
1742+2 increased by 10%, except that all rates shall be at
1743+3 least 90% of the minimum inpatient psychiatric care
1744+4 per diem rate for safety-net hospitals as authorized
1745+5 in subsection (b-5) of Section 5-5.05 of this Code
1746+6 including the adjustments authorized in this Section.
1747+7 The statewide default per diem rate for a hospital
1748+8 opening a new psychiatric distinct part unit, shall be
1749+9 set at 90% of the minimum inpatient psychiatric care
1750+10 per diem rate for safety-net hospitals as authorized
1751+11 in subsection (b-5) of Section 5-5.05 of this Code,
1752+12 including the adjustment authorized in this Section.
1753+13 (C) For all psychiatric specialty hospitals, the
1754+14 per diem rates in effect January 1, 2023, shall be
1755+15 increased by 10%, except that all rates shall be at
1756+16 least 90% of the minimum inpatient per diem rate for
1757+17 safety-net hospitals as authorized in subsection (b-5)
1758+18 of Section 5-5.05 of this Code, including the
1759+19 adjustments authorized in this Section. The statewide
1760+20 default per diem rate for a new psychiatric specialty
1761+21 hospital shall be set at 90% of the minimum inpatient
1762+22 psychiatric care per diem rate for safety-net
1763+23 hospitals as authorized in subsection (b-5) of Section
1764+24 5-5.05 of this Code, including the adjustment
1765+25 authorized in this Section.
1766+26 (3) For inpatient rehabilitative services, all
1767+
1768+
1769+
1770+
1771+
1772+ SB3268 Enrolled - 50 - LRB103 39338 KTG 69500 b
1773+
1774+
1775+SB3268 Enrolled- 51 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 51 - LRB103 39338 KTG 69500 b
1776+ SB3268 Enrolled - 51 - LRB103 39338 KTG 69500 b
1777+1 hospital specific per diem rates in effect January 1,
1778+2 2023, shall be increased by 10%. The statewide default
1779+3 inpatient rehabilitative services per diem rates, for
1780+4 general acute care hospitals and for rehabilitation
1781+5 specialty hospitals respectively, shall be increased by
1782+6 10%.
1783+7 (4) The statewide-standardized amount for outpatient
1784+8 general acute care services in effect January 1, 2023,
1785+9 shall be increased by 10%.
1786+10 (5) The statewide-standardized amount for outpatient
1787+11 psychiatric care services in effect January 1, 2023, shall
1788+12 be increased by 10%.
1789+13 (6) The statewide-standardized amount for outpatient
1790+14 rehabilitative care services in effect January 1, 2023,
1791+15 shall be increased by 10%.
1792+16 (7) The per diem rate in effect January 1, 2023, as
1793+17 authorized in subsection (a) of Section 14-13 of this
1794+18 Article shall be increased by 10%.
1795+19 (8) For services provided Beginning on and after
1796+20 January 1, 2024 through June 30, 2024, and on and after
1797+21 January 1, 2027, subject to federal approval, in addition
1798+22 to the statewide standardized amount, an add-on payment of
1799+23 at least $210 shall be paid for each inpatient General
1800+24 Acute and Psychiatric day of care, excluding
1801+25 Medicare-Medicaid dual eligible crossover days, for all
1802+26 safety-net hospitals defined in Section 5-5e.1 of this
1803+
1804+
1805+
1806+
1807+
1808+ SB3268 Enrolled - 51 - LRB103 39338 KTG 69500 b
1809+
1810+
1811+SB3268 Enrolled- 52 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 52 - LRB103 39338 KTG 69500 b
1812+ SB3268 Enrolled - 52 - LRB103 39338 KTG 69500 b
1813+1 Code.
1814+2 (A) For Psychiatric days of care, the Department
1815+3 may implement payment of this add-on by increasing the
1816+4 hospital specific psychiatric per diem rate, adjusted
1817+5 in accordance with subparagraph (A) of paragraph (2)
1818+6 of subsection (b) by $210, or by a separate add-on
1819+7 payment.
1820+8 (B) If the add-on adjustment is added to the
1821+9 hospital specific psychiatric per diem rate to
1822+10 operationalize payment, the Department shall provide a
1823+11 rate sheet to each safety-net hospital, which
1824+12 identifies the hospital psychiatric per diem rate
1825+13 before and after the adjustment.
1826+14 (C) The add-on adjustment shall not be considered
1827+15 when setting the 90% minimum rate identified in
1828+16 paragraph (2) of subsection (b).
1829+17 (9) For services provided on and after July 1, 2024,
1830+18 and on or before December 31, 2026, subject to federal
1831+19 approval, in addition to the statewide standardized amount
1832+20 and any other payments authorized under this Code, a
1833+21 safety-net hospital health care equity add-on payment
1834+22 shall be paid for each inpatient General Acute and
1835+23 Psychiatric day of care, excluding Medicare-Medicaid dual
1836+24 eligible crossover days, for safety-net hospitals defined
1837+25 in Section 5-5e.1 of this Code, as follows:
1838+26 (A) if the safety-net hospital's Medicaid
1839+
1840+
1841+
1842+
1843+
1844+ SB3268 Enrolled - 52 - LRB103 39338 KTG 69500 b
1845+
1846+
1847+SB3268 Enrolled- 53 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 53 - LRB103 39338 KTG 69500 b
1848+ SB3268 Enrolled - 53 - LRB103 39338 KTG 69500 b
1849+1 inpatient utilization rate, as calculated under
1850+2 Section 5-5e.1 of this Code, is equal to or greater
1851+3 than 70%, the add-on payment shall be $425;
1852+4 (B) if the safety-net hospital's Medicaid
1853+5 inpatient utilization rate, as calculated under
1854+6 Section 5-5e.1 of this Code, is equal to or greater
1855+7 than 50% and less than 70%, the add-on payment shall be
1856+8 $300;
1857+9 (C) if the safety-net hospital's Medicaid
1858+10 inpatient utilization rate, as calculated under
1859+11 Section 5-5e.1 of this Code, is equal to or greater
1860+12 than 40% and less than 50%, the add-on payment shall be
1861+13 $225; and
1862+14 (D) if the safety-net hospital's Medicaid
1863+15 inpatient utilization rate, as calculated under
1864+16 Section 5-5e.1 of this Code, is less than 40%, the
1865+17 add-on payment shall be $210.
1866+18 Qualification for the safety-net hospital health care
1867+19 equity add-on payment shall be updated January 1, 2026,
1868+20 based on the MIUR determination effective 3 months prior
1869+21 to the start of the January 1, 2026 calendar year.
1870+22 Rates described in subparagraphs (A) through (C) shall
1871+23 be adjusted annually beginning January 1, 2026 by applying
1872+24 a uniform factor to each rate to spend an approximate
1873+25 amount of $50,000,000 annually per year using State fiscal
1874+26 year 2024 days as a basis for calendar year 2026 rates.
1875+
1876+
1877+
1878+
1879+
1880+ SB3268 Enrolled - 53 - LRB103 39338 KTG 69500 b
1881+
1882+
1883+SB3268 Enrolled- 54 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 54 - LRB103 39338 KTG 69500 b
1884+ SB3268 Enrolled - 54 - LRB103 39338 KTG 69500 b
1885+1 The add-on adjustment under this paragraph shall not
1886+2 be considered when setting the 90% minimum rate identified
1887+3 in subparagraph (B) of paragraph (2).
1888+4 (10) For services provided on and after July 1, 2024,
1889+5 and on or before December 31, 2026, subject to federal
1890+6 approval, in addition to the statewide standardized amount
1891+7 and any other payments authorized under this Code, a
1892+8 safety-net hospital low volume add-on payment of $200
1893+9 shall be paid for each inpatient General Acute and
1894+10 Psychiatric day of care, excluding Medicare-Medicaid dual
1895+11 eligible crossover days, for any safety-net hospital as
1896+12 defined in Section 5-5e.1 that provided less than 11,000
1897+13 Medicaid inpatient days of care, excluding
1898+14 Medicare-Medicaid dual eligible crossover days, in the
1899+15 base period. As used in this paragraph, "base period"
1900+16 means State fiscal year 2022 admissions received by the
1901+17 Department prior to October 1, 2023 for the payment period
1902+18 July 1, 2024 through December 31, 2025, and beginning in
1903+19 calendar year 2026, the State fiscal year that ends 30
1904+20 months before the applicable calendar year, such as State
1905+21 fiscal year 2023 admissions received by the Department
1906+22 prior to October 1, 2024, for calendar year 2026.
1907+23 (c) The Department shall take all actions necessary to
1908+24 ensure the changes authorized in Public Act 103-102 and this
1909+25 amendatory Act of the 103rd General Assembly are in effect for
1910+26 dates of service on and after the effective date of the changes
1911+
1912+
1913+
1914+
1915+
1916+ SB3268 Enrolled - 54 - LRB103 39338 KTG 69500 b
1917+
1918+
1919+SB3268 Enrolled- 55 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 55 - LRB103 39338 KTG 69500 b
1920+ SB3268 Enrolled - 55 - LRB103 39338 KTG 69500 b
1921+1 made to this Section by this amendatory Act of the 103rd
1922+2 General Assembly, January 1, 2024, including publishing all
1923+3 appropriate public notices, applying for federal approval of
1924+4 amendments to the Illinois Title XIX State Plan, and adopting
1925+5 administrative rules if necessary.
1926+6 (d) The Department of Healthcare and Family Services may
1927+7 adopt rules necessary to implement the changes made by Public
1928+8 Act 103-102 and this amendatory Act of the 103rd General
1929+9 Assembly through the use of emergency rulemaking in accordance
1930+10 with Section 5-45 of the Illinois Administrative Procedure
1931+11 Act. The 24-month limitation on the adoption of emergency
1932+12 rules does not apply to rules adopted under this Section. The
1933+13 General Assembly finds that the adoption of rules to implement
1934+14 the changes made by Public Act 103-102 and this amendatory Act
1935+15 of the 103rd General Assembly is deemed an emergency and
1936+16 necessary for the public interest, safety, and welfare.
1937+17 (e) The Department shall ensure that all necessary
1938+18 adjustments to the managed care organization capitation base
1939+19 rates necessitated by the adjustments in this Section are
1940+20 completed, published, and applied in accordance with Section
1941+21 5-30.8 of this Code 90 days prior to the implementation date of
1942+22 the changes required under Public Act 103-102 and this
1943+23 amendatory Act of the 103rd General Assembly.
1944+24 (f) The Department shall publish updated rate sheets or
1945+25 add-on payment amounts, as applicable, for all hospitals 30
1946+26 days prior to the effective date of the rate increase, or
1947+
1948+
1949+
1950+
1951+
1952+ SB3268 Enrolled - 55 - LRB103 39338 KTG 69500 b
1953+
1954+
1955+SB3268 Enrolled- 56 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 56 - LRB103 39338 KTG 69500 b
1956+ SB3268 Enrolled - 56 - LRB103 39338 KTG 69500 b
1957+1 within 30 days after federal approval by the Centers for
1958+2 Medicare and Medicaid Services, whichever is later.
1959+3 (Source: P.A. 103-102, eff. 6-16-23.)
1960+4 ARTICLE 40.
1961+5 Section 40-5. The Illinois Public Aid Code is amended by
1962+6 changing Section 5A-12.7 as follows:
1963+7 (305 ILCS 5/5A-12.7)
1964+8 (Section scheduled to be repealed on December 31, 2026)
1965+9 Sec. 5A-12.7. Continuation of hospital access payments on
1966+10 and after July 1, 2020.
1967+11 (a) To preserve and improve access to hospital services,
1968+12 for hospital services rendered on and after July 1, 2020, the
1969+13 Department shall, except for hospitals described in subsection
1970+14 (b) of Section 5A-3, make payments to hospitals or require
1971+15 capitated managed care organizations to make payments as set
1972+16 forth in this Section. Payments under this Section are not due
1973+17 and payable, however, until: (i) the methodologies described
1974+18 in this Section are approved by the federal government in an
1975+19 appropriate State Plan amendment or directed payment preprint;
1976+20 and (ii) the assessment imposed under this Article is
1977+21 determined to be a permissible tax under Title XIX of the
1978+22 Social Security Act. In determining the hospital access
1979+23 payments authorized under subsection (g) of this Section, if a
1980+
1981+
1982+
1983+
1984+
1985+ SB3268 Enrolled - 56 - LRB103 39338 KTG 69500 b
1986+
1987+
1988+SB3268 Enrolled- 57 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 57 - LRB103 39338 KTG 69500 b
1989+ SB3268 Enrolled - 57 - LRB103 39338 KTG 69500 b
1990+1 hospital ceases to qualify for payments from the pool, the
1991+2 payments for all hospitals continuing to qualify for payments
1992+3 from such pool shall be uniformly adjusted to fully expend the
1993+4 aggregate net amount of the pool, with such adjustment being
1994+5 effective on the first day of the second month following the
1995+6 date the hospital ceases to receive payments from such pool.
1996+7 (b) Amounts moved into claims-based rates and distributed
1997+8 in accordance with Section 14-12 shall remain in those
1998+9 claims-based rates.
1999+10 (c) Graduate medical education.
2000+11 (1) The calculation of graduate medical education
2001+12 payments shall be based on the hospital's Medicare cost
2002+13 report ending in Calendar Year 2018, as reported in the
2003+14 Healthcare Cost Report Information System file, release
2004+15 date September 30, 2019. An Illinois hospital reporting
2005+16 intern and resident cost on its Medicare cost report shall
2006+17 be eligible for graduate medical education payments.
2007+18 (2) Each hospital's annualized Medicaid Intern
2008+19 Resident Cost is calculated using annualized intern and
2009+20 resident total costs obtained from Worksheet B Part I,
2010+21 Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
2011+22 96-98, and 105-112 multiplied by the percentage that the
2012+23 hospital's Medicaid days (Worksheet S3 Part I, Column 7,
2013+24 Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
2014+25 hospital's total days (Worksheet S3 Part I, Column 8,
2015+26 Lines 14, 16-18, and 32).
2016+
2017+
2018+
2019+
2020+
2021+ SB3268 Enrolled - 57 - LRB103 39338 KTG 69500 b
2022+
2023+
2024+SB3268 Enrolled- 58 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 58 - LRB103 39338 KTG 69500 b
2025+ SB3268 Enrolled - 58 - LRB103 39338 KTG 69500 b
2026+1 (3) An annualized Medicaid indirect medical education
2027+2 (IME) payment is calculated for each hospital using its
2028+3 IME payments (Worksheet E Part A, Line 29, Column 1)
2029+4 multiplied by the percentage that its Medicaid days
2030+5 (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
2031+6 and 32) comprise of its Medicare days (Worksheet S3 Part
2032+7 I, Column 6, Lines 2, 3, 4, 14, and 16-18).
2033+8 (4) For each hospital, its annualized Medicaid Intern
2034+9 Resident Cost and its annualized Medicaid IME payment are
2035+10 summed, and, except as capped at 120% of the average cost
2036+11 per intern and resident for all qualifying hospitals as
2037+12 calculated under this paragraph, is multiplied by the
2038+13 applicable reimbursement factor as described in this
2039+14 paragraph, to determine the hospital's final graduate
2040+15 medical education payment. Each hospital's average cost
2041+16 per intern and resident shall be calculated by summing its
2042+17 total annualized Medicaid Intern Resident Cost plus its
2043+18 annualized Medicaid IME payment and dividing that amount
2044+19 by the hospital's total Full Time Equivalent Residents and
2045+20 Interns. If the hospital's average per intern and resident
2046+21 cost is greater than 120% of the same calculation for all
2047+22 qualifying hospitals, the hospital's per intern and
2048+23 resident cost shall be capped at 120% of the average cost
2049+24 for all qualifying hospitals.
2050+25 (A) For the period of July 1, 2020 through
2051+26 December 31, 2022, the applicable reimbursement factor
2052+
2053+
2054+
2055+
2056+
2057+ SB3268 Enrolled - 58 - LRB103 39338 KTG 69500 b
2058+
2059+
2060+SB3268 Enrolled- 59 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 59 - LRB103 39338 KTG 69500 b
2061+ SB3268 Enrolled - 59 - LRB103 39338 KTG 69500 b
2062+1 shall be 22.6%.
2063+2 (B) For the period of January 1, 2023 through
2064+3 December 31, 2026, the applicable reimbursement factor
2065+4 shall be 35% for all qualified safety-net hospitals,
2066+5 as defined in Section 5-5e.1 of this Code, and all
2067+6 hospitals with 100 or more Full Time Equivalent
2068+7 Residents and Interns, as reported on the hospital's
2069+8 Medicare cost report ending in Calendar Year 2018, and
2070+9 for all other qualified hospitals the applicable
2071+10 reimbursement factor shall be 30%.
2072+11 (d) Fee-for-service supplemental payments. For the period
2073+12 of July 1, 2020 through December 31, 2022, each Illinois
2074+13 hospital shall receive an annual payment equal to the amounts
2075+14 below, to be paid in 12 equal installments on or before the
2076+15 seventh State business day of each month, except that no
2077+16 payment shall be due within 30 days after the later of the date
2078+17 of notification of federal approval of the payment
2079+18 methodologies required under this Section or any waiver
2080+19 required under 42 CFR 433.68, at which time the sum of amounts
2081+20 required under this Section prior to the date of notification
2082+21 is due and payable.
2083+22 (1) For critical access hospitals, $385 per covered
2084+23 inpatient day contained in paid fee-for-service claims and
2085+24 $530 per paid fee-for-service outpatient claim for dates
2086+25 of service in Calendar Year 2019 in the Department's
2087+26 Enterprise Data Warehouse as of May 11, 2020.
2088+
2089+
2090+
2091+
2092+
2093+ SB3268 Enrolled - 59 - LRB103 39338 KTG 69500 b
2094+
2095+
2096+SB3268 Enrolled- 60 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 60 - LRB103 39338 KTG 69500 b
2097+ SB3268 Enrolled - 60 - LRB103 39338 KTG 69500 b
2098+1 (2) For safety-net hospitals, $960 per covered
2099+2 inpatient day contained in paid fee-for-service claims and
2100+3 $625 per paid fee-for-service outpatient claim for dates
2101+4 of service in Calendar Year 2019 in the Department's
2102+5 Enterprise Data Warehouse as of May 11, 2020.
2103+6 (3) For long term acute care hospitals, $295 per
2104+7 covered inpatient day contained in paid fee-for-service
2105+8 claims for dates of service in Calendar Year 2019 in the
2106+9 Department's Enterprise Data Warehouse as of May 11, 2020.
2107+10 (4) For freestanding psychiatric hospitals, $125 per
2108+11 covered inpatient day contained in paid fee-for-service
2109+12 claims and $130 per paid fee-for-service outpatient claim
2110+13 for dates of service in Calendar Year 2019 in the
2111+14 Department's Enterprise Data Warehouse as of May 11, 2020.
2112+15 (5) For freestanding rehabilitation hospitals, $355
2113+16 per covered inpatient day contained in paid
2114+17 fee-for-service claims for dates of service in Calendar
2115+18 Year 2019 in the Department's Enterprise Data Warehouse as
2116+19 of May 11, 2020.
2117+20 (6) For all general acute care hospitals and high
2118+21 Medicaid hospitals as defined in subsection (f), $350 per
2119+22 covered inpatient day for dates of service in Calendar
2120+23 Year 2019 contained in paid fee-for-service claims and
2121+24 $620 per paid fee-for-service outpatient claim in the
2122+25 Department's Enterprise Data Warehouse as of May 11, 2020.
2123+26 (7) Alzheimer's treatment access payment. Each
2124+
2125+
2126+
2127+
2128+
2129+ SB3268 Enrolled - 60 - LRB103 39338 KTG 69500 b
2130+
2131+
2132+SB3268 Enrolled- 61 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 61 - LRB103 39338 KTG 69500 b
2133+ SB3268 Enrolled - 61 - LRB103 39338 KTG 69500 b
2134+1 Illinois academic medical center or teaching hospital, as
2135+2 defined in Section 5-5e.2 of this Code, that is identified
2136+3 as the primary hospital affiliate of one of the Regional
2137+4 Alzheimer's Disease Assistance Centers, as designated by
2138+5 the Alzheimer's Disease Assistance Act and identified in
2139+6 the Department of Public Health's Alzheimer's Disease
2140+7 State Plan dated December 2016, shall be paid an
2141+8 Alzheimer's treatment access payment equal to the product
2142+9 of the qualifying hospital's State Fiscal Year 2018 total
2143+10 inpatient fee-for-service days multiplied by the
2144+11 applicable Alzheimer's treatment rate of $226.30 for
2145+12 hospitals located in Cook County and $116.21 for hospitals
2146+13 located outside Cook County.
2147+14 (d-2) Fee-for-service supplemental payments. Beginning
2148+15 January 1, 2023, each Illinois hospital shall receive an
2149+16 annual payment equal to the amounts listed below, to be paid in
2150+17 12 equal installments on or before the seventh State business
2151+18 day of each month, except that no payment shall be due within
2152+19 30 days after the later of the date of notification of federal
2153+20 approval of the payment methodologies required under this
2154+21 Section or any waiver required under 42 CFR 433.68, at which
2155+22 time the sum of amounts required under this Section prior to
2156+23 the date of notification is due and payable. The Department
2157+24 may adjust the rates in paragraphs (1) through (7) to comply
2158+25 with the federal upper payment limits, with such adjustments
2159+26 being determined so that the total estimated spending by
2160+
2161+
2162+
2163+
2164+
2165+ SB3268 Enrolled - 61 - LRB103 39338 KTG 69500 b
2166+
2167+
2168+SB3268 Enrolled- 62 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 62 - LRB103 39338 KTG 69500 b
2169+ SB3268 Enrolled - 62 - LRB103 39338 KTG 69500 b
2170+1 hospital class, under such adjusted rates, remains
2171+2 substantially similar to the total estimated spending under
2172+3 the original rates set forth in this subsection.
2173+4 (1) For critical access hospitals, as defined in
2174+5 subsection (f), $750 per covered inpatient day contained
2175+6 in paid fee-for-service claims and $750 per paid
2176+7 fee-for-service outpatient claim for dates of service in
2177+8 Calendar Year 2019 in the Department's Enterprise Data
2178+9 Warehouse as of August 6, 2021.
2179+10 (2) For safety-net hospitals, as described in
2180+11 subsection (f), $1,350 per inpatient day contained in paid
2181+12 fee-for-service claims and $1,350 per paid fee-for-service
2182+13 outpatient claim for dates of service in Calendar Year
2183+14 2019 in the Department's Enterprise Data Warehouse as of
2184+15 August 6, 2021.
2185+16 (3) For long term acute care hospitals, $550 per
2186+17 covered inpatient day contained in paid fee-for-service
2187+18 claims for dates of service in Calendar Year 2019 in the
2188+19 Department's Enterprise Data Warehouse as of August 6,
2189+20 2021.
2190+21 (4) For freestanding psychiatric hospitals, $200 per
2191+22 covered inpatient day contained in paid fee-for-service
2192+23 claims and $200 per paid fee-for-service outpatient claim
2193+24 for dates of service in Calendar Year 2019 in the
2194+25 Department's Enterprise Data Warehouse as of August 6,
2195+26 2021.
2196+
2197+
2198+
2199+
2200+
2201+ SB3268 Enrolled - 62 - LRB103 39338 KTG 69500 b
2202+
2203+
2204+SB3268 Enrolled- 63 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 63 - LRB103 39338 KTG 69500 b
2205+ SB3268 Enrolled - 63 - LRB103 39338 KTG 69500 b
2206+1 (5) For freestanding rehabilitation hospitals, $550
2207+2 per covered inpatient day contained in paid
2208+3 fee-for-service claims and $125 per paid fee-for-service
2209+4 outpatient claim for dates of service in Calendar Year
2210+5 2019 in the Department's Enterprise Data Warehouse as of
2211+6 August 6, 2021.
2212+7 (6) For all general acute care hospitals and high
2213+8 Medicaid hospitals as defined in subsection (f), $500 per
2214+9 covered inpatient day for dates of service in Calendar
2215+10 Year 2019 contained in paid fee-for-service claims and
2216+11 $500 per paid fee-for-service outpatient claim in the
2217+12 Department's Enterprise Data Warehouse as of August 6,
2218+13 2021.
2219+14 (7) For public hospitals, as defined in subsection
2220+15 (f), $275 per covered inpatient day contained in paid
2221+16 fee-for-service claims and $275 per paid fee-for-service
2222+17 outpatient claim for dates of service in Calendar Year
2223+18 2019 in the Department's Enterprise Data Warehouse as of
2224+19 August 6, 2021.
2225+20 (8) Alzheimer's treatment access payment. Each
2226+21 Illinois academic medical center or teaching hospital, as
2227+22 defined in Section 5-5e.2 of this Code, that is identified
2228+23 as the primary hospital affiliate of one of the Regional
2229+24 Alzheimer's Disease Assistance Centers, as designated by
2230+25 the Alzheimer's Disease Assistance Act and identified in
2231+26 the Department of Public Health's Alzheimer's Disease
2232+
2233+
2234+
2235+
2236+
2237+ SB3268 Enrolled - 63 - LRB103 39338 KTG 69500 b
2238+
2239+
2240+SB3268 Enrolled- 64 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 64 - LRB103 39338 KTG 69500 b
2241+ SB3268 Enrolled - 64 - LRB103 39338 KTG 69500 b
2242+1 State Plan dated December 2016, shall be paid an
2243+2 Alzheimer's treatment access payment equal to the product
2244+3 of the qualifying hospital's Calendar Year 2019 total
2245+4 inpatient fee-for-service days, in the Department's
2246+5 Enterprise Data Warehouse as of August 6, 2021, multiplied
2247+6 by the applicable Alzheimer's treatment rate of $244.37
2248+7 for hospitals located in Cook County and $312.03 for
2249+8 hospitals located outside Cook County.
2250+9 (e) The Department shall require managed care
2251+10 organizations (MCOs) to make directed payments and
2252+11 pass-through payments according to this Section. Each calendar
2253+12 year, the Department shall require MCOs to pay the maximum
2254+13 amount out of these funds as allowed as pass-through payments
2255+14 under federal regulations. The Department shall require MCOs
2256+15 to make such pass-through payments as specified in this
2257+16 Section. The Department shall require the MCOs to pay the
2258+17 remaining amounts as directed Payments as specified in this
2259+18 Section. The Department shall issue payments to the
2260+19 Comptroller by the seventh business day of each month for all
2261+20 MCOs that are sufficient for MCOs to make the directed
2262+21 payments and pass-through payments according to this Section.
2263+22 The Department shall require the MCOs to make pass-through
2264+23 payments and directed payments using electronic funds
2265+24 transfers (EFT), if the hospital provides the information
2266+25 necessary to process such EFTs, in accordance with directions
2267+26 provided monthly by the Department, within 7 business days of
2268+
2269+
2270+
2271+
2272+
2273+ SB3268 Enrolled - 64 - LRB103 39338 KTG 69500 b
2274+
2275+
2276+SB3268 Enrolled- 65 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 65 - LRB103 39338 KTG 69500 b
2277+ SB3268 Enrolled - 65 - LRB103 39338 KTG 69500 b
2278+1 the date the funds are paid to the MCOs, as indicated by the
2279+2 "Paid Date" on the website of the Office of the Comptroller if
2280+3 the funds are paid by EFT and the MCOs have received directed
2281+4 payment instructions. If funds are not paid through the
2282+5 Comptroller by EFT, payment must be made within 7 business
2283+6 days of the date actually received by the MCO. The MCO will be
2284+7 considered to have paid the pass-through payments when the
2285+8 payment remittance number is generated or the date the MCO
2286+9 sends the check to the hospital, if EFT information is not
2287+10 supplied. If an MCO is late in paying a pass-through payment or
2288+11 directed payment as required under this Section (including any
2289+12 extensions granted by the Department), it shall pay a penalty,
2290+13 unless waived by the Department for reasonable cause, to the
2291+14 Department equal to 5% of the amount of the pass-through
2292+15 payment or directed payment not paid on or before the due date
2293+16 plus 5% of the portion thereof remaining unpaid on the last day
2294+17 of each 30-day period thereafter. Payments to MCOs that would
2295+18 be paid consistent with actuarial certification and enrollment
2296+19 in the absence of the increased capitation payments under this
2297+20 Section shall not be reduced as a consequence of payments made
2298+21 under this subsection. The Department shall publish and
2299+22 maintain on its website for a period of no less than 8 calendar
2300+23 quarters, the quarterly calculation of directed payments and
2301+24 pass-through payments owed to each hospital from each MCO. All
2302+25 calculations and reports shall be posted no later than the
2303+26 first day of the quarter for which the payments are to be
2304+
2305+
2306+
2307+
2308+
2309+ SB3268 Enrolled - 65 - LRB103 39338 KTG 69500 b
2310+
2311+
2312+SB3268 Enrolled- 66 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 66 - LRB103 39338 KTG 69500 b
2313+ SB3268 Enrolled - 66 - LRB103 39338 KTG 69500 b
2314+1 issued.
2315+2 (f)(1) For purposes of allocating the funds included in
2316+3 capitation payments to MCOs, Illinois hospitals shall be
2317+4 divided into the following classes as defined in
2318+5 administrative rules:
2319+6 (A) Beginning July 1, 2020 through December 31, 2022,
2320+7 critical access hospitals. Beginning January 1, 2023,
2321+8 "critical access hospital" means a hospital designated by
2322+9 the Department of Public Health as a critical access
2323+10 hospital, excluding any hospital meeting the definition of
2324+11 a public hospital in subparagraph (F).
2325+12 (B) Safety-net hospitals, except that stand-alone
2326+13 children's hospitals that are not specialty children's
2327+14 hospitals and, for calendar years 2025 and 2026 only,
2328+15 hospitals with over 9,000 Medicaid acute care inpatient
2329+16 admissions per calendar year, excluding admissions for
2330+17 Medicare-Medicaid dual eligible patients, will not be
2331+18 included. For the calendar year beginning January 1, 2023,
2332+19 and each calendar year thereafter, assignment to the
2333+20 safety-net class shall be based on the annual safety-net
2334+21 rate year beginning 15 months before the beginning of the
2335+22 first Payout Quarter of the calendar year.
2336+23 (C) Long term acute care hospitals.
2337+24 (D) Freestanding psychiatric hospitals.
2338+25 (E) Freestanding rehabilitation hospitals.
2339+26 (F) Beginning January 1, 2023, "public hospital" means
2340+
2341+
2342+
2343+
2344+
2345+ SB3268 Enrolled - 66 - LRB103 39338 KTG 69500 b
2346+
2347+
2348+SB3268 Enrolled- 67 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 67 - LRB103 39338 KTG 69500 b
2349+ SB3268 Enrolled - 67 - LRB103 39338 KTG 69500 b
2350+1 a hospital that is owned or operated by an Illinois
2351+2 Government body or municipality, excluding a hospital
2352+3 provider that is a State agency, a State university, or a
2353+4 county with a population of 3,000,000 or more.
2354+5 (G) High Medicaid hospitals.
2355+6 (i) As used in this Section, "high Medicaid
2356+7 hospital" means a general acute care hospital that:
2357+8 (I) For the payout periods July 1, 2020
2358+9 through December 31, 2022, is not a safety-net
2359+10 hospital or critical access hospital and that has
2360+11 a Medicaid Inpatient Utilization Rate above 30% or
2361+12 a hospital that had over 35,000 inpatient Medicaid
2362+13 days during the applicable period. For the period
2363+14 July 1, 2020 through December 31, 2020, the
2364+15 applicable period for the Medicaid Inpatient
2365+16 Utilization Rate (MIUR) is the rate year 2020 MIUR
2366+17 and for the number of inpatient days it is State
2367+18 fiscal year 2018. Beginning in calendar year 2021,
2368+19 the Department shall use the most recently
2369+20 determined MIUR, as defined in subsection (h) of
2370+21 Section 5-5.02, and for the inpatient day
2371+22 threshold, the State fiscal year ending 18 months
2372+23 prior to the beginning of the calendar year. For
2373+24 purposes of calculating MIUR under this Section,
2374+25 children's hospitals and affiliated general acute
2375+26 care hospitals shall be considered a single
2376+
2377+
2378+
2379+
2380+
2381+ SB3268 Enrolled - 67 - LRB103 39338 KTG 69500 b
2382+
2383+
2384+SB3268 Enrolled- 68 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 68 - LRB103 39338 KTG 69500 b
2385+ SB3268 Enrolled - 68 - LRB103 39338 KTG 69500 b
2386+1 hospital.
2387+2 (II) For the calendar year beginning January
2388+3 1, 2023, and each calendar year thereafter, is not
2389+4 a public hospital, safety-net hospital, or
2390+5 critical access hospital and that qualifies as a
2391+6 regional high volume hospital or is a hospital
2392+7 that has a Medicaid Inpatient Utilization Rate
2393+8 (MIUR) above 30%. As used in this item, "regional
2394+9 high volume hospital" means a hospital which ranks
2395+10 in the top 2 quartiles based on total hospital
2396+11 services volume, of all eligible general acute
2397+12 care hospitals, when ranked in descending order
2398+13 based on total hospital services volume, within
2399+14 the same Medicaid managed care region, as
2400+15 designated by the Department, as of January 1,
2401+16 2022. As used in this item, "total hospital
2402+17 services volume" means the total of all Medical
2403+18 Assistance hospital inpatient admissions plus all
2404+19 Medical Assistance hospital outpatient visits. For
2405+20 purposes of determining regional high volume
2406+21 hospital inpatient admissions and outpatient
2407+22 visits, the Department shall use dates of service
2408+23 provided during State Fiscal Year 2020 for the
2409+24 Payout Quarter beginning January 1, 2023. The
2410+25 Department shall use dates of service from the
2411+26 State fiscal year ending 18 month before the
2412+
2413+
2414+
2415+
2416+
2417+ SB3268 Enrolled - 68 - LRB103 39338 KTG 69500 b
2418+
2419+
2420+SB3268 Enrolled- 69 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 69 - LRB103 39338 KTG 69500 b
2421+ SB3268 Enrolled - 69 - LRB103 39338 KTG 69500 b
2422+1 beginning of the first Payout Quarter of the
2423+2 subsequent annual determination period.
2424+3 (ii) For the calendar year beginning January 1,
2425+4 2023, the Department shall use the Rate Year 2022
2426+5 Medicaid inpatient utilization rate (MIUR), as defined
2427+6 in subsection (h) of Section 5-5.02. For each
2428+7 subsequent annual determination, the Department shall
2429+8 use the MIUR applicable to the rate year ending
2430+9 September 30 of the year preceding the beginning of
2431+10 the calendar year.
2432+11 (H) General acute care hospitals. As used under this
2433+12 Section, "general acute care hospitals" means all other
2434+13 Illinois hospitals not identified in subparagraphs (A)
2435+14 through (G).
2436+15 (2) Hospitals' qualification for each class shall be
2437+16 assessed prior to the beginning of each calendar year and the
2438+17 new class designation shall be effective January 1 of the next
2439+18 year. The Department shall publish by rule the process for
2440+19 establishing class determination.
2441+20 (3) Beginning January 1, 2024, the Department may reassign
2442+21 hospitals or entire hospital classes as defined above, if
2443+22 federal limits on the payments to the class to which the
2444+23 hospitals are assigned based on the criteria in this
2445+24 subsection prevent the Department from making payments to the
2446+25 class that would otherwise be due under this Section. The
2447+26 Department shall publish the criteria and composition of each
2448+
2449+
2450+
2451+
2452+
2453+ SB3268 Enrolled - 69 - LRB103 39338 KTG 69500 b
2454+
2455+
2456+SB3268 Enrolled- 70 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 70 - LRB103 39338 KTG 69500 b
2457+ SB3268 Enrolled - 70 - LRB103 39338 KTG 69500 b
2458+1 new class based on the reassignments, and the projected impact
2459+2 on payments to each hospital under the new classes on its
2460+3 website by November 15 of the year before the year in which the
2461+4 class changes become effective.
2462+5 (g) Fixed pool directed payments. Beginning July 1, 2020,
2463+6 the Department shall issue payments to MCOs which shall be
2464+7 used to issue directed payments to qualified Illinois
2465+8 safety-net hospitals and critical access hospitals on a
2466+9 monthly basis in accordance with this subsection. Prior to the
2467+10 beginning of each Payout Quarter beginning July 1, 2020, the
2468+11 Department shall use encounter claims data from the
2469+12 Determination Quarter, accepted by the Department's Medicaid
2470+13 Management Information System for inpatient and outpatient
2471+14 services rendered by safety-net hospitals and critical access
2472+15 hospitals to determine a quarterly uniform per unit add-on for
2473+16 each hospital class.
2474+17 (1) Inpatient per unit add-on. A quarterly uniform per
2475+18 diem add-on shall be derived by dividing the quarterly
2476+19 Inpatient Directed Payments Pool amount allocated to the
2477+20 applicable hospital class by the total inpatient days
2478+21 contained on all encounter claims received during the
2479+22 Determination Quarter, for all hospitals in the class.
2480+23 (A) Each hospital in the class shall have a
2481+24 quarterly inpatient directed payment calculated that
2482+25 is equal to the product of the number of inpatient days
2483+26 attributable to the hospital used in the calculation
2484+
2485+
2486+
2487+
2488+
2489+ SB3268 Enrolled - 70 - LRB103 39338 KTG 69500 b
2490+
2491+
2492+SB3268 Enrolled- 71 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 71 - LRB103 39338 KTG 69500 b
2493+ SB3268 Enrolled - 71 - LRB103 39338 KTG 69500 b
2494+1 of the quarterly uniform class per diem add-on,
2495+2 multiplied by the calculated applicable quarterly
2496+3 uniform class per diem add-on of the hospital class.
2497+4 (B) Each hospital shall be paid 1/3 of its
2498+5 quarterly inpatient directed payment in each of the 3
2499+6 months of the Payout Quarter, in accordance with
2500+7 directions provided to each MCO by the Department.
2501+8 (2) Outpatient per unit add-on. A quarterly uniform
2502+9 per claim add-on shall be derived by dividing the
2503+10 quarterly Outpatient Directed Payments Pool amount
2504+11 allocated to the applicable hospital class by the total
2505+12 outpatient encounter claims received during the
2506+13 Determination Quarter, for all hospitals in the class.
2507+14 (A) Each hospital in the class shall have a
2508+15 quarterly outpatient directed payment calculated that
2509+16 is equal to the product of the number of outpatient
2510+17 encounter claims attributable to the hospital used in
2511+18 the calculation of the quarterly uniform class per
2512+19 claim add-on, multiplied by the calculated applicable
2513+20 quarterly uniform class per claim add-on of the
2514+21 hospital class.
2515+22 (B) Each hospital shall be paid 1/3 of its
2516+23 quarterly outpatient directed payment in each of the 3
2517+24 months of the Payout Quarter, in accordance with
2518+25 directions provided to each MCO by the Department.
2519+26 (3) Each MCO shall pay each hospital the Monthly
2520+
2521+
2522+
2523+
2524+
2525+ SB3268 Enrolled - 71 - LRB103 39338 KTG 69500 b
2526+
2527+
2528+SB3268 Enrolled- 72 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 72 - LRB103 39338 KTG 69500 b
2529+ SB3268 Enrolled - 72 - LRB103 39338 KTG 69500 b
2530+1 Directed Payment as identified by the Department on its
2531+2 quarterly determination report.
2532+3 (4) Definitions. As used in this subsection:
2533+4 (A) "Payout Quarter" means each 3 month calendar
2534+5 quarter, beginning July 1, 2020.
2535+6 (B) "Determination Quarter" means each 3 month
2536+7 calendar quarter, which ends 3 months prior to the
2537+8 first day of each Payout Quarter.
2538+9 (5) For the period July 1, 2020 through December 2020,
2539+10 the following amounts shall be allocated to the following
2540+11 hospital class directed payment pools for the quarterly
2541+12 development of a uniform per unit add-on:
2542+13 (A) $2,894,500 for hospital inpatient services for
2543+14 critical access hospitals.
2544+15 (B) $4,294,374 for hospital outpatient services
2545+16 for critical access hospitals.
2546+17 (C) $29,109,330 for hospital inpatient services
2547+18 for safety-net hospitals.
2548+19 (D) $35,041,218 for hospital outpatient services
2549+20 for safety-net hospitals.
2550+21 (6) For the period January 1, 2023 through December
2551+22 31, 2023, the Department shall establish the amounts that
2552+23 shall be allocated to the hospital class directed payment
2553+24 fixed pools identified in this paragraph for the quarterly
2554+25 development of a uniform per unit add-on. The Department
2555+26 shall establish such amounts so that the total amount of
2556+
2557+
2558+
2559+
2560+
2561+ SB3268 Enrolled - 72 - LRB103 39338 KTG 69500 b
2562+
2563+
2564+SB3268 Enrolled- 73 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 73 - LRB103 39338 KTG 69500 b
2565+ SB3268 Enrolled - 73 - LRB103 39338 KTG 69500 b
2566+1 payments to each hospital under this Section in calendar
2567+2 year 2023 is projected to be substantially similar to the
2568+3 total amount of such payments received by the hospital
2569+4 under this Section in calendar year 2021, adjusted for
2570+5 increased funding provided for fixed pool directed
2571+6 payments under subsection (g) in calendar year 2022,
2572+7 assuming that the volume and acuity of claims are held
2573+8 constant. The Department shall publish the directed
2574+9 payment fixed pool amounts to be established under this
2575+10 paragraph on its website by November 15, 2022.
2576+11 (A) Hospital inpatient services for critical
2577+12 access hospitals.
2578+13 (B) Hospital outpatient services for critical
2579+14 access hospitals.
2580+15 (C) Hospital inpatient services for public
2581+16 hospitals.
2582+17 (D) Hospital outpatient services for public
2583+18 hospitals.
2584+19 (E) Hospital inpatient services for safety-net
2585+20 hospitals.
2586+21 (F) Hospital outpatient services for safety-net
2587+22 hospitals.
2588+23 (7) Semi-annual rate maintenance review. The
2589+24 Department shall ensure that hospitals assigned to the
2590+25 fixed pools in paragraph (6) are paid no less than 95% of
2591+26 the annual initial rate for each 6-month period of each
2592+
2593+
2594+
2595+
2596+
2597+ SB3268 Enrolled - 73 - LRB103 39338 KTG 69500 b
2598+
2599+
2600+SB3268 Enrolled- 74 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 74 - LRB103 39338 KTG 69500 b
2601+ SB3268 Enrolled - 74 - LRB103 39338 KTG 69500 b
2602+1 annual payout period. For each calendar year, the
2603+2 Department shall calculate the annual initial rate per day
2604+3 and per visit for each fixed pool hospital class listed in
2605+4 paragraph (6), by dividing the total of all applicable
2606+5 inpatient or outpatient directed payments issued in the
2607+6 preceding calendar year to the hospitals in each fixed
2608+7 pool class for the calendar year, plus any increase
2609+8 resulting from the annual adjustments described in
2610+9 subsection (i), by the actual applicable total service
2611+10 units for the preceding calendar year which were the basis
2612+11 of the total applicable inpatient or outpatient directed
2613+12 payments issued to the hospitals in each fixed pool class
2614+13 in the calendar year, except that for calendar year 2023,
2615+14 the service units from calendar year 2021 shall be used.
2616+15 (A) The Department shall calculate the effective
2617+16 rate, per day and per visit, for the payout periods of
2618+17 January to June and July to December of each year, for
2619+18 each fixed pool listed in paragraph (6), by dividing
2620+19 50% of the annual pool by the total applicable
2621+20 reported service units for the 2 applicable
2622+21 determination quarters.
2623+22 (B) If the effective rate calculated in
2624+23 subparagraph (A) is less than 95% of the annual
2625+24 initial rate assigned to the class for each pool under
2626+25 paragraph (6), the Department shall adjust the payment
2627+26 for each hospital to a level equal to no less than 95%
2628+
2629+
2630+
2631+
2632+
2633+ SB3268 Enrolled - 74 - LRB103 39338 KTG 69500 b
2634+
2635+
2636+SB3268 Enrolled- 75 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 75 - LRB103 39338 KTG 69500 b
2637+ SB3268 Enrolled - 75 - LRB103 39338 KTG 69500 b
2638+1 of the annual initial rate, by issuing a retroactive
2639+2 adjustment payment for the 6-month period under review
2640+3 as identified in subparagraph (A).
