Illinois Senate Bill SB3268 Latest Draft

                            Public Act 103-0593
SB3268 EnrolledLRB103 39338 KTG 69500 b SB3268 Enrolled LRB103 39338 KTG 69500 b
SB3268 Enrolled LRB103 39338 KTG 69500 b
AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
ARTICLE 5.
Section 5-5. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
(305 ILCS 5/5-5)
Sec. 5-5. Medical services.  The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant individuals, provided by an individual licensed

 

SB3268 Enrolled LRB103 39338 KTG 69500 b


to practice dentistry or dental surgery; for purposes of this
item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and


treatment of sickle cell anemia; (16.5) services performed by
a chiropractic physician licensed under the Medical Practice
Act of 1987 and acting within the scope of his or her license,
including, but not limited to, chiropractic manipulative
treatment; and (17) any other medical care, and any other type
of remedial care recognized under the laws of this State. The
term "any other type of remedial care" shall include nursing
care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided


through the Illinois Tobacco Quitline shall be covered under
the medical assistance program for persons who are otherwise
eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable
Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of
understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the


Illinois Title XIX State Plan for this purpose, the Department
shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in


the diseases of the eye, or by an optometrist, whichever
the person may select.
On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
Subject to federal approval, on and after January 1, 2025,
the rates paid for sedation evaluation and the provision of
deep sedation and intravenous sedation for the purpose of


dental services shall be increased by 33% above the rates in
effect on December 31, 2024. The rates paid for nitrous oxide
sedation shall not be impacted by this paragraph and shall
remain the same as the rates in effect on December 31, 2024.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
On and after January 1, 2022, the Department of Healthcare
and Family Services shall administer and regulate a
school-based dental program that allows for the out-of-office
delivery of preventative dental services in a school setting
to children under 19 years of age. The Department shall
establish, by rule, guidelines for participation by providers
and set requirements for follow-up referral care based on the
requirements established in the Dental Office Reference Manual
published by the Department that establishes the requirements


for dentists participating in the All Kids Dental School
Program. Every effort shall be made by the Department when
developing the program requirements to consider the different
geographic differences of both urban and rural areas of the
State for initial treatment and necessary follow-up care. No
provider shall be charged a fee by any unit of local government
to participate in the school-based dental program administered
by the Department. Nothing in this paragraph shall be
construed to limit or preempt a home rule unit's or school
district's authority to establish, change, or administer a
school-based dental program in addition to, or independent of,
the school-based dental program administered by the
Department.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose


mammography for the presence of occult breast cancer for
individuals 35 years of age or older who are eligible for
medical assistance under this Article, as follows:
(A) A baseline mammogram for individuals 35 to 39
years of age.
(B) An annual mammogram for individuals 40 years of
age or older.
(C) A mammogram at the age and intervals considered
medically necessary by the individual's health care
provider for individuals under 40 years of age and having
a family history of breast cancer, prior personal history
of breast cancer, positive genetic testing, or other risk
factors.
(D) A comprehensive ultrasound screening and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
The Department shall not impose a deductible, coinsurance,


copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.


"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
On and after January 1, 2012, providers participating in a


quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography and, after
January 1, 2023 (the effective date of Public Act 102-1018),
breast tomosynthesis.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other


hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind
individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to


include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for
those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
The Department shall provide coverage and reimbursement
for a human papillomavirus (HPV) vaccine that is approved for
marketing by the federal Food and Drug Administration for all
persons between the ages of 9 and 45. Subject to federal
approval, the Department shall provide coverage and
reimbursement for a human papillomavirus (HPV) vaccine for
persons of the age of 46 and above who have been diagnosed with
cervical dysplasia with a high risk of recurrence or
progression. The Department shall disallow any
preauthorization requirements for the administration of the
human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise


eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be
conditioned on the use of a screening instrument approved by
the Department.
Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information
from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the


Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by


rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.
The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.


Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as


provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The
Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses


for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs
for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the


MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary
operational or structural changes to its information
technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate


the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing
process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon the category of risk
of the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,


the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000


when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 120
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for


payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,


the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre-adjudicated, or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)


immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of
the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant


cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical
equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of the same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care


organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected


agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall


include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General
Assembly shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization
Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3


of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving
emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee-for-service fee for service and managed
care medical assistance programs for persons who are otherwise
eligible for medical assistance under this Article and shall
not be subject to any (1) utilization control, other than
those established under the American Society of Addiction
Medicine patient placement criteria, (2) prior authorization
mandate, or (3) lifetime restriction limit mandate.
On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees or hospital fees related to the dispensing, distribution,
and administration of the opioid antagonist, shall be covered
under the medical assistance program for persons who are


otherwise eligible for medical assistance under this Article.
As used in this Section, "opioid antagonist" means a drug that
binds to opioid receptors and blocks or inhibits the effect of
opioids acting on those receptors, including, but not limited
to, naloxone hydrochloride or any other similarly acting drug
approved by the U.S. Food and Drug Administration. The
Department shall not impose a copayment on the coverage
provided for naloxone hydrochloride under the medical
assistance program.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a


dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date
of Public Act 102-665), the Department shall seek federal
approval of a State Plan amendment to expand coverage for
family planning services that includes presumptive eligibility
to individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare
and Medicaid Services of a Title XIX State Plan amendment
electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of
the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,
subject to criteria established in accordance with all
applicable laws.
Notwithstanding any other provision of this Code,
community-based pediatric palliative care from a trained
interdisciplinary team shall be covered under the medical
assistance program as provided in Section 15 of the Pediatric
Palliative Care Act.


Notwithstanding any other provision of this Code, within
12 months after June 2, 2022 (the effective date of Public Act
102-1037) and subject to federal approval, acupuncture
services performed by an acupuncturist licensed under the
Acupuncture Practice Act who is acting within the scope of his
or her license shall be covered under the medical assistance
program. The Department shall apply for any federal waiver or
State Plan amendment, if required, to implement this
paragraph. The Department may adopt any rules, including
standards and criteria, necessary to implement this paragraph.
Notwithstanding any other provision of this Code, the
medical assistance program shall, subject to appropriation and
federal approval, reimburse hospitals for costs associated
with a newborn screening test for the presence of
metachromatic leukodystrophy, as required under the Newborn
Metabolic Screening Act, at a rate not less than the fee
charged by the Department of Public Health. The Department
shall seek federal approval before the implementation of the
newborn screening test fees by the Department of Public
Health.
Notwithstanding any other provision of this Code,
beginning on January 1, 2024, subject to federal approval,
cognitive assessment and care planning services provided to a
person who experiences signs or symptoms of cognitive
impairment, as defined by the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, shall be covered


under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Code,
medically necessary reconstructive services that are intended
to restore physical appearance shall be covered under the
medical assistance program for persons who are otherwise
eligible for medical assistance under this Article. As used in
this paragraph, "reconstructive services" means treatments
performed on structures of the body damaged by trauma to
restore physical appearance.
(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1-1-24; revised 12-15-23.)
ARTICLE 10.
Section 10-5. The Illinois Public Aid Code is amended by
adding Section 5-5.05h as follows:


(305 ILCS 5/5-5.05h new)
Sec. 5-5.05h. Reimbursement rates for psychiatric
evaluations and medication monitoring. Subject to federal
approval, for dates of service on and after January 1, 2025,
the Department shall make a one-time adjustment to the add-on
rates for services delivered by physicians who are
board-certified in psychiatry and advanced practice registered
nurses who hold a current certification in psychiatric and
mental health nursing. The one-time adjustment shall increase
the add-on rates so that the sum of the Department's base per
service unit rate plus the rate add-on is no less than $264.42
per hour adjusted for time and intensity as determined by the
work relative value units in the 2024 national Medicare
physician fee schedule, indexed to 60 minutes of individual
psychotherapy.
ARTICLE 15.
Section 15-5. The Illinois Public Aid Code is amended by
changing Section 5-5.01a as follows:
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program.
(a) The Department shall establish and provide oversight
for a program of supportive living facilities that seek to
promote resident independence, dignity, respect, and


well-being in the most cost-effective manner.
A supportive living facility is (i) a free-standing
facility or (ii) a distinct physical and operational entity
within a mixed-use building that meets the criteria
established in subsection (d). A supportive living facility
integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents
their own separate, private, and distinct living units.
Sites for the operation of the program shall be selected
by the Department based upon criteria that may include the
need for services in a geographic area, the availability of
funding, and the site's ability to meet the standards.
(b) Beginning July 1, 2014, subject to federal approval,
the Medicaid rates for supportive living facilities shall be
equal to the supportive living facility Medicaid rate
effective on June 30, 2014 increased by 8.85%. Once the
assessment imposed at Article V-G of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act, the Department shall increase the Medicaid rates for
supportive living facilities effective on July 1, 2014 by
9.09%. The Department shall apply this increase retroactively
to coincide with the imposition of the assessment in Article
V-G of this Code in accordance with the approval for federal
financial participation by the Centers for Medicare and
Medicaid Services.
The Medicaid rates for supportive living facilities


effective on July 1, 2017 must be equal to the rates in effect
for supportive living facilities on June 30, 2017 increased by
2.8%.
The Medicaid rates for supportive living facilities
effective on July 1, 2018 must be equal to the rates in effect
for supportive living facilities on June 30, 2018.
Subject to federal approval, the Medicaid rates for
supportive living services on and after July 1, 2019 must be at
least 54.3% of the average total nursing facility services per
diem for the geographic areas defined by the Department while
maintaining the rate differential for dementia care and must
be updated whenever the total nursing facility service per
diems are updated. Beginning July 1, 2022, upon the
implementation of the Patient Driven Payment Model, Medicaid
rates for supportive living services must be at least 54.3% of
the average total nursing services per diem rate for the
geographic areas. For purposes of this provision, the average
total nursing services per diem rate shall include all add-ons
for nursing facilities for the geographic area provided for in
Section 5-5.2. The rate differential for dementia care must be
maintained in these rates and the rates shall be updated
whenever nursing facility per diem rates are updated.
Subject to federal approval, beginning January 1, 2024,
the dementia care rate for supportive living services must be
no less than the non-dementia care supportive living services
rate multiplied by 1.5.


(b-5) Subject to federal approval, beginning January 1,
2025, Medicaid rates for supportive living services must be at
least 54.75% of the average total nursing services per diem
rate for the geographic areas defined by the Department and
shall include all add-ons for nursing facilities for the
geographic area provided for in Section 5-5.2.
(c) The Department may adopt rules to implement this
Section. Rules that establish or modify the services,
standards, and conditions for participation in the program
shall be adopted by the Department in consultation with the
Department on Aging, the Department of Rehabilitation
Services, and the Department of Mental Health and
Developmental Disabilities (or their successor agencies).
(d) Subject to federal approval by the Centers for
Medicare and Medicaid Services, the Department shall accept
for consideration of certification under the program any
application for a site or building where distinct parts of the
site or building are designated for purposes other than the
provision of supportive living services, but only if:
(1) those distinct parts of the site or building are
not designated for the purpose of providing assisted
living services as required under the Assisted Living and
Shared Housing Act;
(2) those distinct parts of the site or building are
completely separate from the part of the building used for
the provision of supportive living program services,


including separate entrances;
(3) those distinct parts of the site or building do
not share any common spaces with the part of the building
used for the provision of supportive living program
services; and
(4) those distinct parts of the site or building do
not share staffing with the part of the building used for
the provision of supportive living program services.
(e) Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good
standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois
Health Facilities Planning Act.
(f) Section 9817 of the American Rescue Plan Act of 2021
(Public Law 117-2) authorizes a 10% enhanced federal medical
assistance percentage for supportive living services for a
12-month period from April 1, 2021 through March 31, 2022.
Subject to federal approval, including the approval of any
necessary waiver amendments or other federally required
documents or assurances, for a 12-month period the Department
must pay a supplemental $26 per diem rate to all supportive
living facilities with the additional federal financial
participation funds that result from the enhanced federal
medical assistance percentage from April 1, 2021 through March
31, 2022. The Department may issue parameters around how the
supplemental payment should be spent, including quality


improvement activities. The Department may alter the form,
methods, or timeframes concerning the supplemental per diem
rate to comply with any subsequent changes to federal law,
changes made by guidance issued by the federal Centers for
Medicare and Medicaid Services, or other changes necessary to
receive the enhanced federal medical assistance percentage.
(g) All applications for the expansion of supportive
living dementia care settings involving sites not approved by
the Department on January 1, 2024 (the effective date of
Public Act 103-102) this amendatory Act of the 103rd General
Assembly may allow new elderly non-dementia units in addition
to new dementia care units. The Department may approve such
applications only if the application has: (1) no more than one
non-dementia care unit for each dementia care unit and (2) the
site is not located within 4 miles of an existing supportive
living program site in Cook County (including the City of
Chicago), not located within 12 miles of an existing
supportive living program site in DuPage County, Kane County,
Lake County, McHenry County, or Will County, or not located
within 25 miles of an existing supportive living program site
in any other county.
(h) Beginning January 1, 2025, subject to federal
approval, for a person who is a resident of a supportive living
facility under this Section, the monthly personal needs
allowance shall be $120 per month.
(Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;