2641+4 (h) Fixed rate directed payments. Effective July 1, 2020,
2642+5 the Department shall issue payments to MCOs which shall be
2643+6 used to issue directed payments to Illinois hospitals not
2644+7 identified in paragraph (g) on a monthly basis. Prior to the
2645+8 beginning of each Payout Quarter beginning July 1, 2020, the
2646+9 Department shall use encounter claims data from the
2647+10 Determination Quarter, accepted by the Department's Medicaid
2648+11 Management Information System for inpatient and outpatient
2649+12 services rendered by hospitals in each hospital class
2650+13 identified in paragraph (f) and not identified in paragraph
2651+14 (g). For the period July 1, 2020 through December 2020, the
2652+15 Department shall direct MCOs to make payments as follows:
2653+16 (1) For general acute care hospitals an amount equal
2654+17 to $1,750 multiplied by the hospital's category of service
2655+18 20 case mix index for the determination quarter multiplied
2656+19 by the hospital's total number of inpatient admissions for
2657+20 category of service 20 for the determination quarter.
2658+21 (2) For general acute care hospitals an amount equal
2659+22 to $160 multiplied by the hospital's category of service
2660+23 21 case mix index for the determination quarter multiplied
2661+24 by the hospital's total number of inpatient admissions for
2662+25 category of service 21 for the determination quarter.
2663+26 (3) For general acute care hospitals an amount equal
2664+
2665+
2666+
2667+
2668+
2669+ SB3268 Enrolled - 75 - LRB103 39338 KTG 69500 b
2670+
2671+
2672+SB3268 Enrolled- 76 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 76 - LRB103 39338 KTG 69500 b
2673+ SB3268 Enrolled - 76 - LRB103 39338 KTG 69500 b
2674+1 to $80 multiplied by the hospital's category of service 22
2675+2 case mix index for the determination quarter multiplied by
2676+3 the hospital's total number of inpatient admissions for
2677+4 category of service 22 for the determination quarter.
2678+5 (4) For general acute care hospitals an amount equal
2679+6 to $375 multiplied by the hospital's category of service
2680+7 24 case mix index for the determination quarter multiplied
2681+8 by the hospital's total number of category of service 24
2682+9 paid EAPG (EAPGs) for the determination quarter.
2683+10 (5) For general acute care hospitals an amount equal
2684+11 to $240 multiplied by the hospital's category of service
2685+12 27 and 28 case mix index for the determination quarter
2686+13 multiplied by the hospital's total number of category of
2687+14 service 27 and 28 paid EAPGs for the determination
2688+15 quarter.
2689+16 (6) For general acute care hospitals an amount equal
2690+17 to $290 multiplied by the hospital's category of service
2691+18 29 case mix index for the determination quarter multiplied
2692+19 by the hospital's total number of category of service 29
2693+20 paid EAPGs for the determination quarter.
2694+21 (7) For high Medicaid hospitals an amount equal to
2695+22 $1,800 multiplied by the hospital's category of service 20
2696+23 case mix index for the determination quarter multiplied by
2697+24 the hospital's total number of inpatient admissions for
2698+25 category of service 20 for the determination quarter.
2699+26 (8) For high Medicaid hospitals an amount equal to
2700+
2701+
2702+
2703+
2704+
2705+ SB3268 Enrolled - 76 - LRB103 39338 KTG 69500 b
2706+
2707+
2708+SB3268 Enrolled- 77 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 77 - LRB103 39338 KTG 69500 b
2709+ SB3268 Enrolled - 77 - LRB103 39338 KTG 69500 b
2710+1 $160 multiplied by the hospital's category of service 21
2711+2 case mix index for the determination quarter multiplied by
2712+3 the hospital's total number of inpatient admissions for
2713+4 category of service 21 for the determination quarter.
2714+5 (9) For high Medicaid hospitals an amount equal to $80
2715+6 multiplied by the hospital's category of service 22 case
2716+7 mix index for the determination quarter multiplied by the
2717+8 hospital's total number of inpatient admissions for
2718+9 category of service 22 for the determination quarter.
2719+10 (10) For high Medicaid hospitals an amount equal to
2720+11 $400 multiplied by the hospital's category of service 24
2721+12 case mix index for the determination quarter multiplied by
2722+13 the hospital's total number of category of service 24 paid
2723+14 EAPG outpatient claims for the determination quarter.
2724+15 (11) For high Medicaid hospitals an amount equal to
2725+16 $240 multiplied by the hospital's category of service 27
2726+17 and 28 case mix index for the determination quarter
2727+18 multiplied by the hospital's total number of category of
2728+19 service 27 and 28 paid EAPGs for the determination
2729+20 quarter.
2730+21 (12) For high Medicaid hospitals an amount equal to
2731+22 $290 multiplied by the hospital's category of service 29
2732+23 case mix index for the determination quarter multiplied by
2733+24 the hospital's total number of category of service 29 paid
2734+25 EAPGs for the determination quarter.
2735+26 (13) For long term acute care hospitals the amount of
2736+
2737+
2738+
2739+
2740+
2741+ SB3268 Enrolled - 77 - LRB103 39338 KTG 69500 b
2742+
2743+
2744+SB3268 Enrolled- 78 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 78 - LRB103 39338 KTG 69500 b
2745+ SB3268 Enrolled - 78 - LRB103 39338 KTG 69500 b
2746+1 $495 multiplied by the hospital's total number of
2747+2 inpatient days for the determination quarter.
2748+3 (14) For psychiatric hospitals the amount of $210
2749+4 multiplied by the hospital's total number of inpatient
2750+5 days for category of service 21 for the determination
2751+6 quarter.
2752+7 (15) For psychiatric hospitals the amount of $250
2753+8 multiplied by the hospital's total number of outpatient
2754+9 claims for category of service 27 and 28 for the
2755+10 determination quarter.
2756+11 (16) For rehabilitation hospitals the amount of $410
2757+12 multiplied by the hospital's total number of inpatient
2758+13 days for category of service 22 for the determination
2759+14 quarter.
2760+15 (17) For rehabilitation hospitals the amount of $100
2761+16 multiplied by the hospital's total number of outpatient
2762+17 claims for category of service 29 for the determination
2763+18 quarter.
2764+19 (18) Effective for the Payout Quarter beginning
2765+20 January 1, 2023, for the directed payments to hospitals
2766+21 required under this subsection, the Department shall
2767+22 establish the amounts that shall be used to calculate such
2768+23 directed payments using the methodologies specified in
2769+24 this paragraph. The Department shall use a single, uniform
2770+25 rate, adjusted for acuity as specified in paragraphs (1)
2771+26 through (12), for all categories of inpatient services
2772+
2773+
2774+
2775+
2776+
2777+ SB3268 Enrolled - 78 - LRB103 39338 KTG 69500 b
2778+
2779+
2780+SB3268 Enrolled- 79 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 79 - LRB103 39338 KTG 69500 b
2781+ SB3268 Enrolled - 79 - LRB103 39338 KTG 69500 b
2782+1 provided by each class of hospitals and a single uniform
2783+2 rate, adjusted for acuity as specified in paragraphs (1)
2784+3 through (12), for all categories of outpatient services
2785+4 provided by each class of hospitals. The Department shall
2786+5 establish such amounts so that the total amount of
2787+6 payments to each hospital under this Section in calendar
2788+7 year 2023 is projected to be substantially similar to the
2789+8 total amount of such payments received by the hospital
2790+9 under this Section in calendar year 2021, adjusted for
2791+10 increased funding provided for fixed pool directed
2792+11 payments under subsection (g) in calendar year 2022,
2793+12 assuming that the volume and acuity of claims are held
2794+13 constant. The Department shall publish the directed
2795+14 payment amounts to be established under this subsection on
2796+15 its website by November 15, 2022.
2797+16 (19) Each hospital shall be paid 1/3 of their
2798+17 quarterly inpatient and outpatient directed payment in
2799+18 each of the 3 months of the Payout Quarter, in accordance
2800+19 with directions provided to each MCO by the Department.
2801+20 (20) Each MCO shall pay each hospital the Monthly
2802+21 Directed Payment amount as identified by the Department on
2803+22 its quarterly determination report.
2804+23 Notwithstanding any other provision of this subsection, if
2805+24 the Department determines that the actual total hospital
2806+25 utilization data that is used to calculate the fixed rate
2807+26 directed payments is substantially different than anticipated
2808+
2809+
2810+
2811+
2812+
2813+ SB3268 Enrolled - 79 - LRB103 39338 KTG 69500 b
2814+
2815+
2816+SB3268 Enrolled- 80 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 80 - LRB103 39338 KTG 69500 b
2817+ SB3268 Enrolled - 80 - LRB103 39338 KTG 69500 b
2818+1 when the rates in this subsection were initially determined
2819+2 for unforeseeable circumstances (such as the COVID-19 pandemic
2820+3 or some other public health emergency), the Department may
2821+4 adjust the rates specified in this subsection so that the
2822+5 total directed payments approximate the total spending amount
2823+6 anticipated when the rates were initially established.
2824+7 Definitions. As used in this subsection:
2825+8 (A) "Payout Quarter" means each calendar quarter,
2826+9 beginning July 1, 2020.
2827+10 (B) "Determination Quarter" means each calendar
2828+11 quarter which ends 3 months prior to the first day of
2829+12 each Payout Quarter.
2830+13 (C) "Case mix index" means a hospital specific
2831+14 calculation. For inpatient claims the case mix index
2832+15 is calculated each quarter by summing the relative
2833+16 weight of all inpatient Diagnosis-Related Group (DRG)
2834+17 claims for a category of service in the applicable
2835+18 Determination Quarter and dividing the sum by the
2836+19 number of sum total of all inpatient DRG admissions
2837+20 for the category of service for the associated claims.
2838+21 The case mix index for outpatient claims is calculated
2839+22 each quarter by summing the relative weight of all
2840+23 paid EAPGs in the applicable Determination Quarter and
2841+24 dividing the sum by the sum total of paid EAPGs for the
2842+25 associated claims.
2843+26 (i) Beginning January 1, 2021, the rates for directed
2844+
2845+
2846+
2847+
2848+
2849+ SB3268 Enrolled - 80 - LRB103 39338 KTG 69500 b
2850+
2851+
2852+SB3268 Enrolled- 81 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 81 - LRB103 39338 KTG 69500 b
2853+ SB3268 Enrolled - 81 - LRB103 39338 KTG 69500 b
2854+1 payments shall be recalculated in order to spend the
2855+2 additional funds for directed payments that result from
2856+3 reduction in the amount of pass-through payments allowed under
2857+4 federal regulations. The additional funds for directed
2858+5 payments shall be allocated proportionally to each class of
2859+6 hospitals based on that class' proportion of services.
2860+7 (1) Beginning January 1, 2024, the fixed pool directed
2861+8 payment amounts and the associated annual initial rates
2862+9 referenced in paragraph (6) of subsection (f) for each
2863+10 hospital class shall be uniformly increased by a ratio of
2864+11 not less than, the ratio of the total pass-through
2865+12 reduction amount pursuant to paragraph (4) of subsection
2866+13 (j), for the hospitals comprising the hospital fixed pool
2867+14 directed payment class for the next calendar year, to the
2868+15 total inpatient and outpatient directed payments for the
2869+16 hospitals comprising the hospital fixed pool directed
2870+17 payment class paid during the preceding calendar year.
2871+18 (2) Beginning January 1, 2024, the fixed rates for the
2872+19 directed payments referenced in paragraph (18) of
2873+20 subsection (h) for each hospital class shall be uniformly
2874+21 increased by a ratio of not less than, the ratio of the
2875+22 total pass-through reduction amount pursuant to paragraph
2876+23 (4) of subsection (j), for the hospitals comprising the
2877+24 hospital directed payment class for the next calendar
2878+25 year, to the total inpatient and outpatient directed
2879+26 payments for the hospitals comprising the hospital fixed
2880+
2881+
2882+
2883+
2884+
2885+ SB3268 Enrolled - 81 - LRB103 39338 KTG 69500 b
2886+
2887+
2888+SB3268 Enrolled- 82 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 82 - LRB103 39338 KTG 69500 b
2889+ SB3268 Enrolled - 82 - LRB103 39338 KTG 69500 b
2890+1 rate directed payment class paid during the preceding
2891+2 calendar year.
2892+3 (j) Pass-through payments.
2893+4 (1) For the period July 1, 2020 through December 31,
2894+5 2020, the Department shall assign quarterly pass-through
2895+6 payments to each class of hospitals equal to one-fourth of
2896+7 the following annual allocations:
2897+8 (A) $390,487,095 to safety-net hospitals.
2898+9 (B) $62,553,886 to critical access hospitals.
2899+10 (C) $345,021,438 to high Medicaid hospitals.
2900+11 (D) $551,429,071 to general acute care hospitals.
2901+12 (E) $27,283,870 to long term acute care hospitals.
2902+13 (F) $40,825,444 to freestanding psychiatric
2903+14 hospitals.
2904+15 (G) $9,652,108 to freestanding rehabilitation
2905+16 hospitals.
2906+17 (2) For the period of July 1, 2020 through December
2907+18 31, 2020, the pass-through payments shall at a minimum
2908+19 ensure hospitals receive a total amount of monthly
2909+20 payments under this Section as received in calendar year
2910+21 2019 in accordance with this Article and paragraph (1) of
2911+22 subsection (d-5) of Section 14-12, exclusive of amounts
2912+23 received through payments referenced in subsection (b).
2913+24 (3) For the calendar year beginning January 1, 2023,
2914+25 the Department shall establish the annual pass-through
2915+26 allocation to each class of hospitals and the pass-through
2916+
2917+
2918+
2919+
2920+
2921+ SB3268 Enrolled - 82 - LRB103 39338 KTG 69500 b
2922+
2923+
2924+SB3268 Enrolled- 83 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 83 - LRB103 39338 KTG 69500 b
2925+ SB3268 Enrolled - 83 - LRB103 39338 KTG 69500 b
2926+1 payments to each hospital so that the total amount of
2927+2 payments to each hospital under this Section in calendar
2928+3 year 2023 is projected to be substantially similar to the
2929+4 total amount of such payments received by the hospital
2930+5 under this Section in calendar year 2021, adjusted for
2931+6 increased funding provided for fixed pool directed
2932+7 payments under subsection (g) in calendar year 2022,
2933+8 assuming that the volume and acuity of claims are held
2934+9 constant. The Department shall publish the pass-through
2935+10 allocation to each class and the pass-through payments to
2936+11 each hospital to be established under this subsection on
2937+12 its website by November 15, 2022.
2938+13 (4) For the calendar years beginning January 1, 2021
2939+14 and January 1, 2022, each hospital's pass-through payment
2940+15 amount shall be reduced proportionally to the reduction of
2941+16 all pass-through payments required by federal regulations.
2942+17 Beginning January 1, 2024, the Department shall reduce
2943+18 total pass-through payments by the minimum amount
2944+19 necessary to comply with federal regulations. Pass-through
2945+20 payments to safety-net hospitals, as defined in Section
2946+21 5-5e.1 of this Code, shall not be reduced until all
2947+22 pass-through payments to other hospitals have been
2948+23 eliminated. All other hospitals shall have their
2949+24 pass-through payments reduced proportionally.
2950+25 (k) At least 30 days prior to each calendar year, the
2951+26 Department shall notify each hospital of changes to the
2952+
2953+
2954+
2955+
2956+
2957+ SB3268 Enrolled - 83 - LRB103 39338 KTG 69500 b
2958+
2959+
2960+SB3268 Enrolled- 84 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 84 - LRB103 39338 KTG 69500 b
2961+ SB3268 Enrolled - 84 - LRB103 39338 KTG 69500 b
2962+1 payment methodologies in this Section, including, but not
2963+2 limited to, changes in the fixed rate directed payment rates,
2964+3 the aggregate pass-through payment amount for all hospitals,
2965+4 and the hospital's pass-through payment amount for the
2966+5 upcoming calendar year.
2967+6 (l) Notwithstanding any other provisions of this Section,
2968+7 the Department may adopt rules to change the methodology for
2969+8 directed and pass-through payments as set forth in this
2970+9 Section, but only to the extent necessary to obtain federal
2971+10 approval of a necessary State Plan amendment or Directed
2972+11 Payment Preprint or to otherwise conform to federal law or
2973+12 federal regulation.
2974+13 (m) As used in this subsection, "managed care
2975+14 organization" or "MCO" means an entity which contracts with
2976+15 the Department to provide services where payment for medical
2977+16 services is made on a capitated basis, excluding contracted
2978+17 entities for dual eligible or Department of Children and
2979+18 Family Services youth populations.
2980+19 (n) In order to address the escalating infant mortality
2981+20 rates among minority communities in Illinois, the State shall,
2982+21 subject to appropriation, create a pool of funding of at least
2983+22 $50,000,000 annually to be disbursed among safety-net
2984+23 hospitals that maintain perinatal designation from the
2985+24 Department of Public Health. The funding shall be used to
2986+25 preserve or enhance OB/GYN services or other specialty
2987+26 services at the receiving hospital, with the distribution of
2988+
2989+
2990+
2991+
2992+
2993+ SB3268 Enrolled - 84 - LRB103 39338 KTG 69500 b
2994+
2995+
2996+SB3268 Enrolled- 85 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 85 - LRB103 39338 KTG 69500 b
2997+ SB3268 Enrolled - 85 - LRB103 39338 KTG 69500 b
2998+1 funding to be established by rule and with consideration to
2999+2 perinatal hospitals with safe birthing levels and quality
3000+3 metrics for healthy mothers and babies.
3001+4 (o) In order to address the growing challenges of
3002+5 providing stable access to healthcare in rural Illinois,
3003+6 including perinatal services, behavioral healthcare including
3004+7 substance use disorder services (SUDs) and other specialty
3005+8 services, and to expand access to telehealth services among
3006+9 rural communities in Illinois, the Department of Healthcare
3007+10 and Family Services shall administer a program to provide at
3008+11 least $10,000,000 in financial support annually to critical
3009+12 access hospitals for delivery of perinatal and OB/GYN
3010+13 services, behavioral healthcare including SUDS, other
3011+14 specialty services and telehealth services. The funding shall
3012+15 be used to preserve or enhance perinatal and OB/GYN services,
3013+16 behavioral healthcare including SUDS, other specialty
3014+17 services, as well as the explanation of telehealth services by
3015+18 the receiving hospital, with the distribution of funding to be
3016+19 established by rule.
3017+20 (p) For calendar year 2023, the final amounts, rates, and
3018+21 payments under subsections (c), (d-2), (g), (h), and (j) shall
3019+22 be established by the Department, so that the sum of the total
3020+23 estimated annual payments under subsections (c), (d-2), (g),
3021+24 (h), and (j) for each hospital class for calendar year 2023, is
3022+25 no less than:
3023+26 (1) $858,260,000 to safety-net hospitals.
3024+
3025+
3026+
3027+
3028+
3029+ SB3268 Enrolled - 85 - LRB103 39338 KTG 69500 b
3030+
3031+
3032+SB3268 Enrolled- 86 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 86 - LRB103 39338 KTG 69500 b
3033+ SB3268 Enrolled - 86 - LRB103 39338 KTG 69500 b
3034+1 (2) $86,200,000 to critical access hospitals.
3035+2 (3) $1,765,000,000 to high Medicaid hospitals.
3036+3 (4) $673,860,000 to general acute care hospitals.
3037+4 (5) $48,330,000 to long term acute care hospitals.
3038+5 (6) $89,110,000 to freestanding psychiatric hospitals.
3039+6 (7) $24,300,000 to freestanding rehabilitation
3040+7 hospitals.
3041+8 (8) $32,570,000 to public hospitals.
3042+9 (q) Hospital Pandemic Recovery Stabilization Payments. The
3043+10 Department shall disburse a pool of $460,000,000 in stability
3044+11 payments to hospitals prior to April 1, 2023. The allocation
3045+12 of the pool shall be based on the hospital directed payment
3046+13 classes and directed payments issued, during Calendar Year
3047+14 2022 with added consideration to safety net hospitals, as
3048+15 defined in subdivision (f)(1)(B) of this Section, and critical
3049+16 access hospitals.
3050+17 (Source: P.A. 102-4, eff. 4-27-21; 102-16, eff. 6-17-21;
3051+18 102-886, eff. 5-17-22; 102-1115, eff. 1-9-23; 103-102, eff.
3052+19 6-16-23; revised 9-21-23.)
3053+20 ARTICLE 45.
3054+21 Section 45-5. The Illinois Public Aid Code is amended by
3055+22 adding Section 5-5.08a as follows:
3056+23 (305 ILCS 5/5-5.08a new)
3057+
3058+
3059+
3060+
3061+
3062+ SB3268 Enrolled - 86 - LRB103 39338 KTG 69500 b
3063+
3064+
3065+SB3268 Enrolled- 87 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 87 - LRB103 39338 KTG 69500 b
3066+ SB3268 Enrolled - 87 - LRB103 39338 KTG 69500 b
3067+1 Sec. 5-5.08a. Renal dialysis; add-on payments for home
3068+2 dialysis providers in skilled nursing facilities.
3069+3 (a) Findings. The General Assembly finds the following:
3070+4 (1) Home dialysis services provided on-site at skilled
3071+5 nursing facilities are beneficial to nursing home
3072+6 residents by permitting more time for other health and
3073+7 wellness activities, and nullifying burdensome off-site
3074+8 travel which carries various health care risks and
3075+9 increased costs.
3076+10 (2) Home dialysis for nursing home residents provides
3077+11 an on-site venue for high-acuity residents to receive
3078+12 dialysis services, effectively creating downstream care
3079+13 opportunities for hospital patients in need of post-acute
3080+14 care and dialysis, and reducing the total cost of dialysis
3081+15 care.
3082+16 (3) On-site home dialysis in nursing homes is costlier
3083+17 for the provider than conventional outpatient dialysis, as
3084+18 labor costs are greater per treatment and such patients
3085+19 typically have higher acuities, necessitating more
3086+20 medication and greater staff involvement to promote
3087+21 patient compliance.
3088+22 (b) Subject to federal approval, for dates of service
3089+23 beginning on and after January 1, 2025, for home renal
3090+24 dialysis provided to residents of skilled nursing facilities,
3091+25 the Department shall reimburse a per-claim add-on payment to
3092+26 certified home dialysis providers in accordance with this
3093+
3094+
3095+
3096+
3097+
3098+ SB3268 Enrolled - 87 - LRB103 39338 KTG 69500 b
3099+
3100+
3101+SB3268 Enrolled- 88 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 88 - LRB103 39338 KTG 69500 b
3102+ SB3268 Enrolled - 88 - LRB103 39338 KTG 69500 b
3103+1 Section. Certified home dialysis providers providing dialysis
3104+2 services within a skilled nursing facility shall receive a
3105+3 per-claim add-on payment of $95 per treatment. As used in this
3106+4 Section, "certified home dialysis provider" means an end-stage
3107+5 renal disease facility that (i) provides dialysis treatment or
3108+6 dialysis training to caregivers or individuals with end-stage
3109+7 renal disease and (ii) has been approved to provide dialysis
3110+8 home training support services by the federal Centers for
3111+9 Medicare and Medicaid Services.
3112+10 ARTICLE 50.
3113+11 Section 50-5. The Illinois Public Aid Code is amended by
3114+12 changing Sections 5-5.07 and 14-13 as follows:
3115+13 (305 ILCS 5/5-5.07)
3116+14 Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem
3117+15 rate. The Department of Children and Family Services shall pay
3118+16 the DCFS per diem rate for inpatient psychiatric stay at a
3119+17 free-standing psychiatric hospital or a hospital with a
3120+18 pediatric or adolescent inpatient psychiatric unit effective
3121+19 the 3rd day 11th day when a child is in the hospital beyond
3122+20 medical necessity, and the parent or caregiver has denied the
3123+21 child access to the home and has refused or failed to make
3124+22 provisions for another living arrangement for the child or the
3125+23 child's discharge is being delayed due to a pending inquiry or
3126+
3127+
3128+
3129+
3130+
3131+ SB3268 Enrolled - 88 - LRB103 39338 KTG 69500 b
3132+
3133+
3134+SB3268 Enrolled- 89 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 89 - LRB103 39338 KTG 69500 b
3135+ SB3268 Enrolled - 89 - LRB103 39338 KTG 69500 b
3136+1 investigation by the Department of Children and Family
3137+2 Services. If any portion of a hospital stay is reimbursed
3138+3 under this Section, the hospital stay shall not be eligible
3139+4 for payment under the provisions of Section 14-13 of this
3140+5 Code.
3141+6 (Source: Reenacted by P.A. 101-15, eff. 6-14-19; reenacted by
3142+7 P.A. 101-209, eff. 8-5-19; P.A. 101-655, eff. 3-12-21;
3143+8 102-201, eff. 7-30-21; 102-558, eff. 8-20-21; 102-1037, eff.
3144+9 6-2-22.)
3145+10 (305 ILCS 5/14-13)
3146+11 Sec. 14-13. Reimbursement for inpatient stays extended
3147+12 beyond medical necessity.
3148+13 (a) By October 1, 2019, the Department shall by rule
3149+14 implement a methodology effective for dates of service July 1,
3150+15 2019 and later to reimburse hospitals for inpatient stays
3151+16 extended beyond medical necessity due to the inability of the
3152+17 Department or the managed care organization in which a
3153+18 recipient is enrolled or the hospital discharge planner to
3154+19 find an appropriate placement after discharge from the
3155+20 hospital. The Department shall evaluate the effectiveness of
3156+21 the current reimbursement rate for inpatient hospital stays
3157+22 beyond medical necessity.
3158+23 (b) The methodology shall provide reasonable compensation
3159+24 for the services provided attributable to the days of the
3160+25 extended stay for which the prevailing rate methodology
3161+
3162+
3163+
3164+
3165+
3166+ SB3268 Enrolled - 89 - LRB103 39338 KTG 69500 b
3167+
3168+
3169+SB3268 Enrolled- 90 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 90 - LRB103 39338 KTG 69500 b
3170+ SB3268 Enrolled - 90 - LRB103 39338 KTG 69500 b
3171+1 provides no reimbursement. The Department may use a day
3172+2 outlier program to satisfy this requirement. The reimbursement
3173+3 rate shall be set at a level so as not to act as an incentive
3174+4 to avoid transfer to the appropriate level of care needed or
3175+5 placement, after discharge.
3176+6 (c) The Department shall require managed care
3177+7 organizations to adopt this methodology or an alternative
3178+8 methodology that pays at least as much as the Department's
3179+9 adopted methodology unless otherwise mutually agreed upon
3180+10 contractual language is developed by the provider and the
3181+11 managed care organization for a risk-based or innovative
3182+12 payment methodology.
3183+13 (d) Days beyond medical necessity shall not be eligible
3184+14 for per diem add-on payments under the Medicaid High Volume
3185+15 Adjustment (MHVA) or the Medicaid Percentage Adjustment (MPA)
3186+16 programs.
3187+17 (e) For services covered by the fee-for-service program,
3188+18 reimbursement under this Section shall only be made for days
3189+19 beyond medical necessity that occur after the hospital has
3190+20 notified the Department of the need for post-discharge
3191+21 placement. For services covered by a managed care
3192+22 organization, hospitals shall notify the appropriate managed
3193+23 care organization of an admission within 24 hours of
3194+24 admission. For every 24-hour period beyond the initial 24
3195+25 hours after admission that the hospital fails to notify the
3196+26 managed care organization of the admission, reimbursement
3197+
3198+
3199+
3200+
3201+
3202+ SB3268 Enrolled - 90 - LRB103 39338 KTG 69500 b
3203+
3204+
3205+SB3268 Enrolled- 91 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 91 - LRB103 39338 KTG 69500 b
3206+ SB3268 Enrolled - 91 - LRB103 39338 KTG 69500 b
3207+1 under this subsection shall be reduced by one day.
3208+2 (f) The Department of Children and Family Services shall
3209+3 pay for all inpatient stays beginning on the 3rd day a child is
3210+4 in the hospital beyond medical necessity, and the parent or
3211+5 caregiver has denied the child access to the home and has
3212+6 refused or failed to make provisions for another living
3213+7 arrangement for the child or the child's discharge is being
3214+8 delayed due to a pending inquiry or investigation by the
3215+9 Department of Children and Family Services.
3216+10 (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.)
3217+11 ARTICLE 55.
3218+12 Section 55-5. The Illinois Public Aid Code is amended by
3219+13 adding Section 5-55 as follows:
3220+14 (305 ILCS 5/5-55 new)
3221+15 Sec. 5-55. Reimbursement for music therapy services.
3222+16 Subject to federal approval, for dates of service beginning on
3223+17 and after July 1, 2025, the Department shall reimburse music
3224+18 therapy services provided by licensed professional music
3225+19 therapists. To be eligible for reimbursement under this
3226+20 Section, music therapy services must be provided by a licensed
3227+21 professional music therapist authorized to practice under the
3228+22 Music Therapy Licensing and Practice Act.
3229+
3230+
3231+
3232+
3233+
3234+ SB3268 Enrolled - 91 - LRB103 39338 KTG 69500 b
3235+
3236+
3237+SB3268 Enrolled- 92 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 92 - LRB103 39338 KTG 69500 b
3238+ SB3268 Enrolled - 92 - LRB103 39338 KTG 69500 b
3239+1 ARTICLE 60.
3240+2 Section 60-5. The Illinois Public Aid Code is amended by
3241+3 adding Section 5-60 as follows:
3242+4 (305 ILCS 5/5-60 new)
3243+5 Sec. 5-60. Optometric services; reimbursement rates.
3244+6 Notwithstanding any other law or rule to the contrary and
3245+7 subject to federal approval, for dates of service beginning on
3246+8 and after January 1, 2025, the reimbursement rates for
3247+9 optometric and optical services for determining refractive
3248+10 state, fitting of spectacles, and fitting of bifocal
3249+11 spectacles shall be increased by 35% above the rates in effect
3250+12 on January 1, 2024.
3251+13 ARTICLE 65.
3252+14 Section 65-5. The Illinois Public Aid Code is amended by
3253+15 changing Section 5-2.06 as follows:
3254+16 (305 ILCS 5/5-2.06)
3255+17 Sec. 5-2.06. Payment rates; Children's Community-Based
3256+18 Health Care Centers. Beginning January 1, 2025 and subject to
3257+19 federal approval 2020, the Department shall, for eligible
3258+20 individuals, reimburse Children's Community-Based Health Care
3259+21 Centers established in the Alternative Health Care Delivery
3260+
3261+
3262+
3263+
3264+
3265+ SB3268 Enrolled - 92 - LRB103 39338 KTG 69500 b
3266+
3267+
3268+SB3268 Enrolled- 93 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 93 - LRB103 39338 KTG 69500 b
3269+ SB3268 Enrolled - 93 - LRB103 39338 KTG 69500 b
3270+1 Act and providing nursing care for the purpose of
3271+2 transitioning children from a hospital to home placement or
3272+3 other appropriate setting and reuniting families for a maximum
3273+4 of up to 120 days on a per diem basis at the lower of the
3274+5 Children's Community-Based Health Care Center's usual and
3275+6 customary charge to the public or at the Department rate of
3276+7 $1,300 $950. Payments at the rate set forth in this Section are
3277+8 exempt from the 2.7% rate reduction required under Section
3278+9 5-5e.
3279+10 (Source: P.A. 101-10, eff. 6-5-19.)
3280+11 ARTICLE 70.
3281+12 Section 70-5. The Illinois Public Aid Code is amended by
3282+13 adding Section 5-5.24a as follows:
3283+14 (305 ILCS 5/5-5.24a new)
3284+15 Sec. 5-5.24a. Remote ultrasounds and remote fetal
3285+16 nonstress tests; reimbursement.
3286+17 (a) Subject to federal approval, for dates of service
3287+18 beginning on and after January 1, 2025, the Department shall
3288+19 reimburse for remote ultrasound procedures and remote fetal
3289+20 nonstress tests when the patient is in a residence or other
3290+21 off-site location from the patient's provider and the same
3291+22 standard of care is met as would be present during an in-person
3292+23 visit.
3293+
3294+
3295+
3296+
3297+
3298+ SB3268 Enrolled - 93 - LRB103 39338 KTG 69500 b
3299+
3300+
3301+SB3268 Enrolled- 94 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 94 - LRB103 39338 KTG 69500 b
3302+ SB3268 Enrolled - 94 - LRB103 39338 KTG 69500 b
3303+1 (b) Remote ultrasounds and remote fetal nonstress tests
3304+2 are only eligible for reimbursement when the provider uses
3305+3 digital technology:
3306+4 (1) to collect medical and other forms of health data
3307+5 from a patient and to electronically transmit that
3308+6 information securely to a health care provider in a
3309+7 different location for interpretation and recommendation;
3310+8 (2) that is compliant with the federal Health
3311+9 Insurance Portability and Accountability Act of 1996; and
3312+10 (3) that is approved by the U.S. Food and Drug
3313+11 Administration.
3314+12 (c) A fetal nonstress test is only eligible for
3315+13 reimbursement with a place of service modifier for at-home
3316+14 monitoring with remote monitoring solutions that are cleared
3317+15 by the U.S. Food and Drug Administration for on-label use for
3318+16 monitoring fetal heart rate, maternal heart rate, and uterine
3319+17 activity.
3320+18 (d) The Department shall issue guidance to implement the
3321+19 provisions of this Section.
3322+20 ARTICLE 75.
3323+21 Section 75-5. The Illinois Public Aid Code is amended by
3324+22 changing Section 5-2b as follows:
3325+23 (305 ILCS 5/5-2b)
3326+
3327+
3328+
3329+
3330+
3331+ SB3268 Enrolled - 94 - LRB103 39338 KTG 69500 b
3332+
3333+
3334+SB3268 Enrolled- 95 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 95 - LRB103 39338 KTG 69500 b
3335+ SB3268 Enrolled - 95 - LRB103 39338 KTG 69500 b
3336+1 Sec. 5-2b. Medically fragile and technology dependent
3337+2 children eligibility and program; provider reimbursement
3338+3 rates.
3339+4 (a) Notwithstanding any other provision of law except as
3340+5 provided in Section 5-30a, on and after September 1, 2012,
3341+6 subject to federal approval, medical assistance under this
3342+7 Article shall be available to children who qualify as persons
3343+8 with a disability, as defined under the federal Supplemental
3344+9 Security Income program and who are medically fragile and
3345+10 technology dependent. The program shall allow eligible
3346+11 children to receive the medical assistance provided under this
3347+12 Article in the community and must maximize, to the fullest
3348+13 extent permissible under federal law, federal reimbursement
3349+14 and family cost-sharing, including co-pays, premiums, or any
3350+15 other family contributions, except that the Department shall
3351+16 be permitted to incentivize the utilization of selected
3352+17 services through the use of cost-sharing adjustments. The
3353+18 Department shall establish the policies, procedures,
3354+19 standards, services, and criteria for this program by rule.
3355+20 (b) Notwithstanding any other provision of this Code,
3356+21 subject to federal approval, on and after January 1, 2024, the
3357+22 reimbursement rates for nursing paid through Nursing and
3358+23 Personal Care Services for non-waiver customers and to
3359+24 providers of private duty nursing services for children
3360+25 eligible for medical assistance under this Section shall be
3361+26 20% higher than the reimbursement rates in effect for nursing
3362+
3363+
3364+
3365+
3366+
3367+ SB3268 Enrolled - 95 - LRB103 39338 KTG 69500 b
3368+
3369+
3370+SB3268 Enrolled- 96 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 96 - LRB103 39338 KTG 69500 b
3371+ SB3268 Enrolled - 96 - LRB103 39338 KTG 69500 b
3372+1 services on December 31, 2023.
3373+2 (c) Notwithstanding any other provision of this Code,
3374+3 subject to federal approval, on and after January 1, 2025, the
3375+4 reimbursement rates for nursing paid through Nursing and
3376+5 Personal Care Services for non-waiver customers and to
3377+6 providers of private duty nursing services for children
3378+7 eligible for medical assistance under this Section shall be 7%
3379+8 higher than the reimbursement rates in effect for nursing
3380+9 services on December 31, 2024.
3381+10 (Source: P.A. 103-102, eff. 1-1-24.)
3382+11 ARTICLE 80.
3383+12 Section 80-5. The Illinois Public Aid Code is amended by
3384+13 adding Section 5-52 as follows:
3385+14 (305 ILCS 5/5-52 new)
3386+15 Sec. 5-52. Custom prosthetic and orthotic devices;
3387+16 reimbursement rates. Subject to federal approval, for dates of
3388+17 service beginning on and after January 1, 2025, the Department
3389+18 shall increase the current 2024 Medicaid rate by 7% under the
3390+19 medical assistance program for custom prosthetic and orthotic
3391+20 devices.
3392+21 ARTICLE 85.
3393+
3394+
3395+
3396+
3397+
3398+ SB3268 Enrolled - 96 - LRB103 39338 KTG 69500 b
3399+
3400+
3401+SB3268 Enrolled- 97 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 97 - LRB103 39338 KTG 69500 b
3402+ SB3268 Enrolled - 97 - LRB103 39338 KTG 69500 b
3403+1 Section 85-5. The Illinois Public Aid Code is amended by
3404+2 changing Section 5-4.2 as follows:
3405+3 (305 ILCS 5/5-4.2)
3406+4 Sec. 5-4.2. Ambulance services payments.
3407+5 (a) For ambulance services provided to a recipient of aid
3408+6 under this Article on or after January 1, 1993, the Illinois
3409+7 Department shall reimburse ambulance service providers at
3410+8 rates calculated in accordance with this Section. It is the
3411+9 intent of the General Assembly to provide adequate
3412+10 reimbursement for ambulance services so as to ensure adequate
3413+11 access to services for recipients of aid under this Article
3414+12 and to provide appropriate incentives to ambulance service
3415+13 providers to provide services in an efficient and
3416+14 cost-effective manner. Thus, it is the intent of the General
3417+15 Assembly that the Illinois Department implement a
3418+16 reimbursement system for ambulance services that, to the
3419+17 extent practicable and subject to the availability of funds
3420+18 appropriated by the General Assembly for this purpose, is
3421+19 consistent with the payment principles of Medicare. To ensure
3422+20 uniformity between the payment principles of Medicare and
3423+21 Medicaid, the Illinois Department shall follow, to the extent
3424+22 necessary and practicable and subject to the availability of
3425+23 funds appropriated by the General Assembly for this purpose,
3426+24 the statutes, laws, regulations, policies, procedures,
3427+25 principles, definitions, guidelines, and manuals used to
3428+
3429+
3430+
3431+
3432+
3433+ SB3268 Enrolled - 97 - LRB103 39338 KTG 69500 b
3434+
3435+
3436+SB3268 Enrolled- 98 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 98 - LRB103 39338 KTG 69500 b
3437+ SB3268 Enrolled - 98 - LRB103 39338 KTG 69500 b
3438+1 determine the amounts paid to ambulance service providers
3439+2 under Title XVIII of the Social Security Act (Medicare).
3440+3 (b) For ambulance services provided to a recipient of aid
3441+4 under this Article on or after January 1, 1996, the Illinois
3442+5 Department shall reimburse ambulance service providers based
3443+6 upon the actual distance traveled if a natural disaster,
3444+7 weather conditions, road repairs, or traffic congestion
3445+8 necessitates the use of a route other than the most direct
3446+9 route.
3447+10 (c) For purposes of this Section, "ambulance services"
3448+11 includes medical transportation services provided by means of
3449+12 an ambulance, air ambulance, medi-car, service car, or taxi.
3450+13 (c-1) For purposes of this Section, "ground ambulance
3451+14 service" means medical transportation services that are
3452+15 described as ground ambulance services by the Centers for
3453+16 Medicare and Medicaid Services and provided in a vehicle that
3454+17 is licensed as an ambulance by the Illinois Department of
3455+18 Public Health pursuant to the Emergency Medical Services (EMS)
3456+19 Systems Act.
3457+20 (c-2) For purposes of this Section, "ground ambulance
3458+21 service provider" means a vehicle service provider as
3459+22 described in the Emergency Medical Services (EMS) Systems Act
3460+23 that operates licensed ambulances for the purpose of providing
3461+24 emergency ambulance services, or non-emergency ambulance
3462+25 services, or both. For purposes of this Section, this includes
3463+26 both ambulance providers and ambulance suppliers as described
3464+
3465+
3466+
3467+
3468+
3469+ SB3268 Enrolled - 98 - LRB103 39338 KTG 69500 b
3470+
3471+
3472+SB3268 Enrolled- 99 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 99 - LRB103 39338 KTG 69500 b
3473+ SB3268 Enrolled - 99 - LRB103 39338 KTG 69500 b
3474+1 by the Centers for Medicare and Medicaid Services.
3475+2 (c-3) For purposes of this Section, "medi-car" means
3476+3 transportation services provided to a patient who is confined
3477+4 to a wheelchair and requires the use of a hydraulic or electric
3478+5 lift or ramp and wheelchair lockdown when the patient's
3479+6 condition does not require medical observation, medical
3480+7 supervision, medical equipment, the administration of
3481+8 medications, or the administration of oxygen.
3482+9 (c-4) For purposes of this Section, "service car" means
3483+10 transportation services provided to a patient by a passenger
3484+11 vehicle where that patient does not require the specialized
3485+12 modes described in subsection (c-1) or (c-3).
3486+13 (c-5) For purposes of this Section, "air ambulance
3487+14 service" means medical transport by helicopter or airplane for
3488+15 patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
3489+16 that is described as an air ambulance service by the federal
3490+17 Centers for Medicare and Medicaid Services.
3491+18 (d) This Section does not prohibit separate billing by
3492+19 ambulance service providers for oxygen furnished while
3493+20 providing advanced life support services.
3494+21 (e) Beginning with services rendered on or after July 1,
3495+22 2008, all providers of non-emergency medi-car and service car
3496+23 transportation must certify that the driver and employee
3497+24 attendant, as applicable, have completed a safety program
3498+25 approved by the Department to protect both the patient and the
3499+26 driver, prior to transporting a patient. The provider must
3500+
3501+
3502+
3503+
3504+
3505+ SB3268 Enrolled - 99 - LRB103 39338 KTG 69500 b
3506+
3507+
3508+SB3268 Enrolled- 100 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 100 - LRB103 39338 KTG 69500 b
3509+ SB3268 Enrolled - 100 - LRB103 39338 KTG 69500 b
3510+1 maintain this certification in its records. The provider shall
3511+2 produce such documentation upon demand by the Department or
3512+3 its representative. Failure to produce documentation of such
3513+4 training shall result in recovery of any payments made by the
3514+5 Department for services rendered by a non-certified driver or
3515+6 employee attendant. Medi-car and service car providers must
3516+7 maintain legible documentation in their records of the driver
3517+8 and, as applicable, employee attendant that actually
3518+9 transported the patient. Providers must recertify all drivers
3519+10 and employee attendants every 3 years. If they meet the
3520+11 established training components set forth by the Department,
3521+12 providers of non-emergency medi-car and service car
3522+13 transportation that are either directly or through an
3523+14 affiliated company licensed by the Department of Public Health
3524+15 shall be approved by the Department to have in-house safety
3525+16 programs for training their own staff.
3526+17 Notwithstanding the requirements above, any public
3527+18 transportation provider of medi-car and service car
3528+19 transportation that receives federal funding under 49 U.S.C.
3529+20 5307 and 5311 need not certify its drivers and employee
3530+21 attendants under this Section, since safety training is
3531+22 already federally mandated.
3532+23 (f) With respect to any policy or program administered by
3533+24 the Department or its agent regarding approval of
3534+25 non-emergency medical transportation by ground ambulance
3535+26 service providers, including, but not limited to, the
3536+
3537+
3538+
3539+
3540+
3541+ SB3268 Enrolled - 100 - LRB103 39338 KTG 69500 b
3542+
3543+
3544+SB3268 Enrolled- 101 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 101 - LRB103 39338 KTG 69500 b
3545+ SB3268 Enrolled - 101 - LRB103 39338 KTG 69500 b
3546+1 Non-Emergency Transportation Services Prior Approval Program
3547+2 (NETSPAP), the Department shall establish by rule a process by
3548+3 which ground ambulance service providers of non-emergency
3549+4 medical transportation may appeal any decision by the
3550+5 Department or its agent for which no denial was received prior
3551+6 to the time of transport that either (i) denies a request for
3552+7 approval for payment of non-emergency transportation by means
3553+8 of ground ambulance service or (ii) grants a request for
3554+9 approval of non-emergency transportation by means of ground
3555+10 ambulance service at a level of service that entitles the
3556+11 ground ambulance service provider to a lower level of
3557+12 compensation from the Department than the ground ambulance
3558+13 service provider would have received as compensation for the
3559+14 level of service requested. The rule shall be filed by
3560+15 December 15, 2012 and shall provide that, for any decision
3561+16 rendered by the Department or its agent on or after the date
3562+17 the rule takes effect, the ground ambulance service provider
3563+18 shall have 60 days from the date the decision is received to
3564+19 file an appeal. The rule established by the Department shall
3565+20 be, insofar as is practical, consistent with the Illinois
3566+21 Administrative Procedure Act. The Director's decision on an
3567+22 appeal under this Section shall be a final administrative
3568+23 decision subject to review under the Administrative Review
3569+24 Law.