103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)
ARTICLE 20.
Section 20-5. The Birth Center Licensing Act is amended by
changing Section 40 as follows:
(210 ILCS 170/40)
Sec. 40. Reimbursement requirements.
(a) A birth center shall seek certification under Titles
XVIII and XIX of the federal Social Security Act.
(b) Services provided to individuals eligible for medical
assistance shall be covered in accordance with Article V of
the Illinois Public Aid Code and reimbursement rates shall be
set by the Department of Healthcare and Family Services.
Reimbursement rates set by the Department of Healthcare and
Family Services should be based on all types of medically
necessary covered services provided to both the birthing
person and the baby, including:
(1) a professional fee for both the birthing person
and baby;
(2) a facility fee for the birthing person that is no
less than 75% of the statewide average facility payment
rate made to a hospital for an uncomplicated vaginal
birth;


(3) a facility fee for the baby that is no less than
75% of the statewide average facility payment rate made to
a hospital for a normal baby; and
(4) additional fees for other services, medications,
laboratory tests, and supplies provided.
(c) A birth center shall provide charitable care
consistent with that provided by comparable health care
providers in the geographic area.
(d) A birth center may not discriminate against any
patient requiring treatment because of the source of payment
for services, including Medicare and Medicaid recipients.
(Source: P.A. 102-518, eff. 8-20-21.)
Section 20-10. The Illinois Public Aid Code is amended by
adding Section 5-18.3 as follows:
(305 ILCS 5/5-18.3 new)
Sec. 5-18.3. Birth center; facility fee.
(a) Reimbursement for services covered under this Article
and provided at a birth center as defined in Section 5 of the
Birth Center Licensing Act shall include:
(1) Beginning January 1, 2025, subject to federal
approval, a facility fee for the birthing person and baby
that is no less than 80% of the statewide average facility
payment rate made to a hospital for an uncomplicated
vaginal birth. The facility fee shall include medications,


laboratory tests, and supplies provided.
(2) Beginning January 1, 2025, no less than 80% of the
Department fee schedule rate for professional services for
the birthing person and baby covered under this Article
that are reimbursable separate from the facility fee and
provided within the scope of licensure or certification of
both the practitioner and birth center.
(b) The Department shall submit any necessary application
to the federal Centers for Medicare and Medicaid Services for
a waiver or State Plan amendment to implement the requirements
of this Section.
ARTICLE 30.
Section 30-5. The Illinois Public Aid Code is amended by
changing Sections 5H-1 and 5H-3 as follows:
(305 ILCS 5/5H-1)
Sec. 5H-1. Definitions. As used in this Article:
"Base year" means the 12-month period from January 1, 2023
2018 to December 31, 2023 2018.
"Department" means the Department of Healthcare and Family
Services.
"Federal employee health benefit" means the program of
health benefits plans, as defined in 5 U.S.C. 8901, available
to federal employees under 5 U.S.C. 8901 to 8914.


"Fund" means the Healthcare Provider Relief Fund.
"Managed care organization" means an entity operating
under a certificate of authority issued pursuant to the Health
Maintenance Organization Act or as a Managed Care Community
Network pursuant to Section 5-11 of this Code.
"Medicaid managed care organization" means a managed care
organization under contract with the Department to provide
services to recipients of benefits in the medical assistance
program pursuant to Article V of this Code, the Children's
Health Insurance Program Act, or the Covering ALL KIDS Health
Insurance Act. It does not include contracts the same entity
or an affiliated entity has for other business.
"Medicare" means the federal Medicare program established
under Title XVIII of the federal Social Security Act.
"Member months" means the aggregate total number of months
all individuals are enrolled for coverage in a Managed Care
Organization during the base year. Member months are
determined by the Department for Medicaid Managed Care
Organizations based on enrollment data in its Medicaid
Management Information System and by the Department of
Insurance for other Managed Care Organizations based on
required filings with the Department of Insurance. Member
months do not include months individuals are enrolled in a
Limited Health Services Organization, including stand-alone
dental or vision plans, a Medicare Advantage Plan, a Medicare
Supplement Plan, a Medicaid Medicare Alignment Initiate Plan


pursuant to a Memorandum of Understanding between the
Department and the Federal Centers for Medicare and Medicaid
Services or a Federal Employee Health Benefits Plan.
(Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5H-3)
Sec. 5H-3. Managed care assessment.
(a) There is For State Fiscal year 2020 through State
Fiscal Year 2025, there is imposed upon managed care
organization member months an assessment, calculated on base
year data, as set forth below for the appropriate tier:
(1) Tier 1: $78.90 $60.20 per member month.
(2) Tier 2: $1.40 $1.20 per member month.
(3) Tier 3: $2.40 per member month.
(b) The tiers are established as follows:
(1) Tier 1 includes the first 4,195,000 member months
in a Medicaid managed care organization for the base year;
(2) (ii) Tier 2 includes member months over 4,195,000
in a Medicaid managed care organization during the base
year; and
(3) (iv) Tier 3 includes member months during the base
year in a managed care organization that is not a Medicaid
managed care organization.
(c) For State fiscal year 2020, and for each State fiscal
year thereafter, through State fiscal year 2025, the
Department may by rule adjust rates or tier parameters or both


in order to maximize the revenue generated by the assessment
consistent with federal regulations and to meet federal
statistical tests necessary for federal financial
participation. Any upward adjustment to the Tier 3 rate shall
be the minimum necessary to meet federal statistical tests.
(Source: P.A. 101-9, eff. 6-5-19.)
ARTICLE 35.
Section 35-5. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.55 as follows:
(5 ILCS 100/5-45.55 new)
Sec. 5-45.55. Emergency rulemaking; Medicaid hospital rate
updates. To provide for the expeditious and timely
implementation of the changes made to Section 14-12.5 of the
Illinois Public Aid Code by this amendatory Act of the 103rd
General Assembly, emergency rules implementing the changes
made by this amendatory Act of the 103rd General Assembly to
Section 14-12.5 of the Illinois Public Aid Code may be adopted
in accordance with Section 5-45 by the Department of
Healthcare and Family Services. The adoption of emergency
rules authorized by Section 5-45 and this Section is deemed to
be necessary for the public interest, safety, and welfare.
This Section is repealed one year after the effective date
of this amendatory Act of the 103rd General Assembly.


Section 35-10. The Illinois Public Aid Code is amended by
changing Section 14-12.5 as follows:
(305 ILCS 5/14-12.5)
Sec. 14-12.5. Hospital rate updates.
(a) Notwithstanding any other provision of this Code, the
hospital rates of reimbursement authorized under Sections
5-5.05, 14-12, and 14-13 of this Code shall be adjusted in
accordance with the provisions of this Section.
(b) Notwithstanding any other provision of this Code,
effective for dates of service on and after January 1, 2024,
subject to federal approval, hospital reimbursement rates
shall be revised as follows:
(1) For inpatient general acute care services, the
statewide-standardized amount and the per diem rates for
hospitals exempt from the APR-DRG reimbursement system, in
effect January 1, 2023, shall be increased by 10%.
(2) For inpatient psychiatric services:
(A) For safety-net hospitals, the hospital
specific per diem rate in effect January 1, 2023 and
the minimum per diem rate of $630, authorized in
subsection (b-5) of Section 5-5.05 of this Code, shall
be increased by 10%.
(B) For all general acute care hospitals that are
not safety-net hospitals, the inpatient psychiatric


care per diem rates in effect January 1, 2023 shall be
increased by 10%, except that all rates shall be at
least 90% of the minimum inpatient psychiatric care
per diem rate for safety-net hospitals as authorized
in subsection (b-5) of Section 5-5.05 of this Code
including the adjustments authorized in this Section.
The statewide default per diem rate for a hospital
opening a new psychiatric distinct part unit, shall be
set at 90% of the minimum inpatient psychiatric care
per diem rate for safety-net hospitals as authorized
in subsection (b-5) of Section 5-5.05 of this Code,
including the adjustment authorized in this Section.
(C) For all psychiatric specialty hospitals, the
per diem rates in effect January 1, 2023, shall be
increased by 10%, except that all rates shall be at
least 90% of the minimum inpatient per diem rate for
safety-net hospitals as authorized in subsection (b-5)
of Section 5-5.05 of this Code, including the
adjustments authorized in this Section. The statewide
default per diem rate for a new psychiatric specialty
hospital shall be set at 90% of the minimum inpatient
psychiatric care per diem rate for safety-net
hospitals as authorized in subsection (b-5) of Section
5-5.05 of this Code, including the adjustment
authorized in this Section.
(3) For inpatient rehabilitative services, all


hospital specific per diem rates in effect January 1,
2023, shall be increased by 10%. The statewide default
inpatient rehabilitative services per diem rates, for
general acute care hospitals and for rehabilitation
specialty hospitals respectively, shall be increased by
10%.
(4) The statewide-standardized amount for outpatient
general acute care services in effect January 1, 2023,
shall be increased by 10%.
(5) The statewide-standardized amount for outpatient
psychiatric care services in effect January 1, 2023, shall
be increased by 10%.
(6) The statewide-standardized amount for outpatient
rehabilitative care services in effect January 1, 2023,
shall be increased by 10%.
(7) The per diem rate in effect January 1, 2023, as
authorized in subsection (a) of Section 14-13 of this
Article shall be increased by 10%.
(8) For services provided Beginning on and after
January 1, 2024 through June 30, 2024, and on and after
January 1, 2027, subject to federal approval, in addition
to the statewide standardized amount, an add-on payment of
at least $210 shall be paid for each inpatient General
Acute and Psychiatric day of care, excluding
Medicare-Medicaid dual eligible crossover days, for all
safety-net hospitals defined in Section 5-5e.1 of this


Code.
(A) For Psychiatric days of care, the Department
may implement payment of this add-on by increasing the
hospital specific psychiatric per diem rate, adjusted
in accordance with subparagraph (A) of paragraph (2)
of subsection (b) by $210, or by a separate add-on
payment.
(B) If the add-on adjustment is added to the
hospital specific psychiatric per diem rate to
operationalize payment, the Department shall provide a
rate sheet to each safety-net hospital, which
identifies the hospital psychiatric per diem rate
before and after the adjustment.
(C) The add-on adjustment shall not be considered
when setting the 90% minimum rate identified in
paragraph (2) of subsection (b).
(9) For services provided on and after July 1, 2024,
and on or before December 31, 2026, subject to federal
approval, in addition to the statewide standardized amount
and any other payments authorized under this Code, a
safety-net hospital health care equity add-on payment
shall be paid for each inpatient General Acute and
Psychiatric day of care, excluding Medicare-Medicaid dual
eligible crossover days, for safety-net hospitals defined
in Section 5-5e.1 of this Code, as follows:
(A) if the safety-net hospital's Medicaid


inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is equal to or greater
than 70%, the add-on payment shall be $425;
(B) if the safety-net hospital's Medicaid
inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is equal to or greater
than 50% and less than 70%, the add-on payment shall be
$300;
(C) if the safety-net hospital's Medicaid
inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is equal to or greater
than 40% and less than 50%, the add-on payment shall be
$225; and
(D) if the safety-net hospital's Medicaid
inpatient utilization rate, as calculated under
Section 5-5e.1 of this Code, is less than 40%, the
add-on payment shall be $210.
Qualification for the safety-net hospital health care
equity add-on payment shall be updated January 1, 2026,
based on the MIUR determination effective 3 months prior
to the start of the January 1, 2026 calendar year.
Rates described in subparagraphs (A) through (C) shall
be adjusted annually beginning January 1, 2026 by applying
a uniform factor to each rate to spend an approximate
amount of $50,000,000 annually per year using State fiscal
year 2024 days as a basis for calendar year 2026 rates.


The add-on adjustment under this paragraph shall not
be considered when setting the 90% minimum rate identified
in subparagraph (B) of paragraph (2).
(10) For services provided on and after July 1, 2024,
and on or before December 31, 2026, subject to federal
approval, in addition to the statewide standardized amount
and any other payments authorized under this Code, a
safety-net hospital low volume add-on payment of $200
shall be paid for each inpatient General Acute and
Psychiatric day of care, excluding Medicare-Medicaid dual
eligible crossover days, for any safety-net hospital as
defined in Section 5-5e.1 that provided less than 11,000
Medicaid inpatient days of care, excluding
Medicare-Medicaid dual eligible crossover days, in the
base period. As used in this paragraph, "base period"
means State fiscal year 2022 admissions received by the
Department prior to October 1, 2023 for the payment period
July 1, 2024 through December 31, 2025, and beginning in
calendar year 2026, the State fiscal year that ends 30
months before the applicable calendar year, such as State
fiscal year 2023 admissions received by the Department
prior to October 1, 2024, for calendar year 2026.
(c) The Department shall take all actions necessary to
ensure the changes authorized in Public Act 103-102 and this
amendatory Act of the 103rd General Assembly are in effect for
dates of service on and after the effective date of the changes