3570+25 (f-5) Beginning 90 days after July 20, 2012 (the effective
3571+26 date of Public Act 97-842), (i) no denial of a request for
3572+
3573+
3574+
3575+
3576+
3577+ SB3268 Enrolled - 101 - LRB103 39338 KTG 69500 b
3578+
3579+
3580+SB3268 Enrolled- 102 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 102 - LRB103 39338 KTG 69500 b
3581+ SB3268 Enrolled - 102 - LRB103 39338 KTG 69500 b
3582+1 approval for payment of non-emergency transportation by means
3583+2 of ground ambulance service, and (ii) no approval of
3584+3 non-emergency transportation by means of ground ambulance
3585+4 service at a level of service that entitles the ground
3586+5 ambulance service provider to a lower level of compensation
3587+6 from the Department than would have been received at the level
3588+7 of service submitted by the ground ambulance service provider,
3589+8 may be issued by the Department or its agent unless the
3590+9 Department has submitted the criteria for determining the
3591+10 appropriateness of the transport for first notice publication
3592+11 in the Illinois Register pursuant to Section 5-40 of the
3593+12 Illinois Administrative Procedure Act.
3594+13 (f-6) Within 90 days after June 2, 2022 (the effective
3595+14 date of Public Act 102-1037) this amendatory Act of the 102nd
3596+15 General Assembly and subject to federal approval, the
3597+16 Department shall file rules to allow for the approval of
3598+17 ground ambulance services when the sole purpose of the
3599+18 transport is for the navigation of stairs or the assisting or
3600+19 lifting of a patient at a medical facility or during a medical
3601+20 appointment in instances where the Department or a contracted
3602+21 Medicaid managed care organization or their transportation
3603+22 broker is unable to secure transportation through any other
3604+23 transportation provider.
3605+24 (f-7) For non-emergency ground ambulance claims properly
3606+25 denied under Department policy at the time the claim is filed
3607+26 due to failure to submit a valid Medical Certification for
3608+
3609+
3610+
3611+
3612+
3613+ SB3268 Enrolled - 102 - LRB103 39338 KTG 69500 b
3614+
3615+
3616+SB3268 Enrolled- 103 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 103 - LRB103 39338 KTG 69500 b
3617+ SB3268 Enrolled - 103 - LRB103 39338 KTG 69500 b
3618+1 Non-Emergency Ambulance on and after December 15, 2012 and
3619+2 prior to January 1, 2021, the Department shall allot
3620+3 $2,000,000 to a pool to reimburse such claims if the provider
3621+4 proves medical necessity for the service by other means.
3622+5 Providers must submit any such denied claims for which they
3623+6 seek compensation to the Department no later than December 31,
3624+7 2021 along with documentation of medical necessity. No later
3625+8 than May 31, 2022, the Department shall determine for which
3626+9 claims medical necessity was established. Such claims for
3627+10 which medical necessity was established shall be paid at the
3628+11 rate in effect at the time of the service, provided the
3629+12 $2,000,000 is sufficient to pay at those rates. If the pool is
3630+13 not sufficient, claims shall be paid at a uniform percentage
3631+14 of the applicable rate such that the pool of $2,000,000 is
3632+15 exhausted. The appeal process described in subsection (f)
3633+16 shall not be applicable to the Department's determinations
3634+17 made in accordance with this subsection.
3635+18 (g) Whenever a patient covered by a medical assistance
3636+19 program under this Code or by another medical program
3637+20 administered by the Department, including a patient covered
3638+21 under the State's Medicaid managed care program, is being
3639+22 transported from a facility and requires non-emergency
3640+23 transportation including ground ambulance, medi-car, or
3641+24 service car transportation, a Physician Certification
3642+25 Statement as described in this Section shall be required for
3643+26 each patient. Facilities shall develop procedures for a
3644+
3645+
3646+
3647+
3648+
3649+ SB3268 Enrolled - 103 - LRB103 39338 KTG 69500 b
3650+
3651+
3652+SB3268 Enrolled- 104 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 104 - LRB103 39338 KTG 69500 b
3653+ SB3268 Enrolled - 104 - LRB103 39338 KTG 69500 b
3654+1 licensed medical professional to provide a written and signed
3655+2 Physician Certification Statement. The Physician Certification
3656+3 Statement shall specify the level of transportation services
3657+4 needed and complete a medical certification establishing the
3658+5 criteria for approval of non-emergency ambulance
3659+6 transportation, as published by the Department of Healthcare
3660+7 and Family Services, that is met by the patient. This
3661+8 certification shall be completed prior to ordering the
3662+9 transportation service and prior to patient discharge. The
3663+10 Physician Certification Statement is not required prior to
3664+11 transport if a delay in transport can be expected to
3665+12 negatively affect the patient outcome. If the ground ambulance
3666+13 provider, medi-car provider, or service car provider is unable
3667+14 to obtain the required Physician Certification Statement
3668+15 within 10 calendar days following the date of the service, the
3669+16 ground ambulance provider, medi-car provider, or service car
3670+17 provider must document its attempt to obtain the requested
3671+18 certification and may then submit the claim for payment.
3672+19 Acceptable documentation includes a signed return receipt from
3673+20 the U.S. Postal Service, facsimile receipt, email receipt, or
3674+21 other similar service that evidences that the ground ambulance
3675+22 provider, medi-car provider, or service car provider attempted
3676+23 to obtain the required Physician Certification Statement.
3677+24 The medical certification specifying the level and type of
3678+25 non-emergency transportation needed shall be in the form of
3679+26 the Physician Certification Statement on a standardized form
3680+
3681+
3682+
3683+
3684+
3685+ SB3268 Enrolled - 104 - LRB103 39338 KTG 69500 b
3686+
3687+
3688+SB3268 Enrolled- 105 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 105 - LRB103 39338 KTG 69500 b
3689+ SB3268 Enrolled - 105 - LRB103 39338 KTG 69500 b
3690+1 prescribed by the Department of Healthcare and Family
3691+2 Services. Within 75 days after July 27, 2018 (the effective
3692+3 date of Public Act 100-646), the Department of Healthcare and
3693+4 Family Services shall develop a standardized form of the
3694+5 Physician Certification Statement specifying the level and
3695+6 type of transportation services needed in consultation with
3696+7 the Department of Public Health, Medicaid managed care
3697+8 organizations, a statewide association representing ambulance
3698+9 providers, a statewide association representing hospitals, 3
3699+10 statewide associations representing nursing homes, and other
3700+11 stakeholders. The Physician Certification Statement shall
3701+12 include, but is not limited to, the criteria necessary to
3702+13 demonstrate medical necessity for the level of transport
3703+14 needed as required by (i) the Department of Healthcare and
3704+15 Family Services and (ii) the federal Centers for Medicare and
3705+16 Medicaid Services as outlined in the Centers for Medicare and
3706+17 Medicaid Services' Medicare Benefit Policy Manual, Pub.
3707+18 100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
3708+19 Certification Statement shall satisfy the obligations of
3709+20 hospitals under Section 6.22 of the Hospital Licensing Act and
3710+21 nursing homes under Section 2-217 of the Nursing Home Care
3711+22 Act. Implementation and acceptance of the Physician
3712+23 Certification Statement shall take place no later than 90 days
3713+24 after the issuance of the Physician Certification Statement by
3714+25 the Department of Healthcare and Family Services.
3715+26 Pursuant to subsection (E) of Section 12-4.25 of this
3716+
3717+
3718+
3719+
3720+
3721+ SB3268 Enrolled - 105 - LRB103 39338 KTG 69500 b
3722+
3723+
3724+SB3268 Enrolled- 106 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 106 - LRB103 39338 KTG 69500 b
3725+ SB3268 Enrolled - 106 - LRB103 39338 KTG 69500 b
3726+1 Code, the Department is entitled to recover overpayments paid
3727+2 to a provider or vendor, including, but not limited to, from
3728+3 the discharging physician, the discharging facility, and the
3729+4 ground ambulance service provider, in instances where a
3730+5 non-emergency ground ambulance service is rendered as the
3731+6 result of improper or false certification.
3732+7 Beginning October 1, 2018, the Department of Healthcare
3733+8 and Family Services shall collect data from Medicaid managed
3734+9 care organizations and transportation brokers, including the
3735+10 Department's NETSPAP broker, regarding denials and appeals
3736+11 related to the missing or incomplete Physician Certification
3737+12 Statement forms and overall compliance with this subsection.
3738+13 The Department of Healthcare and Family Services shall publish
3739+14 quarterly results on its website within 15 days following the
3740+15 end of each quarter.
3741+16 (h) On and after July 1, 2012, the Department shall reduce
3742+17 any rate of reimbursement for services or other payments or
3743+18 alter any methodologies authorized by this Code to reduce any
3744+19 rate of reimbursement for services or other payments in
3745+20 accordance with Section 5-5e.
3746+21 (i) Subject to federal approval, on and after January 1,
3747+22 2024 through June 30, 2026, the Department shall increase the
3748+23 base rate of reimbursement for both base charges and mileage
3749+24 charges for ground ambulance service providers not
3750+25 participating in the Ground Emergency Medical Transportation
3751+26 (GEMT) Program for medical transportation services provided by
3752+
3753+
3754+
3755+
3756+
3757+ SB3268 Enrolled - 106 - LRB103 39338 KTG 69500 b
3758+
3759+
3760+SB3268 Enrolled- 107 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 107 - LRB103 39338 KTG 69500 b
3761+ SB3268 Enrolled - 107 - LRB103 39338 KTG 69500 b
3762+1 means of a ground ambulance to a level not lower than 140% of
3763+2 the base rate in effect as of January 1, 2023.
3764+3 (j) For the purpose of understanding ground ambulance
3765+4 transportation services cost structures and their impact on
3766+5 the Medical Assistance Program, the Department shall engage
3767+6 stakeholders, including, but not limited to, a statewide
3768+7 association representing private ground ambulance service
3769+8 providers in Illinois, to develop recommendations for a plan
3770+9 for the regular collection of cost data for all ground
3771+10 ambulance transportation providers reimbursed under the
3772+11 Illinois Title XIX State Plan. Cost data obtained through this
3773+12 process shall be used to inform on and to ensure the
3774+13 effectiveness and efficiency of Illinois Medicaid rates. The
3775+14 Department shall establish a process to limit public
3776+15 availability of portions of the cost report data determined to
3777+16 be proprietary. This process shall be concluded and
3778+17 recommendations shall be provided no later than December 31,
3779+18 2025 April 1, 2024.
3780+19 (k) (j) Subject to federal approval, beginning on January
3781+20 1, 2024, the Department shall increase the base rate of
3782+21 reimbursement for both base charges and mileage charges for
3783+22 medical transportation services provided by means of an air
3784+23 ambulance to a level not lower than 50% of the Medicare
3785+24 ambulance fee schedule rates, by designated Medicare locality,
3786+25 in effect on January 1, 2023.
3787+26 (Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21;
3788+
3789+
3790+
3791+
3792+
3793+ SB3268 Enrolled - 107 - LRB103 39338 KTG 69500 b
3794+
3795+
3796+SB3268 Enrolled- 108 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 108 - LRB103 39338 KTG 69500 b
3797+ SB3268 Enrolled - 108 - LRB103 39338 KTG 69500 b
3798+1 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article
3799+2 70, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section
3800+3 80-5, eff. 1-1-24; revised 12-15-23.)
3801+4 ARTICLE 90.
3802+5 Section 90-5. The Illinois Public Aid Code is amended by
3803+6 changing Section 5-5 as follows:
3804+7 (305 ILCS 5/5-5)
3805+8 Sec. 5-5. Medical services. The Illinois Department, by
3806+9 rule, shall determine the quantity and quality of and the rate
3807+10 of reimbursement for the medical assistance for which payment
3808+11 will be authorized, and the medical services to be provided,
3809+12 which may include all or part of the following: (1) inpatient
3810+13 hospital services; (2) outpatient hospital services; (3) other
3811+14 laboratory and X-ray services; (4) skilled nursing home
3812+15 services; (5) physicians' services whether furnished in the
3813+16 office, the patient's home, a hospital, a skilled nursing
3814+17 home, or elsewhere; (6) medical care, or any other type of
3815+18 remedial care furnished by licensed practitioners; (7) home
3816+19 health care services; (8) private duty nursing service; (9)
3817+20 clinic services; (10) dental services, including prevention
3818+21 and treatment of periodontal disease and dental caries disease
3819+22 for pregnant individuals, provided by an individual licensed
3820+23 to practice dentistry or dental surgery; for purposes of this
3821+
3822+
3823+
3824+
3825+
3826+ SB3268 Enrolled - 108 - LRB103 39338 KTG 69500 b
3827+
3828+
3829+SB3268 Enrolled- 109 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 109 - LRB103 39338 KTG 69500 b
3830+ SB3268 Enrolled - 109 - LRB103 39338 KTG 69500 b
3831+1 item (10), "dental services" means diagnostic, preventive, or
3832+2 corrective procedures provided by or under the supervision of
3833+3 a dentist in the practice of his or her profession; (11)
3834+4 physical therapy and related services; (12) prescribed drugs,
3835+5 dentures, and prosthetic devices; and eyeglasses prescribed by
3836+6 a physician skilled in the diseases of the eye, or by an
3837+7 optometrist, whichever the person may select; (13) other
3838+8 diagnostic, screening, preventive, and rehabilitative
3839+9 services, including to ensure that the individual's need for
3840+10 intervention or treatment of mental disorders or substance use
3841+11 disorders or co-occurring mental health and substance use
3842+12 disorders is determined using a uniform screening, assessment,
3843+13 and evaluation process inclusive of criteria, for children and
3844+14 adults; for purposes of this item (13), a uniform screening,
3845+15 assessment, and evaluation process refers to a process that
3846+16 includes an appropriate evaluation and, as warranted, a
3847+17 referral; "uniform" does not mean the use of a singular
3848+18 instrument, tool, or process that all must utilize; (14)
3849+19 transportation and such other expenses as may be necessary;
3850+20 (15) medical treatment of sexual assault survivors, as defined
3851+21 in Section 1a of the Sexual Assault Survivors Emergency
3852+22 Treatment Act, for injuries sustained as a result of the
3853+23 sexual assault, including examinations and laboratory tests to
3854+24 discover evidence which may be used in criminal proceedings
3855+25 arising from the sexual assault; (16) the diagnosis and
3856+26 treatment of sickle cell anemia; (16.5) services performed by
3857+
3858+
3859+
3860+
3861+
3862+ SB3268 Enrolled - 109 - LRB103 39338 KTG 69500 b
3863+
3864+
3865+SB3268 Enrolled- 110 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 110 - LRB103 39338 KTG 69500 b
3866+ SB3268 Enrolled - 110 - LRB103 39338 KTG 69500 b
3867+1 a chiropractic physician licensed under the Medical Practice
3868+2 Act of 1987 and acting within the scope of his or her license,
3869+3 including, but not limited to, chiropractic manipulative
3870+4 treatment; and (17) any other medical care, and any other type
3871+5 of remedial care recognized under the laws of this State. The
3872+6 term "any other type of remedial care" shall include nursing
3873+7 care and nursing home service for persons who rely on
3874+8 treatment by spiritual means alone through prayer for healing.
3875+9 Notwithstanding any other provision of this Section, a
3876+10 comprehensive tobacco use cessation program that includes
3877+11 purchasing prescription drugs or prescription medical devices
3878+12 approved by the Food and Drug Administration shall be covered
3879+13 under the medical assistance program under this Article for
3880+14 persons who are otherwise eligible for assistance under this
3881+15 Article.
3882+16 Notwithstanding any other provision of this Code,
3883+17 reproductive health care that is otherwise legal in Illinois
3884+18 shall be covered under the medical assistance program for
3885+19 persons who are otherwise eligible for medical assistance
3886+20 under this Article.
3887+21 Notwithstanding any other provision of this Section, all
3888+22 tobacco cessation medications approved by the United States
3889+23 Food and Drug Administration and all individual and group
3890+24 tobacco cessation counseling services and telephone-based
3891+25 counseling services and tobacco cessation medications provided
3892+26 through the Illinois Tobacco Quitline shall be covered under
3893+
3894+
3895+
3896+
3897+
3898+ SB3268 Enrolled - 110 - LRB103 39338 KTG 69500 b
3899+
3900+
3901+SB3268 Enrolled- 111 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 111 - LRB103 39338 KTG 69500 b
3902+ SB3268 Enrolled - 111 - LRB103 39338 KTG 69500 b
3903+1 the medical assistance program for persons who are otherwise
3904+2 eligible for assistance under this Article. The Department
3905+3 shall comply with all federal requirements necessary to obtain
3906+4 federal financial participation, as specified in 42 CFR
3907+5 433.15(b)(7), for telephone-based counseling services provided
3908+6 through the Illinois Tobacco Quitline, including, but not
3909+7 limited to: (i) entering into a memorandum of understanding or
3910+8 interagency agreement with the Department of Public Health, as
3911+9 administrator of the Illinois Tobacco Quitline; and (ii)
3912+10 developing a cost allocation plan for Medicaid-allowable
3913+11 Illinois Tobacco Quitline services in accordance with 45 CFR
3914+12 95.507. The Department shall submit the memorandum of
3915+13 understanding or interagency agreement, the cost allocation
3916+14 plan, and all other necessary documentation to the Centers for
3917+15 Medicare and Medicaid Services for review and approval.
3918+16 Coverage under this paragraph shall be contingent upon federal
3919+17 approval.
3920+18 Notwithstanding any other provision of this Code, the
3921+19 Illinois Department may not require, as a condition of payment
3922+20 for any laboratory test authorized under this Article, that a
3923+21 physician's handwritten signature appear on the laboratory
3924+22 test order form. The Illinois Department may, however, impose
3925+23 other appropriate requirements regarding laboratory test order
3926+24 documentation.
3927+25 Upon receipt of federal approval of an amendment to the
3928+26 Illinois Title XIX State Plan for this purpose, the Department
3929+
3930+
3931+
3932+
3933+
3934+ SB3268 Enrolled - 111 - LRB103 39338 KTG 69500 b
3935+
3936+
3937+SB3268 Enrolled- 112 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 112 - LRB103 39338 KTG 69500 b
3938+ SB3268 Enrolled - 112 - LRB103 39338 KTG 69500 b
3939+1 shall authorize the Chicago Public Schools (CPS) to procure a
3940+2 vendor or vendors to manufacture eyeglasses for individuals
3941+3 enrolled in a school within the CPS system. CPS shall ensure
3942+4 that its vendor or vendors are enrolled as providers in the
3943+5 medical assistance program and in any capitated Medicaid
3944+6 managed care entity (MCE) serving individuals enrolled in a
3945+7 school within the CPS system. Under any contract procured
3946+8 under this provision, the vendor or vendors must serve only
3947+9 individuals enrolled in a school within the CPS system. Claims
3948+10 for services provided by CPS's vendor or vendors to recipients
3949+11 of benefits in the medical assistance program under this Code,
3950+12 the Children's Health Insurance Program, or the Covering ALL
3951+13 KIDS Health Insurance Program shall be submitted to the
3952+14 Department or the MCE in which the individual is enrolled for
3953+15 payment and shall be reimbursed at the Department's or the
3954+16 MCE's established rates or rate methodologies for eyeglasses.
3955+17 On and after July 1, 2012, the Department of Healthcare
3956+18 and Family Services may provide the following services to
3957+19 persons eligible for assistance under this Article who are
3958+20 participating in education, training or employment programs
3959+21 operated by the Department of Human Services as successor to
3960+22 the Department of Public Aid:
3961+23 (1) dental services provided by or under the
3962+24 supervision of a dentist; and
3963+25 (2) eyeglasses prescribed by a physician skilled in
3964+26 the diseases of the eye, or by an optometrist, whichever
3965+
3966+
3967+
3968+
3969+
3970+ SB3268 Enrolled - 112 - LRB103 39338 KTG 69500 b
3971+
3972+
3973+SB3268 Enrolled- 113 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 113 - LRB103 39338 KTG 69500 b
3974+ SB3268 Enrolled - 113 - LRB103 39338 KTG 69500 b
3975+1 the person may select.
3976+2 On and after July 1, 2018, the Department of Healthcare
3977+3 and Family Services shall provide dental services to any adult
3978+4 who is otherwise eligible for assistance under the medical
3979+5 assistance program. As used in this paragraph, "dental
3980+6 services" means diagnostic, preventative, restorative, or
3981+7 corrective procedures, including procedures and services for
3982+8 the prevention and treatment of periodontal disease and dental
3983+9 caries disease, provided by an individual who is licensed to
3984+10 practice dentistry or dental surgery or who is under the
3985+11 supervision of a dentist in the practice of his or her
3986+12 profession.
3987+13 On and after July 1, 2018, targeted dental services, as
3988+14 set forth in Exhibit D of the Consent Decree entered by the
3989+15 United States District Court for the Northern District of
3990+16 Illinois, Eastern Division, in the matter of Memisovski v.
3991+17 Maram, Case No. 92 C 1982, that are provided to adults under
3992+18 the medical assistance program shall be established at no less
3993+19 than the rates set forth in the "New Rate" column in Exhibit D
3994+20 of the Consent Decree for targeted dental services that are
3995+21 provided to persons under the age of 18 under the medical
3996+22 assistance program.
3997+23 Notwithstanding any other provision of this Code and
3998+24 subject to federal approval, the Department may adopt rules to
3999+25 allow a dentist who is volunteering his or her service at no
4000+26 cost to render dental services through an enrolled
4001+
4002+
4003+
4004+
4005+
4006+ SB3268 Enrolled - 113 - LRB103 39338 KTG 69500 b
4007+
4008+
4009+SB3268 Enrolled- 114 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 114 - LRB103 39338 KTG 69500 b
4010+ SB3268 Enrolled - 114 - LRB103 39338 KTG 69500 b
4011+1 not-for-profit health clinic without the dentist personally
4012+2 enrolling as a participating provider in the medical
4013+3 assistance program. A not-for-profit health clinic shall
4014+4 include a public health clinic or Federally Qualified Health
4015+5 Center or other enrolled provider, as determined by the
4016+6 Department, through which dental services covered under this
4017+7 Section are performed. The Department shall establish a
4018+8 process for payment of claims for reimbursement for covered
4019+9 dental services rendered under this provision.
4020+10 Subject to appropriation and to federal approval, the
4021+11 Department shall file administrative rules updating the
4022+12 Handicapping Labio-Lingual Deviation orthodontic scoring tool
4023+13 by January 1, 2025, or as soon as practicable.
4024+14 On and after January 1, 2022, the Department of Healthcare
4025+15 and Family Services shall administer and regulate a
4026+16 school-based dental program that allows for the out-of-office
4027+17 delivery of preventative dental services in a school setting
4028+18 to children under 19 years of age. The Department shall
4029+19 establish, by rule, guidelines for participation by providers
4030+20 and set requirements for follow-up referral care based on the
4031+21 requirements established in the Dental Office Reference Manual
4032+22 published by the Department that establishes the requirements
4033+23 for dentists participating in the All Kids Dental School
4034+24 Program. Every effort shall be made by the Department when
4035+25 developing the program requirements to consider the different
4036+26 geographic differences of both urban and rural areas of the
4037+
4038+
4039+
4040+
4041+
4042+ SB3268 Enrolled - 114 - LRB103 39338 KTG 69500 b
4043+
4044+
4045+SB3268 Enrolled- 115 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 115 - LRB103 39338 KTG 69500 b
4046+ SB3268 Enrolled - 115 - LRB103 39338 KTG 69500 b
4047+1 State for initial treatment and necessary follow-up care. No
4048+2 provider shall be charged a fee by any unit of local government
4049+3 to participate in the school-based dental program administered
4050+4 by the Department. Nothing in this paragraph shall be
4051+5 construed to limit or preempt a home rule unit's or school
4052+6 district's authority to establish, change, or administer a
4053+7 school-based dental program in addition to, or independent of,
4054+8 the school-based dental program administered by the
4055+9 Department.
4056+10 The Illinois Department, by rule, may distinguish and
4057+11 classify the medical services to be provided only in
4058+12 accordance with the classes of persons designated in Section
4059+13 5-2.
4060+14 The Department of Healthcare and Family Services must
4061+15 provide coverage and reimbursement for amino acid-based
4062+16 elemental formulas, regardless of delivery method, for the
4063+17 diagnosis and treatment of (i) eosinophilic disorders and (ii)
4064+18 short bowel syndrome when the prescribing physician has issued
4065+19 a written order stating that the amino acid-based elemental
4066+20 formula is medically necessary.
4067+21 The Illinois Department shall authorize the provision of,
4068+22 and shall authorize payment for, screening by low-dose
4069+23 mammography for the presence of occult breast cancer for
4070+24 individuals 35 years of age or older who are eligible for
4071+25 medical assistance under this Article, as follows:
4072+26 (A) A baseline mammogram for individuals 35 to 39
4073+
4074+
4075+
4076+
4077+
4078+ SB3268 Enrolled - 115 - LRB103 39338 KTG 69500 b
4079+
4080+
4081+SB3268 Enrolled- 116 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 116 - LRB103 39338 KTG 69500 b
4082+ SB3268 Enrolled - 116 - LRB103 39338 KTG 69500 b
4083+1 years of age.
4084+2 (B) An annual mammogram for individuals 40 years of
4085+3 age or older.
4086+4 (C) A mammogram at the age and intervals considered
4087+5 medically necessary by the individual's health care
4088+6 provider for individuals under 40 years of age and having
4089+7 a family history of breast cancer, prior personal history
4090+8 of breast cancer, positive genetic testing, or other risk
4091+9 factors.
4092+10 (D) A comprehensive ultrasound screening and MRI of an
4093+11 entire breast or breasts if a mammogram demonstrates
4094+12 heterogeneous or dense breast tissue or when medically
4095+13 necessary as determined by a physician licensed to
4096+14 practice medicine in all of its branches.
4097+15 (E) A screening MRI when medically necessary, as
4098+16 determined by a physician licensed to practice medicine in
4099+17 all of its branches.
4100+18 (F) A diagnostic mammogram when medically necessary,
4101+19 as determined by a physician licensed to practice medicine
4102+20 in all its branches, advanced practice registered nurse,
4103+21 or physician assistant.
4104+22 The Department shall not impose a deductible, coinsurance,
4105+23 copayment, or any other cost-sharing requirement on the
4106+24 coverage provided under this paragraph; except that this
4107+25 sentence does not apply to coverage of diagnostic mammograms
4108+26 to the extent such coverage would disqualify a high-deductible
4109+
4110+
4111+
4112+
4113+
4114+ SB3268 Enrolled - 116 - LRB103 39338 KTG 69500 b
4115+
4116+
4117+SB3268 Enrolled- 117 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 117 - LRB103 39338 KTG 69500 b
4118+ SB3268 Enrolled - 117 - LRB103 39338 KTG 69500 b
4119+1 health plan from eligibility for a health savings account
4120+2 pursuant to Section 223 of the Internal Revenue Code (26
4121+3 U.S.C. 223).
4122+4 All screenings shall include a physical breast exam,
4123+5 instruction on self-examination and information regarding the
4124+6 frequency of self-examination and its value as a preventative
4125+7 tool.
4126+8 For purposes of this Section:
4127+9 "Diagnostic mammogram" means a mammogram obtained using
4128+10 diagnostic mammography.
4129+11 "Diagnostic mammography" means a method of screening that
4130+12 is designed to evaluate an abnormality in a breast, including
4131+13 an abnormality seen or suspected on a screening mammogram or a
4132+14 subjective or objective abnormality otherwise detected in the
4133+15 breast.
4134+16 "Low-dose mammography" means the x-ray examination of the
4135+17 breast using equipment dedicated specifically for mammography,
4136+18 including the x-ray tube, filter, compression device, and
4137+19 image receptor, with an average radiation exposure delivery of
4138+20 less than one rad per breast for 2 views of an average size
4139+21 breast. The term also includes digital mammography and
4140+22 includes breast tomosynthesis.
4141+23 "Breast tomosynthesis" means a radiologic procedure that
4142+24 involves the acquisition of projection images over the
4143+25 stationary breast to produce cross-sectional digital
4144+26 three-dimensional images of the breast.
4145+
4146+
4147+
4148+
4149+
4150+ SB3268 Enrolled - 117 - LRB103 39338 KTG 69500 b
4151+
4152+
4153+SB3268 Enrolled- 118 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 118 - LRB103 39338 KTG 69500 b
4154+ SB3268 Enrolled - 118 - LRB103 39338 KTG 69500 b
4155+1 If, at any time, the Secretary of the United States
4156+2 Department of Health and Human Services, or its successor
4157+3 agency, promulgates rules or regulations to be published in
4158+4 the Federal Register or publishes a comment in the Federal
4159+5 Register or issues an opinion, guidance, or other action that
4160+6 would require the State, pursuant to any provision of the
4161+7 Patient Protection and Affordable Care Act (Public Law
4162+8 111-148), including, but not limited to, 42 U.S.C.
4163+9 18031(d)(3)(B) or any successor provision, to defray the cost
4164+10 of any coverage for breast tomosynthesis outlined in this
4165+11 paragraph, then the requirement that an insurer cover breast
4166+12 tomosynthesis is inoperative other than any such coverage
4167+13 authorized under Section 1902 of the Social Security Act, 42
4168+14 U.S.C. 1396a, and the State shall not assume any obligation
4169+15 for the cost of coverage for breast tomosynthesis set forth in
4170+16 this paragraph.
4171+17 On and after January 1, 2016, the Department shall ensure
4172+18 that all networks of care for adult clients of the Department
4173+19 include access to at least one breast imaging Center of
4174+20 Imaging Excellence as certified by the American College of
4175+21 Radiology.
4176+22 On and after January 1, 2012, providers participating in a
4177+23 quality improvement program approved by the Department shall
4178+24 be reimbursed for screening and diagnostic mammography at the
4179+25 same rate as the Medicare program's rates, including the
4180+26 increased reimbursement for digital mammography and, after
4181+
4182+
4183+
4184+
4185+
4186+ SB3268 Enrolled - 118 - LRB103 39338 KTG 69500 b
4187+
4188+
4189+SB3268 Enrolled- 119 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 119 - LRB103 39338 KTG 69500 b
4190+ SB3268 Enrolled - 119 - LRB103 39338 KTG 69500 b
4191+1 January 1, 2023 (the effective date of Public Act 102-1018),
4192+2 breast tomosynthesis.
4193+3 The Department shall convene an expert panel including
4194+4 representatives of hospitals, free-standing mammography
4195+5 facilities, and doctors, including radiologists, to establish
4196+6 quality standards for mammography.
4197+7 On and after January 1, 2017, providers participating in a
4198+8 breast cancer treatment quality improvement program approved
4199+9 by the Department shall be reimbursed for breast cancer
4200+10 treatment at a rate that is no lower than 95% of the Medicare
4201+11 program's rates for the data elements included in the breast
4202+12 cancer treatment quality program.
4203+13 The Department shall convene an expert panel, including
4204+14 representatives of hospitals, free-standing breast cancer
4205+15 treatment centers, breast cancer quality organizations, and
4206+16 doctors, including breast surgeons, reconstructive breast
4207+17 surgeons, oncologists, and primary care providers to establish
4208+18 quality standards for breast cancer treatment.
4209+19 Subject to federal approval, the Department shall
4210+20 establish a rate methodology for mammography at federally
4211+21 qualified health centers and other encounter-rate clinics.
4212+22 These clinics or centers may also collaborate with other
4213+23 hospital-based mammography facilities. By January 1, 2016, the
4214+24 Department shall report to the General Assembly on the status
4215+25 of the provision set forth in this paragraph.
4216+26 The Department shall establish a methodology to remind
4217+
4218+
4219+
4220+
4221+
4222+ SB3268 Enrolled - 119 - LRB103 39338 KTG 69500 b
4223+
4224+
4225+SB3268 Enrolled- 120 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 120 - LRB103 39338 KTG 69500 b
4226+ SB3268 Enrolled - 120 - LRB103 39338 KTG 69500 b
4227+1 individuals who are age-appropriate for screening mammography,
4228+2 but who have not received a mammogram within the previous 18
4229+3 months, of the importance and benefit of screening
4230+4 mammography. The Department shall work with experts in breast
4231+5 cancer outreach and patient navigation to optimize these
4232+6 reminders and shall establish a methodology for evaluating
4233+7 their effectiveness and modifying the methodology based on the
4234+8 evaluation.
4235+9 The Department shall establish a performance goal for
4236+10 primary care providers with respect to their female patients
4237+11 over age 40 receiving an annual mammogram. This performance
4238+12 goal shall be used to provide additional reimbursement in the
4239+13 form of a quality performance bonus to primary care providers
4240+14 who meet that goal.
4241+15 The Department shall devise a means of case-managing or
4242+16 patient navigation for beneficiaries diagnosed with breast
4243+17 cancer. This program shall initially operate as a pilot
4244+18 program in areas of the State with the highest incidence of
4245+19 mortality related to breast cancer. At least one pilot program
4246+20 site shall be in the metropolitan Chicago area and at least one
4247+21 site shall be outside the metropolitan Chicago area. On or
4248+22 after July 1, 2016, the pilot program shall be expanded to
4249+23 include one site in western Illinois, one site in southern
4250+24 Illinois, one site in central Illinois, and 4 sites within
4251+25 metropolitan Chicago. An evaluation of the pilot program shall
4252+26 be carried out measuring health outcomes and cost of care for
4253+
4254+
4255+
4256+
4257+
4258+ SB3268 Enrolled - 120 - LRB103 39338 KTG 69500 b
4259+
4260+
4261+SB3268 Enrolled- 121 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 121 - LRB103 39338 KTG 69500 b
4262+ SB3268 Enrolled - 121 - LRB103 39338 KTG 69500 b
4263+1 those served by the pilot program compared to similarly
4264+2 situated patients who are not served by the pilot program.
4265+3 The Department shall require all networks of care to
4266+4 develop a means either internally or by contract with experts
4267+5 in navigation and community outreach to navigate cancer
4268+6 patients to comprehensive care in a timely fashion. The
4269+7 Department shall require all networks of care to include
4270+8 access for patients diagnosed with cancer to at least one
4271+9 academic commission on cancer-accredited cancer program as an
4272+10 in-network covered benefit.
4273+11 The Department shall provide coverage and reimbursement
4274+12 for a human papillomavirus (HPV) vaccine that is approved for
4275+13 marketing by the federal Food and Drug Administration for all
4276+14 persons between the ages of 9 and 45. Subject to federal
4277+15 approval, the Department shall provide coverage and
4278+16 reimbursement for a human papillomavirus (HPV) vaccine for
4279+17 persons of the age of 46 and above who have been diagnosed with
4280+18 cervical dysplasia with a high risk of recurrence or
4281+19 progression. The Department shall disallow any
4282+20 preauthorization requirements for the administration of the
4283+21 human papillomavirus (HPV) vaccine.
4284+22 On or after July 1, 2022, individuals who are otherwise
4285+23 eligible for medical assistance under this Article shall
4286+24 receive coverage for perinatal depression screenings for the
4287+25 12-month period beginning on the last day of their pregnancy.
4288+26 Medical assistance coverage under this paragraph shall be
4289+
4290+
4291+
4292+
4293+
4294+ SB3268 Enrolled - 121 - LRB103 39338 KTG 69500 b
4295+
4296+
4297+SB3268 Enrolled- 122 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 122 - LRB103 39338 KTG 69500 b
4298+ SB3268 Enrolled - 122 - LRB103 39338 KTG 69500 b
4299+1 conditioned on the use of a screening instrument approved by
4300+2 the Department.
4301+3 Any medical or health care provider shall immediately
4302+4 recommend, to any pregnant individual who is being provided
4303+5 prenatal services and is suspected of having a substance use
4304+6 disorder as defined in the Substance Use Disorder Act,
4305+7 referral to a local substance use disorder treatment program
4306+8 licensed by the Department of Human Services or to a licensed
4307+9 hospital which provides substance abuse treatment services.
4308+10 The Department of Healthcare and Family Services shall assure
4309+11 coverage for the cost of treatment of the drug abuse or
4310+12 addiction for pregnant recipients in accordance with the
4311+13 Illinois Medicaid Program in conjunction with the Department
4312+14 of Human Services.
4313+15 All medical providers providing medical assistance to
4314+16 pregnant individuals under this Code shall receive information
4315+17 from the Department on the availability of services under any
4316+18 program providing case management services for addicted
4317+19 individuals, including information on appropriate referrals
4318+20 for other social services that may be needed by addicted
4319+21 individuals in addition to treatment for addiction.
4320+22 The Illinois Department, in cooperation with the
4321+23 Departments of Human Services (as successor to the Department
4322+24 of Alcoholism and Substance Abuse) and Public Health, through
4323+25 a public awareness campaign, may provide information
4324+26 concerning treatment for alcoholism and drug abuse and
4325+
4326+
4327+
4328+
4329+
4330+ SB3268 Enrolled - 122 - LRB103 39338 KTG 69500 b
4331+
4332+
4333+SB3268 Enrolled- 123 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 123 - LRB103 39338 KTG 69500 b
4334+ SB3268 Enrolled - 123 - LRB103 39338 KTG 69500 b
4335+1 addiction, prenatal health care, and other pertinent programs
4336+2 directed at reducing the number of drug-affected infants born
4337+3 to recipients of medical assistance.
4338+4 Neither the Department of Healthcare and Family Services
4339+5 nor the Department of Human Services shall sanction the
4340+6 recipient solely on the basis of the recipient's substance
4341+7 abuse.
4342+8 The Illinois Department shall establish such regulations
4343+9 governing the dispensing of health services under this Article
4344+10 as it shall deem appropriate. The Department should seek the
4345+11 advice of formal professional advisory committees appointed by
4346+12 the Director of the Illinois Department for the purpose of
4347+13 providing regular advice on policy and administrative matters,
4348+14 information dissemination and educational activities for
4349+15 medical and health care providers, and consistency in
4350+16 procedures to the Illinois Department.
4351+17 The Illinois Department may develop and contract with
4352+18 Partnerships of medical providers to arrange medical services
4353+19 for persons eligible under Section 5-2 of this Code.
4354+20 Implementation of this Section may be by demonstration
4355+21 projects in certain geographic areas. The Partnership shall be
4356+22 represented by a sponsor organization. The Department, by
4357+23 rule, shall develop qualifications for sponsors of
4358+24 Partnerships. Nothing in this Section shall be construed to
4359+25 require that the sponsor organization be a medical
4360+26 organization.
4361+
4362+
4363+
4364+
4365+
4366+ SB3268 Enrolled - 123 - LRB103 39338 KTG 69500 b
4367+
4368+
4369+SB3268 Enrolled- 124 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 124 - LRB103 39338 KTG 69500 b
4370+ SB3268 Enrolled - 124 - LRB103 39338 KTG 69500 b
4371+1 The sponsor must negotiate formal written contracts with
4372+2 medical providers for physician services, inpatient and
4373+3 outpatient hospital care, home health services, treatment for
4374+4 alcoholism and substance abuse, and other services determined
4375+5 necessary by the Illinois Department by rule for delivery by
4376+6 Partnerships. Physician services must include prenatal and
4377+7 obstetrical care. The Illinois Department shall reimburse
4378+8 medical services delivered by Partnership providers to clients
4379+9 in target areas according to provisions of this Article and
4380+10 the Illinois Health Finance Reform Act, except that:
4381+11 (1) Physicians participating in a Partnership and
4382+12 providing certain services, which shall be determined by
4383+13 the Illinois Department, to persons in areas covered by
4384+14 the Partnership may receive an additional surcharge for
4385+15 such services.
4386+16 (2) The Department may elect to consider and negotiate
4387+17 financial incentives to encourage the development of
4388+18 Partnerships and the efficient delivery of medical care.
4389+19 (3) Persons receiving medical services through
4390+20 Partnerships may receive medical and case management
4391+21 services above the level usually offered through the
4392+22 medical assistance program.
4393+23 Medical providers shall be required to meet certain
4394+24 qualifications to participate in Partnerships to ensure the
4395+25 delivery of high quality medical services. These
4396+26 qualifications shall be determined by rule of the Illinois
4397+
4398+
4399+
4400+
4401+
4402+ SB3268 Enrolled - 124 - LRB103 39338 KTG 69500 b
4403+
4404+
4405+SB3268 Enrolled- 125 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 125 - LRB103 39338 KTG 69500 b
4406+ SB3268 Enrolled - 125 - LRB103 39338 KTG 69500 b
4407+1 Department and may be higher than qualifications for
4408+2 participation in the medical assistance program. Partnership
4409+3 sponsors may prescribe reasonable additional qualifications
4410+4 for participation by medical providers, only with the prior
4411+5 written approval of the Illinois Department.
4412+6 Nothing in this Section shall limit the free choice of
4413+7 practitioners, hospitals, and other providers of medical
4414+8 services by clients. In order to ensure patient freedom of
4415+9 choice, the Illinois Department shall immediately promulgate
4416+10 all rules and take all other necessary actions so that
4417+11 provided services may be accessed from therapeutically
4418+12 certified optometrists to the full extent of the Illinois
4419+13 Optometric Practice Act of 1987 without discriminating between
4420+14 service providers.
4421+15 The Department shall apply for a waiver from the United
4422+16 States Health Care Financing Administration to allow for the
4423+17 implementation of Partnerships under this Section.
4424+18 The Illinois Department shall require health care
4425+19 providers to maintain records that document the medical care
4426+20 and services provided to recipients of Medical Assistance
4427+21 under this Article. Such records must be retained for a period
4428+22 of not less than 6 years from the date of service or as
4429+23 provided by applicable State law, whichever period is longer,
4430+24 except that if an audit is initiated within the required
4431+25 retention period then the records must be retained until the
4432+26 audit is completed and every exception is resolved. The
4433+
4434+
4435+
4436+
4437+
4438+ SB3268 Enrolled - 125 - LRB103 39338 KTG 69500 b
4439+
4440+
4441+SB3268 Enrolled- 126 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 126 - LRB103 39338 KTG 69500 b
4442+ SB3268 Enrolled - 126 - LRB103 39338 KTG 69500 b
4443+1 Illinois Department shall require health care providers to
4444+2 make available, when authorized by the patient, in writing,
4445+3 the medical records in a timely fashion to other health care
4446+4 providers who are treating or serving persons eligible for
4447+5 Medical Assistance under this Article. All dispensers of
4448+6 medical services shall be required to maintain and retain
4449+7 business and professional records sufficient to fully and
4450+8 accurately document the nature, scope, details and receipt of
4451+9 the health care provided to persons eligible for medical
4452+10 assistance under this Code, in accordance with regulations
4453+11 promulgated by the Illinois Department. The rules and
4454+12 regulations shall require that proof of the receipt of
4455+13 prescription drugs, dentures, prosthetic devices and
4456+14 eyeglasses by eligible persons under this Section accompany
4457+15 each claim for reimbursement submitted by the dispenser of
4458+16 such medical services. No such claims for reimbursement shall
4459+17 be approved for payment by the Illinois Department without
4460+18 such proof of receipt, unless the Illinois Department shall
4461+19 have put into effect and shall be operating a system of
4462+20 post-payment audit and review which shall, on a sampling
4463+21 basis, be deemed adequate by the Illinois Department to assure
4464+22 that such drugs, dentures, prosthetic devices and eyeglasses
4465+23 for which payment is being made are actually being received by
4466+24 eligible recipients. Within 90 days after September 16, 1984
4467+25 (the effective date of Public Act 83-1439), the Illinois
4468+26 Department shall establish a current list of acquisition costs
4469+
4470+
4471+
4472+
4473+
4474+ SB3268 Enrolled - 126 - LRB103 39338 KTG 69500 b
4475+
4476+
4477+SB3268 Enrolled- 127 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 127 - LRB103 39338 KTG 69500 b
4478+ SB3268 Enrolled - 127 - LRB103 39338 KTG 69500 b
4479+1 for all prosthetic devices and any other items recognized as
4480+2 medical equipment and supplies reimbursable under this Article
4481+3 and shall update such list on a quarterly basis, except that
4482+4 the acquisition costs of all prescription drugs shall be
4483+5 updated no less frequently than every 30 days as required by
4484+6 Section 5-5.12.