made to this Section by this amendatory Act of the 103rd
General Assembly, January 1, 2024, including publishing all
appropriate public notices, applying for federal approval of
amendments to the Illinois Title XIX State Plan, and adopting
administrative rules if necessary.
(d) The Department of Healthcare and Family Services may
adopt rules necessary to implement the changes made by Public
Act 103-102 and this amendatory Act of the 103rd General
Assembly through the use of emergency rulemaking in accordance
with Section 5-45 of the Illinois Administrative Procedure
Act. The 24-month limitation on the adoption of emergency
rules does not apply to rules adopted under this Section. The
General Assembly finds that the adoption of rules to implement
the changes made by Public Act 103-102 and this amendatory Act
of the 103rd General Assembly is deemed an emergency and
necessary for the public interest, safety, and welfare.
(e) The Department shall ensure that all necessary
adjustments to the managed care organization capitation base
rates necessitated by the adjustments in this Section are
completed, published, and applied in accordance with Section
5-30.8 of this Code 90 days prior to the implementation date of
the changes required under Public Act 103-102 and this
amendatory Act of the 103rd General Assembly.
(f) The Department shall publish updated rate sheets or
add-on payment amounts, as applicable, for all hospitals 30
days prior to the effective date of the rate increase, or


within 30 days after federal approval by the Centers for
Medicare and Medicaid Services, whichever is later.
(Source: P.A. 103-102, eff. 6-16-23.)
ARTICLE 40.
Section 40-5. The Illinois Public Aid Code is amended by
changing Section 5A-12.7 as follows:
(305 ILCS 5/5A-12.7)
(Section scheduled to be repealed on December 31, 2026)
Sec. 5A-12.7. Continuation of hospital access payments on
and after July 1, 2020.
(a) To preserve and improve access to hospital services,
for hospital services rendered on and after July 1, 2020, the
Department shall, except for hospitals described in subsection
(b) of Section 5A-3, make payments to hospitals or require
capitated managed care organizations to make payments as set
forth in this Section. Payments under this Section are not due
and payable, however, until: (i) the methodologies described
in this Section are approved by the federal government in an
appropriate State Plan amendment or directed payment preprint;
and (ii) the assessment imposed under this Article is
determined to be a permissible tax under Title XIX of the
Social Security Act. In determining the hospital access
payments authorized under subsection (g) of this Section, if a


hospital ceases to qualify for payments from the pool, the
payments for all hospitals continuing to qualify for payments
from such pool shall be uniformly adjusted to fully expend the
aggregate net amount of the pool, with such adjustment being
effective on the first day of the second month following the
date the hospital ceases to receive payments from such pool.
(b) Amounts moved into claims-based rates and distributed
in accordance with Section 14-12 shall remain in those
claims-based rates.
(c) Graduate medical education.
(1) The calculation of graduate medical education
payments shall be based on the hospital's Medicare cost
report ending in Calendar Year 2018, as reported in the
Healthcare Cost Report Information System file, release
date September 30, 2019. An Illinois hospital reporting
intern and resident cost on its Medicare cost report shall
be eligible for graduate medical education payments.
(2) Each hospital's annualized Medicaid Intern
Resident Cost is calculated using annualized intern and
resident total costs obtained from Worksheet B Part I,
Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
96-98, and 105-112 multiplied by the percentage that the
hospital's Medicaid days (Worksheet S3 Part I, Column 7,
Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
hospital's total days (Worksheet S3 Part I, Column 8,
Lines 14, 16-18, and 32).


(3) An annualized Medicaid indirect medical education
(IME) payment is calculated for each hospital using its
IME payments (Worksheet E Part A, Line 29, Column 1)
multiplied by the percentage that its Medicaid days
(Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
and 32) comprise of its Medicare days (Worksheet S3 Part
I, Column 6, Lines 2, 3, 4, 14, and 16-18).
(4) For each hospital, its annualized Medicaid Intern
Resident Cost and its annualized Medicaid IME payment are
summed, and, except as capped at 120% of the average cost
per intern and resident for all qualifying hospitals as
calculated under this paragraph, is multiplied by the
applicable reimbursement factor as described in this
paragraph, to determine the hospital's final graduate
medical education payment. Each hospital's average cost
per intern and resident shall be calculated by summing its
total annualized Medicaid Intern Resident Cost plus its
annualized Medicaid IME payment and dividing that amount
by the hospital's total Full Time Equivalent Residents and
Interns. If the hospital's average per intern and resident
cost is greater than 120% of the same calculation for all
qualifying hospitals, the hospital's per intern and
resident cost shall be capped at 120% of the average cost
for all qualifying hospitals.
(A) For the period of July 1, 2020 through
December 31, 2022, the applicable reimbursement factor


shall be 22.6%.
(B) For the period of January 1, 2023 through
December 31, 2026, the applicable reimbursement factor
shall be 35% for all qualified safety-net hospitals,
as defined in Section 5-5e.1 of this Code, and all
hospitals with 100 or more Full Time Equivalent
Residents and Interns, as reported on the hospital's
Medicare cost report ending in Calendar Year 2018, and
for all other qualified hospitals the applicable
reimbursement factor shall be 30%.
(d) Fee-for-service supplemental payments. For the period
of July 1, 2020 through December 31, 2022, each Illinois
hospital shall receive an annual payment equal to the amounts
below, to be paid in 12 equal installments on or before the
seventh State business day of each month, except that no
payment shall be due within 30 days after the later of the date
of notification of federal approval of the payment
methodologies required under this Section or any waiver
required under 42 CFR 433.68, at which time the sum of amounts
required under this Section prior to the date of notification
is due and payable.
(1) For critical access hospitals, $385 per covered
inpatient day contained in paid fee-for-service claims and
$530 per paid fee-for-service outpatient claim for dates
of service in Calendar Year 2019 in the Department's
Enterprise Data Warehouse as of May 11, 2020.


(2) For safety-net hospitals, $960 per covered
inpatient day contained in paid fee-for-service claims and
$625 per paid fee-for-service outpatient claim for dates
of service in Calendar Year 2019 in the Department's
Enterprise Data Warehouse as of May 11, 2020.
(3) For long term acute care hospitals, $295 per
covered inpatient day contained in paid fee-for-service
claims for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of May 11, 2020.
(4) For freestanding psychiatric hospitals, $125 per
covered inpatient day contained in paid fee-for-service
claims and $130 per paid fee-for-service outpatient claim
for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of May 11, 2020.
(5) For freestanding rehabilitation hospitals, $355
per covered inpatient day contained in paid
fee-for-service claims for dates of service in Calendar
Year 2019 in the Department's Enterprise Data Warehouse as
of May 11, 2020.
(6) For all general acute care hospitals and high
Medicaid hospitals as defined in subsection (f), $350 per
covered inpatient day for dates of service in Calendar
Year 2019 contained in paid fee-for-service claims and
$620 per paid fee-for-service outpatient claim in the
Department's Enterprise Data Warehouse as of May 11, 2020.
(7) Alzheimer's treatment access payment. Each


Illinois academic medical center or teaching hospital, as
defined in Section 5-5e.2 of this Code, that is identified
as the primary hospital affiliate of one of the Regional
Alzheimer's Disease Assistance Centers, as designated by
the Alzheimer's Disease Assistance Act and identified in
the Department of Public Health's Alzheimer's Disease
State Plan dated December 2016, shall be paid an
Alzheimer's treatment access payment equal to the product
of the qualifying hospital's State Fiscal Year 2018 total
inpatient fee-for-service days multiplied by the
applicable Alzheimer's treatment rate of $226.30 for
hospitals located in Cook County and $116.21 for hospitals
located outside Cook County.
(d-2) Fee-for-service supplemental payments. Beginning
January 1, 2023, each Illinois hospital shall receive an
annual payment equal to the amounts listed below, to be paid in
12 equal installments on or before the seventh State business
day of each month, except that no payment shall be due within
30 days after the later of the date of notification of federal
approval of the payment methodologies required under this
Section or any waiver required under 42 CFR 433.68, at which
time the sum of amounts required under this Section prior to
the date of notification is due and payable. The Department
may adjust the rates in paragraphs (1) through (7) to comply
with the federal upper payment limits, with such adjustments
being determined so that the total estimated spending by


hospital class, under such adjusted rates, remains
substantially similar to the total estimated spending under
the original rates set forth in this subsection.
(1) For critical access hospitals, as defined in
subsection (f), $750 per covered inpatient day contained
in paid fee-for-service claims and $750 per paid
fee-for-service outpatient claim for dates of service in
Calendar Year 2019 in the Department's Enterprise Data
Warehouse as of August 6, 2021.
(2) For safety-net hospitals, as described in
subsection (f), $1,350 per inpatient day contained in paid
fee-for-service claims and $1,350 per paid fee-for-service
outpatient claim for dates of service in Calendar Year
2019 in the Department's Enterprise Data Warehouse as of
August 6, 2021.
(3) For long term acute care hospitals, $550 per
covered inpatient day contained in paid fee-for-service
claims for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of August 6,
2021.
(4) For freestanding psychiatric hospitals, $200 per
covered inpatient day contained in paid fee-for-service
claims and $200 per paid fee-for-service outpatient claim
for dates of service in Calendar Year 2019 in the
Department's Enterprise Data Warehouse as of August 6,
2021.


(5) For freestanding rehabilitation hospitals, $550
per covered inpatient day contained in paid
fee-for-service claims and $125 per paid fee-for-service
outpatient claim for dates of service in Calendar Year
2019 in the Department's Enterprise Data Warehouse as of
August 6, 2021.
(6) For all general acute care hospitals and high
Medicaid hospitals as defined in subsection (f), $500 per
covered inpatient day for dates of service in Calendar
Year 2019 contained in paid fee-for-service claims and
$500 per paid fee-for-service outpatient claim in the
Department's Enterprise Data Warehouse as of August 6,
2021.
(7) For public hospitals, as defined in subsection
(f), $275 per covered inpatient day contained in paid
fee-for-service claims and $275 per paid fee-for-service
outpatient claim for dates of service in Calendar Year
2019 in the Department's Enterprise Data Warehouse as of
August 6, 2021.
(8) Alzheimer's treatment access payment. Each
Illinois academic medical center or teaching hospital, as
defined in Section 5-5e.2 of this Code, that is identified
as the primary hospital affiliate of one of the Regional
Alzheimer's Disease Assistance Centers, as designated by
the Alzheimer's Disease Assistance Act and identified in
the Department of Public Health's Alzheimer's Disease


State Plan dated December 2016, shall be paid an
Alzheimer's treatment access payment equal to the product
of the qualifying hospital's Calendar Year 2019 total
inpatient fee-for-service days, in the Department's
Enterprise Data Warehouse as of August 6, 2021, multiplied
by the applicable Alzheimer's treatment rate of $244.37
for hospitals located in Cook County and $312.03 for
hospitals located outside Cook County.
(e) The Department shall require managed care
organizations (MCOs) to make directed payments and
pass-through payments according to this Section. Each calendar
year, the Department shall require MCOs to pay the maximum
amount out of these funds as allowed as pass-through payments
under federal regulations. The Department shall require MCOs
to make such pass-through payments as specified in this
Section. The Department shall require the MCOs to pay the
remaining amounts as directed Payments as specified in this
Section. The Department shall issue payments to the
Comptroller by the seventh business day of each month for all
MCOs that are sufficient for MCOs to make the directed
payments and pass-through payments according to this Section.
The Department shall require the MCOs to make pass-through
payments and directed payments using electronic funds
transfers (EFT), if the hospital provides the information
necessary to process such EFTs, in accordance with directions
provided monthly by the Department, within 7 business days of


the date the funds are paid to the MCOs, as indicated by the
"Paid Date" on the website of the Office of the Comptroller if
the funds are paid by EFT and the MCOs have received directed
payment instructions. If funds are not paid through the
Comptroller by EFT, payment must be made within 7 business
days of the date actually received by the MCO. The MCO will be
considered to have paid the pass-through payments when the
payment remittance number is generated or the date the MCO
sends the check to the hospital, if EFT information is not
supplied. If an MCO is late in paying a pass-through payment or
directed payment as required under this Section (including any
extensions granted by the Department), it shall pay a penalty,
unless waived by the Department for reasonable cause, to the
Department equal to 5% of the amount of the pass-through
payment or directed payment not paid on or before the due date
plus 5% of the portion thereof remaining unpaid on the last day
of each 30-day period thereafter. Payments to MCOs that would
be paid consistent with actuarial certification and enrollment
in the absence of the increased capitation payments under this
Section shall not be reduced as a consequence of payments made
under this subsection. The Department shall publish and
maintain on its website for a period of no less than 8 calendar
quarters, the quarterly calculation of directed payments and
pass-through payments owed to each hospital from each MCO. All
calculations and reports shall be posted no later than the
first day of the quarter for which the payments are to be