4485+7 Notwithstanding any other law to the contrary, the
4486+8 Illinois Department shall, within 365 days after July 22, 2013
4487+9 (the effective date of Public Act 98-104), establish
4488+10 procedures to permit skilled care facilities licensed under
4489+11 the Nursing Home Care Act to submit monthly billing claims for
4490+12 reimbursement purposes. Following development of these
4491+13 procedures, the Department shall, by July 1, 2016, test the
4492+14 viability of the new system and implement any necessary
4493+15 operational or structural changes to its information
4494+16 technology platforms in order to allow for the direct
4495+17 acceptance and payment of nursing home claims.
4496+18 Notwithstanding any other law to the contrary, the
4497+19 Illinois Department shall, within 365 days after August 15,
4498+20 2014 (the effective date of Public Act 98-963), establish
4499+21 procedures to permit ID/DD facilities licensed under the ID/DD
4500+22 Community Care Act and MC/DD facilities licensed under the
4501+23 MC/DD Act to submit monthly billing claims for reimbursement
4502+24 purposes. Following development of these procedures, the
4503+25 Department shall have an additional 365 days to test the
4504+26 viability of the new system and to ensure that any necessary
4505+
4506+
4507+
4508+
4509+
4510+ SB3268 Enrolled - 127 - LRB103 39338 KTG 69500 b
4511+
4512+
4513+SB3268 Enrolled- 128 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 128 - LRB103 39338 KTG 69500 b
4514+ SB3268 Enrolled - 128 - LRB103 39338 KTG 69500 b
4515+1 operational or structural changes to its information
4516+2 technology platforms are implemented.
4517+3 The Illinois Department shall require all dispensers of
4518+4 medical services, other than an individual practitioner or
4519+5 group of practitioners, desiring to participate in the Medical
4520+6 Assistance program established under this Article to disclose
4521+7 all financial, beneficial, ownership, equity, surety or other
4522+8 interests in any and all firms, corporations, partnerships,
4523+9 associations, business enterprises, joint ventures, agencies,
4524+10 institutions or other legal entities providing any form of
4525+11 health care services in this State under this Article.
4526+12 The Illinois Department may require that all dispensers of
4527+13 medical services desiring to participate in the medical
4528+14 assistance program established under this Article disclose,
4529+15 under such terms and conditions as the Illinois Department may
4530+16 by rule establish, all inquiries from clients and attorneys
4531+17 regarding medical bills paid by the Illinois Department, which
4532+18 inquiries could indicate potential existence of claims or
4533+19 liens for the Illinois Department.
4534+20 Enrollment of a vendor shall be subject to a provisional
4535+21 period and shall be conditional for one year. During the
4536+22 period of conditional enrollment, the Department may terminate
4537+23 the vendor's eligibility to participate in, or may disenroll
4538+24 the vendor from, the medical assistance program without cause.
4539+25 Unless otherwise specified, such termination of eligibility or
4540+26 disenrollment is not subject to the Department's hearing
4541+
4542+
4543+
4544+
4545+
4546+ SB3268 Enrolled - 128 - LRB103 39338 KTG 69500 b
4547+
4548+
4549+SB3268 Enrolled- 129 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 129 - LRB103 39338 KTG 69500 b
4550+ SB3268 Enrolled - 129 - LRB103 39338 KTG 69500 b
4551+1 process. However, a disenrolled vendor may reapply without
4552+2 penalty.
4553+3 The Department has the discretion to limit the conditional
4554+4 enrollment period for vendors based upon the category of risk
4555+5 of the vendor.
4556+6 Prior to enrollment and during the conditional enrollment
4557+7 period in the medical assistance program, all vendors shall be
4558+8 subject to enhanced oversight, screening, and review based on
4559+9 the risk of fraud, waste, and abuse that is posed by the
4560+10 category of risk of the vendor. The Illinois Department shall
4561+11 establish the procedures for oversight, screening, and review,
4562+12 which may include, but need not be limited to: criminal and
4563+13 financial background checks; fingerprinting; license,
4564+14 certification, and authorization verifications; unscheduled or
4565+15 unannounced site visits; database checks; prepayment audit
4566+16 reviews; audits; payment caps; payment suspensions; and other
4567+17 screening as required by federal or State law.
4568+18 The Department shall define or specify the following: (i)
4569+19 by provider notice, the "category of risk of the vendor" for
4570+20 each type of vendor, which shall take into account the level of
4571+21 screening applicable to a particular category of vendor under
4572+22 federal law and regulations; (ii) by rule or provider notice,
4573+23 the maximum length of the conditional enrollment period for
4574+24 each category of risk of the vendor; and (iii) by rule, the
4575+25 hearing rights, if any, afforded to a vendor in each category
4576+26 of risk of the vendor that is terminated or disenrolled during
4577+
4578+
4579+
4580+
4581+
4582+ SB3268 Enrolled - 129 - LRB103 39338 KTG 69500 b
4583+
4584+
4585+SB3268 Enrolled- 130 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 130 - LRB103 39338 KTG 69500 b
4586+ SB3268 Enrolled - 130 - LRB103 39338 KTG 69500 b
4587+1 the conditional enrollment period.
4588+2 To be eligible for payment consideration, a vendor's
4589+3 payment claim or bill, either as an initial claim or as a
4590+4 resubmitted claim following prior rejection, must be received
4591+5 by the Illinois Department, or its fiscal intermediary, no
4592+6 later than 180 days after the latest date on the claim on which
4593+7 medical goods or services were provided, with the following
4594+8 exceptions:
4595+9 (1) In the case of a provider whose enrollment is in
4596+10 process by the Illinois Department, the 180-day period
4597+11 shall not begin until the date on the written notice from
4598+12 the Illinois Department that the provider enrollment is
4599+13 complete.
4600+14 (2) In the case of errors attributable to the Illinois
4601+15 Department or any of its claims processing intermediaries
4602+16 which result in an inability to receive, process, or
4603+17 adjudicate a claim, the 180-day period shall not begin
4604+18 until the provider has been notified of the error.
4605+19 (3) In the case of a provider for whom the Illinois
4606+20 Department initiates the monthly billing process.
4607+21 (4) In the case of a provider operated by a unit of
4608+22 local government with a population exceeding 3,000,000
4609+23 when local government funds finance federal participation
4610+24 for claims payments.
4611+25 For claims for services rendered during a period for which
4612+26 a recipient received retroactive eligibility, claims must be
4613+
4614+
4615+
4616+
4617+
4618+ SB3268 Enrolled - 130 - LRB103 39338 KTG 69500 b
4619+
4620+
4621+SB3268 Enrolled- 131 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 131 - LRB103 39338 KTG 69500 b
4622+ SB3268 Enrolled - 131 - LRB103 39338 KTG 69500 b
4623+1 filed within 180 days after the Department determines the
4624+2 applicant is eligible. For claims for which the Illinois
4625+3 Department is not the primary payer, claims must be submitted
4626+4 to the Illinois Department within 180 days after the final
4627+5 adjudication by the primary payer.
4628+6 In the case of long term care facilities, within 120
4629+7 calendar days of receipt by the facility of required
4630+8 prescreening information, new admissions with associated
4631+9 admission documents shall be submitted through the Medical
4632+10 Electronic Data Interchange (MEDI) or the Recipient
4633+11 Eligibility Verification (REV) System or shall be submitted
4634+12 directly to the Department of Human Services using required
4635+13 admission forms. Effective September 1, 2014, admission
4636+14 documents, including all prescreening information, must be
4637+15 submitted through MEDI or REV. Confirmation numbers assigned
4638+16 to an accepted transaction shall be retained by a facility to
4639+17 verify timely submittal. Once an admission transaction has
4640+18 been completed, all resubmitted claims following prior
4641+19 rejection are subject to receipt no later than 180 days after
4642+20 the admission transaction has been completed.
4643+21 Claims that are not submitted and received in compliance
4644+22 with the foregoing requirements shall not be eligible for
4645+23 payment under the medical assistance program, and the State
4646+24 shall have no liability for payment of those claims.
4647+25 To the extent consistent with applicable information and
4648+26 privacy, security, and disclosure laws, State and federal
4649+
4650+
4651+
4652+
4653+
4654+ SB3268 Enrolled - 131 - LRB103 39338 KTG 69500 b
4655+
4656+
4657+SB3268 Enrolled- 132 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 132 - LRB103 39338 KTG 69500 b
4658+ SB3268 Enrolled - 132 - LRB103 39338 KTG 69500 b
4659+1 agencies and departments shall provide the Illinois Department
4660+2 access to confidential and other information and data
4661+3 necessary to perform eligibility and payment verifications and
4662+4 other Illinois Department functions. This includes, but is not
4663+5 limited to: information pertaining to licensure;
4664+6 certification; earnings; immigration status; citizenship; wage
4665+7 reporting; unearned and earned income; pension income;
4666+8 employment; supplemental security income; social security
4667+9 numbers; National Provider Identifier (NPI) numbers; the
4668+10 National Practitioner Data Bank (NPDB); program and agency
4669+11 exclusions; taxpayer identification numbers; tax delinquency;
4670+12 corporate information; and death records.
4671+13 The Illinois Department shall enter into agreements with
4672+14 State agencies and departments, and is authorized to enter
4673+15 into agreements with federal agencies and departments, under
4674+16 which such agencies and departments shall share data necessary
4675+17 for medical assistance program integrity functions and
4676+18 oversight. The Illinois Department shall develop, in
4677+19 cooperation with other State departments and agencies, and in
4678+20 compliance with applicable federal laws and regulations,
4679+21 appropriate and effective methods to share such data. At a
4680+22 minimum, and to the extent necessary to provide data sharing,
4681+23 the Illinois Department shall enter into agreements with State
4682+24 agencies and departments, and is authorized to enter into
4683+25 agreements with federal agencies and departments, including,
4684+26 but not limited to: the Secretary of State; the Department of
4685+
4686+
4687+
4688+
4689+
4690+ SB3268 Enrolled - 132 - LRB103 39338 KTG 69500 b
4691+
4692+
4693+SB3268 Enrolled- 133 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 133 - LRB103 39338 KTG 69500 b
4694+ SB3268 Enrolled - 133 - LRB103 39338 KTG 69500 b
4695+1 Revenue; the Department of Public Health; the Department of
4696+2 Human Services; and the Department of Financial and
4697+3 Professional Regulation.
4698+4 Beginning in fiscal year 2013, the Illinois Department
4699+5 shall set forth a request for information to identify the
4700+6 benefits of a pre-payment, post-adjudication, and post-edit
4701+7 claims system with the goals of streamlining claims processing
4702+8 and provider reimbursement, reducing the number of pending or
4703+9 rejected claims, and helping to ensure a more transparent
4704+10 adjudication process through the utilization of: (i) provider
4705+11 data verification and provider screening technology; and (ii)
4706+12 clinical code editing; and (iii) pre-pay, pre-adjudicated, or
4707+13 post-adjudicated predictive modeling with an integrated case
4708+14 management system with link analysis. Such a request for
4709+15 information shall not be considered as a request for proposal
4710+16 or as an obligation on the part of the Illinois Department to
4711+17 take any action or acquire any products or services.
4712+18 The Illinois Department shall establish policies,
4713+19 procedures, standards and criteria by rule for the
4714+20 acquisition, repair and replacement of orthotic and prosthetic
4715+21 devices and durable medical equipment. Such rules shall
4716+22 provide, but not be limited to, the following services: (1)
4717+23 immediate repair or replacement of such devices by recipients;
4718+24 and (2) rental, lease, purchase or lease-purchase of durable
4719+25 medical equipment in a cost-effective manner, taking into
4720+26 consideration the recipient's medical prognosis, the extent of
4721+
4722+
4723+
4724+
4725+
4726+ SB3268 Enrolled - 133 - LRB103 39338 KTG 69500 b
4727+
4728+
4729+SB3268 Enrolled- 134 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 134 - LRB103 39338 KTG 69500 b
4730+ SB3268 Enrolled - 134 - LRB103 39338 KTG 69500 b
4731+1 the recipient's needs, and the requirements and costs for
4732+2 maintaining such equipment. Subject to prior approval, such
4733+3 rules shall enable a recipient to temporarily acquire and use
4734+4 alternative or substitute devices or equipment pending repairs
4735+5 or replacements of any device or equipment previously
4736+6 authorized for such recipient by the Department.
4737+7 Notwithstanding any provision of Section 5-5f to the contrary,
4738+8 the Department may, by rule, exempt certain replacement
4739+9 wheelchair parts from prior approval and, for wheelchairs,
4740+10 wheelchair parts, wheelchair accessories, and related seating
4741+11 and positioning items, determine the wholesale price by
4742+12 methods other than actual acquisition costs.
4743+13 The Department shall require, by rule, all providers of
4744+14 durable medical equipment to be accredited by an accreditation
4745+15 organization approved by the federal Centers for Medicare and
4746+16 Medicaid Services and recognized by the Department in order to
4747+17 bill the Department for providing durable medical equipment to
4748+18 recipients. No later than 15 months after the effective date
4749+19 of the rule adopted pursuant to this paragraph, all providers
4750+20 must meet the accreditation requirement.
4751+21 In order to promote environmental responsibility, meet the
4752+22 needs of recipients and enrollees, and achieve significant
4753+23 cost savings, the Department, or a managed care organization
4754+24 under contract with the Department, may provide recipients or
4755+25 managed care enrollees who have a prescription or Certificate
4756+26 of Medical Necessity access to refurbished durable medical
4757+
4758+
4759+
4760+
4761+
4762+ SB3268 Enrolled - 134 - LRB103 39338 KTG 69500 b
4763+
4764+
4765+SB3268 Enrolled- 135 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 135 - LRB103 39338 KTG 69500 b
4766+ SB3268 Enrolled - 135 - LRB103 39338 KTG 69500 b
4767+1 equipment under this Section (excluding prosthetic and
4768+2 orthotic devices as defined in the Orthotics, Prosthetics, and
4769+3 Pedorthics Practice Act and complex rehabilitation technology
4770+4 products and associated services) through the State's
4771+5 assistive technology program's reutilization program, using
4772+6 staff with the Assistive Technology Professional (ATP)
4773+7 Certification if the refurbished durable medical equipment:
4774+8 (i) is available; (ii) is less expensive, including shipping
4775+9 costs, than new durable medical equipment of the same type;
4776+10 (iii) is able to withstand at least 3 years of use; (iv) is
4777+11 cleaned, disinfected, sterilized, and safe in accordance with
4778+12 federal Food and Drug Administration regulations and guidance
4779+13 governing the reprocessing of medical devices in health care
4780+14 settings; and (v) equally meets the needs of the recipient or
4781+15 enrollee. The reutilization program shall confirm that the
4782+16 recipient or enrollee is not already in receipt of the same or
4783+17 similar equipment from another service provider, and that the
4784+18 refurbished durable medical equipment equally meets the needs
4785+19 of the recipient or enrollee. Nothing in this paragraph shall
4786+20 be construed to limit recipient or enrollee choice to obtain
4787+21 new durable medical equipment or place any additional prior
4788+22 authorization conditions on enrollees of managed care
4789+23 organizations.
4790+24 The Department shall execute, relative to the nursing home
4791+25 prescreening project, written inter-agency agreements with the
4792+26 Department of Human Services and the Department on Aging, to
4793+
4794+
4795+
4796+
4797+
4798+ SB3268 Enrolled - 135 - LRB103 39338 KTG 69500 b
4799+
4800+
4801+SB3268 Enrolled- 136 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 136 - LRB103 39338 KTG 69500 b
4802+ SB3268 Enrolled - 136 - LRB103 39338 KTG 69500 b
4803+1 effect the following: (i) intake procedures and common
4804+2 eligibility criteria for those persons who are receiving
4805+3 non-institutional services; and (ii) the establishment and
4806+4 development of non-institutional services in areas of the
4807+5 State where they are not currently available or are
4808+6 undeveloped; and (iii) notwithstanding any other provision of
4809+7 law, subject to federal approval, on and after July 1, 2012, an
4810+8 increase in the determination of need (DON) scores from 29 to
4811+9 37 for applicants for institutional and home and
4812+10 community-based long term care; if and only if federal
4813+11 approval is not granted, the Department may, in conjunction
4814+12 with other affected agencies, implement utilization controls
4815+13 or changes in benefit packages to effectuate a similar savings
4816+14 amount for this population; and (iv) no later than July 1,
4817+15 2013, minimum level of care eligibility criteria for
4818+16 institutional and home and community-based long term care; and
4819+17 (v) no later than October 1, 2013, establish procedures to
4820+18 permit long term care providers access to eligibility scores
4821+19 for individuals with an admission date who are seeking or
4822+20 receiving services from the long term care provider. In order
4823+21 to select the minimum level of care eligibility criteria, the
4824+22 Governor shall establish a workgroup that includes affected
4825+23 agency representatives and stakeholders representing the
4826+24 institutional and home and community-based long term care
4827+25 interests. This Section shall not restrict the Department from
4828+26 implementing lower level of care eligibility criteria for
4829+
4830+
4831+
4832+
4833+
4834+ SB3268 Enrolled - 136 - LRB103 39338 KTG 69500 b
4835+
4836+
4837+SB3268 Enrolled- 137 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 137 - LRB103 39338 KTG 69500 b
4838+ SB3268 Enrolled - 137 - LRB103 39338 KTG 69500 b
4839+1 community-based services in circumstances where federal
4840+2 approval has been granted.
4841+3 The Illinois Department shall develop and operate, in
4842+4 cooperation with other State Departments and agencies and in
4843+5 compliance with applicable federal laws and regulations,
4844+6 appropriate and effective systems of health care evaluation
4845+7 and programs for monitoring of utilization of health care
4846+8 services and facilities, as it affects persons eligible for
4847+9 medical assistance under this Code.
4848+10 The Illinois Department shall report annually to the
4849+11 General Assembly, no later than the second Friday in April of
4850+12 1979 and each year thereafter, in regard to:
4851+13 (a) actual statistics and trends in utilization of
4852+14 medical services by public aid recipients;
4853+15 (b) actual statistics and trends in the provision of
4854+16 the various medical services by medical vendors;
4855+17 (c) current rate structures and proposed changes in
4856+18 those rate structures for the various medical vendors; and
4857+19 (d) efforts at utilization review and control by the
4858+20 Illinois Department.
4859+21 The period covered by each report shall be the 3 years
4860+22 ending on the June 30 prior to the report. The report shall
4861+23 include suggested legislation for consideration by the General
4862+24 Assembly. The requirement for reporting to the General
4863+25 Assembly shall be satisfied by filing copies of the report as
4864+26 required by Section 3.1 of the General Assembly Organization
4865+
4866+
4867+
4868+
4869+
4870+ SB3268 Enrolled - 137 - LRB103 39338 KTG 69500 b
4871+
4872+
4873+SB3268 Enrolled- 138 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 138 - LRB103 39338 KTG 69500 b
4874+ SB3268 Enrolled - 138 - LRB103 39338 KTG 69500 b
4875+1 Act, and filing such additional copies with the State
4876+2 Government Report Distribution Center for the General Assembly
4877+3 as is required under paragraph (t) of Section 7 of the State
4878+4 Library Act.
4879+5 Rulemaking authority to implement Public Act 95-1045, if
4880+6 any, is conditioned on the rules being adopted in accordance
4881+7 with all provisions of the Illinois Administrative Procedure
4882+8 Act and all rules and procedures of the Joint Committee on
4883+9 Administrative Rules; any purported rule not so adopted, for
4884+10 whatever reason, is unauthorized.
4885+11 On and after July 1, 2012, the Department shall reduce any
4886+12 rate of reimbursement for services or other payments or alter
4887+13 any methodologies authorized by this Code to reduce any rate
4888+14 of reimbursement for services or other payments in accordance
4889+15 with Section 5-5e.
4890+16 Because kidney transplantation can be an appropriate,
4891+17 cost-effective alternative to renal dialysis when medically
4892+18 necessary and notwithstanding the provisions of Section 1-11
4893+19 of this Code, beginning October 1, 2014, the Department shall
4894+20 cover kidney transplantation for noncitizens with end-stage
4895+21 renal disease who are not eligible for comprehensive medical
4896+22 benefits, who meet the residency requirements of Section 5-3
4897+23 of this Code, and who would otherwise meet the financial
4898+24 requirements of the appropriate class of eligible persons
4899+25 under Section 5-2 of this Code. To qualify for coverage of
4900+26 kidney transplantation, such person must be receiving
4901+
4902+
4903+
4904+
4905+
4906+ SB3268 Enrolled - 138 - LRB103 39338 KTG 69500 b
4907+
4908+
4909+SB3268 Enrolled- 139 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 139 - LRB103 39338 KTG 69500 b
4910+ SB3268 Enrolled - 139 - LRB103 39338 KTG 69500 b
4911+1 emergency renal dialysis services covered by the Department.
4912+2 Providers under this Section shall be prior approved and
4913+3 certified by the Department to perform kidney transplantation
4914+4 and the services under this Section shall be limited to
4915+5 services associated with kidney transplantation.
4916+6 Notwithstanding any other provision of this Code to the
4917+7 contrary, on or after July 1, 2015, all FDA approved forms of
4918+8 medication assisted treatment prescribed for the treatment of
4919+9 alcohol dependence or treatment of opioid dependence shall be
4920+10 covered under both fee-for-service fee for service and managed
4921+11 care medical assistance programs for persons who are otherwise
4922+12 eligible for medical assistance under this Article and shall
4923+13 not be subject to any (1) utilization control, other than
4924+14 those established under the American Society of Addiction
4925+15 Medicine patient placement criteria, (2) prior authorization
4926+16 mandate, or (3) lifetime restriction limit mandate.
4927+17 On or after July 1, 2015, opioid antagonists prescribed
4928+18 for the treatment of an opioid overdose, including the
4929+19 medication product, administration devices, and any pharmacy
4930+20 fees or hospital fees related to the dispensing, distribution,
4931+21 and administration of the opioid antagonist, shall be covered
4932+22 under the medical assistance program for persons who are
4933+23 otherwise eligible for medical assistance under this Article.
4934+24 As used in this Section, "opioid antagonist" means a drug that
4935+25 binds to opioid receptors and blocks or inhibits the effect of
4936+26 opioids acting on those receptors, including, but not limited
4937+
4938+
4939+
4940+
4941+
4942+ SB3268 Enrolled - 139 - LRB103 39338 KTG 69500 b
4943+
4944+
4945+SB3268 Enrolled- 140 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 140 - LRB103 39338 KTG 69500 b
4946+ SB3268 Enrolled - 140 - LRB103 39338 KTG 69500 b
4947+1 to, naloxone hydrochloride or any other similarly acting drug
4948+2 approved by the U.S. Food and Drug Administration. The
4949+3 Department shall not impose a copayment on the coverage
4950+4 provided for naloxone hydrochloride under the medical
4951+5 assistance program.
4952+6 Upon federal approval, the Department shall provide
4953+7 coverage and reimbursement for all drugs that are approved for
4954+8 marketing by the federal Food and Drug Administration and that
4955+9 are recommended by the federal Public Health Service or the
4956+10 United States Centers for Disease Control and Prevention for
4957+11 pre-exposure prophylaxis and related pre-exposure prophylaxis
4958+12 services, including, but not limited to, HIV and sexually
4959+13 transmitted infection screening, treatment for sexually
4960+14 transmitted infections, medical monitoring, assorted labs, and
4961+15 counseling to reduce the likelihood of HIV infection among
4962+16 individuals who are not infected with HIV but who are at high
4963+17 risk of HIV infection.
4964+18 A federally qualified health center, as defined in Section
4965+19 1905(l)(2)(B) of the federal Social Security Act, shall be
4966+20 reimbursed by the Department in accordance with the federally
4967+21 qualified health center's encounter rate for services provided
4968+22 to medical assistance recipients that are performed by a
4969+23 dental hygienist, as defined under the Illinois Dental
4970+24 Practice Act, working under the general supervision of a
4971+25 dentist and employed by a federally qualified health center.
4972+26 Within 90 days after October 8, 2021 (the effective date
4973+
4974+
4975+
4976+
4977+
4978+ SB3268 Enrolled - 140 - LRB103 39338 KTG 69500 b
4979+
4980+
4981+SB3268 Enrolled- 141 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 141 - LRB103 39338 KTG 69500 b
4982+ SB3268 Enrolled - 141 - LRB103 39338 KTG 69500 b
4983+1 of Public Act 102-665), the Department shall seek federal
4984+2 approval of a State Plan amendment to expand coverage for
4985+3 family planning services that includes presumptive eligibility
4986+4 to individuals whose income is at or below 208% of the federal
4987+5 poverty level. Coverage under this Section shall be effective
4988+6 beginning no later than December 1, 2022.
4989+7 Subject to approval by the federal Centers for Medicare
4990+8 and Medicaid Services of a Title XIX State Plan amendment
4991+9 electing the Program of All-Inclusive Care for the Elderly
4992+10 (PACE) as a State Medicaid option, as provided for by Subtitle
4993+11 I (commencing with Section 4801) of Title IV of the Balanced
4994+12 Budget Act of 1997 (Public Law 105-33) and Part 460
4995+13 (commencing with Section 460.2) of Subchapter E of Title 42 of
4996+14 the Code of Federal Regulations, PACE program services shall
4997+15 become a covered benefit of the medical assistance program,
4998+16 subject to criteria established in accordance with all
4999+17 applicable laws.
5000+18 Notwithstanding any other provision of this Code,
5001+19 community-based pediatric palliative care from a trained
5002+20 interdisciplinary team shall be covered under the medical
5003+21 assistance program as provided in Section 15 of the Pediatric
5004+22 Palliative Care Act.
5005+23 Notwithstanding any other provision of this Code, within
5006+24 12 months after June 2, 2022 (the effective date of Public Act
5007+25 102-1037) and subject to federal approval, acupuncture
5008+26 services performed by an acupuncturist licensed under the
5009+
5010+
5011+
5012+
5013+
5014+ SB3268 Enrolled - 141 - LRB103 39338 KTG 69500 b
5015+
5016+
5017+SB3268 Enrolled- 142 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 142 - LRB103 39338 KTG 69500 b
5018+ SB3268 Enrolled - 142 - LRB103 39338 KTG 69500 b
5019+1 Acupuncture Practice Act who is acting within the scope of his
5020+2 or her license shall be covered under the medical assistance
5021+3 program. The Department shall apply for any federal waiver or
5022+4 State Plan amendment, if required, to implement this
5023+5 paragraph. The Department may adopt any rules, including
5024+6 standards and criteria, necessary to implement this paragraph.
5025+7 Notwithstanding any other provision of this Code, the
5026+8 medical assistance program shall, subject to appropriation and
5027+9 federal approval, reimburse hospitals for costs associated
5028+10 with a newborn screening test for the presence of
5029+11 metachromatic leukodystrophy, as required under the Newborn
5030+12 Metabolic Screening Act, at a rate not less than the fee
5031+13 charged by the Department of Public Health. The Department
5032+14 shall seek federal approval before the implementation of the
5033+15 newborn screening test fees by the Department of Public
5034+16 Health.
5035+17 Notwithstanding any other provision of this Code,
5036+18 beginning on January 1, 2024, subject to federal approval,
5037+19 cognitive assessment and care planning services provided to a
5038+20 person who experiences signs or symptoms of cognitive
5039+21 impairment, as defined by the Diagnostic and Statistical
5040+22 Manual of Mental Disorders, Fifth Edition, shall be covered
5041+23 under the medical assistance program for persons who are
5042+24 otherwise eligible for medical assistance under this Article.
5043+25 Notwithstanding any other provision of this Code,
5044+26 medically necessary reconstructive services that are intended
5045+
5046+
5047+
5048+
5049+
5050+ SB3268 Enrolled - 142 - LRB103 39338 KTG 69500 b
5051+
5052+
5053+SB3268 Enrolled- 143 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 143 - LRB103 39338 KTG 69500 b
5054+ SB3268 Enrolled - 143 - LRB103 39338 KTG 69500 b
5055+1 to restore physical appearance shall be covered under the
5056+2 medical assistance program for persons who are otherwise
5057+3 eligible for medical assistance under this Article. As used in
5058+4 this paragraph, "reconstructive services" means treatments
5059+5 performed on structures of the body damaged by trauma to
5060+6 restore physical appearance.
5061+7 (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
5062+8 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
5063+9 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
5064+10 eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
5065+11 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
5066+12 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
5067+13 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
5068+14 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
5069+15 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
5070+16 1-1-24; revised 12-15-23.)
5071+17 ARTICLE 95.
5072+18 Section 95-5. The Specialized Mental Health Rehabilitation
5073+19 Act of 2013 is amended by changing Section 5-107 as follows:
5074+20 (210 ILCS 49/5-107)
5075+21 Sec. 5-107. Quality of life enhancement. Beginning on July
5076+22 1, 2019, for improving the quality of life and the quality of
5077+23 care, an additional payment shall be awarded to a facility for
5078+
5079+
5080+
5081+
5082+
5083+ SB3268 Enrolled - 143 - LRB103 39338 KTG 69500 b
5084+
5085+
5086+SB3268 Enrolled- 144 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 144 - LRB103 39338 KTG 69500 b
5087+ SB3268 Enrolled - 144 - LRB103 39338 KTG 69500 b
5088+1 their single occupancy rooms. This payment shall be in
5089+2 addition to the rate for recovery and rehabilitation. The
5090+3 additional rate for single room occupancy shall be no less
5091+4 than $10 per day, per single room occupancy. The Department of
5092+5 Healthcare and Family Services shall adjust payment to
5093+6 Medicaid managed care entities to cover these costs. Beginning
5094+7 July 1, 2022, for improving the quality of life and the quality
5095+8 of care, a payment of no less than $5 per day, per single room
5096+9 occupancy shall be added to the existing $10 additional per
5097+10 day, per single room occupancy rate for a total of at least $15
5098+11 per day, per single room occupancy. For improving the quality
5099+12 of life and the quality of care, on January 1, 2024, a payment
5100+13 of no less than $10.50 per day, per single room occupancy shall
5101+14 be added to the existing $15 additional per day, per single
5102+15 room occupancy rate for a total of at least $25.50 per day, per
5103+16 single room occupancy. For improving the quality of life and
5104+17 the quality of care, beginning on January 1, 2025, a payment of
5105+18 no less than $10 per day, per single room occupancy shall be
5106+19 added to the existing $25.50 additional per day, per single
5107+20 room occupancy rate for a total of at least $35.50 per day, per
5108+21 single room occupancy. Beginning July 1, 2022, for improving
5109+22 the quality of life and the quality of care, an additional
5110+23 payment shall be awarded to a facility for its dual-occupancy
5111+24 rooms. This payment shall be in addition to the rate for
5112+25 recovery and rehabilitation. The additional rate for
5113+26 dual-occupancy rooms shall be no less than $10 per day, per
5114+
5115+
5116+
5117+
5118+
5119+ SB3268 Enrolled - 144 - LRB103 39338 KTG 69500 b
5120+
5121+
5122+SB3268 Enrolled- 145 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 145 - LRB103 39338 KTG 69500 b
5123+ SB3268 Enrolled - 145 - LRB103 39338 KTG 69500 b
5124+1 Medicaid-occupied bed, in each dual-occupancy room. Beginning
5125+2 January 1, 2024, for improving the quality of life and the
5126+3 quality of care, a payment of no less than $4.50 per day, per
5127+4 dual-occupancy room shall be added to the existing $10
5128+5 additional per day, per dual-occupancy room rate for a total
5129+6 of at least $14.50, per Medicaid-occupied bed, in each
5130+7 dual-occupancy room. Beginning January 1, 2025, for improving
5131+8 the quality of life and the quality of care, a payment of no
5132+9 less than $8.75 per day, per dual-occupancy room shall be
5133+10 added to the existing $14.50 additional per day, per
5134+11 dual-occupancy room rate for a total of at least $23.25, per
5135+12 Medicaid-occupied bed, in each dual-occupancy room. The
5136+13 Department of Healthcare and Family Services shall adjust
5137+14 payment to Medicaid managed care entities to cover these
5138+15 costs. As used in this Section, "dual-occupancy room" means a
5139+16 room that contains 2 resident beds.
5140+17 (Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24.)
5141+18 ARTICLE 100.
5142+19 Section 100-5. The Illinois Public Aid Code is amended by
5143+20 changing Section 5-5.01a as follows:
5144+21 (305 ILCS 5/5-5.01a)
5145+22 Sec. 5-5.01a. Supportive living facilities program.
5146+23 (a) The Department shall establish and provide oversight
5147+
5148+
5149+
5150+
5151+
5152+ SB3268 Enrolled - 145 - LRB103 39338 KTG 69500 b
5153+
5154+
5155+SB3268 Enrolled- 146 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 146 - LRB103 39338 KTG 69500 b
5156+ SB3268 Enrolled - 146 - LRB103 39338 KTG 69500 b
5157+1 for a program of supportive living facilities that seek to
5158+2 promote resident independence, dignity, respect, and
5159+3 well-being in the most cost-effective manner.
5160+4 A supportive living facility is (i) a free-standing
5161+5 facility or (ii) a distinct physical and operational entity
5162+6 within a mixed-use building that meets the criteria
5163+7 established in subsection (d). A supportive living facility
5164+8 integrates housing with health, personal care, and supportive
5165+9 services and is a designated setting that offers residents
5166+10 their own separate, private, and distinct living units.
5167+11 Sites for the operation of the program shall be selected
5168+12 by the Department based upon criteria that may include the
5169+13 need for services in a geographic area, the availability of
5170+14 funding, and the site's ability to meet the standards.
5171+15 (b) Beginning July 1, 2014, subject to federal approval,
5172+16 the Medicaid rates for supportive living facilities shall be
5173+17 equal to the supportive living facility Medicaid rate
5174+18 effective on June 30, 2014 increased by 8.85%. Once the
5175+19 assessment imposed at Article V-G of this Code is determined
5176+20 to be a permissible tax under Title XIX of the Social Security
5177+21 Act, the Department shall increase the Medicaid rates for
5178+22 supportive living facilities effective on July 1, 2014 by
5179+23 9.09%. The Department shall apply this increase retroactively
5180+24 to coincide with the imposition of the assessment in Article
5181+25 V-G of this Code in accordance with the approval for federal
5182+26 financial participation by the Centers for Medicare and
5183+
5184+
5185+
5186+
5187+
5188+ SB3268 Enrolled - 146 - LRB103 39338 KTG 69500 b
5189+
5190+
5191+SB3268 Enrolled- 147 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 147 - LRB103 39338 KTG 69500 b
5192+ SB3268 Enrolled - 147 - LRB103 39338 KTG 69500 b
5193+1 Medicaid Services.
5194+2 The Medicaid rates for supportive living facilities
5195+3 effective on July 1, 2017 must be equal to the rates in effect
5196+4 for supportive living facilities on June 30, 2017 increased by
5197+5 2.8%.
5198+6 The Medicaid rates for supportive living facilities
5199+7 effective on July 1, 2018 must be equal to the rates in effect
5200+8 for supportive living facilities on June 30, 2018.
5201+9 Subject to federal approval, the Medicaid rates for
5202+10 supportive living services on and after July 1, 2019 must be at
5203+11 least 54.3% of the average total nursing facility services per
5204+12 diem for the geographic areas defined by the Department while
5205+13 maintaining the rate differential for dementia care and must
5206+14 be updated whenever the total nursing facility service per
5207+15 diems are updated. Beginning July 1, 2022, upon the
5208+16 implementation of the Patient Driven Payment Model, Medicaid
5209+17 rates for supportive living services must be at least 54.3% of
5210+18 the average total nursing services per diem rate for the
5211+19 geographic areas. For purposes of this provision, the average
5212+20 total nursing services per diem rate shall include all add-ons
5213+21 for nursing facilities for the geographic area provided for in
5214+22 Section 5-5.2. The rate differential for dementia care must be
5215+23 maintained in these rates and the rates shall be updated
5216+24 whenever nursing facility per diem rates are updated.
5217+25 Subject to federal approval, beginning January 1, 2024,
5218+26 the dementia care rate for supportive living services must be
5219+
5220+
5221+
5222+
5223+
5224+ SB3268 Enrolled - 147 - LRB103 39338 KTG 69500 b
5225+
5226+
5227+SB3268 Enrolled- 148 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 148 - LRB103 39338 KTG 69500 b
5228+ SB3268 Enrolled - 148 - LRB103 39338 KTG 69500 b
5229+1 no less than the non-dementia care supportive living services
5230+2 rate multiplied by 1.5.
5231+3 (c) The Department may adopt rules to implement this
5232+4 Section. Rules that establish or modify the services,
5233+5 standards, and conditions for participation in the program
5234+6 shall be adopted by the Department in consultation with the
5235+7 Department on Aging, the Department of Rehabilitation
5236+8 Services, and the Department of Mental Health and
5237+9 Developmental Disabilities (or their successor agencies).
5238+10 (d) Subject to federal approval by the Centers for
5239+11 Medicare and Medicaid Services, the Department shall accept
5240+12 for consideration of certification under the program any
5241+13 application for a site or building where distinct parts of the
5242+14 site or building are designated for purposes other than the
5243+15 provision of supportive living services, but only if:
5244+16 (1) those distinct parts of the site or building are
5245+17 not designated for the purpose of providing assisted
5246+18 living services as required under the Assisted Living and
5247+19 Shared Housing Act;
5248+20 (2) those distinct parts of the site or building are
5249+21 completely separate from the part of the building used for
5250+22 the provision of supportive living program services,
5251+23 including separate entrances;
5252+24 (3) those distinct parts of the site or building do
5253+25 not share any common spaces with the part of the building
5254+26 used for the provision of supportive living program
5255+
5256+
5257+
5258+
5259+
5260+ SB3268 Enrolled - 148 - LRB103 39338 KTG 69500 b
5261+
5262+
5263+SB3268 Enrolled- 149 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 149 - LRB103 39338 KTG 69500 b
5264+ SB3268 Enrolled - 149 - LRB103 39338 KTG 69500 b
5265+1 services; and
5266+2 (4) those distinct parts of the site or building do
5267+3 not share staffing with the part of the building used for
5268+4 the provision of supportive living program services.
5269+5 (e) Facilities or distinct parts of facilities which are
5270+6 selected as supportive living facilities and are in good
5271+7 standing with the Department's rules are exempt from the
5272+8 provisions of the Nursing Home Care Act and the Illinois
5273+9 Health Facilities Planning Act.
5274+10 (f) Section 9817 of the American Rescue Plan Act of 2021
5275+11 (Public Law 117-2) authorizes a 10% enhanced federal medical
5276+12 assistance percentage for supportive living services for a
5277+13 12-month period from April 1, 2021 through March 31, 2022.
5278+14 Subject to federal approval, including the approval of any
5279+15 necessary waiver amendments or other federally required
5280+16 documents or assurances, for a 12-month period the Department
5281+17 must pay a supplemental $26 per diem rate to all supportive
5282+18 living facilities with the additional federal financial
5283+19 participation funds that result from the enhanced federal
5284+20 medical assistance percentage from April 1, 2021 through March
5285+21 31, 2022. The Department may issue parameters around how the
5286+22 supplemental payment should be spent, including quality
5287+23 improvement activities. The Department may alter the form,
5288+24 methods, or timeframes concerning the supplemental per diem
5289+25 rate to comply with any subsequent changes to federal law,
5290+26 changes made by guidance issued by the federal Centers for
5291+
5292+
5293+
5294+
5295+
5296+ SB3268 Enrolled - 149 - LRB103 39338 KTG 69500 b
5297+
5298+
5299+SB3268 Enrolled- 150 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 150 - LRB103 39338 KTG 69500 b
5300+ SB3268 Enrolled - 150 - LRB103 39338 KTG 69500 b
5301+1 Medicare and Medicaid Services, or other changes necessary to
5302+2 receive the enhanced federal medical assistance percentage.
5303+3 (g) All applications for the expansion of supportive
5304+4 living dementia care settings involving sites not approved by
5305+5 the Department by January 1, 2024 on the effective date of this
5306+6 amendatory Act of the 103rd General Assembly may allow new
5307+7 elderly non-dementia units in addition to new dementia care
5308+8 units. The Department may approve such applications only if
5309+9 the application has: (1) no more than one non-dementia care
5310+10 unit for each dementia care unit and (2) the site is not
5311+11 located within 4 miles of an existing supportive living
5312+12 program site in Cook County (including the City of Chicago),
5313+13 not located within 12 miles of an existing supportive living
5314+14 program site in Alexander, Bond, Boone, Calhoun, Champaign,
5315+15 Clinton, DeKalb, DuPage Fulton, Grundy, Henry, Jackson,
5316+16 Jersey, Johnson, Kane, Kankakee, Kendall, Lake, Macon,
5317+17 Macoupin, Madison, Marshall, McHenry, McLean, Menard, Mercer,
5318+18 Monroe, Peoria, Piatt, Rock Island, Sangamon, Stark, St.
5319+19 Clair, Tazewell, Vermilion, Will, Williamson, Winnebago, or
5320+20 Woodford counties County, Kane County, Lake County, McHenry
5321+21 County, or Will County, or not located within 25 miles of an
5322+22 existing supportive living program site in any other county.
5323+23 (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
5324+24 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
5325+25 Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)
5326+
5327+
5328+
5329+
5330+
5331+ SB3268 Enrolled - 150 - LRB103 39338 KTG 69500 b
5332+
5333+
5334+SB3268 Enrolled- 151 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 151 - LRB103 39338 KTG 69500 b
5335+ SB3268 Enrolled - 151 - LRB103 39338 KTG 69500 b
5336+1 ARTICLE 105.
5337+2 Section 105-5. The Illinois Public Aid Code is amended by
5338+3 changing Section 5-36 as follows:
5339+4 (305 ILCS 5/5-36)
5340+5 Sec. 5-36. Pharmacy benefits.
5341+6 (a)(1) The Department may enter into a contract with a
5342+7 third party on a fee-for-service reimbursement model for the
5343+8 purpose of administering pharmacy benefits as provided in this
5344+9 Section for members not enrolled in a Medicaid managed care
5345+10 organization; however, these services shall be approved by the
5346+11 Department. The Department shall ensure coordination of care
5347+12 between the third-party administrator and managed care
5348+13 organizations as a consideration in any contracts established
5349+14 in accordance with this Section. Any managed care techniques,
5350+15 principles, or administration of benefits utilized in
5351+16 accordance with this subsection shall comply with State law.
5352+17 (2) The following shall apply to contracts between
5353+18 entities contracting relating to the Department's third-party
5354+19 administrators and pharmacies:
5355+20 (A) the Department shall approve any contract between
5356+21 a third-party administrator and a pharmacy;
5357+22 (B) the Department's third-party administrator shall
5358+23 not change the terms of a contract between a third-party
5359+24 administrator and a pharmacy without written approval by
5360+
5361+
5362+
5363+
5364+
5365+ SB3268 Enrolled - 151 - LRB103 39338 KTG 69500 b
5366+
5367+
5368+SB3268 Enrolled- 152 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 152 - LRB103 39338 KTG 69500 b
5369+ SB3268 Enrolled - 152 - LRB103 39338 KTG 69500 b
5370+1 the Department; and
5371+2 (C) the Department's third-party administrator shall
5372+3 not create, modify, implement, or indirectly establish any
5373+4 fee on a pharmacy, pharmacist, or a recipient of medical
5374+5 assistance without written approval by the Department.
5375+6 (b) The provisions of this Section shall not apply to
5376+7 outpatient pharmacy services provided by a health care
5377+8 facility registered as a covered entity pursuant to 42 U.S.C.
5378+9 256b or any pharmacy owned by or contracted with the covered
5379+10 entity. A Medicaid managed care organization shall, either
5380+11 directly or through a pharmacy benefit manager, administer and
5381+12 reimburse outpatient pharmacy claims submitted by a health
5382+13 care facility registered as a covered entity pursuant to 42
5383+14 U.S.C. 256b, its owned pharmacies, and contracted pharmacies
5384+15 in accordance with the contractual agreements the Medicaid
5385+16 managed care organization or its pharmacy benefit manager has
5386+17 with such facilities and pharmacies and in accordance with
5387+18 subsection (h-5).
5388+19 (b-5) Any pharmacy benefit manager that contracts with a
5389+20 Medicaid managed care organization to administer and reimburse
5390+21 pharmacy claims as provided in this Section must be registered
5391+22 with the Director of Insurance in accordance with Section
5392+23 513b2 of the Illinois Insurance Code.