issued.
(f)(1) For purposes of allocating the funds included in
capitation payments to MCOs, Illinois hospitals shall be
divided into the following classes as defined in
administrative rules:
(A) Beginning July 1, 2020 through December 31, 2022,
critical access hospitals. Beginning January 1, 2023,
"critical access hospital" means a hospital designated by
the Department of Public Health as a critical access
hospital, excluding any hospital meeting the definition of
a public hospital in subparagraph (F).
(B) Safety-net hospitals, except that stand-alone
children's hospitals that are not specialty children's
hospitals and, for calendar years 2025 and 2026 only,
hospitals with over 9,000 Medicaid acute care inpatient
admissions per calendar year, excluding admissions for
Medicare-Medicaid dual eligible patients, will not be
included. For the calendar year beginning January 1, 2023,
and each calendar year thereafter, assignment to the
safety-net class shall be based on the annual safety-net
rate year beginning 15 months before the beginning of the
first Payout Quarter of the calendar year.
(C) Long term acute care hospitals.
(D) Freestanding psychiatric hospitals.
(E) Freestanding rehabilitation hospitals.
(F) Beginning January 1, 2023, "public hospital" means


a hospital that is owned or operated by an Illinois
Government body or municipality, excluding a hospital
provider that is a State agency, a State university, or a
county with a population of 3,000,000 or more.
(G) High Medicaid hospitals.
(i) As used in this Section, "high Medicaid
hospital" means a general acute care hospital that:
(I) For the payout periods July 1, 2020
through December 31, 2022, is not a safety-net
hospital or critical access hospital and that has
a Medicaid Inpatient Utilization Rate above 30% or
a hospital that had over 35,000 inpatient Medicaid
days during the applicable period. For the period
July 1, 2020 through December 31, 2020, the
applicable period for the Medicaid Inpatient
Utilization Rate (MIUR) is the rate year 2020 MIUR
and for the number of inpatient days it is State
fiscal year 2018. Beginning in calendar year 2021,
the Department shall use the most recently
determined MIUR, as defined in subsection (h) of
Section 5-5.02, and for the inpatient day
threshold, the State fiscal year ending 18 months
prior to the beginning of the calendar year. For
purposes of calculating MIUR under this Section,
children's hospitals and affiliated general acute
care hospitals shall be considered a single


hospital.
(II) For the calendar year beginning January
1, 2023, and each calendar year thereafter, is not
a public hospital, safety-net hospital, or
critical access hospital and that qualifies as a
regional high volume hospital or is a hospital
that has a Medicaid Inpatient Utilization Rate
(MIUR) above 30%. As used in this item, "regional
high volume hospital" means a hospital which ranks
in the top 2 quartiles based on total hospital
services volume, of all eligible general acute
care hospitals, when ranked in descending order
based on total hospital services volume, within
the same Medicaid managed care region, as
designated by the Department, as of January 1,
2022. As used in this item, "total hospital
services volume" means the total of all Medical
Assistance hospital inpatient admissions plus all
Medical Assistance hospital outpatient visits. For
purposes of determining regional high volume
hospital inpatient admissions and outpatient
visits, the Department shall use dates of service
provided during State Fiscal Year 2020 for the
Payout Quarter beginning January 1, 2023. The
Department shall use dates of service from the
State fiscal year ending 18 month before the


beginning of the first Payout Quarter of the
subsequent annual determination period.
(ii) For the calendar year beginning January 1,
2023, the Department shall use the Rate Year 2022
Medicaid inpatient utilization rate (MIUR), as defined
in subsection (h) of Section 5-5.02. For each
subsequent annual determination, the Department shall
use the MIUR applicable to the rate year ending
September 30 of the year preceding the beginning of
the calendar year.
(H) General acute care hospitals. As used under this
Section, "general acute care hospitals" means all other
Illinois hospitals not identified in subparagraphs (A)
through (G).
(2) Hospitals' qualification for each class shall be
assessed prior to the beginning of each calendar year and the
new class designation shall be effective January 1 of the next
year. The Department shall publish by rule the process for
establishing class determination.
(3) Beginning January 1, 2024, the Department may reassign
hospitals or entire hospital classes as defined above, if
federal limits on the payments to the class to which the
hospitals are assigned based on the criteria in this
subsection prevent the Department from making payments to the
class that would otherwise be due under this Section. The
Department shall publish the criteria and composition of each


new class based on the reassignments, and the projected impact
on payments to each hospital under the new classes on its
website by November 15 of the year before the year in which the
class changes become effective.
(g) Fixed pool directed payments. Beginning July 1, 2020,
the Department shall issue payments to MCOs which shall be
used to issue directed payments to qualified Illinois
safety-net hospitals and critical access hospitals on a
monthly basis in accordance with this subsection. Prior to the
beginning of each Payout Quarter beginning July 1, 2020, the
Department shall use encounter claims data from the
Determination Quarter, accepted by the Department's Medicaid
Management Information System for inpatient and outpatient
services rendered by safety-net hospitals and critical access
hospitals to determine a quarterly uniform per unit add-on for
each hospital class.
(1) Inpatient per unit add-on. A quarterly uniform per
diem add-on shall be derived by dividing the quarterly
Inpatient Directed Payments Pool amount allocated to the
applicable hospital class by the total inpatient days
contained on all encounter claims received during the
Determination Quarter, for all hospitals in the class.
(A) Each hospital in the class shall have a
quarterly inpatient directed payment calculated that
is equal to the product of the number of inpatient days
attributable to the hospital used in the calculation


of the quarterly uniform class per diem add-on,
multiplied by the calculated applicable quarterly
uniform class per diem add-on of the hospital class.
(B) Each hospital shall be paid 1/3 of its
quarterly inpatient directed payment in each of the 3
months of the Payout Quarter, in accordance with
directions provided to each MCO by the Department.
(2) Outpatient per unit add-on. A quarterly uniform
per claim add-on shall be derived by dividing the
quarterly Outpatient Directed Payments Pool amount
allocated to the applicable hospital class by the total
outpatient encounter claims received during the
Determination Quarter, for all hospitals in the class.
(A) Each hospital in the class shall have a
quarterly outpatient directed payment calculated that
is equal to the product of the number of outpatient
encounter claims attributable to the hospital used in
the calculation of the quarterly uniform class per
claim add-on, multiplied by the calculated applicable
quarterly uniform class per claim add-on of the
hospital class.
(B) Each hospital shall be paid 1/3 of its
quarterly outpatient directed payment in each of the 3
months of the Payout Quarter, in accordance with
directions provided to each MCO by the Department.
(3) Each MCO shall pay each hospital the Monthly