5393+24 (c) On at least an annual basis, the Director of the
5394+25 Department of Healthcare and Family Services shall submit a
5395+26 report beginning no later than one year after January 1, 2020
5396+
5397+
5398+
5399+
5400+
5401+ SB3268 Enrolled - 152 - LRB103 39338 KTG 69500 b
5402+
5403+
5404+SB3268 Enrolled- 153 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 153 - LRB103 39338 KTG 69500 b
5405+ SB3268 Enrolled - 153 - LRB103 39338 KTG 69500 b
5406+1 (the effective date of Public Act 101-452) that provides an
5407+2 update on any contract, contract issues, formulary, dispensing
5408+3 fees, and maximum allowable cost concerns regarding a
5409+4 third-party administrator and managed care. The requirement
5410+5 for reporting to the General Assembly shall be satisfied by
5411+6 filing copies of the report with the Speaker, the Minority
5412+7 Leader, and the Clerk of the House of Representatives and with
5413+8 the President, the Minority Leader, and the Secretary of the
5414+9 Senate. The Department shall take care that no proprietary
5415+10 information is included in the report required under this
5416+11 Section.
5417+12 (d) A pharmacy benefit manager shall notify the Department
5418+13 in writing of any activity, policy, or practice of the
5419+14 pharmacy benefit manager that directly or indirectly presents
5420+15 a conflict of interest that interferes with the discharge of
5421+16 the pharmacy benefit manager's duty to a managed care
5422+17 organization to exercise its contractual duties. "Conflict of
5423+18 interest" shall be defined by rule by the Department.
5424+19 (e) A pharmacy benefit manager shall, upon request,
5425+20 disclose to the Department the following information:
5426+21 (1) whether the pharmacy benefit manager has a
5427+22 contract, agreement, or other arrangement with a
5428+23 pharmaceutical manufacturer to exclusively dispense or
5429+24 provide a drug to a managed care organization's enrollees,
5430+25 and the aggregate amounts of consideration of economic
5431+26 benefits collected or received pursuant to that
5432+
5433+
5434+
5435+
5436+
5437+ SB3268 Enrolled - 153 - LRB103 39338 KTG 69500 b
5438+
5439+
5440+SB3268 Enrolled- 154 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 154 - LRB103 39338 KTG 69500 b
5441+ SB3268 Enrolled - 154 - LRB103 39338 KTG 69500 b
5442+1 arrangement;
5443+2 (2) the percentage of claims payments made by the
5444+3 pharmacy benefit manager to pharmacies owned, managed, or
5445+4 controlled by the pharmacy benefit manager or any of the
5446+5 pharmacy benefit manager's management companies, parent
5447+6 companies, subsidiary companies, or jointly held
5448+7 companies;
5449+8 (3) the aggregate amount of the fees or assessments
5450+9 imposed on, or collected from, pharmacy providers; and
5451+10 (4) the average annualized percentage of revenue
5452+11 collected by the pharmacy benefit manager as a result of
5453+12 each contract it has executed with a managed care
5454+13 organization contracted by the Department to provide
5455+14 medical assistance benefits which is not paid by the
5456+15 pharmacy benefit manager to pharmacy providers and
5457+16 pharmaceutical manufacturers or labelers or in order to
5458+17 perform administrative functions pursuant to its contracts
5459+18 with managed care organizations; .
5460+19 (5) the total number of prescriptions dispensed under
5461+20 each contract the pharmacy benefit manager has with a
5462+21 managed care organization (MCO) contracted by the
5463+22 Department to provide medical assistance benefits;
5464+23 (6) the aggregate wholesale acquisition cost for drugs
5465+24 that were dispensed to enrollees in each MCO with which
5466+25 the pharmacy benefit manager has a contract by any
5467+26 pharmacy owned, managed, or controlled by the pharmacy
5468+
5469+
5470+
5471+
5472+
5473+ SB3268 Enrolled - 154 - LRB103 39338 KTG 69500 b
5474+
5475+
5476+SB3268 Enrolled- 155 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 155 - LRB103 39338 KTG 69500 b
5477+ SB3268 Enrolled - 155 - LRB103 39338 KTG 69500 b
5478+1 benefit manager or any of the pharmacy benefit manager's
5479+2 management companies, parent companies, subsidiary
5480+3 companies, or jointly-held companies;
5481+4 (7) the aggregate amount of administrative fees that
5482+5 the pharmacy benefit manager received from all
5483+6 pharmaceutical manufacturers for prescriptions dispensed
5484+7 to MCO enrollees;
5485+8 (8) for each MCO with which the pharmacy benefit
5486+9 manager has a contract, the aggregate amount of payments
5487+10 received by the pharmacy benefit manager from the MCO;
5488+11 (9) for each MCO with which the pharmacy benefit
5489+12 manager has a contract, the aggregate amount of
5490+13 reimbursements the pharmacy benefit manager paid to
5491+14 contracting pharmacies; and
5492+15 (10) any other information considered necessary by the
5493+16 Department.
5494+17 (f) The information disclosed under subsection (e) shall
5495+18 include all retail, mail order, specialty, and compounded
5496+19 prescription products. All information made available to the
5497+20 Department under subsection (e) is confidential and not
5498+21 subject to disclosure under the Freedom of Information Act.
5499+22 All information made available to the Department under
5500+23 subsection (e) shall not be reported or distributed in any way
5501+24 that compromises its competitive, proprietary, or financial
5502+25 value. The information shall only be used by the Department to
5503+26 assess the contract, agreement, or other arrangements made
5504+
5505+
5506+
5507+
5508+
5509+ SB3268 Enrolled - 155 - LRB103 39338 KTG 69500 b
5510+
5511+
5512+SB3268 Enrolled- 156 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 156 - LRB103 39338 KTG 69500 b
5513+ SB3268 Enrolled - 156 - LRB103 39338 KTG 69500 b
5514+1 between a pharmacy benefit manager and a pharmacy provider,
5515+2 pharmaceutical manufacturer or labeler, managed care
5516+3 organization, or other entity, as applicable.
5517+4 (g) A pharmacy benefit manager shall disclose directly in
5518+5 writing to a pharmacy provider or pharmacy services
5519+6 administrative organization contracting with the pharmacy
5520+7 benefit manager of any material change to a contract provision
5521+8 that affects the terms of the reimbursement, the process for
5522+9 verifying benefits and eligibility, dispute resolution,
5523+10 procedures for verifying drugs included on the formulary, and
5524+11 contract termination at least 30 days prior to the date of the
5525+12 change to the provision. The terms of this subsection shall be
5526+13 deemed met if the pharmacy benefit manager posts the
5527+14 information on a website, viewable by the public. A pharmacy
5528+15 service administration organization shall notify all contract
5529+16 pharmacies of any material change, as described in this
5530+17 subsection, within 2 days of notification. As used in this
5531+18 Section, "pharmacy services administrative organization" means
5532+19 an entity operating within the State that contracts with
5533+20 independent pharmacies to conduct business on their behalf
5534+21 with third-party payers. A pharmacy services administrative
5535+22 organization may provide administrative services to pharmacies
5536+23 and negotiate and enter into contracts with third-party payers
5537+24 or pharmacy benefit managers on behalf of pharmacies.
5538+25 (h) A pharmacy benefit manager shall not include the
5539+26 following in a contract with a pharmacy provider:
5540+
5541+
5542+
5543+
5544+
5545+ SB3268 Enrolled - 156 - LRB103 39338 KTG 69500 b
5546+
5547+
5548+SB3268 Enrolled- 157 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 157 - LRB103 39338 KTG 69500 b
5549+ SB3268 Enrolled - 157 - LRB103 39338 KTG 69500 b
5550+1 (1) a provision prohibiting the provider from
5551+2 informing a patient of a less costly alternative to a
5552+3 prescribed medication; or
5553+4 (2) a provision that prohibits the provider from
5554+5 dispensing a particular amount of a prescribed medication,
5555+6 if the pharmacy benefit manager allows that amount to be
5556+7 dispensed through a pharmacy owned or controlled by the
5557+8 pharmacy benefit manager, unless the prescription drug is
5558+9 subject to restricted distribution by the United States
5559+10 Food and Drug Administration or requires special handling,
5560+11 provider coordination, or patient education that cannot be
5561+12 provided by a retail pharmacy.
5562+13 (h-5) Unless required by law, a Medicaid managed care
5563+14 organization or pharmacy benefit manager administering or
5564+15 managing benefits on behalf of a Medicaid managed care
5565+16 organization shall not refuse to contract with a 340B entity
5566+17 or 340B pharmacy for refusing to accept less favorable payment
5567+18 terms or reimbursement methodologies when compared to
5568+19 similarly situated non-340B entities and shall not include in
5569+20 a contract with a 340B entity or 340B pharmacy a provision
5570+21 that:
5571+22 (1) imposes any fee, chargeback, or rate adjustment
5572+23 that is not similarly imposed on similarly situated
5573+24 pharmacies that are not 340B entities or 340B pharmacies;
5574+25 (2) imposes any fee, chargeback, or rate adjustment
5575+26 that exceeds the fee, chargeback, or rate adjustment that
5576+
5577+
5578+
5579+
5580+
5581+ SB3268 Enrolled - 157 - LRB103 39338 KTG 69500 b
5582+
5583+
5584+SB3268 Enrolled- 158 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 158 - LRB103 39338 KTG 69500 b
5585+ SB3268 Enrolled - 158 - LRB103 39338 KTG 69500 b
5586+1 is not similarly imposed on similarly situated pharmacies
5587+2 that are not 340B entities or 340B pharmacies;
5588+3 (3) prevents or interferes with an individual's choice
5589+4 to receive a prescription drug from a 340B entity or 340B
5590+5 pharmacy through any legally permissible means;
5591+6 (4) excludes a 340B entity or 340B pharmacy from a
5592+7 pharmacy network on the basis of whether the 340B entity
5593+8 or 340B pharmacy participates in the 340B drug discount
5594+9 program;
5595+10 (5) prevents a 340B entity or 340B pharmacy from using
5596+11 a drug purchased under the 340B drug discount program so
5597+12 long as the drug recipient is a patient of the 340B entity;
5598+13 nothing in this Section exempts a 340B pharmacy from
5599+14 following the Department's preferred drug list or from any
5600+15 prior approval requirements of the Department or the
5601+16 Medicaid managed care organization that are imposed on the
5602+17 drug for all pharmacies; or
5603+18 (6) any other provision that discriminates against a
5604+19 340B entity or 340B pharmacy by treating a 340B entity or
5605+20 340B pharmacy differently than non-340B entities or
5606+21 non-340B pharmacies for any reason relating to the
5607+22 entity's participation in the 340B drug discount program.
5608+23 A provision that violates this subsection in any contract
5609+24 between a Medicaid managed care organization or its pharmacy
5610+25 benefit manager and a 340B entity entered into, amended, or
5611+26 renewed after July 1, 2022 shall be void and unenforceable.
5612+
5613+
5614+
5615+
5616+
5617+ SB3268 Enrolled - 158 - LRB103 39338 KTG 69500 b
5618+
5619+
5620+SB3268 Enrolled- 159 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 159 - LRB103 39338 KTG 69500 b
5621+ SB3268 Enrolled - 159 - LRB103 39338 KTG 69500 b
5622+1 In this subsection (h-5):
5623+2 "340B entity" means a covered entity as defined in 42
5624+3 U.S.C. 256b(a)(4) authorized to participate in the 340B drug
5625+4 discount program.
5626+5 "340B pharmacy" means any pharmacy used to dispense 340B
5627+6 drugs for a covered entity, whether entity-owned or external.
5628+7 (i) Nothing in this Section shall be construed to prohibit
5629+8 a pharmacy benefit manager from requiring the same
5630+9 reimbursement and terms and conditions for a pharmacy provider
5631+10 as for a pharmacy owned, controlled, or otherwise associated
5632+11 with the pharmacy benefit manager.
5633+12 (j) A pharmacy benefit manager shall establish and
5634+13 implement a process for the resolution of disputes arising out
5635+14 of this Section, which shall be approved by the Department.
5636+15 (k) The Department shall adopt rules establishing
5637+16 reasonable dispensing fees for fee-for-service payments in
5638+17 accordance with guidance or guidelines from the federal
5639+18 Centers for Medicare and Medicaid Services.
5640+19 (Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21;
5641+20 102-778, eff. 7-1-22.)
5642+21 ARTICLE 110.
5643+22 Section 110-5. The Specialized Mental Health
5644+23 Rehabilitation Act of 2013 is amended by adding Section 5-113
5645+24 as follows:
5646+
5647+
5648+
5649+
5650+
5651+ SB3268 Enrolled - 159 - LRB103 39338 KTG 69500 b
5652+
5653+
5654+SB3268 Enrolled- 160 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 160 - LRB103 39338 KTG 69500 b
5655+ SB3268 Enrolled - 160 - LRB103 39338 KTG 69500 b
5656+1 (210 ILCS 49/5-113 new)
5657+2 Sec. 5-113. Specialized mental health rehabilitation
5658+3 facility; one payment. Notwithstanding any other provision of
5659+4 this Act to the contrary, beginning January 1, 2025, there
5660+5 shall be a separate per diem add-on paid solely and
5661+6 exclusively to facilities licensed under this Act that are
5662+7 licensed for only single occupancy rooms and have reduced
5663+8 their licensed capacity. No facility licensed under this Act
5664+9 shall be eligible for these payments if the facility contains
5665+10 any rooms that house more than a single occupant and have
5666+11 failed to reduce the facilities' licensed capacity.
5667+12 The payment shall be a per diem add-on payment. For
5668+13 facilities with less than 100 licensed beds, the add-on
5669+14 payment shall result in a rate not less than $240 per day. For
5670+15 facilities with 100 licensed beds to 130 licensed beds, the
5671+16 add-on payment shall result in a rate not less than $230 per
5672+17 day. For facilities with more than 130 licensed beds, the
5673+18 add-on payment shall result in a rate of not less than $220 per
5674+19 day. All add-on rates shall be based upon the new licensed
5675+20 capacity.
5676+21 Any additional payments in effect after January 1, 2025
5677+22 under Section 5-107 shall be paid in addition to the amounts
5678+23 listed in this Section. Facilities receiving payments under
5679+24 this Section shall receive payment as prescribed under Section
5680+25 5-101.
5681+
5682+
5683+
5684+
5685+
5686+ SB3268 Enrolled - 160 - LRB103 39338 KTG 69500 b
5687+
5688+
5689+SB3268 Enrolled- 161 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 161 - LRB103 39338 KTG 69500 b
5690+ SB3268 Enrolled - 161 - LRB103 39338 KTG 69500 b
5691+1 ARTICLE 115.
5692+2 Section 115-5. The Illinois Public Aid Code is amended by
5693+3 adding Section 5-53 as follows:
5694+4 (305 ILCS 5/5-53 new)
5695+5 Sec. 5-53. Coverage for self-measure blood pressure
5696+6 monitoring services. Subject to federal approval and
5697+7 notwithstanding any other provision of this Code, for services
5698+8 on and after January 1, 2025, the following self-measure blood
5699+9 pressure monitoring services shall be covered and reimbursed
5700+10 under the medical assistance program for persons who are
5701+11 otherwise eligible for medical assistance under this Article:
5702+12 (1) patient education and training services on the
5703+13 set-up and use of a self-measure blood pressure
5704+14 measurement device validated for clinical accuracy and
5705+15 device calibration; and
5706+16 (2) separate self-measurement readings and the
5707+17 collection of data reports by the patient or caregiver to
5708+18 the health care provider in order to communicate blood
5709+19 pressure readings and create or modify treatment plans.
5710+20 ARTICLE 120.
5711+21 (305 ILCS 5/15-6 rep.)
5712+
5713+
5714+
5715+
5716+
5717+ SB3268 Enrolled - 161 - LRB103 39338 KTG 69500 b
5718+
5719+
5720+SB3268 Enrolled- 162 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 162 - LRB103 39338 KTG 69500 b
5721+ SB3268 Enrolled - 162 - LRB103 39338 KTG 69500 b
5722+1 Section 120-5. The Illinois Public Aid Code is amended by
5723+2 repealing Section 15-6.
5724+3 Article 125.
5725+4 Section 125-5. The State Finance Act is amended by
5726+5 changing Section 5.797 as follows:
5727+6 (30 ILCS 105/5.797)
5728+7 Sec. 5.797. The Electronic Health Record Incentive Fund.
5729+8 This Section is repealed on January 1, 2025.
5730+9 (Source: P.A. 97-169, eff. 7-22-11; 97-813, eff. 7-13-12.)
5731+10 Section 125-10. The Illinois Public Aid Code is amended by
5732+11 changing Section 12-10.6a as follows:
5733+12 (305 ILCS 5/12-10.6a)
5734+13 Sec. 12-10.6a. The Electronic Health Record Incentive
5735+14 Fund.
5736+15 (a) The Electronic Health Record Incentive Fund is a
5737+16 special fund created in the State treasury. All federal moneys
5738+17 received by the Department of Healthcare and Family Services
5739+18 for payments to qualifying health care providers to encourage
5740+19 the adoption and use of certified electronic health records
5741+20 technology pursuant to paragraph 1903(t)(1) of the Social
5742+21 Security Act, shall be deposited into the Fund.
5743+
5744+
5745+
5746+
5747+
5748+ SB3268 Enrolled - 162 - LRB103 39338 KTG 69500 b
5749+
5750+
5751+SB3268 Enrolled- 163 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 163 - LRB103 39338 KTG 69500 b
5752+ SB3268 Enrolled - 163 - LRB103 39338 KTG 69500 b
5753+1 (b) Disbursements from the Fund shall be made at the
5754+2 direction of the Director of Healthcare and Family Services to
5755+3 qualifying health care providers, in amounts established under
5756+4 applicable federal regulation (42 CFR 495 et seq.), in order
5757+5 to encourage the adoption and use of certified electronic
5758+6 health records technology.
5759+7 (c) On January 1, 2025, or as soon thereafter as
5760+8 practical, the State Comptroller shall direct and the State
5761+9 Treasurer shall transfer the remaining balance from the
5762+10 Electronic Health Record Incentive Fund into the Public Aid
5763+11 Recoveries Trust Fund. Upon completion of the transfer, the
5764+12 Electronic Health Record Incentive Fund is dissolved, and any
5765+13 future deposits due to that Fund and any outstanding
5766+14 obligations or liabilities of that Fund shall pass to the
5767+15 Public Aid Recoveries Trust Fund.
5768+16 (Source: P.A. 97-169, eff. 7-22-11.)
5769+17 Article 130.
5770+18 (30 ILCS 105/5.836 rep.)
5771+19 Section 130-5. The State Finance Act is amended by
5772+20 repealing Section 5.836.
5773+21 (305 ILCS 5/5-31 rep.)
5774+22 (305 ILCS 5/5-32 rep.)
5775+23 Section 130-10. The Illinois Public Aid Code is amended by
5776+
5777+
5778+
5779+
5780+
5781+ SB3268 Enrolled - 163 - LRB103 39338 KTG 69500 b
5782+
5783+
5784+SB3268 Enrolled- 164 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 164 - LRB103 39338 KTG 69500 b
5785+ SB3268 Enrolled - 164 - LRB103 39338 KTG 69500 b
5786+1 repealing Sections 5-31 and 5-32.
5787+2 Article 135.
5788+3 Section 135-5. The State Finance Act is amended by
5789+4 changing Section 5.481 as follows:
5790+5 (30 ILCS 105/5.481)
5791+6 Sec. 5.481. The Juvenile Rehabilitation Services Medicaid
5792+7 Matching Fund. This Section is repealed on January 1, 2026.
5793+8 (Source: P.A. 90-587, eff. 7-1-98.)
5794+9 Section 135-10. The Illinois Public Aid Code is amended by
5795+10 changing Sections 12-9 and 12-10.4 as follows:
5796+11 (305 ILCS 5/12-9) (from Ch. 23, par. 12-9)
5797+12 Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
5798+13 Public Aid Recoveries Trust Fund shall consist of (1)
5799+14 recoveries by the Department of Healthcare and Family Services
5800+15 (formerly Illinois Department of Public Aid) authorized by
5801+16 this Code in respect to applicants or recipients under
5802+17 Articles III, IV, V, and VI, including recoveries made by the
5803+18 Department of Healthcare and Family Services (formerly
5804+19 Illinois Department of Public Aid) from the estates of
5805+20 deceased recipients, (2) recoveries made by the Department of
5806+21 Healthcare and Family Services (formerly Illinois Department
5807+
5808+
5809+
5810+
5811+
5812+ SB3268 Enrolled - 164 - LRB103 39338 KTG 69500 b
5813+
5814+
5815+SB3268 Enrolled- 165 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 165 - LRB103 39338 KTG 69500 b
5816+ SB3268 Enrolled - 165 - LRB103 39338 KTG 69500 b
5817+1 of Public Aid) in respect to applicants and recipients under
5818+2 the Children's Health Insurance Program Act, and the Covering
5819+3 ALL KIDS Health Insurance Act, (2.5) recoveries made by the
5820+4 Department of Healthcare and Family Services in connection
5821+5 with the imposition of an administrative penalty as provided
5822+6 under Section 12-4.45, (3) federal funds received on behalf of
5823+7 and earned by State universities, other State agencies or
5824+8 departments, and local governmental entities for services
5825+9 provided to applicants or recipients covered under this Code,
5826+10 the Children's Health Insurance Program Act, and the Covering
5827+11 ALL KIDS Health Insurance Act, (3.5) federal financial
5828+12 participation revenue related to eligible disbursements made
5829+13 by the Department of Healthcare and Family Services from
5830+14 appropriations required by this Section, and (4) all other
5831+15 moneys received to the Fund, including interest thereon. The
5832+16 Fund shall be held as a special fund in the State Treasury.
5833+17 Disbursements from this Fund shall be only (1) for the
5834+18 reimbursement of claims collected by the Department of
5835+19 Healthcare and Family Services (formerly Illinois Department
5836+20 of Public Aid) through error or mistake, (2) for payment to
5837+21 persons or agencies designated as payees or co-payees on any
5838+22 instrument, whether or not negotiable, delivered to the
5839+23 Department of Healthcare and Family Services (formerly
5840+24 Illinois Department of Public Aid) as a recovery under this
5841+25 Section, such payment to be in proportion to the respective
5842+26 interests of the payees in the amount so collected, (3) for
5843+
5844+
5845+
5846+
5847+
5848+ SB3268 Enrolled - 165 - LRB103 39338 KTG 69500 b
5849+
5850+
5851+SB3268 Enrolled- 166 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 166 - LRB103 39338 KTG 69500 b
5852+ SB3268 Enrolled - 166 - LRB103 39338 KTG 69500 b
5853+1 payments to the Department of Human Services for collections
5854+2 made by the Department of Healthcare and Family Services
5855+3 (formerly Illinois Department of Public Aid) on behalf of the
5856+4 Department of Human Services under this Code, the Children's
5857+5 Health Insurance Program Act, and the Covering ALL KIDS Health
5858+6 Insurance Act, (4) for payment of administrative expenses
5859+7 incurred in performing the activities authorized under this
5860+8 Code, the Children's Health Insurance Program Act, and the
5861+9 Covering ALL KIDS Health Insurance Act, (5) for payment of
5862+10 fees to persons or agencies in the performance of activities
5863+11 pursuant to the collection of monies owed the State that are
5864+12 collected under this Code, the Children's Health Insurance
5865+13 Program Act, and the Covering ALL KIDS Health Insurance Act,
5866+14 (6) for payments of any amounts which are reimbursable to the
5867+15 federal government which are required to be paid by State
5868+16 warrant by either the State or federal government, and (7) for
5869+17 payments to State universities, other State agencies or
5870+18 departments, and local governmental entities of federal funds
5871+19 for services provided to applicants or recipients covered
5872+20 under this Code, the Children's Health Insurance Program Act,
5873+21 and the Covering ALL KIDS Health Insurance Act. Disbursements
5874+22 from this Fund for purposes of items (4) and (5) of this
5875+23 paragraph shall be subject to appropriations from the Fund to
5876+24 the Department of Healthcare and Family Services (formerly
5877+25 Illinois Department of Public Aid).
5878+26 The balance in this Fund after payment therefrom of any
5879+
5880+
5881+
5882+
5883+
5884+ SB3268 Enrolled - 166 - LRB103 39338 KTG 69500 b
5885+
5886+
5887+SB3268 Enrolled- 167 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 167 - LRB103 39338 KTG 69500 b
5888+ SB3268 Enrolled - 167 - LRB103 39338 KTG 69500 b
5889+1 amounts reimbursable to the federal government, and minus the
5890+2 amount reasonably anticipated to be needed to make the
5891+3 disbursements authorized by this Section during the current
5892+4 and following 3 calendar months, shall be certified by the
5893+5 Director of Healthcare and Family Services and transferred by
5894+6 the State Comptroller to the Drug Rebate Fund or the
5895+7 Healthcare Provider Relief Fund in the State Treasury, as
5896+8 appropriate, on at least an annual basis by June 30th of each
5897+9 fiscal year. The Director of Healthcare and Family Services
5898+10 may certify and the State Comptroller shall transfer to the
5899+11 Drug Rebate Fund or the Healthcare Provider Relief Fund
5900+12 amounts on a more frequent basis.
5901+13 On July 1, 1999, the State Comptroller shall transfer the
5902+14 sum of $5,000,000 from the Public Aid Recoveries Trust Fund
5903+15 (formerly the Public Assistance Recoveries Trust Fund) into
5904+16 the DHS Recoveries Trust Fund.
5905+17 (Source: P.A. 97-647, eff. 1-1-12; 97-689, eff. 6-14-12;
5906+18 98-130, eff. 8-2-13; 98-651, eff. 6-16-14.)
5907+19 (305 ILCS 5/12-10.4)
5908+20 Sec. 12-10.4. Juvenile Rehabilitation Services Medicaid
5909+21 Matching Fund. There is created in the State Treasury the
5910+22 Juvenile Rehabilitation Services Medicaid Matching Fund.
5911+23 Deposits to this Fund shall consist of all moneys received
5912+24 from the federal government for behavioral health services
5913+25 secured by counties pursuant to an agreement with the
5914+
5915+
5916+
5917+
5918+
5919+ SB3268 Enrolled - 167 - LRB103 39338 KTG 69500 b
5920+
5921+
5922+SB3268 Enrolled- 168 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 168 - LRB103 39338 KTG 69500 b
5923+ SB3268 Enrolled - 168 - LRB103 39338 KTG 69500 b
5924+1 Department of Healthcare and Family Services with respect to
5925+2 Title XIX of the Social Security Act or under the Children's
5926+3 Health Insurance Program pursuant to the Children's Health
5927+4 Insurance Program Act and Title XXI of the Social Security Act
5928+5 for minors who are committed to mental health facilities by
5929+6 the Illinois court system and for residential placements
5930+7 secured by the Department of Juvenile Justice for minors as a
5931+8 condition of their aftercare release.
5932+9 Disbursements from the Fund shall be made, subject to
5933+10 appropriation, by the Department of Healthcare and Family
5934+11 Services for grants to the Department of Juvenile Justice and
5935+12 those counties which secure behavioral health services ordered
5936+13 by the courts and which have an interagency agreement with the
5937+14 Department and submit detailed bills according to standards
5938+15 determined by the Department.
5939+16 On January 1, 2026, or as soon thereafter as practical,
5940+17 the State Comptroller shall direct and the State Treasurer
5941+18 shall transfer the remaining balance from the Juvenile
5942+19 Rehabilitation Services Medicaid Matching Fund into the Public
5943+20 Aid Recoveries Trust Fund. Upon completion of the transfer,
5944+21 the Juvenile Rehabilitation Services Medicaid Matching Fund is
5945+22 dissolved, and any future deposits due to that Fund and any
5946+23 outstanding obligations or liabilities of that Fund shall pass
5947+24 to the Public Aid Recoveries Trust Fund.
5948+25 (Source: P.A. 98-558, eff. 1-1-14.)
5949+
5950+
5951+
5952+
5953+
5954+ SB3268 Enrolled - 168 - LRB103 39338 KTG 69500 b
5955+
5956+
5957+SB3268 Enrolled- 169 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 169 - LRB103 39338 KTG 69500 b
5958+ SB3268 Enrolled - 169 - LRB103 39338 KTG 69500 b
5959+1 Article 140.
5960+2 (30 ILCS 105/5.856 rep.)
5961+3 Section 140-5. The State Finance Act is amended by
5962+4 repealing Section 5.856.
5963+5 (305 ILCS 5/Art. V-G rep.)
5964+6 Section 140-10. The Illinois Public Aid Code is amended by
5965+7 repealing Article V-G.
5966+8 Article 145.
5967+9 Section 145-5. The State Finance Act is amended by
5968+10 changing Sections 5.409 and 6z-40 as follows:
5969+11 (30 ILCS 105/5.409)
5970+12 Sec. 5.409. The Provider Inquiry Trust Fund. This Section
5971+13 is repealed on January 1, 2025.
5972+14 (Source: P.A. 89-21, eff. 7-1-95.)
5973+15 (30 ILCS 105/6z-40)
5974+16 Sec. 6z-40. Provider Inquiry Trust Fund. The Provider
5975+17 Inquiry Trust Fund is created as a special fund in the State
5976+18 treasury. Payments into the fund shall consist of fees or
5977+19 other moneys owed by providers of services or their agents,
5978+20 including other State agencies, for access to and utilization
5979+
5980+
5981+
5982+
5983+
5984+ SB3268 Enrolled - 169 - LRB103 39338 KTG 69500 b
5985+
5986+
5987+SB3268 Enrolled- 170 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 170 - LRB103 39338 KTG 69500 b
5988+ SB3268 Enrolled - 170 - LRB103 39338 KTG 69500 b
5989+1 of Illinois Department of Healthcare and Family Services
5990+2 Public Aid eligibility files to verify eligibility of clients,
5991+3 bills for services, or other similar, related uses.
5992+4 Disbursements from the fund shall consist of payments to the
5993+5 Department of Innovation and Technology Central Management
5994+6 Services for communication and statistical services and for
5995+7 payments for administrative expenses incurred by the Illinois
5996+8 Department of Healthcare and Family Services Public Aid in the
5997+9 operation of the fund.
5998+10 On January 1, 2025, or as soon thereafter as practical,
5999+11 the State Comptroller shall direct and the State Treasurer
6000+12 shall transfer the remaining balance from the Provider Inquiry
6001+13 Trust Fund into the Healthcare Provider Relief Fund. Upon
6002+14 completion of the transfer, the Provider Inquiry Trust Fund is
6003+15 dissolved, and any future deposits due to that Fund and any
6004+16 outstanding obligations or liabilities of that Fund shall pass
6005+17 to the Healthcare Provider Relief Fund.
6006+18 (Source: P.A. 94-91, eff. 7-1-05.)
6007+19 ARTICLE 150.
6008+20 Section 150-5. The Illinois Public Aid Code is amended by
6009+21 changing Section 5-30.1 and by adding Section 5-30.18 as
6010+22 follows:
6011+23 (305 ILCS 5/5-30.1)
6012+
6013+
6014+
6015+
6016+
6017+ SB3268 Enrolled - 170 - LRB103 39338 KTG 69500 b
6018+
6019+
6020+SB3268 Enrolled- 171 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 171 - LRB103 39338 KTG 69500 b
6021+ SB3268 Enrolled - 171 - LRB103 39338 KTG 69500 b
6022+1 Sec. 5-30.1. Managed care protections.
6023+2 (a) As used in this Section:
6024+3 "Managed care organization" or "MCO" means any entity
6025+4 which contracts with the Department to provide services where
6026+5 payment for medical services is made on a capitated basis.
6027+6 "Emergency services" means health care items and services,
6028+7 including inpatient and outpatient hospital services,
6029+8 furnished or required to evaluate and stabilize an emergency
6030+9 medical condition. "Emergency services" include inpatient
6031+10 stabilization services furnished during the inpatient
6032+11 stabilization period. "Emergency services" do not include
6033+12 post-stabilization medical services. include:
6034+13 (1) emergency services, as defined by Section 10 of
6035+14 the Managed Care Reform and Patient Rights Act;
6036+15 (2) emergency medical screening examinations, as
6037+16 defined by Section 10 of the Managed Care Reform and
6038+17 Patient Rights Act;
6039+18 (3) post-stabilization medical services, as defined by
6040+19 Section 10 of the Managed Care Reform and Patient Rights
6041+20 Act; and
6042+21 (4) emergency medical conditions, as defined by
6043+22 Section 10 of the Managed Care Reform and Patient Rights
6044+23 Act.
6045+24 "Emergency medical condition" means a medical condition
6046+25 manifesting itself by acute symptoms of sufficient severity,
6047+26 regardless of the final diagnosis given, such that a prudent
6048+
6049+
6050+
6051+
6052+
6053+ SB3268 Enrolled - 171 - LRB103 39338 KTG 69500 b
6054+
6055+
6056+SB3268 Enrolled- 172 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 172 - LRB103 39338 KTG 69500 b
6057+ SB3268 Enrolled - 172 - LRB103 39338 KTG 69500 b
6058+1 layperson, who possesses an average knowledge of health and
6059+2 medicine, could reasonably expect the absence of immediate
6060+3 medical attention to result in:
6061+4 (1) placing the health of the individual (or, with
6062+5 respect to a pregnant woman, the health of the woman or her
6063+6 unborn child) in serious jeopardy;
6064+7 (2) serious impairment to bodily functions;
6065+8 (3) serious dysfunction of any bodily organ or part;
6066+9 (4) inadequately controlled pain; or
6067+10 (5) with respect to a pregnant woman who is having
6068+11 contractions:
6069+12 (A) inadequate time to complete a safe transfer to
6070+13 another hospital before delivery; or
6071+14 (B) a transfer to another hospital may pose a
6072+15 threat to the health or safety of the woman or unborn
6073+16 child.
6074+17 "Emergency medical screening examination" means a medical
6075+18 screening examination and evaluation by a physician licensed
6076+19 to practice medicine in all its branches or, to the extent
6077+20 permitted by applicable laws, by other appropriately licensed
6078+21 personnel under the supervision of or in collaboration with a
6079+22 physician licensed to practice medicine in all its branches to
6080+23 determine whether the need for emergency services exists.
6081+24 "Health care services" mean any medical or behavioral
6082+25 health services covered under the medical assistance program
6083+26 that are subject to review under a service authorization
6084+
6085+
6086+
6087+
6088+
6089+ SB3268 Enrolled - 172 - LRB103 39338 KTG 69500 b
6090+
6091+
6092+SB3268 Enrolled- 173 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 173 - LRB103 39338 KTG 69500 b
6093+ SB3268 Enrolled - 173 - LRB103 39338 KTG 69500 b
6094+1 program.
6095+2 "Inpatient stabilization period" means the initial 72
6096+3 hours of inpatient stabilization services, beginning from the
6097+4 date and time of the order for inpatient admission to the
6098+5 hospital.
6099+6 "Inpatient stabilization services" mean emergency services
6100+7 furnished in the inpatient setting at a hospital pursuant to
6101+8 an order for inpatient admission by a physician or other
6102+9 qualified practitioner who has admitting privileges at the
6103+10 hospital, as permitted by State law, to stabilize an emergency
6104+11 medical condition following an emergency medical screening
6105+12 examination.
6106+13 "Post-stabilization medical services" means health care
6107+14 services provided to an enrollee that are furnished in a
6108+15 hospital by a provider that is qualified to furnish such
6109+16 services and determined to be medically necessary by the
6110+17 provider and directly related to the emergency medical
6111+18 condition following stabilization.
6112+19 "Provider" means a facility or individual who is actively
6113+20 enrolled in the medical assistance program and licensed or
6114+21 otherwise authorized to order, prescribe, refer, or render
6115+22 health care services in this State.
6116+23 "Service authorization determination" means a decision
6117+24 made by a service authorization program in advance of,
6118+25 concurrent to, or after the provision of a health care service
6119+26 to approve, change the level of care, partially deny, deny, or
6120+
6121+
6122+
6123+
6124+
6125+ SB3268 Enrolled - 173 - LRB103 39338 KTG 69500 b
6126+
6127+
6128+SB3268 Enrolled- 174 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 174 - LRB103 39338 KTG 69500 b
6129+ SB3268 Enrolled - 174 - LRB103 39338 KTG 69500 b
6130+1 otherwise limit coverage and reimbursement for a health care
6131+2 service upon review of a service authorization request.
6132+3 "Service authorization program" means any utilization
6133+4 review, utilization management, peer review, quality review,
6134+5 or other medical management activity conducted by an MCO, or
6135+6 its contracted utilization review organization, including, but
6136+7 not limited to, prior authorization, prior approval,
6137+8 pre-certification, concurrent review, retrospective review, or
6138+9 certification of admission, of health care services provided
6139+10 in the inpatient or outpatient hospital setting.
6140+11 "Service authorization request" means a request by a
6141+12 provider to a service authorization program to determine
6142+13 whether a health care service meets the reimbursement
6143+14 eligibility requirements for medically necessary, clinically
6144+15 appropriate care, resulting in the issuance of a service
6145+16 authorization determination.
6146+17 "Utilization review organization" or "URO" means an MCO's
6147+18 utilization review department or a peer review organization or
6148+19 quality improvement organization that contracts with an MCO to
6149+20 administer a service authorization program and make service
6150+21 authorization determinations.
6151+22 (b) As provided by Section 5-16.12, managed care
6152+23 organizations are subject to the provisions of the Managed
6153+24 Care Reform and Patient Rights Act.
6154+25 (c) An MCO shall pay any provider of emergency services,
6155+26 including for inpatient stabilization services provided during
6156+
6157+
6158+
6159+
6160+
6161+ SB3268 Enrolled - 174 - LRB103 39338 KTG 69500 b
6162+
6163+
6164+SB3268 Enrolled- 175 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 175 - LRB103 39338 KTG 69500 b
6165+ SB3268 Enrolled - 175 - LRB103 39338 KTG 69500 b
6166+1 the inpatient stabilization period, that does not have in
6167+2 effect a contract with the contracted Medicaid MCO. The
6168+3 default rate of reimbursement shall be the rate paid under
6169+4 Illinois Medicaid fee-for-service program methodology,
6170+5 including all policy adjusters, including but not limited to
6171+6 Medicaid High Volume Adjustments, Medicaid Percentage
6172+7 Adjustments, Outpatient High Volume Adjustments, and all
6173+8 outlier add-on adjustments to the extent such adjustments are
6174+9 incorporated in the development of the applicable MCO
6175+10 capitated rates.
6176+11 (d) (Blank). An MCO shall pay for all post-stabilization
6177+12 services as a covered service in any of the following
6178+13 situations:
6179+14 (1) the MCO authorized such services;
6180+15 (2) such services were administered to maintain the
6181+16 enrollee's stabilized condition within one hour after a
6182+17 request to the MCO for authorization of further
6183+18 post-stabilization services;
6184+19 (3) the MCO did not respond to a request to authorize
6185+20 such services within one hour;
6186+21 (4) the MCO could not be contacted; or
6187+22 (5) the MCO and the treating provider, if the treating
6188+23 provider is a non-affiliated provider, could not reach an
6189+24 agreement concerning the enrollee's care and an affiliated
6190+25 provider was unavailable for a consultation, in which case
6191+26 the MCO must pay for such services rendered by the
6192+
6193+
6194+
6195+
6196+
6197+ SB3268 Enrolled - 175 - LRB103 39338 KTG 69500 b
6198+
6199+
6200+SB3268 Enrolled- 176 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 176 - LRB103 39338 KTG 69500 b
6201+ SB3268 Enrolled - 176 - LRB103 39338 KTG 69500 b
6202+1 treating non-affiliated provider until an affiliated
6203+2 provider was reached and either concurred with the
6204+3 treating non-affiliated provider's plan of care or assumed
6205+4 responsibility for the enrollee's care. Such payment shall
6206+5 be made at the default rate of reimbursement paid under
6207+6 Illinois Medicaid fee-for-service program methodology,
6208+7 including all policy adjusters, including but not limited
6209+8 to Medicaid High Volume Adjustments, Medicaid Percentage
6210+9 Adjustments, Outpatient High Volume Adjustments and all
6211+10 outlier add-on adjustments to the extent that such
6212+11 adjustments are incorporated in the development of the
6213+12 applicable MCO capitated rates.
6214+13 (e) Notwithstanding any other provision of law, the The
6215+14 following requirements apply to MCOs in determining payment
6216+15 for all emergency services, including inpatient stabilization
6217+16 services provided during the inpatient stabilization period:
6218+17 (1) The MCO MCOs shall not impose any service
6219+18 authorization program requirements for prior approval of
6220+19 emergency services, including, but not limited to, prior
6221+20 authorization, prior approval, pre-certification,
6222+21 certification of admission, concurrent review, or
6223+22 retrospective review.
6224+23 (A) Notification period: Hospitals shall notify
6225+24 the enrollee's Medicaid MCO within 48 hours of the
6226+25 date and time the order for inpatient admission is
6227+26 written. Notification shall be limited to advising the
6228+
6229+
6230+
6231+
6232+
6233+ SB3268 Enrolled - 176 - LRB103 39338 KTG 69500 b
6234+
6235+
6236+SB3268 Enrolled- 177 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 177 - LRB103 39338 KTG 69500 b
6237+ SB3268 Enrolled - 177 - LRB103 39338 KTG 69500 b
6238+1 MCO that the patient has been admitted to a hospital
6239+2 inpatient level of care.
6240+3 (B) If the admitting hospital complies with the
6241+4 notification provisions of subparagraph (A), the
6242+5 Medicaid MCO may not initiate concurrent review before
6243+6 the end of the inpatient stabilization period. If the
6244+7 admitting hospital does not comply with the
6245+8 notification requirements in subparagraph (A), the
6246+9 Medicaid MCO may initiate concurrent review for the
6247+10 continuation of the stay beginning at the end of the
6248+11 48-hour notification period.
6249+12 (C) Coverage for services provided during the
6250+13 48-hour notification period may not be retrospectively
6251+14 denied.
6252+15 (2) The MCO shall cover emergency services provided to
6253+16 enrollees who are temporarily away from their residence
6254+17 and outside the contracting area to the extent that the
6255+18 enrollees would be entitled to the emergency services if
6256+19 they still were within the contracting area.
6257+20 (3) The MCO shall have no obligation to cover
6258+21 emergency medical services provided on an emergency basis
6259+22 that are not covered services under the contract between
6260+23 the MCO and the Department.
6261+24 (4) The MCO shall not condition coverage for emergency
6262+25 services on the treating provider notifying the MCO of the
6263+26 enrollee's emergency medical screening examination and
6264+
6265+
6266+
6267+
6268+
6269+ SB3268 Enrolled - 177 - LRB103 39338 KTG 69500 b
6270+
6271+
6272+SB3268 Enrolled- 178 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 178 - LRB103 39338 KTG 69500 b
6273+ SB3268 Enrolled - 178 - LRB103 39338 KTG 69500 b
6274+1 treatment within 10 days after presentation for emergency
6275+2 services.
6276+3 (5) The determination of the attending emergency
6277+4 physician, or the practitioner responsible for the
6278+5 enrollee's care at the hospital the provider actually
6279+6 treating the enrollee, of whether an enrollee requires
6280+7 inpatient stabilization services, can be stabilized in the
6281+8 outpatient setting, or is sufficiently stabilized for
6282+9 discharge or transfer to another setting facility, shall
6283+10 be binding on the MCO. The MCO shall cover and reimburse
6284+11 providers for emergency services as billed by the provider
6285+12 for all enrollees whether the emergency services are
6286+13 provided by an affiliated or non-affiliated provider,
6287+14 except in cases of fraud. The MCO shall reimburse
6288+15 inpatient stabilization services provided during the
6289+16 inpatient stabilization period and billed as inpatient
6290+17 level of care based on the appropriate inpatient
6291+18 reimbursement methodology.
6292+19 (6) The MCO's financial responsibility for
6293+20 post-stabilization medical care services it has not
6294+21 pre-approved ends when:
6295+22 (A) a plan physician with privileges at the
6296+23 treating hospital assumes responsibility for the
6297+24 enrollee's care;
6298+25 (B) a plan physician assumes responsibility for
6299+26 the enrollee's care through transfer;
6300+
6301+
6302+
6303+
6304+
6305+ SB3268 Enrolled - 178 - LRB103 39338 KTG 69500 b
6306+
6307+
6308+SB3268 Enrolled- 179 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 179 - LRB103 39338 KTG 69500 b
6309+ SB3268 Enrolled - 179 - LRB103 39338 KTG 69500 b
6310+1 (C) a contracting entity representative and the
6311+2 treating physician reach an agreement concerning the
6312+3 enrollee's care; or
6313+4 (D) the enrollee is discharged.
6314+5 (e-5) An MCO shall pay for all post-stabilization medical
6315+6 services as a covered service in any of the following
6316+7 situations:
6317+8 (1) the MCO or its URO authorized such services;
6318+9 (2) such services were administered to maintain the
6319+10 enrollee's stabilized condition within one hour after a
6320+11 request to the MCO for authorization of further
6321+12 post-stabilization services;
6322+13 (3) the MCO or its URO did not respond to a request to
6323+14 authorize such services within one hour;
6324+15 (4) the MCO or its URO could not be contacted; or
6325+16 (5) the MCO or its URO and the treating provider, if
6326+17 the treating provider is a non-affiliated provider, could
6327+18 not reach an agreement concerning the enrollee's care and
6328+19 an affiliated provider was unavailable for a consultation,
6329+20 in which case the MCO must pay for such services rendered
6330+21 by the treating non-affiliated provider until an
6331+22 affiliated provider was reached and either concurred with
6332+23 the treating non-affiliated provider's plan of care or
6333+24 assumed responsibility for the enrollee's care. Such
6334+25 payment shall be made at the default rate of reimbursement
6335+26 paid under the State's Medicaid fee-for-service program
6336+
6337+
6338+
6339+
6340+
6341+ SB3268 Enrolled - 179 - LRB103 39338 KTG 69500 b
6342+
6343+
6344+SB3268 Enrolled- 180 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 180 - LRB103 39338 KTG 69500 b
6345+ SB3268 Enrolled - 180 - LRB103 39338 KTG 69500 b
6346+1 methodology, including all policy adjusters, including,
6347+2 but not limited to, Medicaid High Volume Adjustments,
6348+3 Medicaid Percentage Adjustments, Outpatient High Volume
6349+4 Adjustments, and all outlier add-on adjustments to the
6350+5 extent that such adjustments are incorporated in the
6351+6 development of the applicable MCO capitated rates.
6352+7 (f) Network adequacy and transparency.
6353+8 (1) The Department shall:
6354+9 (A) ensure that an adequate provider network is in
6355+10 place, taking into consideration health professional
6356+11 shortage areas and medically underserved areas;
6357+12 (B) publicly release an explanation of its process
6358+13 for analyzing network adequacy;
6359+14 (C) periodically ensure that an MCO continues to
6360+15 have an adequate network in place;
6361+16 (D) require MCOs, including Medicaid Managed Care
6362+17 Entities as defined in Section 5-30.2, to meet
6363+18 provider directory requirements under Section 5-30.3;
6364+19 (E) require MCOs to ensure that any
6365+20 Medicaid-certified provider under contract with an MCO
6366+21 and previously submitted on a roster on the date of
6367+22 service is paid for any medically necessary,
6368+23 Medicaid-covered, and authorized service rendered to
6369+24 any of the MCO's enrollees, regardless of inclusion on
6370+25 the MCO's published and publicly available directory
6371+26 of available providers; and
6372+
6373+
6374+
6375+
6376+
6377+ SB3268 Enrolled - 180 - LRB103 39338 KTG 69500 b
6378+
6379+
6380+SB3268 Enrolled- 181 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 181 - LRB103 39338 KTG 69500 b
6381+ SB3268 Enrolled - 181 - LRB103 39338 KTG 69500 b
6382+1 (F) require MCOs, including Medicaid Managed Care
6383+2 Entities as defined in Section 5-30.2, to meet each of
6384+3 the requirements under subsection (d-5) of Section 10
6385+4 of the Network Adequacy and Transparency Act; with
6386+5 necessary exceptions to the MCO's network to ensure
6387+6 that admission and treatment with a provider or at a
6388+7 treatment facility in accordance with the network
6389+8 adequacy standards in paragraph (3) of subsection
6390+9 (d-5) of Section 10 of the Network Adequacy and
6391+10 Transparency Act is limited to providers or facilities
6392+11 that are Medicaid certified.
6393+12 (2) Each MCO shall confirm its receipt of information
6394+13 submitted specific to physician or dentist additions or
6395+14 physician or dentist deletions from the MCO's provider
6396+15 network within 3 days after receiving all required
6397+16 information from contracted physicians or dentists, and
6398+17 electronic physician and dental directories must be
6399+18 updated consistent with current rules as published by the
6400+19 Centers for Medicare and Medicaid Services or its
6401+20 successor agency.
6402+21 (g) Timely payment of claims.
6403+22 (1) The MCO shall pay a claim within 30 days of
6404+23 receiving a claim that contains all the essential
6405+24 information needed to adjudicate the claim.
6406+25 (2) The MCO shall notify the billing party of its
6407+26 inability to adjudicate a claim within 30 days of
6408+
6409+
6410+
6411+
6412+
6413+ SB3268 Enrolled - 181 - LRB103 39338 KTG 69500 b
6414+
6415+
6416+SB3268 Enrolled- 182 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 182 - LRB103 39338 KTG 69500 b
6417+ SB3268 Enrolled - 182 - LRB103 39338 KTG 69500 b
6418+1 receiving that claim.
6419+2 (3) The MCO shall pay a penalty that is at least equal
6420+3 to the timely payment interest penalty imposed under
6421+4 Section 368a of the Illinois Insurance Code for any claims
6422+5 not timely paid.
6423+6 (A) When an MCO is required to pay a timely payment
6424+7 interest penalty to a provider, the MCO must calculate
6425+8 and pay the timely payment interest penalty that is
6426+9 due to the provider within 30 days after the payment of
6427+10 the claim. In no event shall a provider be required to
6428+11 request or apply for payment of any owed timely
6429+12 payment interest penalties.
6430+13 (B) Such payments shall be reported separately
6431+14 from the claim payment for services rendered to the
6432+15 MCO's enrollee and clearly identified as interest
6433+16 payments.
6434+17 (4)(A) The Department shall require MCOs to expedite
6435+18 payments to providers identified on the Department's
6436+19 expedited provider list, determined in accordance with 89
6437+20 Ill. Adm. Code 140.71(b), on a schedule at least as
6438+21 frequently as the providers are paid under the
6439+22 Department's fee-for-service expedited provider schedule.
6440+23 (B) Compliance with the expedited provider requirement
6441+24 may be satisfied by an MCO through the use of a Periodic
6442+25 Interim Payment (PIP) program that has been mutually
6443+26 agreed to and documented between the MCO and the provider,
6444+
6445+
6446+
6447+
6448+
6449+ SB3268 Enrolled - 182 - LRB103 39338 KTG 69500 b
6450+
6451+
6452+SB3268 Enrolled- 183 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 183 - LRB103 39338 KTG 69500 b
6453+ SB3268 Enrolled - 183 - LRB103 39338 KTG 69500 b
6454+1 if the PIP program ensures that any expedited provider
6455+2 receives regular and periodic payments based on prior
6456+3 period payment experience from that MCO. Total payments
6457+4 under the PIP program may be reconciled against future PIP
6458+5 payments on a schedule mutually agreed to between the MCO
6459+6 and the provider.
6460+7 (C) The Department shall share at least monthly its
6461+8 expedited provider list and the frequency with which it
6462+9 pays providers on the expedited list.
6463+10 (g-5) Recognizing that the rapid transformation of the
6464+11 Illinois Medicaid program may have unintended operational
6465+12 challenges for both payers and providers:
6466+13 (1) in no instance shall a medically necessary covered
6467+14 service rendered in good faith, based upon eligibility
6468+15 information documented by the provider, be denied coverage
6469+16 or diminished in payment amount if the eligibility or
6470+17 coverage information available at the time the service was
6471+18 rendered is later found to be inaccurate in the assignment
6472+19 of coverage responsibility between MCOs or the
6473+20 fee-for-service system, except for instances when an
6474+21 individual is deemed to have not been eligible for
6475+22 coverage under the Illinois Medicaid program; and
6476+23 (2) the Department shall, by December 31, 2016, adopt
6477+24 rules establishing policies that shall be included in the
6478+25 Medicaid managed care policy and procedures manual
6479+26 addressing payment resolutions in situations in which a
6480+
6481+
6482+
6483+
6484+
6485+ SB3268 Enrolled - 183 - LRB103 39338 KTG 69500 b
6486+
6487+
6488+SB3268 Enrolled- 184 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 184 - LRB103 39338 KTG 69500 b
6489+ SB3268 Enrolled - 184 - LRB103 39338 KTG 69500 b
6490+1 provider renders services based upon information obtained
6491+2 after verifying a patient's eligibility and coverage plan
6492+3 through either the Department's current enrollment system
6493+4 or a system operated by the coverage plan identified by
6494+5 the patient presenting for services:
6495+6 (A) such medically necessary covered services
6496+7 shall be considered rendered in good faith;
6497+8 (B) such policies and procedures shall be
6498+9 developed in consultation with industry
6499+10 representatives of the Medicaid managed care health
6500+11 plans and representatives of provider associations
6501+12 representing the majority of providers within the
6502+13 identified provider industry; and
6503+14 (C) such rules shall be published for a review and
6504+15 comment period of no less than 30 days on the
6505+16 Department's website with final rules remaining
6506+17 available on the Department's website.
6507+18 The rules on payment resolutions shall include, but
6508+19 not be limited to:
6509+20 (A) the extension of the timely filing period;
6510+21 (B) retroactive prior authorizations; and
6511+22 (C) guaranteed minimum payment rate of no less
6512+23 than the current, as of the date of service,
6513+24 fee-for-service rate, plus all applicable add-ons,
6514+25 when the resulting service relationship is out of
6515+26 network.
6516+
6517+
6518+
6519+
6520+
6521+ SB3268 Enrolled - 184 - LRB103 39338 KTG 69500 b
6522+
6523+
6524+SB3268 Enrolled- 185 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 185 - LRB103 39338 KTG 69500 b
6525+ SB3268 Enrolled - 185 - LRB103 39338 KTG 69500 b
6526+1 The rules shall be applicable for both MCO coverage
6527+2 and fee-for-service coverage.
6528+3 If the fee-for-service system is ultimately determined to
6529+4 have been responsible for coverage on the date of service, the
6530+5 Department shall provide for an extended period for claims
6531+6 submission outside the standard timely filing requirements.
6532+7 (g-6) MCO Performance Metrics Report.
6533+8 (1) The Department shall publish, on at least a
6534+9 quarterly basis, each MCO's operational performance,
6535+10 including, but not limited to, the following categories of
6536+11 metrics:
6537+12 (A) claims payment, including timeliness and
6538+13 accuracy;
6539+14 (B) prior authorizations;
6540+15 (C) grievance and appeals;
6541+16 (D) utilization statistics;
6542+17 (E) provider disputes;
6543+18 (F) provider credentialing; and
6544+19 (G) member and provider customer service.
6545+20 (2) The Department shall ensure that the metrics
6546+21 report is accessible to providers online by January 1,
6547+22 2017.
6548+23 (3) The metrics shall be developed in consultation
6549+24 with industry representatives of the Medicaid managed care
6550+25 health plans and representatives of associations
6551+26 representing the majority of providers within the
6552+
6553+
6554+
6555+
6556+
6557+ SB3268 Enrolled - 185 - LRB103 39338 KTG 69500 b
6558+
6559+
6560+SB3268 Enrolled- 186 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 186 - LRB103 39338 KTG 69500 b
6561+ SB3268 Enrolled - 186 - LRB103 39338 KTG 69500 b
6562+1 identified industry.
6563+2 (4) Metrics shall be defined and incorporated into the
6564+3 applicable Managed Care Policy Manual issued by the
6565+4 Department.
6566+5 (g-7) MCO claims processing and performance analysis. In
6567+6 order to monitor MCO payments to hospital providers, pursuant
6568+7 to Public Act 100-580, the Department shall post an analysis
6569+8 of MCO claims processing and payment performance on its
6570+9 website every 6 months. Such analysis shall include a review
6571+10 and evaluation of a representative sample of hospital claims
6572+11 that are rejected and denied for clean and unclean claims and
6573+12 the top 5 reasons for such actions and timeliness of claims
6574+13 adjudication, which identifies the percentage of claims
6575+14 adjudicated within 30, 60, 90, and over 90 days, and the dollar
6576+15 amounts associated with those claims.
6577+16 (g-8) Dispute resolution process. The Department shall
6578+17 maintain a provider complaint portal through which a provider
6579+18 can submit to the Department unresolved disputes with an MCO.
6580+19 An unresolved dispute means an MCO's decision that denies in
6581+20 whole or in part a claim for reimbursement to a provider for
6582+21 health care services rendered by the provider to an enrollee
6583+22 of the MCO with which the provider disagrees. Disputes shall
6584+23 not be submitted to the portal until the provider has availed
6585+24 itself of the MCO's internal dispute resolution process.
6586+25 Disputes that are submitted to the MCO internal dispute
6587+26 resolution process may be submitted to the Department of
6588+
6589+
6590+
6591+
6592+
6593+ SB3268 Enrolled - 186 - LRB103 39338 KTG 69500 b
6594+
6595+
6596+SB3268 Enrolled- 187 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 187 - LRB103 39338 KTG 69500 b
6597+ SB3268 Enrolled - 187 - LRB103 39338 KTG 69500 b
6598+1 Healthcare and Family Services' complaint portal no sooner
6599+2 than 30 days after submitting to the MCO's internal process
6600+3 and not later than 30 days after the unsatisfactory resolution
6601+4 of the internal MCO process or 60 days after submitting the
6602+5 dispute to the MCO internal process. Multiple claim disputes
6603+6 involving the same MCO may be submitted in one complaint,
6604+7 regardless of whether the claims are for different enrollees,
6605+8 when the specific reason for non-payment of the claims
6606+9 involves a common question of fact or policy. Within 10
6607+10 business days of receipt of a complaint, the Department shall
6608+11 present such disputes to the appropriate MCO, which shall then
6609+12 have 30 days to issue its written proposal to resolve the
6610+13 dispute. The Department may grant one 30-day extension of this
6611+14 time frame to one of the parties to resolve the dispute. If the
6612+15 dispute remains unresolved at the end of this time frame or the
6613+16 provider is not satisfied with the MCO's written proposal to
6614+17 resolve the dispute, the provider may, within 30 days, request
6615+18 the Department to review the dispute and make a final
6616+19 determination. Within 30 days of the request for Department
6617+20 review of the dispute, both the provider and the MCO shall
6618+21 present all relevant information to the Department for
6619+22 resolution and make individuals with knowledge of the issues
6620+23 available to the Department for further inquiry if needed.
6621+24 Within 30 days of receiving the relevant information on the
6622+25 dispute, or the lapse of the period for submitting such
6623+26 information, the Department shall issue a written decision on
6624+
6625+
6626+
6627+
6628+
6629+ SB3268 Enrolled - 187 - LRB103 39338 KTG 69500 b
6630+
6631+
6632+SB3268 Enrolled- 188 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 188 - LRB103 39338 KTG 69500 b
6633+ SB3268 Enrolled - 188 - LRB103 39338 KTG 69500 b
6634+1 the dispute based on contractual terms between the provider
6635+2 and the MCO, contractual terms between the MCO and the
6636+3 Department of Healthcare and Family Services and applicable
6637+4 Medicaid policy. The decision of the Department shall be
6638+5 final. By January 1, 2020, the Department shall establish by
6639+6 rule further details of this dispute resolution process.
6640+7 Disputes between MCOs and providers presented to the
6641+8 Department for resolution are not contested cases, as defined
6642+9 in Section 1-30 of the Illinois Administrative Procedure Act,
6643+10 conferring any right to an administrative hearing.
6644+11 (g-9)(1) The Department shall publish annually on its
6645+12 website a report on the calculation of each managed care
6646+13 organization's medical loss ratio showing the following:
6647+14 (A) Premium revenue, with appropriate adjustments.
6648+15 (B) Benefit expense, setting forth the aggregate
6649+16 amount spent for the following:
6650+17 (i) Direct paid claims.
6651+18 (ii) Subcapitation payments.
6652+19 (iii) Other claim payments.
6653+20 (iv) Direct reserves.
6654+21 (v) Gross recoveries.
6655+22 (vi) Expenses for activities that improve health
6656+23 care quality as allowed by the Department.
6657+24 (2) The medical loss ratio shall be calculated consistent
6658+25 with federal law and regulation following a claims runout
6659+26 period determined by the Department.
6660+
6661+
6662+
6663+
6664+
6665+ SB3268 Enrolled - 188 - LRB103 39338 KTG 69500 b
6666+
6667+
6668+SB3268 Enrolled- 189 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 189 - LRB103 39338 KTG 69500 b
6669+ SB3268 Enrolled - 189 - LRB103 39338 KTG 69500 b
6670+1 (g-10)(1) "Liability effective date" means the date on
6671+2 which an MCO becomes responsible for payment for medically
6672+3 necessary and covered services rendered by a provider to one
6673+4 of its enrollees in accordance with the contract terms between
6674+5 the MCO and the provider. The liability effective date shall
6675+6 be the later of:
6676+7 (A) The execution date of a network participation
6677+8 contract agreement.
6678+9 (B) The date the provider or its representative
6679+10 submits to the MCO the complete and accurate standardized
6680+11 roster form for the provider in the format approved by the
6681+12 Department.
6682+13 (C) The provider effective date contained within the
6683+14 Department's provider enrollment subsystem within the
6684+15 Illinois Medicaid Program Advanced Cloud Technology
6685+16 (IMPACT) System.
6686+17 (2) The standardized roster form may be submitted to the
6687+18 MCO at the same time that the provider submits an enrollment
6688+19 application to the Department through IMPACT.
6689+20 (3) By October 1, 2019, the Department shall require all
6690+21 MCOs to update their provider directory with information for
6691+22 new practitioners of existing contracted providers within 30
6692+23 days of receipt of a complete and accurate standardized roster
6693+24 template in the format approved by the Department provided
6694+25 that the provider is effective in the Department's provider
6695+26 enrollment subsystem within the IMPACT system. Such provider
6696+
6697+
6698+
6699+
6700+
6701+ SB3268 Enrolled - 189 - LRB103 39338 KTG 69500 b
6702+
6703+
6704+SB3268 Enrolled- 190 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 190 - LRB103 39338 KTG 69500 b
6705+ SB3268 Enrolled - 190 - LRB103 39338 KTG 69500 b
6706+1 directory shall be readily accessible for purposes of
6707+2 selecting an approved health care provider and comply with all
6708+3 other federal and State requirements.
6709+4 (g-11) The Department shall work with relevant
6710+5 stakeholders on the development of operational guidelines to
6711+6 enhance and improve operational performance of Illinois'
6712+7 Medicaid managed care program, including, but not limited to,
6713+8 improving provider billing practices, reducing claim
6714+9 rejections and inappropriate payment denials, and
6715+10 standardizing processes, procedures, definitions, and response
6716+11 timelines, with the goal of reducing provider and MCO
6717+12 administrative burdens and conflict. The Department shall
6718+13 include a report on the progress of these program improvements
6719+14 and other topics in its Fiscal Year 2020 annual report to the
6720+15 General Assembly.
6721+16 (g-12) Notwithstanding any other provision of law, if the
6722+17 Department or an MCO requires submission of a claim for
6723+18 payment in a non-electronic format, a provider shall always be
6724+19 afforded a period of no less than 90 business days, as a
6725+20 correction period, following any notification of rejection by
6726+21 either the Department or the MCO to correct errors or
6727+22 omissions in the original submission.
6728+23 Under no circumstances, either by an MCO or under the
6729+24 State's fee-for-service system, shall a provider be denied
6730+25 payment for failure to comply with any timely submission
6731+26 requirements under this Code or under any existing contract,
6732+
6733+
6734+
6735+
6736+
6737+ SB3268 Enrolled - 190 - LRB103 39338 KTG 69500 b
6738+
6739+
6740+SB3268 Enrolled- 191 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 191 - LRB103 39338 KTG 69500 b
6741+ SB3268 Enrolled - 191 - LRB103 39338 KTG 69500 b
6742+1 unless the non-electronic format claim submission occurs after
6743+2 the initial 180 days following the latest date of service on
6744+3 the claim, or after the 90 business days correction period
6745+4 following notification to the provider of rejection or denial
6746+5 of payment.
6747+6 (g-13) Utilization Review Standardization and
6748+7 Transparency.
6749+8 (1) To ensure greater standardization and transparency
6750+9 related to service authorization determinations, for all
6751+10 individuals covered under the medical assistance program,
6752+11 including both the fee-for-service and managed care
6753+12 programs, the Department shall, in consultation with the
6754+13 MCOs, a statewide association representing the MCOs, a
6755+14 statewide association representing the majority of
6756+15 Illinois hospitals, a statewide association representing
6757+16 physicians, or any other interested parties deemed
6758+17 appropriate by the Department, adopt administrative rules
6759+18 consistent with this subsection, in accordance with the
6760+19 Illinois Administrative Procedure Act.
6761+20 (2) Prior to July 1, 2025, the Department shall in
6762+21 accordance with the Illinois Administrative Procedure Act
6763+22 adopt rules which govern MCO practices for dates of
6764+23 services on and after July 1, 2025, as follows:
6765+24 (A) guidelines related to the publication of MCO
6766+25 authorization policies;
6767+26 (B) procedures that, due to medical complexity,
6768+
6769+
6770+
6771+
6772+
6773+ SB3268 Enrolled - 191 - LRB103 39338 KTG 69500 b
6774+
6775+
6776+SB3268 Enrolled- 192 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 192 - LRB103 39338 KTG 69500 b
6777+ SB3268 Enrolled - 192 - LRB103 39338 KTG 69500 b
6778+1 must be reimbursed under the applicable inpatient
6779+2 methodology, when provided in the inpatient setting
6780+3 and billed as an inpatient service;
6781+4 (C) standardization of administrative forms used
6782+5 in the member appeal process;
6783+6 (D) limitations on second or subsequent medical
6784+7 necessity review of a health care service already
6785+8 authorized by the MCO or URO under a service
6786+9 authorization program;
6787+10 (E) standardization of peer-to-peer processes and
6788+11 timelines;
6789+12 (F) defined criteria for urgent and standard
6790+13 post-acute care service authorization requests; and
6791+14 (G) standardized criteria for service
6792+15 authorization programs for authorization of admission
6793+16 to a long-term acute care hospital.
6794+17 (3) The Department shall expand the scope of the
6795+18 quality and compliance audits conducted by its contracted
6796+19 external quality review organization to include, but not
6797+20 be limited to:
6798+21 (A) an analysis of the Medicaid MCO's compliance
6799+22 with nationally recognized clinical decision
6800+23 guidelines;
6801+24 (B) an analysis that compares and contrasts the
6802+25 Medicaid MCO's service authorization determination
6803+26 outcomes to the outcomes of each other MCO plan and the
6804+
6805+
6806+
6807+
6808+
6809+ SB3268 Enrolled - 192 - LRB103 39338 KTG 69500 b
6810+
6811+
6812+SB3268 Enrolled- 193 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 193 - LRB103 39338 KTG 69500 b
6813+ SB3268 Enrolled - 193 - LRB103 39338 KTG 69500 b
6814+1 State's fee-for-service program model to evaluate
6815+2 whether service authorization determinations are being
6816+3 made consistently by all Medicaid MCOs to ensure that
6817+4 all individuals are being treated in accordance with
6818+5 equitable standards of care;
6819+6 (C) an analysis, for each Medicaid MCO, of the
6820+7 number of service authorization requests, including
6821+8 requests for concurrent review and certification of
6822+9 admissions, received, initially denied, overturned
6823+10 through any post-denial process including, but not
6824+11 limited to, enrollee or provider appeal, peer-to-peer
6825+12 review, or the provider dispute resolution process,
6826+13 denied but approved for a lower or different level of
6827+14 care, and the number denied on final determination;
6828+15 and
6829+16 (D) provide a written report to the General
6830+17 Assembly, detailing the items listed in this
6831+18 subsection and any other metrics deemed necessary by
6832+19 the Department, by the second April, following the
6833+20 effective date of this amendatory Act of the 103rd
6834+21 General Assembly, and each April thereafter. The
6835+22 Department shall make this report available within 30
6836+23 days of delivery to the General Assembly, on its
6837+24 public facing website.
6838+25 (h) The Department shall not expand mandatory MCO
6839+26 enrollment into new counties beyond those counties already
6840+
6841+
6842+
6843+
6844+
6845+ SB3268 Enrolled - 193 - LRB103 39338 KTG 69500 b
6846+
6847+
6848+SB3268 Enrolled- 194 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 194 - LRB103 39338 KTG 69500 b
6849+ SB3268 Enrolled - 194 - LRB103 39338 KTG 69500 b
6850+1 designated by the Department as of June 1, 2014 for the
6851+2 individuals whose eligibility for medical assistance is not
6852+3 the seniors or people with disabilities population until the
6853+4 Department provides an opportunity for accountable care
6854+5 entities and MCOs to participate in such newly designated
6855+6 counties.
6856+7 (h-5) Leading indicator data sharing. By January 1, 2024,
6857+8 the Department shall obtain input from the Department of Human
6858+9 Services, the Department of Juvenile Justice, the Department
6859+10 of Children and Family Services, the State Board of Education,
6860+11 managed care organizations, providers, and clinical experts to
6861+12 identify and analyze key indicators from assessments and data
6862+13 sets available to the Department that can be shared with
6863+14 managed care organizations and similar care coordination
6864+15 entities contracted with the Department as leading indicators
6865+16 for elevated behavioral health crisis risk for children. To
6866+17 the extent permitted by State and federal law, the identified
6867+18 leading indicators shall be shared with managed care
6868+19 organizations and similar care coordination entities
6869+20 contracted with the Department within 6 months of
6870+21 identification for the purpose of improving care coordination
6871+22 with the early detection of elevated risk. Leading indicators
6872+23 shall be reassessed annually with stakeholder input.
6873+24 (i) The requirements of this Section apply to contracts
6874+25 with accountable care entities and MCOs entered into, amended,
6875+26 or renewed after June 16, 2014 (the effective date of Public
6876+
6877+
6878+
6879+
6880+
6881+ SB3268 Enrolled - 194 - LRB103 39338 KTG 69500 b
6882+
6883+
6884+SB3268 Enrolled- 195 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 195 - LRB103 39338 KTG 69500 b
6885+ SB3268 Enrolled - 195 - LRB103 39338 KTG 69500 b
6886+1 Act 98-651).
6887+2 (j) Health care information released to managed care
6888+3 organizations. A health care provider shall release to a
6889+4 Medicaid managed care organization, upon request, and subject
6890+5 to the Health Insurance Portability and Accountability Act of
6891+6 1996 and any other law applicable to the release of health
6892+7 information, the health care information of the MCO's
6893+8 enrollee, if the enrollee has completed and signed a general
6894+9 release form that grants to the health care provider
6895+10 permission to release the recipient's health care information
6896+11 to the recipient's insurance carrier.
6897+12 (k) The Department of Healthcare and Family Services,
6898+13 managed care organizations, a statewide organization
6899+14 representing hospitals, and a statewide organization
6900+15 representing safety-net hospitals shall explore ways to
6901+16 support billing departments in safety-net hospitals.
6902+17 (l) The requirements of this Section added by Public Act
6903+18 102-4 shall apply to services provided on or after the first
6904+19 day of the month that begins 60 days after April 27, 2021 (the
6905+20 effective date of Public Act 102-4).
6906+21 (m) Except where otherwise expressly specified, the
6907+22 requirements of this Section added by this amendatory Act of
6908+23 the 103rd General Assembly shall apply to services provided on
6909+24 or after July 1, 2025.
6910+25 (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21;
6911+26 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff.
6912+
6913+
6914+
6915+
6916+
6917+ SB3268 Enrolled - 195 - LRB103 39338 KTG 69500 b
6918+
6919+
6920+SB3268 Enrolled- 196 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 196 - LRB103 39338 KTG 69500 b
6921+ SB3268 Enrolled - 196 - LRB103 39338 KTG 69500 b
6922+1 5-13-22; 103-546, eff. 8-11-23.)
6923+2 (305 ILCS 5/5-30.18 new)
6924+3 Sec. 5-30.18. Service authorization program performance.
6925+4 (a) Definitions. As used in this Section:
6926+5 "Gold Card provider" means a provider identified by each
6927+6 Medicaid Managed Care Organization (MCO) as qualified under
6928+7 the guidelines outlined by the Department in accordance with
6929+8 subsection (c) and thereby granted a service authorization
6930+9 exemption when ordering a health care service.
6931+10 "Health care service" means any medical or behavioral
6932+11 health service covered under the medical assistance program
6933+12 that is rendered in the inpatient or outpatient hospital
6934+13 setting, including hospital-based clinics, and subject to
6935+14 review under a service authorization program.
6936+15 "Provider" means an individual actively enrolled in the
6937+16 medical assistance program and licensed or otherwise
6938+17 authorized to order, prescribe, refer, or render health care
6939+18 services in this State, and, as determined by the Department,
6940+19 may also include hospitals that submit service authorization
6941+20 requests.
6942+21 "Service authorization exemption" means an exception
6943+22 granted by a Medicaid MCO to a provider under which all service
6944+23 authorization requests for covered health care services,
6945+24 excluding pharmacy services and durable medical equipment, are
6946+25 automatically deemed to be medically necessary, clinically
6947+
6948+
6949+
6950+
6951+
6952+ SB3268 Enrolled - 196 - LRB103 39338 KTG 69500 b
6953+
6954+
6955+SB3268 Enrolled- 197 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 197 - LRB103 39338 KTG 69500 b
6956+ SB3268 Enrolled - 197 - LRB103 39338 KTG 69500 b
6957+1 appropriate, and approved for reimbursement as ordered.
6958+2 "Service authorization program" means any utilization
6959+3 review, utilization management, peer review, quality review,
6960+4 or other medical management activity conducted in advance of,
6961+5 concurrent to, or after the provision of a health care service
6962+6 by a Medicaid MCO, either directly or through a contracted
6963+7 utilization review organization (URO), including, but not
6964+8 limited to, prior authorization, pre-certification,
6965+9 certification of admission, concurrent review, and
6966+10 retrospective review of health care services.
6967+11 "Service authorization request" means a request by a
6968+12 provider to a service authorization program to determine
6969+13 whether a health care service that is otherwise covered under
6970+14 the medical assistance program meets the reimbursement
6971+15 requirements established by the Medicaid MCO, or its
6972+16 contracted URO, for medically necessary, clinically
6973+17 appropriate care and to issue a service authorization
6974+18 determination.
6975+19 "Utilization review organization" or "URO" means a managed
6976+20 care organization or other entity that has established or
6977+21 administers one or more service authorization programs.
6978+22 (b) In consultation with the Medicaid MCOs, a statewide
6979+23 association representing managed care organizations, a
6980+24 statewide association representing the majority of Illinois
6981+25 hospitals, and a statewide association representing
6982+26 physicians, the Department shall in accordance with the
6983+
6984+
6985+
6986+
6987+
6988+ SB3268 Enrolled - 197 - LRB103 39338 KTG 69500 b
6989+
6990+
6991+SB3268 Enrolled- 198 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 198 - LRB103 39338 KTG 69500 b
6992+ SB3268 Enrolled - 198 - LRB103 39338 KTG 69500 b
6993+1 Illinois Administrative Procedure Act, adopt administrative
6994+2 rules, consistent with this Section, to require each Medicaid
6995+3 MCO to identify Gold Card providers with such identification
6996+4 initially being effective for health care services provided on
6997+5 and after July 1, 2025.
6998+6 (c) The Department shall adopt rules, in accordance with
6999+7 the Illinois Administrative Procedure Act, to implement this
7000+8 Section that include, but are not limited to, the following
7001+9 provisions:
7002+10 (1) Require each Medicaid MCO to provide a service
7003+11 authorization exemption to a provider if the provider has
7004+12 submitted at least 50 service authorization requests to
7005+13 its service authorization program in the preceding
7006+14 calendar year and the service authorization program
7007+15 approved at least 90% of all service authorization
7008+16 requests, regardless of the type of health care services
7009+17 requested.
7010+18 (2) Require that service authorization exemptions be
7011+19 limited to services provided in an inpatient or outpatient
7012+20 hospital setting inclusive of hospital-based clinics.
7013+21 Service authorization exemptions under this Section shall
7014+22 not pertain to pharmacy services and durable medical
7015+23 equipment and supplies.
7016+24 (3) The service authorization exemption shall be valid
7017+25 for at least one year, shall be made by each Medicaid MCO
7018+26 or its URO, and shall be binding on the Medicaid MCO and
7019+
7020+
7021+
7022+
7023+
7024+ SB3268 Enrolled - 198 - LRB103 39338 KTG 69500 b
7025+
7026+
7027+SB3268 Enrolled- 199 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 199 - LRB103 39338 KTG 69500 b
7028+ SB3268 Enrolled - 199 - LRB103 39338 KTG 69500 b
7029+1 its URO.
7030+2 (4) The provider shall be required to continue to
7031+3 document medically necessary, clinically appropriate care
7032+4 and submit such documentation to the Medicaid MCO for the
7033+5 purpose of continuous performance monitoring. If a
7034+6 provider fails to maintain the 90% service authorization
7035+7 standard, as determined on no more frequent a basis than
7036+8 bi-annually, the provider's service authorization
7037+9 exemption is subject to temporary or permanent suspension.
7038+10 (5) Require that each Medicaid MCO publish on its
7039+11 provider portal a list of all providers that have
7040+12 qualified for a service authorization exemption or
7041+13 indicate that a provider has qualified for a service
7042+14 authorization exemption on its provider-facing provider
7043+15 roster.
7044+16 (6) Require that no later than December 1 of each
7045+17 calendar year, each Medicaid MCO shall provide written
7046+18 notification to all providers who qualify for a service
7047+19 authorization exemption, for the subsequent calendar year.
7048+20 (7) Require that each Medicaid MCO or its URO use the
7049+21 policies and guidelines published by the Department to
7050+22 evaluate whether a provider meets the criteria to qualify
7051+23 for a service authorization exemption and the conditions
7052+24 under which a service authorization exemption may be
7053+25 rescinded, including review of the provider's service
7054+26 authorization determinations during the preceding calendar
7055+
7056+
7057+
7058+
7059+
7060+ SB3268 Enrolled - 199 - LRB103 39338 KTG 69500 b
7061+
7062+
7063+SB3268 Enrolled- 200 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 200 - LRB103 39338 KTG 69500 b
7064+ SB3268 Enrolled - 200 - LRB103 39338 KTG 69500 b
7065+1 year.
7066+2 (8) Require each Medicaid MCO to provide the
7067+3 Department a list of all providers who were denied a
7068+4 service authorization exemption or had a previously
7069+5 granted service authorization exemption suspended, with
7070+6 such denials being subject to an annual audit conducted by
7071+7 an independent third-party URO to ensure their
7072+8 appropriateness.
7073+9 (A) The independent third-party URO shall issue a
7074+10 written report consistent with this paragraph.
7075+11 (B) The independent third-party URO shall not be
7076+12 owned by, affiliated with, or employed by any Medicaid
7077+13 MCO or its contracted URO, nor shall it have any
7078+14 financial interest in the Medicaid MCO's service
7079+15 authorization exemption program.
7080+16 (d) Each Medicaid MCO must have a standard method to
7081+17 accept and process professional claims and facility claims, as
7082+18 billed by the provider, for a health care service that is
7083+19 rendered, prescribed, or ordered by a provider granted a
7084+20 service authorization exemption, except in cases of fraud.
7085+21 (e) A service authorization program shall not deny,
7086+22 partially deny, reduce the level of care, or otherwise limit
7087+23 reimbursement to the rendering or supervising provider,
7088+24 including the rendering facility, for health care services
7089+25 ordered by a provider who qualifies for a service
7090+26 authorization exemption, except in cases of fraud.
7091+
7092+
7093+
7094+
7095+
7096+ SB3268 Enrolled - 200 - LRB103 39338 KTG 69500 b
7097+
7098+
7099+SB3268 Enrolled- 201 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 201 - LRB103 39338 KTG 69500 b
7100+ SB3268 Enrolled - 201 - LRB103 39338 KTG 69500 b
7101+1 (f) This Section is repealed on December 31, 2030.
7102+2 ARTICLE 155.
7103+3 Section 155-5. The Community-Integrated Living
7104+4 Arrangements Licensure and Certification Act is amended by
7105+5 adding Section 13.3 as follows:
7106+6 (210 ILCS 135/13.3 new)
7107+7 Sec. 13.3. Community-integrated living arrangement per
7108+8 diem reimbursement. As used in this Section, "medical absence"
7109+9 means a situation in which a resident is temporarily absent
7110+10 from a community-integrated living arrangement to receive
7111+11 medical treatment or for other reasons that have been
7112+12 recommended by third-party medical personnel, including, but
7113+13 not limited to, hospitalizations, placements in short-term
7114+14 stabilization homes or State-operated facilities, stays in
7115+15 nursing facilities, rehabilitation in long-term care
7116+16 facilities, or other absences for legitimate medical reasons.
7117+17 Beginning January 1, 2025, the Department's Division of
7118+18 Developmental Disabilities shall provide 100% of the per diem
7119+19 reimbursement to a 24-hour community-integrated living
7120+20 arrangement provider for up to 20 days for any resident
7121+21 requiring a medical absence. During the medical absence, the
7122+22 provider shall hold the bed for the resident. After the
7123+23 medical absence, the resident shall return to the
7124+
7125+
7126+
7127+
7128+
7129+ SB3268 Enrolled - 201 - LRB103 39338 KTG 69500 b
7130+
7131+
7132+SB3268 Enrolled- 202 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 202 - LRB103 39338 KTG 69500 b
7133+ SB3268 Enrolled - 202 - LRB103 39338 KTG 69500 b
7134+1 community-integrated living arrangement when the resident is
7135+2 medically able to return in order for the provider to receive
7136+3 the full per diem reimbursement for the absent days. The per
7137+4 diem reimbursement shall be in addition to the existing
7138+5 occupancy factor policy set by the Division of Developmental
7139+6 Disabilities.
7140+7 ARTICLE 160.
7141+8 Section 160-5. The Illinois Public Aid Code is amended by
7142+9 adding Section 5-5.12f as follows:
7143+10 (305 ILCS 5/5-5.12f new)
7144+11 Sec. 5-5.12f. Prescription drugs for mental illness; no
7145+12 utilization or prior approval mandates.
7146+13 (a) Notwithstanding any other provision of this Code to
7147+14 the contrary, except as otherwise provided in subsection (b),
7148+15 for the purpose of removing barriers to the timely treatment
7149+16 of serious mental illnesses, prior authorization mandates and
7150+17 utilization management controls shall not be imposed under the
7151+18 fee-for-service and managed care medical assistance programs
7152+19 on any FDA-approved prescription drug that is recognized by a
7153+20 generally accepted standard medical reference as effective in
7154+21 the treatment of conditions specified in the most recent
7155+22 Diagnostic and Statistical Manual of Mental Disorders
7156+23 published by the American Psychiatric Association if a
7157+
7158+
7159+
7160+
7161+
7162+ SB3268 Enrolled - 202 - LRB103 39338 KTG 69500 b
7163+
7164+
7165+SB3268 Enrolled- 203 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 203 - LRB103 39338 KTG 69500 b
7166+ SB3268 Enrolled - 203 - LRB103 39338 KTG 69500 b
7167+1 preferred or non-preferred drug is prescribed to an adult
7168+2 patient to treat serious mental illness and one of the
7169+3 following applies:
7170+4 (1) the patient has changed providers, including, but
7171+5 not limited to, a change from an inpatient to an
7172+6 outpatient provider, and is stable on the drug that has
7173+7 been previously prescribed, and received prior
7174+8 authorization, if required;
7175+9 (2) the patient has changed insurance coverage and is
7176+10 stable on the drug that has been previously prescribed and
7177+11 received prior authorization under the previous source of
7178+12 coverage; or
7179+13 (3) subject to federal law on maximum dosage limits
7180+14 and safety edits adopted by the Department's Drug and
7181+15 Therapeutics Board, including those safety edits and
7182+16 limits needed to comply with federal requirements
7183+17 contained in 42 CFR 456.703, the patient has previously
7184+18 been prescribed and obtained prior authorization for the
7185+19 drug and the prescription modifies the dosage, dosage
7186+20 frequency, or both, of the drug as part of the same
7187+21 treatment for which the drug was previously prescribed.
7188+22 (b) The following safety edits shall be permitted for
7189+23 prescription drugs covered under this Section:
7190+24 (1) clinically appropriate drug utilization review
7191+25 (DUR) edits, including, but not limited to, drug-to-drug,
7192+26 drug-age, and drug-dose;
7193+
7194+
7195+
7196+
7197+
7198+ SB3268 Enrolled - 203 - LRB103 39338 KTG 69500 b
7199+
7200+
7201+SB3268 Enrolled- 204 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 204 - LRB103 39338 KTG 69500 b
7202+ SB3268 Enrolled - 204 - LRB103 39338 KTG 69500 b
7203+1 (2) generic drug substitution if a generic drug is
7204+2 available for the prescribed medication in the same dosage
7205+3 and formulation; and
7206+4 (3) any utilization management control that is
7207+5 necessary for the Department to comply with any current
7208+6 consent decrees or federal waivers.
7209+7 (c) As used in this Section, "serious mental illness"
7210+8 means any one or more of the following diagnoses and
7211+9 International Classification of Diseases, Tenth Revision,
7212+10 Clinical Modification (ICD-10-CM) codes listed by the
7213+11 Department of Human Services' Division of Mental Health, as
7214+12 amended, on its official website:
7215+13 (1) Delusional Disorder (F22)
7216+14 (2) Brief Psychotic Disorder (F23)
7217+15 (3) Schizophreniform Disorder (F20.81)
7218+16 (4) Schizophrenia (F20.9)
7219+17 (5) Schizoaffective Disorder (F25.x)
7220+18 (6) Catatonia Associated with Another Mental Disorder
7221+19 (Catatonia Specifier) (F06.1)
7222+20 (7) Other Specified Schizophrenia Spectrum and Other
7223+21 Psychotic Disorder (F28)
7224+22 (8) Unspecified Schizophrenia Spectrum and Other
7225+23 Psychotic Disorder (F29)
7226+24 (9) Bipolar I Disorder (F31.xx)
7227+25 (10) Bipolar II Disorder (F31.81)
7228+26 (11) Cyclothymic Disorder (F34.0)
7229+
7230+
7231+
7232+
7233+
7234+ SB3268 Enrolled - 204 - LRB103 39338 KTG 69500 b
7235+
7236+
7237+SB3268 Enrolled- 205 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 205 - LRB103 39338 KTG 69500 b
7238+ SB3268 Enrolled - 205 - LRB103 39338 KTG 69500 b
7239+1 (12) Unspecified Bipolar and Related Disorder (F31.9)
7240+2 (13) Disruptive Mood Dysregulation Disorder (F34.8)
7241+3 (14) Major Depressive Disorder Single episode (F32.xx)
7242+4 (15) Major Depressive Disorder, Recurrent episode
7243+5 (F33.xx)
7244+6 (16) Obsessive-Compulsive Disorder (F42)
7245+7 (17) Posttraumatic Stress Disorder (F43.10)
7246+8 (18) Anorexia Nervosa (F50.0x)
7247+9 (19) Bulimia Nervosa (F50.2)
7248+10 (20) Postpartum Depression (F53.0)
7249+11 (21) Puerperal Psychosis (F53.1)
7250+12 (22) Factitious Disorder Imposed on Another (F68.A)
7251+13 (d) Notwithstanding any other provision of law, nothing in
7252+14 this Section shall not be construed to conflict with Section
7253+15 1927(a)(1) and (b)(1)(A) of the federal Social Security Act
7254+16 and any implementing regulations and agreements.
7255+17 ARTICLE 165.
7256+18 Section 165-5. The Illinois Public Aid Code is amended by
7257+19 changing Section 5-5.01a as follows:
7258+20 (305 ILCS 5/5-5.01a)
7259+21 Sec. 5-5.01a. Supportive living facilities program.
7260+22 (a) The Department shall establish and provide oversight
7261+23 for a program of supportive living facilities that seek to
7262+
7263+
7264+
7265+
7266+
7267+ SB3268 Enrolled - 205 - LRB103 39338 KTG 69500 b
7268+
7269+
7270+SB3268 Enrolled- 206 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 206 - LRB103 39338 KTG 69500 b
7271+ SB3268 Enrolled - 206 - LRB103 39338 KTG 69500 b
7272+1 promote resident independence, dignity, respect, and
7273+2 well-being in the most cost-effective manner.
7274+3 A supportive living facility is (i) a free-standing
7275+4 facility or (ii) a distinct physical and operational entity
7276+5 within a mixed-use building that meets the criteria
7277+6 established in subsection (d). A supportive living facility
7278+7 integrates housing with health, personal care, and supportive
7279+8 services and is a designated setting that offers residents
7280+9 their own separate, private, and distinct living units.
7281+10 Sites for the operation of the program shall be selected
7282+11 by the Department based upon criteria that may include the
7283+12 need for services in a geographic area, the availability of
7284+13 funding, and the site's ability to meet the standards.
7285+14 (b) Beginning July 1, 2014, subject to federal approval,
7286+15 the Medicaid rates for supportive living facilities shall be
7287+16 equal to the supportive living facility Medicaid rate
7288+17 effective on June 30, 2014 increased by 8.85%. Once the
7289+18 assessment imposed at Article V-G of this Code is determined
7290+19 to be a permissible tax under Title XIX of the Social Security
7291+20 Act, the Department shall increase the Medicaid rates for
7292+21 supportive living facilities effective on July 1, 2014 by
7293+22 9.09%. The Department shall apply this increase retroactively
7294+23 to coincide with the imposition of the assessment in Article
7295+24 V-G of this Code in accordance with the approval for federal
7296+25 financial participation by the Centers for Medicare and
7297+26 Medicaid Services.
7298+
7299+
7300+
7301+
7302+
7303+ SB3268 Enrolled - 206 - LRB103 39338 KTG 69500 b
7304+
7305+
7306+SB3268 Enrolled- 207 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 207 - LRB103 39338 KTG 69500 b
7307+ SB3268 Enrolled - 207 - LRB103 39338 KTG 69500 b
7308+1 The Medicaid rates for supportive living facilities
7309+2 effective on July 1, 2017 must be equal to the rates in effect
7310+3 for supportive living facilities on June 30, 2017 increased by
7311+4 2.8%.
7312+5 The Medicaid rates for supportive living facilities
7313+6 effective on July 1, 2018 must be equal to the rates in effect
7314+7 for supportive living facilities on June 30, 2018.
7315+8 Subject to federal approval, the Medicaid rates for
7316+9 supportive living services on and after July 1, 2019 must be at
7317+10 least 54.3% of the average total nursing facility services per
7318+11 diem for the geographic areas defined by the Department while
7319+12 maintaining the rate differential for dementia care and must
7320+13 be updated whenever the total nursing facility service per
7321+14 diems are updated. Beginning July 1, 2022, upon the
7322+15 implementation of the Patient Driven Payment Model, Medicaid
7323+16 rates for supportive living services must be at least 54.3% of
7324+17 the average total nursing services per diem rate for the
7325+18 geographic areas. For purposes of this provision, the average
7326+19 total nursing services per diem rate shall include all add-ons
7327+20 for nursing facilities for the geographic area provided for in
7328+21 Section 5-5.2. The rate differential for dementia care must be
7329+22 maintained in these rates and the rates shall be updated
7330+23 whenever nursing facility per diem rates are updated.
7331+24 Subject to federal approval, beginning January 1, 2024,
7332+25 the dementia care rate for supportive living services must be
7333+26 no less than the non-dementia care supportive living services
7334+
7335+
7336+
7337+
7338+
7339+ SB3268 Enrolled - 207 - LRB103 39338 KTG 69500 b
7340+
7341+
7342+SB3268 Enrolled- 208 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 208 - LRB103 39338 KTG 69500 b
7343+ SB3268 Enrolled - 208 - LRB103 39338 KTG 69500 b
7344+1 rate multiplied by 1.5.
7345+2 (c) The Department may adopt rules to implement this
7346+3 Section. Rules that establish or modify the services,
7347+4 standards, and conditions for participation in the program
7348+5 shall be adopted by the Department in consultation with the
7349+6 Department on Aging, the Department of Rehabilitation
7350+7 Services, and the Department of Mental Health and
7351+8 Developmental Disabilities (or their successor agencies).
7352+9 (d) Subject to federal approval by the Centers for
7353+10 Medicare and Medicaid Services, the Department shall accept
7354+11 for consideration of certification under the program any
7355+12 application for a site or building where distinct parts of the
7356+13 site or building are designated for purposes other than the
7357+14 provision of supportive living services, but only if:
7358+15 (1) those distinct parts of the site or building are
7359+16 not designated for the purpose of providing assisted
7360+17 living services as required under the Assisted Living and
7361+18 Shared Housing Act;
7362+19 (2) those distinct parts of the site or building are
7363+20 completely separate from the part of the building used for
7364+21 the provision of supportive living program services,
7365+22 including separate entrances;
7366+23 (3) those distinct parts of the site or building do
7367+24 not share any common spaces with the part of the building
7368+25 used for the provision of supportive living program
7369+26 services; and
7370+
7371+
7372+
7373+
7374+
7375+ SB3268 Enrolled - 208 - LRB103 39338 KTG 69500 b
7376+
7377+
7378+SB3268 Enrolled- 209 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 209 - LRB103 39338 KTG 69500 b
7379+ SB3268 Enrolled - 209 - LRB103 39338 KTG 69500 b
7380+1 (4) those distinct parts of the site or building do
7381+2 not share staffing with the part of the building used for
7382+3 the provision of supportive living program services.
7383+4 (e) Facilities or distinct parts of facilities which are
7384+5 selected as supportive living facilities and are in good
7385+6 standing with the Department's rules are exempt from the
7386+7 provisions of the Nursing Home Care Act and the Illinois
7387+8 Health Facilities Planning Act.
7388+9 (f) Section 9817 of the American Rescue Plan Act of 2021
7389+10 (Public Law 117-2) authorizes a 10% enhanced federal medical
7390+11 assistance percentage for supportive living services for a
7391+12 12-month period from April 1, 2021 through March 31, 2022.
7392+13 Subject to federal approval, including the approval of any
7393+14 necessary waiver amendments or other federally required
7394+15 documents or assurances, for a 12-month period the Department
7395+16 must pay a supplemental $26 per diem rate to all supportive
7396+17 living facilities with the additional federal financial
7397+18 participation funds that result from the enhanced federal
7398+19 medical assistance percentage from April 1, 2021 through March
7399+20 31, 2022. The Department may issue parameters around how the
7400+21 supplemental payment should be spent, including quality
7401+22 improvement activities. The Department may alter the form,
7402+23 methods, or timeframes concerning the supplemental per diem
7403+24 rate to comply with any subsequent changes to federal law,
7404+25 changes made by guidance issued by the federal Centers for
7405+26 Medicare and Medicaid Services, or other changes necessary to
7406+
7407+
7408+
7409+
7410+
7411+ SB3268 Enrolled - 209 - LRB103 39338 KTG 69500 b
7412+
7413+
7414+SB3268 Enrolled- 210 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 210 - LRB103 39338 KTG 69500 b
7415+ SB3268 Enrolled - 210 - LRB103 39338 KTG 69500 b
7416+1 receive the enhanced federal medical assistance percentage.
7417+2 (g) All applications for the expansion of supportive
7418+3 living dementia care settings involving sites not approved by
7419+4 the Department on January 1, 2024 (the effective date of
7420+5 Public Act 103-102) this amendatory Act of the 103rd General
7421+6 Assembly may allow new elderly non-dementia units in addition
7422+7 to new dementia care units. The Department may approve such
7423+8 applications only if the application has: (1) no more than one
7424+9 non-dementia care unit for each dementia care unit and (2) the
7425+10 site is not located within 4 miles of an existing supportive
7426+11 living program site in Cook County (including the City of
7427+12 Chicago), not located within 12 miles of an existing
7428+13 supportive living program site in DuPage County, Kane County,
7429+14 Lake County, McHenry County, or Will County, or not located
7430+15 within 25 miles of an existing supportive living program site
7431+16 in any other county.
7432+17 (h) As stated in the supportive living program home and
7433+18 community-based service waiver approved by the federal Centers
7434+19 for Medicare and Medicaid Services, and beginning July 1,
7435+20 2025, the Department must maintain the rate add-on implemented
7436+21 on January 1, 2023 for the provision of 2 meals per day at no
7437+22 less than $6.15 per day.
7438+23 (Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
7439+24 103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
7440+25 Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)
7441+
7442+
7443+
7444+
7445+
7446+ SB3268 Enrolled - 210 - LRB103 39338 KTG 69500 b
7447+
7448+
7449+SB3268 Enrolled- 211 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 211 - LRB103 39338 KTG 69500 b
7450+ SB3268 Enrolled - 211 - LRB103 39338 KTG 69500 b
7451+1 ARTICLE 170.
7452+2 Section 170-5. The Illinois Public Aid Code is amended by
7453+3 adding Section 5-2.06a as follows:
7454+4 (305 ILCS 5/5-2.06a new)
7455+5 Sec. 5-2.06a. Medically fragile children; reimbursement
7456+6 for legally responsible family caregivers. By January 1, 2025,
7457+7 the Department of Healthcare and Family Services shall apply
7458+8 for a Home and Community-Based Services State Plan amendment
7459+9 and any federal waiver necessary to reimburse legally
7460+10 responsible family caregivers as providers of personal care or
7461+11 home health aide services under the Illinois Title XIX State
7462+12 Plan Home and Community-Based Services benefit and the home
7463+13 and community-based services waiver program authorized under
7464+14 Section 1915(c) of the Social Security Act for persons who are
7465+15 medically fragile and technology dependent. To be eligible for
7466+16 reimbursement under this Section, a legally responsible family
7467+17 caregiver must be a certified nursing assistant or certified
7468+18 nurse aide and must provide services to a medically fragile
7469+19 relative who is receiving in-home shift nursing services
7470+20 coordinated by the University of Illinois at Chicago, Division
7471+21 of Specialized Care for Children. Upon federal approval of the
7472+22 State Plan amendment and waiver, the Department shall
7473+23 promulgate rules that define who qualifies for reimbursement
7474+24 as a legally responsible family caregiver, specify which
7475+
7476+
7477+
7478+
7479+
7480+ SB3268 Enrolled - 211 - LRB103 39338 KTG 69500 b
7481+
7482+
7483+SB3268 Enrolled- 212 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 212 - LRB103 39338 KTG 69500 b
7484+ SB3268 Enrolled - 212 - LRB103 39338 KTG 69500 b
7485+1 personal care and home health aide services are eligible for
7486+2 reimbursement if the provider is a legally responsible family
7487+3 caregiver, establish oversight policies to ensure legally
7488+4 responsible family caregivers meet and comply with licensing
7489+5 and program requirements, and adopt any other policies or
7490+6 procedures necessary to implement this Section.
7491+7 ARTICLE 175.
7492+8 Section 175-5. The Illinois Public Aid Code is amended by
7493+9 changing Section 5-5.5 as follows:
7494+10 (305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5)
7495+11 Sec. 5-5.5. Elements of Payment Rate.
7496+12 (a) The Department of Healthcare and Family Services shall
7497+13 develop a prospective method for determining payment rates for
7498+14 nursing facility and ICF/DD services in nursing facilities
7499+15 composed of the following cost elements:
7500+16 (1) Standard Services, with the cost of this component
7501+17 being determined by taking into account the actual costs
7502+18 to the facilities of these services subject to cost
7503+19 ceilings to be defined in the Department's rules.
7504+20 (2) Resident Services, with the cost of this component
7505+21 being determined by taking into account the actual costs,
7506+22 needs and utilization of these services, as derived from
7507+23 an assessment of the resident needs in the nursing
7508+
7509+
7510+
7511+
7512+
7513+ SB3268 Enrolled - 212 - LRB103 39338 KTG 69500 b
7514+
7515+
7516+SB3268 Enrolled- 213 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 213 - LRB103 39338 KTG 69500 b
7517+ SB3268 Enrolled - 213 - LRB103 39338 KTG 69500 b
7518+1 facilities.
7519+2 (3) Ancillary Services, with the payment rate being
7520+3 developed for each individual type of service. Payment
7521+4 shall be made only when authorized under procedures
7522+5 developed by the Department of Healthcare and Family
7523+6 Services.
7524+7 (4) Nurse's Aide Training, with the cost of this
7525+8 component being determined by taking into account the
7526+9 actual cost to the facilities of such training.
7527+10 (5) Real Estate Taxes, with the cost of this component
7528+11 being determined by taking into account the figures
7529+12 contained in the most currently available cost reports
7530+13 (with no imposition of maximums) updated to the midpoint
7531+14 of the current rate year for long term care services
7532+15 rendered between July 1, 1984 and June 30, 1985, and with
7533+16 the cost of this component being determined by taking into
7534+17 account the actual 1983 taxes for which the nursing homes
7535+18 were assessed (with no imposition of maximums) updated to
7536+19 the midpoint of the current rate year for long term care
7537+20 services rendered between July 1, 1985 and June 30, 1986.
7538+21 (b) In developing a prospective method for determining
7539+22 payment rates for nursing facility and ICF/DD services in
7540+23 nursing facilities and ICF/DDs, the Department of Healthcare
7541+24 and Family Services shall consider the following cost
7542+25 elements:
7543+26 (1) Reasonable capital cost determined by utilizing
7544+
7545+
7546+
7547+
7548+
7549+ SB3268 Enrolled - 213 - LRB103 39338 KTG 69500 b
7550+
7551+
7552+SB3268 Enrolled- 214 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 214 - LRB103 39338 KTG 69500 b
7553+ SB3268 Enrolled - 214 - LRB103 39338 KTG 69500 b
7554+1 incurred interest rate and the current value of the
7555+2 investment, including land, utilizing composite rates, or
7556+3 by utilizing such other reasonable cost related methods
7557+4 determined by the Department. However, beginning with the
7558+5 rate reimbursement period effective July 1, 1987, the
7559+6 Department shall be prohibited from establishing,
7560+7 including, and implementing any depreciation factor in
7561+8 calculating the capital cost element.
7562+9 (2) Profit, with the actual amount being produced and
7563+10 accruing to the providers in the form of a return on their
7564+11 total investment, on the basis of their ability to
7565+12 economically and efficiently deliver a type of service.
7566+13 The method of payment may assure the opportunity for a
7567+14 profit, but shall not guarantee or establish a specific
7568+15 amount as a cost.
7569+16 (c) The Illinois Department may implement the amendatory
7570+17 changes to this Section made by this amendatory Act of 1991
7571+18 through the use of emergency rules in accordance with the
7572+19 provisions of Section 5.02 of the Illinois Administrative
7573+20 Procedure Act. For purposes of the Illinois Administrative
7574+21 Procedure Act, the adoption of rules to implement the
7575+22 amendatory changes to this Section made by this amendatory Act
7576+23 of 1991 shall be deemed an emergency and necessary for the
7577+24 public interest, safety and welfare.
7578+25 (d) No later than January 1, 2001, the Department of
7579+26 Public Aid shall file with the Joint Committee on
7580+
7581+
7582+
7583+
7584+
7585+ SB3268 Enrolled - 214 - LRB103 39338 KTG 69500 b
7586+
7587+
7588+SB3268 Enrolled- 215 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 215 - LRB103 39338 KTG 69500 b
7589+ SB3268 Enrolled - 215 - LRB103 39338 KTG 69500 b
7590+1 Administrative Rules, pursuant to the Illinois Administrative
7591+2 Procedure Act, a proposed rule, or a proposed amendment to an
7592+3 existing rule, regarding payment for appropriate services,
7593+4 including assessment, care planning, discharge planning, and
7594+5 treatment provided by nursing facilities to residents who have
7595+6 a serious mental illness.
7596+7 (e) On and after July 1, 2012, the Department shall reduce
7597+8 any rate of reimbursement for services or other payments or
7598+9 alter any methodologies authorized by this Code to reduce any
7599+10 rate of reimbursement for services or other payments in
7600+11 accordance with Section 5-5e.
7601+12 (f) Beginning January 1, 2025, the real estate tax
7602+13 component of the payment rate shall be updated using the most
7603+14 recent property tax bill on file with the Department for
7604+15 facilities licensed under the Nursing Home Care Act and
7605+16 facilities licensed under the Specialized Mental Health
7606+17 Rehabilitation Act of 2013. The per diem rate shall be
7607+18 computed by dividing the real estate tax costs reported in the
7608+19 cost report inflated to the midpoint of the rate year by the
7609+20 total number of patient days reported in the same cost report.
7610+21 Computation of the real estate tax component shall be based on
7611+22 capital days.
7612+23 (Source: P.A. 96-1123, eff. 1-1-11; 96-1530, eff. 2-16-11;
7613+24 97-689, eff. 6-14-12.)
7614+25 ARTICLE 180.
7615+
7616+
7617+
7618+
7619+
7620+ SB3268 Enrolled - 215 - LRB103 39338 KTG 69500 b
7621+
7622+
7623+SB3268 Enrolled- 216 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 216 - LRB103 39338 KTG 69500 b
7624+ SB3268 Enrolled - 216 - LRB103 39338 KTG 69500 b
7625+1 Section 180-5. The Illinois Public Aid Code is amended by
7626+2 changing Section 5-5.2 as follows:
7627+3 (305 ILCS 5/5-5.2)
7628+4 Sec. 5-5.2. Payment.
7629+5 (a) All nursing facilities that are grouped pursuant to
7630+6 Section 5-5.1 of this Act shall receive the same rate of
7631+7 payment for similar services.
7632+8 (b) It shall be a matter of State policy that the Illinois
7633+9 Department shall utilize a uniform billing cycle throughout
7634+10 the State for the long-term care providers.
7635+11 (c) (Blank).
7636+12 (c-1) Notwithstanding any other provisions of this Code,
7637+13 the methodologies for reimbursement of nursing services as
7638+14 provided under this Article shall no longer be applicable for
7639+15 bills payable for nursing services rendered on or after a new
7640+16 reimbursement system based on the Patient Driven Payment Model
7641+17 (PDPM) has been fully operationalized, which shall take effect
7642+18 for services provided on or after the implementation of the
7643+19 PDPM reimbursement system begins. For the purposes of Public
7644+20 Act 102-1035 this amendatory Act of the 102nd General
7645+21 Assembly, the implementation date of the PDPM reimbursement
7646+22 system and all related provisions shall be July 1, 2022 if the
7647+23 following conditions are met: (i) the Centers for Medicare and
7648+24 Medicaid Services has approved corresponding changes in the
7649+
7650+
7651+
7652+
7653+
7654+ SB3268 Enrolled - 216 - LRB103 39338 KTG 69500 b
7655+
7656+
7657+SB3268 Enrolled- 217 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 217 - LRB103 39338 KTG 69500 b
7658+ SB3268 Enrolled - 217 - LRB103 39338 KTG 69500 b
7659+1 reimbursement system and bed assessment; and (ii) the
7660+2 Department has filed rules to implement these changes no later
7661+3 than June 1, 2022. Failure of the Department to file rules to
7662+4 implement the changes provided in Public Act 102-1035 this
7663+5 amendatory Act of the 102nd General Assembly no later than
7664+6 June 1, 2022 shall result in the implementation date being
7665+7 delayed to October 1, 2022.
7666+8 (d) The new nursing services reimbursement methodology
7667+9 utilizing the Patient Driven Payment Model, which shall be
7668+10 referred to as the PDPM reimbursement system, taking effect
7669+11 July 1, 2022, upon federal approval by the Centers for
7670+12 Medicare and Medicaid Services, shall be based on the
7671+13 following:
7672+14 (1) The methodology shall be resident-centered,
7673+15 facility-specific, cost-based, and based on guidance from
7674+16 the Centers for Medicare and Medicaid Services.
7675+17 (2) Costs shall be annually rebased and case mix index
7676+18 quarterly updated. The nursing services methodology will
7677+19 be assigned to the Medicaid enrolled residents on record
7678+20 as of 30 days prior to the beginning of the rate period in
7679+21 the Department's Medicaid Management Information System
7680+22 (MMIS) as present on the last day of the second quarter
7681+23 preceding the rate period based upon the Assessment
7682+24 Reference Date of the Minimum Data Set (MDS).
7683+25 (3) Regional wage adjustors based on the Health
7684+26 Service Areas (HSA) groupings and adjusters in effect on
7685+
7686+
7687+
7688+
7689+
7690+ SB3268 Enrolled - 217 - LRB103 39338 KTG 69500 b
7691+
7692+
7693+SB3268 Enrolled- 218 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 218 - LRB103 39338 KTG 69500 b
7694+ SB3268 Enrolled - 218 - LRB103 39338 KTG 69500 b
7695+1 April 30, 2012 shall be included, except no adjuster shall
7696+2 be lower than 1.06.
7697+3 (4) PDPM nursing case mix indices in effect on March
7698+4 1, 2022 shall be assigned to each resident class at no less
7699+5 than 0.7858 of the Centers for Medicare and Medicaid
7700+6 Services PDPM unadjusted case mix values, in effect on
7701+7 March 1, 2022.
7702+8 (5) The pool of funds available for distribution by
7703+9 case mix and the base facility rate shall be determined
7704+10 using the formula contained in subsection (d-1).
7705+11 (6) The Department shall establish a variable per diem
7706+12 staffing add-on in accordance with the most recent
7707+13 available federal staffing report, currently the Payroll
7708+14 Based Journal, for the same period of time, and if
7709+15 applicable adjusted for acuity using the same quarter's
7710+16 MDS. The Department shall rely on Payroll Based Journals
7711+17 provided to the Department of Public Health to make a
7712+18 determination of non-submission. If the Department is
7713+19 notified by a facility of missing or inaccurate Payroll
7714+20 Based Journal data or an incorrect calculation of
7715+21 staffing, the Department must make a correction as soon as
7716+22 the error is verified for the applicable quarter.
7717+23 Beginning October 1, 2024, the staffing percentage
7718+24 used in the calculation of the per diem staffing add-on
7719+25 shall be its PDPM STRIVE Staffing Ratio which equals: its
7720+26 Reported Total Nurse Staffing Hours Per Resident Per Day
7721+
7722+
7723+
7724+
7725+
7726+ SB3268 Enrolled - 218 - LRB103 39338 KTG 69500 b
7727+
7728+
7729+SB3268 Enrolled- 219 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 219 - LRB103 39338 KTG 69500 b
7730+ SB3268 Enrolled - 219 - LRB103 39338 KTG 69500 b
7731+1 as published in the most recent federal staffing report
7732+2 (the Provider Information File), divided by the facility's
7733+3 PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
7734+4 Staffing Target is equal to .82 times the facility's
7735+5 Illinois Adjusted Facility Case-Mix Hours Per Resident Per
7736+6 Day. A facility's Illinois Adjusted Facility Case Mix
7737+7 Hours Per Resident Per Day is equal to its Case-Mix Total
7738+8 Nurse Staffing Hours Per Resident Per Day (as published in
7739+9 the most recent federal staffing report) times 3.662
7740+10 (which reflects the national resident days-weighted mean
7741+11 Reported Total Nurse Staffing Hours Per Resident Per Day
7742+12 as calculated using the January 2024 federal Provider
7743+13 Information Files), divided by the national resident
7744+14 days-weighted mean Reported Total Nurse Staffing Hours Per
7745+15 Resident Per Day calculated using the most recent federal
7746+16 Provider Information File.
7747+17 (6.5) Beginning July 1, 2024, the paid per diem
7748+18 staffing add-on shall be the paid per diem staffing add-on
7749+19 in effect April 1, 2024. For dates beginning October 1,
7750+20 2024 and through September 30, 2025, the denominator for
7751+21 the staffing percentage shall be the lesser of the
7752+22 facility's PDPM STRIVE Staffing Target and:
7753+23 (A) For the quarter beginning October 1, 2024, the
7754+24 sum of 20% of the facility's PDPM STRIVE Staffing
7755+25 Target and 80% of the facility's Case-Mix Total Nurse
7756+26 Staffing Hours Per Resident Per Day (as published in
7757+
7758+
7759+
7760+
7761+
7762+ SB3268 Enrolled - 219 - LRB103 39338 KTG 69500 b
7763+
7764+
7765+SB3268 Enrolled- 220 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 220 - LRB103 39338 KTG 69500 b
7766+ SB3268 Enrolled - 220 - LRB103 39338 KTG 69500 b
7767+1 the January 2024 federal staffing report).
7768+2 (B) For the quarter beginning January 1, 2025, the
7769+3 sum of 40% of the facility's PDPM STRIVE Staffing
7770+4 Target and 60% of the facility's Case-Mix Total Nurse
7771+5 Staffing Hours Per Resident Per Day (as published in
7772+6 the January 2024 federal staffing report).
7773+7 (C) For the quarter beginning March 1, 2025, the
7774+8 sum of 60% of the facility's PDPM STRIVE Staffing
7775+9 Target and 40% of the facility's Case-Mix Total Nurse
7776+10 Staffing Hours Per Resident Per Day (as published in
7777+11 the January 2024 federal staffing report).
7778+12 (D) For the quarter beginning July 1, 2025, the
7779+13 sum of 80% of the facility's PDPM STRIVE Staffing
7780+14 Target and 20% of the facility's Case-Mix Total Nurse
7781+15 Staffing Hours Per Resident Per Day (as published in
7782+16 the January 2024 federal staffing report).
7783+17 Facilities with at least 70% of the staffing
7784+18 indicated by the STRIVE study shall be paid a per diem
7785+19 add-on of $9, increasing by equivalent steps for each
7786+20 whole percentage point until the facilities reach a per
7787+21 diem of $16.52 $14.88. Facilities with at least 80% of the
7788+22 staffing indicated by the STRIVE study shall be paid a per
7789+23 diem add-on of $16.52 $14.88, increasing by equivalent
7790+24 steps for each whole percentage point until the facilities
7791+25 reach a per diem add-on of $25.77 $23.80. Facilities with
7792+26 at least 92% of the staffing indicated by the STRIVE study
7793+
7794+
7795+
7796+
7797+
7798+ SB3268 Enrolled - 220 - LRB103 39338 KTG 69500 b
7799+
7800+
7801+SB3268 Enrolled- 221 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 221 - LRB103 39338 KTG 69500 b
7802+ SB3268 Enrolled - 221 - LRB103 39338 KTG 69500 b
7803+1 shall be paid a per diem add-on of $25.77 $23.80,
7804+2 increasing by equivalent steps for each whole percentage
7805+3 point until the facilities reach a per diem add-on of
7806+4 $30.98 $29.75. Facilities with at least 100% of the
7807+5 staffing indicated by the STRIVE study shall be paid a per
7808+6 diem add-on of $30.98 $29.75, increasing by equivalent
7809+7 steps for each whole percentage point until the facilities
7810+8 reach a per diem add-on of $36.44 $35.70. Facilities with
7811+9 at least 110% of the staffing indicated by the STRIVE
7812+10 study shall be paid a per diem add-on of $36.44 $35.70,
7813+11 increasing by equivalent steps for each whole percentage
7814+12 point until the facilities reach a per diem add-on of
7815+13 $38.68. Facilities with at least 125% or higher of the
7816+14 staffing indicated by the STRIVE study shall be paid a per
7817+15 diem add-on of $38.68. No Beginning April 1, 2023, no
7818+16 nursing facility's variable staffing per diem add-on shall
7819+17 be reduced by more than 5% in 2 consecutive quarters. For
7820+18 the quarters beginning July 1, 2022 and October 1, 2022,
7821+19 no facility's variable per diem staffing add-on shall be
7822+20 calculated at a rate lower than 85% of the staffing
7823+21 indicated by the STRIVE study. No facility below 70% of
7824+22 the staffing indicated by the STRIVE study shall receive a
7825+23 variable per diem staffing add-on after December 31, 2022.
7826+24 (7) For dates of services beginning July 1, 2022, the
7827+25 PDPM nursing component per diem for each nursing facility
7828+26 shall be the product of the facility's (i) statewide PDPM
7829+
7830+
7831+
7832+
7833+
7834+ SB3268 Enrolled - 221 - LRB103 39338 KTG 69500 b
7835+
7836+
7837+SB3268 Enrolled- 222 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 222 - LRB103 39338 KTG 69500 b
7838+ SB3268 Enrolled - 222 - LRB103 39338 KTG 69500 b
7839+1 nursing base per diem rate, $92.25, adjusted for the
7840+2 facility average PDPM case mix index calculated quarterly
7841+3 and (ii) the regional wage adjuster, and then add the
7842+4 Medicaid access adjustment as defined in (e-3) of this
7843+5 Section. Transition rates for services provided between
7844+6 July 1, 2022 and October 1, 2023 shall be the greater of
7845+7 the PDPM nursing component per diem or:
7846+8 (A) for the quarter beginning July 1, 2022, the
7847+9 RUG-IV nursing component per diem;
7848+10 (B) for the quarter beginning October 1, 2022, the
7849+11 sum of the RUG-IV nursing component per diem
7850+12 multiplied by 0.80 and the PDPM nursing component per
7851+13 diem multiplied by 0.20;
7852+14 (C) for the quarter beginning January 1, 2023, the
7853+15 sum of the RUG-IV nursing component per diem
7854+16 multiplied by 0.60 and the PDPM nursing component per
7855+17 diem multiplied by 0.40;
7856+18 (D) for the quarter beginning April 1, 2023, the
7857+19 sum of the RUG-IV nursing component per diem
7858+20 multiplied by 0.40 and the PDPM nursing component per
7859+21 diem multiplied by 0.60;
7860+22 (E) for the quarter beginning July 1, 2023, the
7861+23 sum of the RUG-IV nursing component per diem
7862+24 multiplied by 0.20 and the PDPM nursing component per
7863+25 diem multiplied by 0.80; or
7864+26 (F) for the quarter beginning October 1, 2023 and
7865+
7866+
7867+
7868+
7869+
7870+ SB3268 Enrolled - 222 - LRB103 39338 KTG 69500 b
7871+
7872+
7873+SB3268 Enrolled- 223 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 223 - LRB103 39338 KTG 69500 b
7874+ SB3268 Enrolled - 223 - LRB103 39338 KTG 69500 b
7875+1 each subsequent quarter, the transition rate shall end
7876+2 and a nursing facility shall be paid 100% of the PDPM
7877+3 nursing component per diem.
7878+4 (d-1) Calculation of base year Statewide RUG-IV nursing
7879+5 base per diem rate.
7880+6 (1) Base rate spending pool shall be:
7881+7 (A) The base year resident days which are
7882+8 calculated by multiplying the number of Medicaid
7883+9 residents in each nursing home as indicated in the MDS
7884+10 data defined in paragraph (4) by 365.
7885+11 (B) Each facility's nursing component per diem in
7886+12 effect on July 1, 2012 shall be multiplied by
7887+13 subsection (A).
7888+14 (C) Thirteen million is added to the product of
7889+15 subparagraph (A) and subparagraph (B) to adjust for
7890+16 the exclusion of nursing homes defined in paragraph
7891+17 (5).
7892+18 (2) For each nursing home with Medicaid residents as
7893+19 indicated by the MDS data defined in paragraph (4),
7894+20 weighted days adjusted for case mix and regional wage
7895+21 adjustment shall be calculated. For each home this
7896+22 calculation is the product of:
7897+23 (A) Base year resident days as calculated in
7898+24 subparagraph (A) of paragraph (1).
7899+25 (B) The nursing home's regional wage adjustor
7900+26 based on the Health Service Areas (HSA) groupings and
7901+
7902+
7903+
7904+
7905+
7906+ SB3268 Enrolled - 223 - LRB103 39338 KTG 69500 b
7907+
7908+
7909+SB3268 Enrolled- 224 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 224 - LRB103 39338 KTG 69500 b
7910+ SB3268 Enrolled - 224 - LRB103 39338 KTG 69500 b
7911+1 adjustors in effect on April 30, 2012.
7912+2 (C) Facility weighted case mix which is the number
7913+3 of Medicaid residents as indicated by the MDS data
7914+4 defined in paragraph (4) multiplied by the associated
7915+5 case weight for the RUG-IV 48 grouper model using
7916+6 standard RUG-IV procedures for index maximization.
7917+7 (D) The sum of the products calculated for each
7918+8 nursing home in subparagraphs (A) through (C) above
7919+9 shall be the base year case mix, rate adjusted
7920+10 weighted days.
7921+11 (3) The Statewide RUG-IV nursing base per diem rate:
7922+12 (A) on January 1, 2014 shall be the quotient of the
7923+13 paragraph (1) divided by the sum calculated under
7924+14 subparagraph (D) of paragraph (2);
7925+15 (B) on and after July 1, 2014 and until July 1,
7926+16 2022, shall be the amount calculated under
7927+17 subparagraph (A) of this paragraph (3) plus $1.76; and
7928+18 (C) beginning July 1, 2022 and thereafter, $7
7929+19 shall be added to the amount calculated under
7930+20 subparagraph (B) of this paragraph (3) of this
7931+21 Section.
7932+22 (4) Minimum Data Set (MDS) comprehensive assessments
7933+23 for Medicaid residents on the last day of the quarter used
7934+24 to establish the base rate.
7935+25 (5) Nursing facilities designated as of July 1, 2012
7936+26 by the Department as "Institutions for Mental Disease"
7937+
7938+
7939+
7940+
7941+
7942+ SB3268 Enrolled - 224 - LRB103 39338 KTG 69500 b
7943+
7944+
7945+SB3268 Enrolled- 225 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 225 - LRB103 39338 KTG 69500 b
7946+ SB3268 Enrolled - 225 - LRB103 39338 KTG 69500 b
7947+1 shall be excluded from all calculations under this
7948+2 subsection. The data from these facilities shall not be
7949+3 used in the computations described in paragraphs (1)
7950+4 through (4) above to establish the base rate.
7951+5 (e) Beginning July 1, 2014, the Department shall allocate
7952+6 funding in the amount up to $10,000,000 for per diem add-ons to
7953+7 the RUGS methodology for dates of service on and after July 1,
7954+8 2014:
7955+9 (1) $0.63 for each resident who scores in I4200
7956+10 Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
7957+11 (2) $2.67 for each resident who scores either a "1" or
7958+12 "2" in any items S1200A through S1200I and also scores in
7959+13 RUG groups PA1, PA2, BA1, or BA2.
7960+14 (e-1) (Blank).
7961+15 (e-2) For dates of services beginning January 1, 2014 and
7962+16 ending September 30, 2023, the RUG-IV nursing component per
7963+17 diem for a nursing home shall be the product of the statewide
7964+18 RUG-IV nursing base per diem rate, the facility average case
7965+19 mix index, and the regional wage adjustor. For dates of
7966+20 service beginning July 1, 2022 and ending September 30, 2023,
7967+21 the Medicaid access adjustment described in subsection (e-3)
7968+22 shall be added to the product.
7969+23 (e-3) A Medicaid Access Adjustment of $4 adjusted for the
7970+24 facility average PDPM case mix index calculated quarterly
7971+25 shall be added to the statewide PDPM nursing per diem for all
7972+26 facilities with annual Medicaid bed days of at least 70% of all
7973+
7974+
7975+
7976+
7977+
7978+ SB3268 Enrolled - 225 - LRB103 39338 KTG 69500 b
7979+
7980+
7981+SB3268 Enrolled- 226 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 226 - LRB103 39338 KTG 69500 b
7982+ SB3268 Enrolled - 226 - LRB103 39338 KTG 69500 b
7983+1 occupied bed days adjusted quarterly. For each new calendar
7984+2 year and for the 6-month period beginning July 1, 2022, the
7985+3 percentage of a facility's occupied bed days comprised of
7986+4 Medicaid bed days shall be determined by the Department
7987+5 quarterly. For dates of service beginning January 1, 2023, the
7988+6 Medicaid Access Adjustment shall be increased to $4.75. This
7989+7 subsection shall be inoperative on and after January 1, 2028.
7990+8 (e-4) Subject to federal approval, on and after January 1,
7991+9 2024, the Department shall increase the rate add-on at
7992+10 paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
7993+11 for ventilator services from $208 per day to $481 per day.
7994+12 Payment is subject to the criteria and requirements under 89
7995+13 Ill. Adm. Code 147.335.
7996+14 (f) (Blank).
7997+15 (g) Notwithstanding any other provision of this Code, on
7998+16 and after July 1, 2012, for facilities not designated by the
7999+17 Department of Healthcare and Family Services as "Institutions
8000+18 for Mental Disease", rates effective May 1, 2011 shall be
8001+19 adjusted as follows:
8002+20 (1) (Blank);
8003+21 (2) (Blank);
8004+22 (3) Facility rates for the capital and support
8005+23 components shall be reduced by 1.7%.
8006+24 (h) Notwithstanding any other provision of this Code, on
8007+25 and after July 1, 2012, nursing facilities designated by the
8008+26 Department of Healthcare and Family Services as "Institutions
8009+
8010+
8011+
8012+
8013+
8014+ SB3268 Enrolled - 226 - LRB103 39338 KTG 69500 b
8015+
8016+
8017+SB3268 Enrolled- 227 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 227 - LRB103 39338 KTG 69500 b
8018+ SB3268 Enrolled - 227 - LRB103 39338 KTG 69500 b
8019+1 for Mental Disease" and "Institutions for Mental Disease" that
8020+2 are facilities licensed under the Specialized Mental Health
8021+3 Rehabilitation Act of 2013 shall have the nursing,
8022+4 socio-developmental, capital, and support components of their
8023+5 reimbursement rate effective May 1, 2011 reduced in total by
8024+6 2.7%.
8025+7 (i) On and after July 1, 2014, the reimbursement rates for
8026+8 the support component of the nursing facility rate for
8027+9 facilities licensed under the Nursing Home Care Act as skilled
8028+10 or intermediate care facilities shall be the rate in effect on
8029+11 June 30, 2014 increased by 8.17%.
8030+12 (i-1) Subject to federal approval, on and after January 1,
8031+13 2024, the reimbursement rates for the support component of the
8032+14 nursing facility rate for facilities licensed under the
8033+15 Nursing Home Care Act as skilled or intermediate care
8034+16 facilities shall be the rate in effect on June 30, 2023
8035+17 increased by 12%.
8036+18 (j) Notwithstanding any other provision of law, subject to
8037+19 federal approval, effective July 1, 2019, sufficient funds
8038+20 shall be allocated for changes to rates for facilities
8039+21 licensed under the Nursing Home Care Act as skilled nursing
8040+22 facilities or intermediate care facilities for dates of
8041+23 services on and after July 1, 2019: (i) to establish, through
8042+24 June 30, 2022 a per diem add-on to the direct care per diem
8043+25 rate not to exceed $70,000,000 annually in the aggregate
8044+26 taking into account federal matching funds for the purpose of
8045+
8046+
8047+
8048+
8049+
8050+ SB3268 Enrolled - 227 - LRB103 39338 KTG 69500 b
8051+
8052+
8053+SB3268 Enrolled- 228 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 228 - LRB103 39338 KTG 69500 b
8054+ SB3268 Enrolled - 228 - LRB103 39338 KTG 69500 b
8055+1 addressing the facility's unique staffing needs, adjusted
8056+2 quarterly and distributed by a weighted formula based on
8057+3 Medicaid bed days on the last day of the second quarter
8058+4 preceding the quarter for which the rate is being adjusted.
8059+5 Beginning July 1, 2022, the annual $70,000,000 described in
8060+6 the preceding sentence shall be dedicated to the variable per
8061+7 diem add-on for staffing under paragraph (6) of subsection
8062+8 (d); and (ii) in an amount not to exceed $170,000,000 annually
8063+9 in the aggregate taking into account federal matching funds to
8064+10 permit the support component of the nursing facility rate to
8065+11 be updated as follows:
8066+12 (1) 80%, or $136,000,000, of the funds shall be used
8067+13 to update each facility's rate in effect on June 30, 2019
8068+14 using the most recent cost reports on file, which have had
8069+15 a limited review conducted by the Department of Healthcare
8070+16 and Family Services and will not hold up enacting the rate
8071+17 increase, with the Department of Healthcare and Family
8072+18 Services.
8073+19 (2) After completing the calculation in paragraph (1),
8074+20 any facility whose rate is less than the rate in effect on
8075+21 June 30, 2019 shall have its rate restored to the rate in
8076+22 effect on June 30, 2019 from the 20% of the funds set
8077+23 aside.
8078+24 (3) The remainder of the 20%, or $34,000,000, shall be
8079+25 used to increase each facility's rate by an equal
8080+26 percentage.
8081+
8082+
8083+
8084+
8085+
8086+ SB3268 Enrolled - 228 - LRB103 39338 KTG 69500 b
8087+
8088+
8089+SB3268 Enrolled- 229 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 229 - LRB103 39338 KTG 69500 b
8090+ SB3268 Enrolled - 229 - LRB103 39338 KTG 69500 b
8091+1 (k) During the first quarter of State Fiscal Year 2020,
8092+2 the Department of Healthcare of Family Services must convene a
8093+3 technical advisory group consisting of members of all trade
8094+4 associations representing Illinois skilled nursing providers
8095+5 to discuss changes necessary with federal implementation of
8096+6 Medicare's Patient-Driven Payment Model. Implementation of
8097+7 Medicare's Patient-Driven Payment Model shall, by September 1,
8098+8 2020, end the collection of the MDS data that is necessary to
8099+9 maintain the current RUG-IV Medicaid payment methodology. The
8100+10 technical advisory group must consider a revised reimbursement
8101+11 methodology that takes into account transparency,
8102+12 accountability, actual staffing as reported under the
8103+13 federally required Payroll Based Journal system, changes to
8104+14 the minimum wage, adequacy in coverage of the cost of care, and
8105+15 a quality component that rewards quality improvements.
8106+16 (l) The Department shall establish per diem add-on
8107+17 payments to improve the quality of care delivered by
8108+18 facilities, including:
8109+19 (1) Incentive payments determined by facility
8110+20 performance on specified quality measures in an initial
8111+21 amount of $70,000,000. Nothing in this subsection shall be
8112+22 construed to limit the quality of care payments in the
8113+23 aggregate statewide to $70,000,000, and, if quality of
8114+24 care has improved across nursing facilities, the
8115+25 Department shall adjust those add-on payments accordingly.
8116+26 The quality payment methodology described in this
8117+
8118+
8119+
8120+
8121+
8122+ SB3268 Enrolled - 229 - LRB103 39338 KTG 69500 b
8123+
8124+
8125+SB3268 Enrolled- 230 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 230 - LRB103 39338 KTG 69500 b
8126+ SB3268 Enrolled - 230 - LRB103 39338 KTG 69500 b
8127+1 subsection must be used for at least State Fiscal Year
8128+2 2023. Beginning with the quarter starting July 1, 2023,
8129+3 the Department may add, remove, or change quality metrics
8130+4 and make associated changes to the quality payment
8131+5 methodology as outlined in subparagraph (E). Facilities
8132+6 designated by the Centers for Medicare and Medicaid
8133+7 Services as a special focus facility or a hospital-based
8134+8 nursing home do not qualify for quality payments.
8135+9 (A) Each quality pool must be distributed by
8136+10 assigning a quality weighted score for each nursing
8137+11 home which is calculated by multiplying the nursing
8138+12 home's quality base period Medicaid days by the
8139+13 nursing home's star rating weight in that period.
8140+14 (B) Star rating weights are assigned based on the
8141+15 nursing home's star rating for the LTS quality star
8142+16 rating. As used in this subparagraph, "LTS quality
8143+17 star rating" means the long-term stay quality rating
8144+18 for each nursing facility, as assigned by the Centers
8145+19 for Medicare and Medicaid Services under the Five-Star
8146+20 Quality Rating System. The rating is a number ranging
8147+21 from 0 (lowest) to 5 (highest).
8148+22 (i) Zero-star or one-star rating has a weight
8149+23 of 0.
8150+24 (ii) Two-star rating has a weight of 0.75.
8151+25 (iii) Three-star rating has a weight of 1.5.
8152+26 (iv) Four-star rating has a weight of 2.5.
8153+
8154+
8155+
8156+
8157+
8158+ SB3268 Enrolled - 230 - LRB103 39338 KTG 69500 b
8159+
8160+
8161+SB3268 Enrolled- 231 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 231 - LRB103 39338 KTG 69500 b
8162+ SB3268 Enrolled - 231 - LRB103 39338 KTG 69500 b
8163+1 (v) Five-star rating has a weight of 3.5.
8164+2 (C) Each nursing home's quality weight score is
8165+3 divided by the sum of all quality weight scores for
8166+4 qualifying nursing homes to determine the proportion
8167+5 of the quality pool to be paid to the nursing home.
8168+6 (D) The quality pool is no less than $70,000,000
8169+7 annually or $17,500,000 per quarter. The Department
8170+8 shall publish on its website the estimated payments
8171+9 and the associated weights for each facility 45 days
8172+10 prior to when the initial payments for the quarter are
8173+11 to be paid. The Department shall assign each facility
8174+12 the most recent and applicable quarter's STAR value
8175+13 unless the facility notifies the Department within 15
8176+14 days of an issue and the facility provides reasonable
8177+15 evidence demonstrating its timely compliance with
8178+16 federal data submission requirements for the quarter
8179+17 of record. If such evidence cannot be provided to the
8180+18 Department, the STAR rating assigned to the facility
8181+19 shall be reduced by one from the prior quarter.
8182+20 (E) The Department shall review quality metrics
8183+21 used for payment of the quality pool and make
8184+22 recommendations for any associated changes to the
8185+23 methodology for distributing quality pool payments in
8186+24 consultation with associations representing long-term
8187+25 care providers, consumer advocates, organizations
8188+26 representing workers of long-term care facilities, and
8189+
8190+
8191+
8192+
8193+
8194+ SB3268 Enrolled - 231 - LRB103 39338 KTG 69500 b
8195+
8196+
8197+SB3268 Enrolled- 232 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 232 - LRB103 39338 KTG 69500 b
8198+ SB3268 Enrolled - 232 - LRB103 39338 KTG 69500 b
8199+1 payors. The Department may establish, by rule, changes
8200+2 to the methodology for distributing quality pool
8201+3 payments.
8202+4 (F) The Department shall disburse quality pool
8203+5 payments from the Long-Term Care Provider Fund on a
8204+6 monthly basis in amounts proportional to the total
8205+7 quality pool payment determined for the quarter.
8206+8 (G) The Department shall publish any changes in
8207+9 the methodology for distributing quality pool payments
8208+10 prior to the beginning of the measurement period or
8209+11 quality base period for any metric added to the
8210+12 distribution's methodology.
8211+13 (2) Payments based on CNA tenure, promotion, and CNA
8212+14 training for the purpose of increasing CNA compensation.
8213+15 It is the intent of this subsection that payments made in
8214+16 accordance with this paragraph be directly incorporated
8215+17 into increased compensation for CNAs. As used in this
8216+18 paragraph, "CNA" means a certified nursing assistant as
8217+19 that term is described in Section 3-206 of the Nursing
8218+20 Home Care Act, Section 3-206 of the ID/DD Community Care
8219+21 Act, and Section 3-206 of the MC/DD Act. The Department
8220+22 shall establish, by rule, payments to nursing facilities
8221+23 equal to Medicaid's share of the tenure wage increments
8222+24 specified in this paragraph for all reported CNA employee
8223+25 hours compensated according to a posted schedule
8224+26 consisting of increments at least as large as those
8225+
8226+
8227+
8228+
8229+
8230+ SB3268 Enrolled - 232 - LRB103 39338 KTG 69500 b
8231+
8232+
8233+SB3268 Enrolled- 233 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 233 - LRB103 39338 KTG 69500 b
8234+ SB3268 Enrolled - 233 - LRB103 39338 KTG 69500 b
8235+1 specified in this paragraph. The increments are as
8236+2 follows: an additional $1.50 per hour for CNAs with at
8237+3 least one and less than 2 years' experience plus another
8238+4 $1 per hour for each additional year of experience up to a
8239+5 maximum of $6.50 for CNAs with at least 6 years of
8240+6 experience. For purposes of this paragraph, Medicaid's
8241+7 share shall be the ratio determined by paid Medicaid bed
8242+8 days divided by total bed days for the applicable time
8243+9 period used in the calculation. In addition, and additive
8244+10 to any tenure increments paid as specified in this
8245+11 paragraph, the Department shall establish, by rule,
8246+12 payments supporting Medicaid's share of the
8247+13 promotion-based wage increments for CNA employee hours
8248+14 compensated for that promotion with at least a $1.50
8249+15 hourly increase. Medicaid's share shall be established as
8250+16 it is for the tenure increments described in this
8251+17 paragraph. Qualifying promotions shall be defined by the
8252+18 Department in rules for an expected 10-15% subset of CNAs
8253+19 assigned intermediate, specialized, or added roles such as
8254+20 CNA trainers, CNA scheduling "captains", and CNA
8255+21 specialists for resident conditions like dementia or
8256+22 memory care or behavioral health.
8257+23 (m) The Department shall work with nursing facility
8258+24 industry representatives to design policies and procedures to
8259+25 permit facilities to address the integrity of data from
8260+26 federal reporting sites used by the Department in setting
8261+
8262+
8263+
8264+
8265+
8266+ SB3268 Enrolled - 233 - LRB103 39338 KTG 69500 b
8267+
8268+
8269+SB3268 Enrolled- 234 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 234 - LRB103 39338 KTG 69500 b
8270+ SB3268 Enrolled - 234 - LRB103 39338 KTG 69500 b
8271+1 facility rates.
8272+2 (Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
8273+3 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
8274+4 Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
8275+5 Section 50-5, eff. 1-1-24; revised 12-15-23.)
8276+6 ARTICLE 185.
8277+7 Section 185-5. The Illinois Public Aid Code is amended by
8278+8 changing Section 5-5a.1 as follows:
8279+9 (305 ILCS 5/5-5a.1)
8280+10 Sec. 5-5a.1. Telehealth services for persons with
8281+11 intellectual and developmental disabilities. The Department
8282+12 shall file an amendment to the Home and Community-Based
8283+13 Services Waiver Program for Adults with Developmental
8284+14 Disabilities authorized under Section 1915(c) of the Social
8285+15 Security Act to incorporate telehealth services administered
8286+16 by a provider of telehealth services that demonstrates
8287+17 knowledge and experience in providing medical and emergency
8288+18 services for persons with intellectual and developmental
8289+19 disabilities. For dates of service on and after January 1,
8290+20 2025, the Department shall pay negotiated, agreed upon
8291+21 administrative fees associated with implementing telehealth
8292+22 services for persons with intellectual and developmental
8293+23 disabilities who are receiving Community Integrated Living
8294+
8295+
8296+
8297+
8298+
8299+ SB3268 Enrolled - 234 - LRB103 39338 KTG 69500 b
8300+
8301+
8302+SB3268 Enrolled- 235 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 235 - LRB103 39338 KTG 69500 b
8303+ SB3268 Enrolled - 235 - LRB103 39338 KTG 69500 b
8304+1 Arrangement residential services under the Home and
8305+2 Community-Based Services Waiver Program for Adults with
8306+3 Developmental Disabilities. The implementation of telehealth
8307+4 services shall not impede the choice of any individual
8308+5 receiving waiver-funded services through the Home and
8309+6 Community-Based Services Waiver Program for Adults with
8310+7 Developmental Disabilities to receive in-person health care
8311+8 services at any time. The Department shall ensure individuals
8312+9 enrolled in the waiver, or their guardians, request to opt-in
8313+10 to these services. For individuals who opt in, this service
8314+11 shall be included in the individual's person-centered plan.
8315+12 The use of telehealth services shall not be used for the
8316+13 convenience of staff at any time nor shall it replace primary
8317+14 care physician services. The Department shall pay
8318+15 administrative fees associated with implementing telehealth
8319+16 services for all persons with intellectual and developmental
8320+17 disabilities who are receiving services under the Home and
8321+18 Community-Based Services Waiver Program for Adults with
8322+19 Developmental Disabilities.
8323+20 (Source: P.A. 103-102, eff. 7-1-23.)
8324+21 ARTICLE 190.
8325+22 Section 190-5. The Pharmacy Practice Act is amended by
8326+23 changing Sections 3 and 9.6 as follows:
8327+
8328+
8329+
8330+
8331+
8332+ SB3268 Enrolled - 235 - LRB103 39338 KTG 69500 b
8333+
8334+
8335+SB3268 Enrolled- 236 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 236 - LRB103 39338 KTG 69500 b
8336+ SB3268 Enrolled - 236 - LRB103 39338 KTG 69500 b
8337+1 (225 ILCS 85/3)
8338+2 (Section scheduled to be repealed on January 1, 2028)
8339+3 Sec. 3. Definitions. For the purpose of this Act, except
8340+4 where otherwise limited therein:
8341+5 (a) "Pharmacy" or "drugstore" means and includes every
8342+6 store, shop, pharmacy department, or other place where
8343+7 pharmacist care is provided by a pharmacist (1) where drugs,
8344+8 medicines, or poisons are dispensed, sold or offered for sale
8345+9 at retail, or displayed for sale at retail; or (2) where
8346+10 prescriptions of physicians, dentists, advanced practice
8347+11 registered nurses, physician assistants, veterinarians,
8348+12 podiatric physicians, or optometrists, within the limits of
8349+13 their licenses, are compounded, filled, or dispensed; or (3)
8350+14 which has upon it or displayed within it, or affixed to or used
8351+15 in connection with it, a sign bearing the word or words
8352+16 "Pharmacist", "Druggist", "Pharmacy", "Pharmaceutical Care",
8353+17 "Apothecary", "Drugstore", "Medicine Store", "Prescriptions",
8354+18 "Drugs", "Dispensary", "Medicines", or any word or words of
8355+19 similar or like import, either in the English language or any
8356+20 other language; or (4) where the characteristic prescription
8357+21 sign (Rx) or similar design is exhibited; or (5) any store, or
8358+22 shop, or other place with respect to which any of the above
8359+23 words, objects, signs or designs are used in any
8360+24 advertisement.
8361+25 (b) "Drugs" means and includes (1) articles recognized in
8362+26 the official United States Pharmacopoeia/National Formulary
8363+
8364+
8365+
8366+
8367+
8368+ SB3268 Enrolled - 236 - LRB103 39338 KTG 69500 b
8369+
8370+
8371+SB3268 Enrolled- 237 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 237 - LRB103 39338 KTG 69500 b
8372+ SB3268 Enrolled - 237 - LRB103 39338 KTG 69500 b
8373+1 (USP/NF), or any supplement thereto and being intended for and
8374+2 having for their main use the diagnosis, cure, mitigation,
8375+3 treatment or prevention of disease in man or other animals, as
8376+4 approved by the United States Food and Drug Administration,
8377+5 but does not include devices or their components, parts, or
8378+6 accessories; and (2) all other articles intended for and
8379+7 having for their main use the diagnosis, cure, mitigation,
8380+8 treatment or prevention of disease in man or other animals, as
8381+9 approved by the United States Food and Drug Administration,
8382+10 but does not include devices or their components, parts, or
8383+11 accessories; and (3) articles (other than food) having for
8384+12 their main use and intended to affect the structure or any
8385+13 function of the body of man or other animals; and (4) articles
8386+14 having for their main use and intended for use as a component
8387+15 or any articles specified in clause (1), (2) or (3); but does
8388+16 not include devices or their components, parts or accessories.
8389+17 (c) "Medicines" means and includes all drugs intended for
8390+18 human or veterinary use approved by the United States Food and
8391+19 Drug Administration.
8392+20 (d) "Practice of pharmacy" means:
8393+21 (1) the interpretation and the provision of assistance
8394+22 in the monitoring, evaluation, and implementation of
8395+23 prescription drug orders;
8396+24 (2) the dispensing of prescription drug orders;
8397+25 (3) participation in drug and device selection;
8398+26 (4) drug administration limited to the administration
8399+
8400+
8401+
8402+
8403+
8404+ SB3268 Enrolled - 237 - LRB103 39338 KTG 69500 b
8405+
8406+
8407+SB3268 Enrolled- 238 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 238 - LRB103 39338 KTG 69500 b
8408+ SB3268 Enrolled - 238 - LRB103 39338 KTG 69500 b
8409+1 of oral, topical, injectable, and inhalation as follows:
8410+2 (A) in the context of patient education on the
8411+3 proper use or delivery of medications;
8412+4 (B) vaccination of patients 7 years of age and
8413+5 older pursuant to a valid prescription or standing
8414+6 order, by a physician licensed to practice medicine in
8415+7 all its branches, except for vaccinations covered by
8416+8 paragraph (15), upon completion of appropriate
8417+9 training, including how to address contraindications
8418+10 and adverse reactions set forth by rule, with
8419+11 notification to the patient's physician and
8420+12 appropriate record retention, or pursuant to hospital
8421+13 pharmacy and therapeutics committee policies and
8422+14 procedures. Eligible vaccines are those listed on the
8423+15 U.S. Centers for Disease Control and Prevention (CDC)
8424+16 Recommended Immunization Schedule, the CDC's Health
8425+17 Information for International Travel, or the U.S. Food
8426+18 and Drug Administration's Vaccines Licensed and
8427+19 Authorized for Use in the United States. As applicable
8428+20 to the State's Medicaid program and other payers,
8429+21 vaccines ordered and administered in accordance with
8430+22 this subsection shall be covered and reimbursed at no
8431+23 less than the rate that the vaccine is reimbursed when
8432+24 ordered and administered by a physician;
8433+25 (B-5) following the initial administration of
8434+26 long-acting or extended-release form opioid
8435+
8436+
8437+
8438+
8439+
8440+ SB3268 Enrolled - 238 - LRB103 39338 KTG 69500 b
8441+
8442+
8443+SB3268 Enrolled- 239 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 239 - LRB103 39338 KTG 69500 b
8444+ SB3268 Enrolled - 239 - LRB103 39338 KTG 69500 b
8445+1 antagonists by a physician licensed to practice
8446+2 medicine in all its branches, administration of
8447+3 injections of long-acting or extended-release form
8448+4 opioid antagonists for the treatment of substance use
8449+5 disorder, pursuant to a valid prescription by a
8450+6 physician licensed to practice medicine in all its
8451+7 branches, upon completion of appropriate training,
8452+8 including how to address contraindications and adverse
8453+9 reactions, including, but not limited to, respiratory
8454+10 depression and the performance of cardiopulmonary
8455+11 resuscitation, set forth by rule, with notification to
8456+12 the patient's physician and appropriate record
8457+13 retention, or pursuant to hospital pharmacy and
8458+14 therapeutics committee policies and procedures;
8459+15 (C) administration of injections of
8460+16 alpha-hydroxyprogesterone caproate, pursuant to a
8461+17 valid prescription, by a physician licensed to
8462+18 practice medicine in all its branches, upon completion
8463+19 of appropriate training, including how to address
8464+20 contraindications and adverse reactions set forth by
8465+21 rule, with notification to the patient's physician and
8466+22 appropriate record retention, or pursuant to hospital
8467+23 pharmacy and therapeutics committee policies and
8468+24 procedures; and
8469+25 (D) administration of injections of long-term
8470+26 antipsychotic medications pursuant to a valid
8471+
8472+
8473+
8474+
8475+
8476+ SB3268 Enrolled - 239 - LRB103 39338 KTG 69500 b
8477+
8478+
8479+SB3268 Enrolled- 240 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 240 - LRB103 39338 KTG 69500 b
8480+ SB3268 Enrolled - 240 - LRB103 39338 KTG 69500 b
8481+1 prescription by a physician licensed to practice
8482+2 medicine in all its branches, upon completion of
8483+3 appropriate training conducted by an Accreditation
8484+4 Council of Pharmaceutical Education accredited
8485+5 provider, including how to address contraindications
8486+6 and adverse reactions set forth by rule, with
8487+7 notification to the patient's physician and
8488+8 appropriate record retention, or pursuant to hospital
8489+9 pharmacy and therapeutics committee policies and
8490+10 procedures.
8491+11 (5) (blank);
8492+12 (6) drug regimen review;
8493+13 (7) drug or drug-related research;
8494+14 (8) the provision of patient counseling;
8495+15 (9) the practice of telepharmacy;
8496+16 (10) the provision of those acts or services necessary
8497+17 to provide pharmacist care;
8498+18 (11) medication therapy management;
8499+19 (12) the responsibility for compounding and labeling
8500+20 of drugs and devices (except labeling by a manufacturer,
8501+21 repackager, or distributor of non-prescription drugs and
8502+22 commercially packaged legend drugs and devices), proper
8503+23 and safe storage of drugs and devices, and maintenance of
8504+24 required records;
8505+25 (13) the assessment and consultation of patients and
8506+26 dispensing of hormonal contraceptives;
8507+
8508+
8509+
8510+
8511+
8512+ SB3268 Enrolled - 240 - LRB103 39338 KTG 69500 b
8513+
8514+
8515+SB3268 Enrolled- 241 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 241 - LRB103 39338 KTG 69500 b
8516+ SB3268 Enrolled - 241 - LRB103 39338 KTG 69500 b
8517+1 (14) the initiation, dispensing, or administration of
8518+2 drugs, laboratory tests, assessments, referrals, and
8519+3 consultations for human immunodeficiency virus
8520+4 pre-exposure prophylaxis and human immunodeficiency virus
8521+5 post-exposure prophylaxis under Section 43.5;
8522+6 (15) vaccination of patients 7 years of age and older
8523+7 for COVID-19 or influenza subcutaneously, intramuscularly,
8524+8 or orally as authorized, approved, or licensed by the
8525+9 United States Food and Drug Administration, pursuant to
8526+10 the following conditions:
8527+11 (A) the vaccine must be authorized or licensed by
8528+12 the United States Food and Drug Administration;
8529+13 (B) the vaccine must be ordered and administered
8530+14 according to the Advisory Committee on Immunization
8531+15 Practices standard immunization schedule;
8532+16 (C) the pharmacist must complete a course of
8533+17 training accredited by the Accreditation Council on
8534+18 Pharmacy Education or a similar health authority or
8535+19 professional body approved by the Division of
8536+20 Professional Regulation;
8537+21 (D) the pharmacist must have a current certificate
8538+22 in basic cardiopulmonary resuscitation;
8539+23 (E) the pharmacist must complete, during each
8540+24 State licensing period, a minimum of 2 hours of
8541+25 immunization-related continuing pharmacy education
8542+26 approved by the Accreditation Council on Pharmacy
8543+
8544+
8545+
8546+
8547+
8548+ SB3268 Enrolled - 241 - LRB103 39338 KTG 69500 b
8549+
8550+
8551+SB3268 Enrolled- 242 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 242 - LRB103 39338 KTG 69500 b
8552+ SB3268 Enrolled - 242 - LRB103 39338 KTG 69500 b
8553+1 Education;
8554+2 (F) the pharmacist must comply with recordkeeping
8555+3 and reporting requirements of the jurisdiction in
8556+4 which the pharmacist administers vaccines, including
8557+5 informing the patient's primary-care provider, when
8558+6 available, and complying with requirements whereby the
8559+7 person administering a vaccine must review the vaccine
8560+8 registry or other vaccination records prior to
8561+9 administering the vaccine; and
8562+10 (G) the pharmacist must inform the pharmacist's
8563+11 patients who are less than 18 years old, as well as the
8564+12 adult caregiver accompanying the child, of the
8565+13 importance of a well-child visit with a pediatrician
8566+14 or other licensed primary-care provider and must refer
8567+15 patients as appropriate;
8568+16 (16) the ordering and administration of COVID-19
8569+17 therapeutics subcutaneously, intramuscularly, or orally
8570+18 with notification to the patient's physician and
8571+19 appropriate record retention or pursuant to hospital
8572+20 pharmacy and therapeutics committee policies and
8573+21 procedures. Eligible therapeutics are those approved,
8574+22 authorized, or licensed by the United States Food and Drug
8575+23 Administration and must be administered subcutaneously,
8576+24 intramuscularly, or orally in accordance with that
8577+25 approval, authorization, or licensing; and
8578+26 (17) the ordering and administration of point of care
8579+
8580+
8581+
8582+
8583+
8584+ SB3268 Enrolled - 242 - LRB103 39338 KTG 69500 b
8585+
8586+
8587+SB3268 Enrolled- 243 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 243 - LRB103 39338 KTG 69500 b
8588+ SB3268 Enrolled - 243 - LRB103 39338 KTG 69500 b
8589+1 tests, and screenings, and treatments for (i) influenza,
8590+2 (ii) SARS-CoV-2 SARS-COV 2, (iii) Group A Streptococcus,
8591+3 (iv) respiratory syncytial virus, (v) adult-stage head
8592+4 louse, and (vi) (iii) health conditions identified by a
8593+5 statewide public health emergency, as defined in the
8594+6 Illinois Emergency Management Agency Act, with
8595+7 notification to the patient's physician, if any, and
8596+8 appropriate record retention or pursuant to hospital
8597+9 pharmacy and therapeutics committee policies and
8598+10 procedures. Eligible tests and screenings are those
8599+11 approved, authorized, or licensed by the United States
8600+12 Food and Drug Administration and must be administered in
8601+13 accordance with that approval, authorization, or
8602+14 licensing.
8603+15 A pharmacist who orders or administers tests or
8604+16 screenings for health conditions described in this
8605+17 paragraph may use a test that may guide clinical
8606+18 decision-making for the health condition that is waived
8607+19 under the federal Clinical Laboratory Improvement
8608+20 Amendments of 1988 and regulations promulgated thereunder
8609+21 or any established screening procedure that is established
8610+22 under a statewide protocol.
8611+23 A pharmacist may delegate the administrative and
8612+24 technical tasks of performing a test for the health
8613+25 conditions described in this paragraph to a registered
8614+26 pharmacy technician or student pharmacist acting under the
8615+
8616+
8617+
8618+
8619+
8620+ SB3268 Enrolled - 243 - LRB103 39338 KTG 69500 b
8621+
8622+
8623+SB3268 Enrolled- 244 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 244 - LRB103 39338 KTG 69500 b
8624+ SB3268 Enrolled - 244 - LRB103 39338 KTG 69500 b
8625+1 supervision of the pharmacist.
8626+2 The testing, screening, and treatment ordered under
8627+3 this paragraph by a pharmacist shall not be denied
8628+4 reimbursement under health benefit plans that are within
8629+5 the scope of the pharmacist's license and shall be covered
8630+6 as if the services or procedures were performed by a
8631+7 physician, an advanced practice registered nurse, or a
8632+8 physician assistant.
8633+9 A pharmacy benefit manager, health carrier, health
8634+10 benefit plan, or third-party payor shall not discriminate
8635+11 against a pharmacy or a pharmacist with respect to
8636+12 participation referral, reimbursement of a covered
8637+13 service, or indemnification if a pharmacist is acting
8638+14 within the scope of the pharmacist's license and the
8639+15 pharmacy is operating in compliance with all applicable
8640+16 laws and rules.
8641+17 A pharmacist who performs any of the acts defined as the
8642+18 practice of pharmacy in this State must be actively licensed
8643+19 as a pharmacist under this Act.
8644+20 (e) "Prescription" means and includes any written, oral,
8645+21 facsimile, or electronically transmitted order for drugs or
8646+22 medical devices, issued by a physician licensed to practice
8647+23 medicine in all its branches, dentist, veterinarian, podiatric
8648+24 physician, or optometrist, within the limits of his or her
8649+25 license, by a physician assistant in accordance with
8650+26 subsection (f) of Section 4, or by an advanced practice
8651+
8652+
8653+
8654+
8655+
8656+ SB3268 Enrolled - 244 - LRB103 39338 KTG 69500 b
8657+
8658+
8659+SB3268 Enrolled- 245 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 245 - LRB103 39338 KTG 69500 b
8660+ SB3268 Enrolled - 245 - LRB103 39338 KTG 69500 b
8661+1 registered nurse in accordance with subsection (g) of Section
8662+2 4, containing the following: (1) name of the patient; (2) date
8663+3 when prescription was issued; (3) name and strength of drug or
8664+4 description of the medical device prescribed; and (4)
8665+5 quantity; (5) directions for use; (6) prescriber's name,
8666+6 address, and signature; and (7) DEA registration number where
8667+7 required, for controlled substances. The prescription may, but
8668+8 is not required to, list the illness, disease, or condition
8669+9 for which the drug or device is being prescribed. DEA
8670+10 registration numbers shall not be required on inpatient drug
8671+11 orders. A prescription for medication other than controlled
8672+12 substances shall be valid for up to 15 months from the date
8673+13 issued for the purpose of refills, unless the prescription
8674+14 states otherwise.
8675+15 (f) "Person" means and includes a natural person,
8676+16 partnership, association, corporation, government entity, or
8677+17 any other legal entity.
8678+18 (g) "Department" means the Department of Financial and
8679+19 Professional Regulation.
8680+20 (h) "Board of Pharmacy" or "Board" means the State Board
8681+21 of Pharmacy of the Department of Financial and Professional
8682+22 Regulation.
8683+23 (i) "Secretary" means the Secretary of Financial and
8684+24 Professional Regulation.
8685+25 (j) "Drug product selection" means the interchange for a
8686+26 prescribed pharmaceutical product in accordance with Section
8687+
8688+
8689+
8690+
8691+
8692+ SB3268 Enrolled - 245 - LRB103 39338 KTG 69500 b
8693+
8694+
8695+SB3268 Enrolled- 246 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 246 - LRB103 39338 KTG 69500 b
8696+ SB3268 Enrolled - 246 - LRB103 39338 KTG 69500 b
8697+1 25 of this Act and Section 3.14 of the Illinois Food, Drug and
8698+2 Cosmetic Act.
8699+3 (k) "Inpatient drug order" means an order issued by an
8700+4 authorized prescriber for a resident or patient of a facility
8701+5 licensed under the Nursing Home Care Act, the ID/DD Community
8702+6 Care Act, the MC/DD Act, the Specialized Mental Health
8703+7 Rehabilitation Act of 2013, the Hospital Licensing Act, or the
8704+8 University of Illinois Hospital Act, or a facility which is
8705+9 operated by the Department of Human Services (as successor to
8706+10 the Department of Mental Health and Developmental
8707+11 Disabilities) or the Department of Corrections.
8708+12 (k-5) "Pharmacist" means an individual health care
8709+13 professional and provider currently licensed by this State to
8710+14 engage in the practice of pharmacy.
8711+15 (l) "Pharmacist in charge" means the licensed pharmacist
8712+16 whose name appears on a pharmacy license and who is
8713+17 responsible for all aspects of the operation related to the
8714+18 practice of pharmacy.
8715+19 (m) "Dispense" or "dispensing" means the interpretation,
8716+20 evaluation, and implementation of a prescription drug order,
8717+21 including the preparation and delivery of a drug or device to a
8718+22 patient or patient's agent in a suitable container
8719+23 appropriately labeled for subsequent administration to or use
8720+24 by a patient in accordance with applicable State and federal
8721+25 laws and regulations. "Dispense" or "dispensing" does not mean
8722+26 the physical delivery to a patient or a patient's
8723+
8724+
8725+
8726+
8727+
8728+ SB3268 Enrolled - 246 - LRB103 39338 KTG 69500 b
8729+
8730+
8731+SB3268 Enrolled- 247 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 247 - LRB103 39338 KTG 69500 b
8732+ SB3268 Enrolled - 247 - LRB103 39338 KTG 69500 b
8733+1 representative in a home or institution by a designee of a
8734+2 pharmacist or by common carrier. "Dispense" or "dispensing"
8735+3 also does not mean the physical delivery of a drug or medical
8736+4 device to a patient or patient's representative by a
8737+5 pharmacist's designee within a pharmacy or drugstore while the
8738+6 pharmacist is on duty and the pharmacy is open.
8739+7 (n) "Nonresident pharmacy" means a pharmacy that is
8740+8 located in a state, commonwealth, or territory of the United
8741+9 States, other than Illinois, that delivers, dispenses, or
8742+10 distributes, through the United States Postal Service,
8743+11 commercially acceptable parcel delivery service, or other
8744+12 common carrier, to Illinois residents, any substance which
8745+13 requires a prescription.
8746+14 (o) "Compounding" means the preparation and mixing of
8747+15 components, excluding flavorings, (1) as the result of a
8748+16 prescriber's prescription drug order or initiative based on
8749+17 the prescriber-patient-pharmacist relationship in the course
8750+18 of professional practice or (2) for the purpose of, or
8751+19 incident to, research, teaching, or chemical analysis and not
8752+20 for sale or dispensing. "Compounding" includes the preparation
8753+21 of drugs or devices in anticipation of receiving prescription
8754+22 drug orders based on routine, regularly observed dispensing
8755+23 patterns. Commercially available products may be compounded
8756+24 for dispensing to individual patients only if all of the
8757+25 following conditions are met: (i) the commercial product is
8758+26 not reasonably available from normal distribution channels in
8759+
8760+
8761+
8762+
8763+
8764+ SB3268 Enrolled - 247 - LRB103 39338 KTG 69500 b
8765+
8766+
8767+SB3268 Enrolled- 248 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 248 - LRB103 39338 KTG 69500 b
8768+ SB3268 Enrolled - 248 - LRB103 39338 KTG 69500 b
8769+1 a timely manner to meet the patient's needs and (ii) the
8770+2 prescribing practitioner has requested that the drug be
8771+3 compounded.
8772+4 (p) (Blank).
8773+5 (q) (Blank).
8774+6 (r) "Patient counseling" means the communication between a
8775+7 pharmacist or a student pharmacist under the supervision of a
8776+8 pharmacist and a patient or the patient's representative about
8777+9 the patient's medication or device for the purpose of
8778+10 optimizing proper use of prescription medications or devices.
8779+11 "Patient counseling" may include without limitation (1)
8780+12 obtaining a medication history; (2) acquiring a patient's
8781+13 allergies and health conditions; (3) facilitation of the
8782+14 patient's understanding of the intended use of the medication;
8783+15 (4) proper directions for use; (5) significant potential
8784+16 adverse events; (6) potential food-drug interactions; and (7)
8785+17 the need to be compliant with the medication therapy. A
8786+18 pharmacy technician may only participate in the following
8787+19 aspects of patient counseling under the supervision of a
8788+20 pharmacist: (1) obtaining medication history; (2) providing
8789+21 the offer for counseling by a pharmacist or student
8790+22 pharmacist; and (3) acquiring a patient's allergies and health
8791+23 conditions.
8792+24 (s) "Patient profiles" or "patient drug therapy record"
8793+25 means the obtaining, recording, and maintenance of patient
8794+26 prescription information, including prescriptions for
8795+
8796+
8797+
8798+
8799+
8800+ SB3268 Enrolled - 248 - LRB103 39338 KTG 69500 b
8801+
8802+
8803+SB3268 Enrolled- 249 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 249 - LRB103 39338 KTG 69500 b
8804+ SB3268 Enrolled - 249 - LRB103 39338 KTG 69500 b
8805+1 controlled substances, and personal information.
8806+2 (t) (Blank).
8807+3 (u) "Medical device" or "device" means an instrument,
8808+4 apparatus, implement, machine, contrivance, implant, in vitro
8809+5 reagent, or other similar or related article, including any
8810+6 component part or accessory, required under federal law to
8811+7 bear the label "Caution: Federal law requires dispensing by or
8812+8 on the order of a physician". A seller of goods and services
8813+9 who, only for the purpose of retail sales, compounds, sells,
8814+10 rents, or leases medical devices shall not, by reasons
8815+11 thereof, be required to be a licensed pharmacy.
8816+12 (v) "Unique identifier" means an electronic signature,
8817+13 handwritten signature or initials, thumb print, or other
8818+14 acceptable biometric or electronic identification process as
8819+15 approved by the Department.
8820+16 (w) "Current usual and customary retail price" means the
8821+17 price that a pharmacy charges to a non-third-party payor.
8822+18 (x) "Automated pharmacy system" means a mechanical system
8823+19 located within the confines of the pharmacy or remote location
8824+20 that performs operations or activities, other than compounding
8825+21 or administration, relative to storage, packaging, dispensing,
8826+22 or distribution of medication, and which collects, controls,
8827+23 and maintains all transaction information.
8828+24 (y) "Drug regimen review" means and includes the
8829+25 evaluation of prescription drug orders and patient records for
8830+26 (1) known allergies; (2) drug or potential therapy
8831+
8832+
8833+
8834+
8835+
8836+ SB3268 Enrolled - 249 - LRB103 39338 KTG 69500 b
8837+
8838+
8839+SB3268 Enrolled- 250 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 250 - LRB103 39338 KTG 69500 b
8840+ SB3268 Enrolled - 250 - LRB103 39338 KTG 69500 b
8841+1 contraindications; (3) reasonable dose, duration of use, and
8842+2 route of administration, taking into consideration factors
8843+3 such as age, gender, and contraindications; (4) reasonable
8844+4 directions for use; (5) potential or actual adverse drug
8845+5 reactions; (6) drug-drug interactions; (7) drug-food
8846+6 interactions; (8) drug-disease contraindications; (9)
8847+7 therapeutic duplication; (10) patient laboratory values when
8848+8 authorized and available; (11) proper utilization (including
8849+9 over or under utilization) and optimum therapeutic outcomes;
8850+10 and (12) abuse and misuse.
8851+11 (z) "Electronically transmitted prescription" means a
8852+12 prescription that is created, recorded, or stored by
8853+13 electronic means; issued and validated with an electronic
8854+14 signature; and transmitted by electronic means directly from
8855+15 the prescriber to a pharmacy. An electronic prescription is
8856+16 not an image of a physical prescription that is transferred by
8857+17 electronic means from computer to computer, facsimile to
8858+18 facsimile, or facsimile to computer.
8859+19 (aa) "Medication therapy management services" means a
8860+20 distinct service or group of services offered by licensed
8861+21 pharmacists, physicians licensed to practice medicine in all
8862+22 its branches, advanced practice registered nurses authorized
8863+23 in a written agreement with a physician licensed to practice
8864+24 medicine in all its branches, or physician assistants
8865+25 authorized in guidelines by a supervising physician that
8866+26 optimize therapeutic outcomes for individual patients through
8867+
8868+
8869+
8870+
8871+
8872+ SB3268 Enrolled - 250 - LRB103 39338 KTG 69500 b
8873+
8874+
8875+SB3268 Enrolled- 251 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 251 - LRB103 39338 KTG 69500 b
8876+ SB3268 Enrolled - 251 - LRB103 39338 KTG 69500 b
8877+1 improved medication use. In a retail or other non-hospital
8878+2 pharmacy, medication therapy management services shall consist
8879+3 of the evaluation of prescription drug orders and patient
8880+4 medication records to resolve conflicts with the following:
8881+5 (1) known allergies;
8882+6 (2) drug or potential therapy contraindications;
8883+7 (3) reasonable dose, duration of use, and route of
8884+8 administration, taking into consideration factors such as
8885+9 age, gender, and contraindications;
8886+10 (4) reasonable directions for use;
8887+11 (5) potential or actual adverse drug reactions;
8888+12 (6) drug-drug interactions;
8889+13 (7) drug-food interactions;
8890+14 (8) drug-disease contraindications;
8891+15 (9) identification of therapeutic duplication;
8892+16 (10) patient laboratory values when authorized and
8893+17 available;
8894+18 (11) proper utilization (including over or under
8895+19 utilization) and optimum therapeutic outcomes; and
8896+20 (12) drug abuse and misuse.
8897+21 "Medication therapy management services" includes the
8898+22 following:
8899+23 (1) documenting the services delivered and
8900+24 communicating the information provided to patients'
8901+25 prescribers within an appropriate time frame, not to
8902+26 exceed 48 hours;
8903+
8904+
8905+
8906+
8907+
8908+ SB3268 Enrolled - 251 - LRB103 39338 KTG 69500 b
8909+
8910+
8911+SB3268 Enrolled- 252 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 252 - LRB103 39338 KTG 69500 b
8912+ SB3268 Enrolled - 252 - LRB103 39338 KTG 69500 b
8913+1 (2) providing patient counseling designed to enhance a
8914+2 patient's understanding and the appropriate use of his or
8915+3 her medications; and
8916+4 (3) providing information, support services, and
8917+5 resources designed to enhance a patient's adherence with
8918+6 his or her prescribed therapeutic regimens.
8919+7 "Medication therapy management services" may also include
8920+8 patient care functions authorized by a physician licensed to
8921+9 practice medicine in all its branches for his or her
8922+10 identified patient or groups of patients under specified
8923+11 conditions or limitations in a standing order from the
8924+12 physician.
8925+13 "Medication therapy management services" in a licensed
8926+14 hospital may also include the following:
8927+15 (1) reviewing assessments of the patient's health
8928+16 status; and
8929+17 (2) following protocols of a hospital pharmacy and
8930+18 therapeutics committee with respect to the fulfillment of
8931+19 medication orders.
8932+20 (bb) "Pharmacist care" means the provision by a pharmacist
8933+21 of medication therapy management services, with or without the
8934+22 dispensing of drugs or devices, intended to achieve outcomes
8935+23 that improve patient health, quality of life, and comfort and
8936+24 enhance patient safety.
8937+25 (cc) "Protected health information" means individually
8938+26 identifiable health information that, except as otherwise
8939+
8940+
8941+
8942+
8943+
8944+ SB3268 Enrolled - 252 - LRB103 39338 KTG 69500 b
8945+
8946+
8947+SB3268 Enrolled- 253 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 253 - LRB103 39338 KTG 69500 b
8948+ SB3268 Enrolled - 253 - LRB103 39338 KTG 69500 b
8949+1 provided, is:
8950+2 (1) transmitted by electronic media;
8951+3 (2) maintained in any medium set forth in the
8952+4 definition of "electronic media" in the federal Health
8953+5 Insurance Portability and Accountability Act; or
8954+6 (3) transmitted or maintained in any other form or
8955+7 medium.
8956+8 "Protected health information" does not include
8957+9 individually identifiable health information found in:
8958+10 (1) education records covered by the federal Family
8959+11 Educational Right and Privacy Act; or
8960+12 (2) employment records held by a licensee in its role
8961+13 as an employer.
8962+14 (dd) "Standing order" means a specific order for a patient
8963+15 or group of patients issued by a physician licensed to
8964+16 practice medicine in all its branches in Illinois.
8965+17 (ee) "Address of record" means the designated address
8966+18 recorded by the Department in the applicant's application file
8967+19 or licensee's license file maintained by the Department's
8968+20 licensure maintenance unit.
8969+21 (ff) "Home pharmacy" means the location of a pharmacy's
8970+22 primary operations.
8971+23 (gg) "Email address of record" means the designated email
8972+24 address recorded by the Department in the applicant's
8973+25 application file or the licensee's license file, as maintained
8974+26 by the Department's licensure maintenance unit.
8975+
8976+
8977+
8978+
8979+
8980+ SB3268 Enrolled - 253 - LRB103 39338 KTG 69500 b
8981+
8982+
8983+SB3268 Enrolled- 254 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 254 - LRB103 39338 KTG 69500 b
8984+ SB3268 Enrolled - 254 - LRB103 39338 KTG 69500 b
8985+1 (Source: P.A. 102-16, eff. 6-17-21; 102-103, eff. 1-1-22;
8986+2 102-558, eff. 8-20-21; 102-813, eff. 5-13-22; 102-1051, eff.
8987+3 1-1-23; 103-1, eff. 4-27-23.)
8988+4 (225 ILCS 85/9.6)
8989+5 Sec. 9.6. Administration of vaccines and therapeutics by
8990+6 registered pharmacy technicians and student pharmacists.
8991+7 (a) Under the supervision of an appropriately trained
8992+8 pharmacist, a registered pharmacy technician or student
8993+9 pharmacist may administer COVID-19, SARS-CoV-2, respiratory
8994+10 syncytial virus, and influenza vaccines subcutaneously,
8995+11 intramuscularly, or orally as authorized, approved, or
8996+12 licensed by the United States Food and Drug Administration,
8997+13 subject to the following conditions:
8998+14 (1) the vaccination must be ordered by the supervising
8999+15 pharmacist;
9000+16 (2) the supervising pharmacist must be readily and
9001+17 immediately available to the immunizing pharmacy
9002+18 technician or student pharmacist;
9003+19 (3) the pharmacy technician or student pharmacist must
9004+20 complete a practical training program that is approved by
9005+21 the Accreditation Council for Pharmacy Education and that
9006+22 includes hands-on injection technique training and
9007+23 training in the recognition and treatment of emergency
9008+24 reactions to vaccines;
9009+25 (4) the pharmacy technician or student pharmacist must
9010+
9011+
9012+
9013+
9014+
9015+ SB3268 Enrolled - 254 - LRB103 39338 KTG 69500 b
9016+
9017+
9018+SB3268 Enrolled- 255 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 255 - LRB103 39338 KTG 69500 b
9019+ SB3268 Enrolled - 255 - LRB103 39338 KTG 69500 b
9020+1 have a current certificate in basic cardiopulmonary
9021+2 resuscitation;
9022+3 (5) the pharmacy technician or student pharmacist must
9023+4 complete, during the relevant licensing period, a minimum
9024+5 of 2 hours of immunization-related continuing pharmacy
9025+6 education that is approved by the Accreditation Council
9026+7 for Pharmacy Education;
9027+8 (6) the supervising pharmacist must comply with all
9028+9 relevant recordkeeping and reporting requirements;
9029+10 (7) the supervising pharmacist must be responsible for
9030+11 complying with requirements related to reporting adverse
9031+12 events;
9032+13 (8) the supervising pharmacist must review the vaccine
9033+14 registry or other vaccination records prior to ordering
9034+15 the vaccination to be administered by the pharmacy
9035+16 technician or student pharmacist;
9036+17 (9) the pharmacy technician or student pharmacist
9037+18 must, if the patient is 18 years of age or younger, inform
9038+19 the patient and the adult caregiver accompanying the
9039+20 patient of the importance of a well-child visit with a
9040+21 pediatrician or other licensed primary-care provider and
9041+22 must refer patients as appropriate;
9042+23 (10) in the case of a COVID-19 vaccine, the
9043+24 vaccination must be ordered and administered according to
9044+25 the Advisory Committee on Immunization Practices' COVID-19
9045+26 vaccine recommendations;
9046+
9047+
9048+
9049+
9050+
9051+ SB3268 Enrolled - 255 - LRB103 39338 KTG 69500 b
9052+
9053+
9054+SB3268 Enrolled- 256 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 256 - LRB103 39338 KTG 69500 b
9055+ SB3268 Enrolled - 256 - LRB103 39338 KTG 69500 b
9056+1 (11) in the case of a COVID-19 vaccine, the
9057+2 supervising pharmacist must comply with any applicable
9058+3 requirements or conditions of use as set forth in the
9059+4 Centers for Disease Control and Prevention COVID-19
9060+5 vaccination provider agreement and any other federal
9061+6 requirements that apply to the administration of COVID-19
9062+7 vaccines being administered; and
9063+8 (12) the registered pharmacy technician or student
9064+9 pharmacist and the supervising pharmacist must comply with
9065+10 all other requirements of this Act and the rules adopted
9066+11 thereunder pertaining to the administration of drugs.
9067+12 (b) Under the supervision of an appropriately trained
9068+13 pharmacist, a registered pharmacy technician or student
9069+14 pharmacist may administer COVID-19 therapeutics
9070+15 subcutaneously, intramuscularly, or orally as authorized,
9071+16 approved, or licensed by the United States Food and Drug
9072+17 Administration, subject to the following conditions:
9073+18 (1) the COVID-19 therapeutic must be authorized,
9074+19 approved or licensed by the United States Food and Drug
9075+20 Administration;
9076+21 (2) the COVID-19 therapeutic must be administered
9077+22 subcutaneously, intramuscularly, or orally in accordance
9078+23 with the United States Food and Drug Administration
9079+24 approval, authorization, or licensing;
9080+25 (3) a pharmacy technician or student pharmacist
9081+26 practicing pursuant to this Section must complete a
9082+
9083+
9084+
9085+
9086+
9087+ SB3268 Enrolled - 256 - LRB103 39338 KTG 69500 b
9088+
9089+
9090+SB3268 Enrolled- 257 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 257 - LRB103 39338 KTG 69500 b
9091+ SB3268 Enrolled - 257 - LRB103 39338 KTG 69500 b
9092+1 practical training program that is approved by the
9093+2 Accreditation Council for Pharmacy Education and that
9094+3 includes hands-on injection technique training, clinical
9095+4 evaluation of indications and contraindications of
9096+5 COVID-19 therapeutics training, training in the
9097+6 recognition and treatment of emergency reactions to
9098+7 COVID-19 therapeutics, and any additional training
9099+8 required in the United States Food and Drug Administration
9100+9 approval, authorization, or licensing;
9101+10 (4) the pharmacy technician or student pharmacist must
9102+11 have a current certificate in basic cardiopulmonary
9103+12 resuscitation;
9104+13 (5) the pharmacy technician or student pharmacist must
9105+14 comply with any applicable requirements or conditions of
9106+15 use that apply to the administration of COVID-19
9107+16 therapeutics;
9108+17 (6) the supervising pharmacist must comply with all
9109+18 relevant recordkeeping and reporting requirements;
9110+19 (7) the supervising pharmacist must be readily and
9111+20 immediately available to the pharmacy technician or
9112+21 student pharmacist; and
9113+22 (8) the registered pharmacy technician or student
9114+23 pharmacist and the supervising pharmacist must comply with
9115+24 all other requirements of this Act and the rules adopted
9116+25 thereunder pertaining to the administration of drugs.
9117+26 (Source: P.A. 103-1, eff. 4-27-23.)
9118+
9119+
9120+
9121+
9122+
9123+ SB3268 Enrolled - 257 - LRB103 39338 KTG 69500 b
9124+
9125+
9126+SB3268 Enrolled- 258 -LRB103 39338 KTG 69500 b SB3268 Enrolled - 258 - LRB103 39338 KTG 69500 b
9127+ SB3268 Enrolled - 258 - LRB103 39338 KTG 69500 b
9128+1 ARTICLE 999.
9129+
9130+
9131+
9132+
9133+
9134+ SB3268 Enrolled - 258 - LRB103 39338 KTG 69500 b