Directed Payment as identified by the Department on its
quarterly determination report.
(4) Definitions. As used in this subsection:
(A) "Payout Quarter" means each 3 month calendar
quarter, beginning July 1, 2020.
(B) "Determination Quarter" means each 3 month
calendar quarter, which ends 3 months prior to the
first day of each Payout Quarter.
(5) For the period July 1, 2020 through December 2020,
the following amounts shall be allocated to the following
hospital class directed payment pools for the quarterly
development of a uniform per unit add-on:
(A) $2,894,500 for hospital inpatient services for
critical access hospitals.
(B) $4,294,374 for hospital outpatient services
for critical access hospitals.
(C) $29,109,330 for hospital inpatient services
for safety-net hospitals.
(D) $35,041,218 for hospital outpatient services
for safety-net hospitals.
(6) For the period January 1, 2023 through December
31, 2023, the Department shall establish the amounts that
shall be allocated to the hospital class directed payment
fixed pools identified in this paragraph for the quarterly
development of a uniform per unit add-on. The Department
shall establish such amounts so that the total amount of


payments to each hospital under this Section in calendar
year 2023 is projected to be substantially similar to the
total amount of such payments received by the hospital
under this Section in calendar year 2021, adjusted for
increased funding provided for fixed pool directed
payments under subsection (g) in calendar year 2022,
assuming that the volume and acuity of claims are held
constant. The Department shall publish the directed
payment fixed pool amounts to be established under this
paragraph on its website by November 15, 2022.
(A) Hospital inpatient services for critical
access hospitals.
(B) Hospital outpatient services for critical
access hospitals.
(C) Hospital inpatient services for public
hospitals.
(D) Hospital outpatient services for public
hospitals.
(E) Hospital inpatient services for safety-net
hospitals.
(F) Hospital outpatient services for safety-net
hospitals.
(7) Semi-annual rate maintenance review. The
Department shall ensure that hospitals assigned to the
fixed pools in paragraph (6) are paid no less than 95% of
the annual initial rate for each 6-month period of each


annual payout period. For each calendar year, the
Department shall calculate the annual initial rate per day
and per visit for each fixed pool hospital class listed in
paragraph (6), by dividing the total of all applicable
inpatient or outpatient directed payments issued in the
preceding calendar year to the hospitals in each fixed
pool class for the calendar year, plus any increase
resulting from the annual adjustments described in
subsection (i), by the actual applicable total service
units for the preceding calendar year which were the basis
of the total applicable inpatient or outpatient directed
payments issued to the hospitals in each fixed pool class
in the calendar year, except that for calendar year 2023,
the service units from calendar year 2021 shall be used.
(A) The Department shall calculate the effective
rate, per day and per visit, for the payout periods of
January to June and July to December of each year, for
each fixed pool listed in paragraph (6), by dividing
50% of the annual pool by the total applicable
reported service units for the 2 applicable
determination quarters.
(B) If the effective rate calculated in
subparagraph (A) is less than 95% of the annual
initial rate assigned to the class for each pool under
paragraph (6), the Department shall adjust the payment
for each hospital to a level equal to no less than 95%


of the annual initial rate, by issuing a retroactive
adjustment payment for the 6-month period under review
as identified in subparagraph (A).
(h) Fixed rate directed payments. Effective July 1, 2020,
the Department shall issue payments to MCOs which shall be
used to issue directed payments to Illinois hospitals not
identified in paragraph (g) on a monthly basis. Prior to the
beginning of each Payout Quarter beginning July 1, 2020, the
Department shall use encounter claims data from the
Determination Quarter, accepted by the Department's Medicaid
Management Information System for inpatient and outpatient
services rendered by hospitals in each hospital class
identified in paragraph (f) and not identified in paragraph
(g). For the period July 1, 2020 through December 2020, the
Department shall direct MCOs to make payments as follows:
(1) For general acute care hospitals an amount equal
to $1,750 multiplied by the hospital's category of service
20 case mix index for the determination quarter multiplied
by the hospital's total number of inpatient admissions for
category of service 20 for the determination quarter.
(2) For general acute care hospitals an amount equal
to $160 multiplied by the hospital's category of service
21 case mix index for the determination quarter multiplied
by the hospital's total number of inpatient admissions for
category of service 21 for the determination quarter.
(3) For general acute care hospitals an amount equal


to $80 multiplied by the hospital's category of service 22
case mix index for the determination quarter multiplied by
the hospital's total number of inpatient admissions for
category of service 22 for the determination quarter.
(4) For general acute care hospitals an amount equal
to $375 multiplied by the hospital's category of service
24 case mix index for the determination quarter multiplied
by the hospital's total number of category of service 24
paid EAPG (EAPGs) for the determination quarter.
(5) For general acute care hospitals an amount equal
to $240 multiplied by the hospital's category of service
27 and 28 case mix index for the determination quarter
multiplied by the hospital's total number of category of
service 27 and 28 paid EAPGs for the determination
quarter.
(6) For general acute care hospitals an amount equal
to $290 multiplied by the hospital's category of service
29 case mix index for the determination quarter multiplied
by the hospital's total number of category of service 29
paid EAPGs for the determination quarter.
(7) For high Medicaid hospitals an amount equal to
$1,800 multiplied by the hospital's category of service 20
case mix index for the determination quarter multiplied by
the hospital's total number of inpatient admissions for
category of service 20 for the determination quarter.
(8) For high Medicaid hospitals an amount equal to


$160 multiplied by the hospital's category of service 21
case mix index for the determination quarter multiplied by
the hospital's total number of inpatient admissions for
category of service 21 for the determination quarter.
(9) For high Medicaid hospitals an amount equal to $80
multiplied by the hospital's category of service 22 case
mix index for the determination quarter multiplied by the
hospital's total number of inpatient admissions for
category of service 22 for the determination quarter.
(10) For high Medicaid hospitals an amount equal to
$400 multiplied by the hospital's category of service 24
case mix index for the determination quarter multiplied by
the hospital's total number of category of service 24 paid
EAPG outpatient claims for the determination quarter.
(11) For high Medicaid hospitals an amount equal to
$240 multiplied by the hospital's category of service 27
and 28 case mix index for the determination quarter
multiplied by the hospital's total number of category of
service 27 and 28 paid EAPGs for the determination
quarter.
(12) For high Medicaid hospitals an amount equal to
$290 multiplied by the hospital's category of service 29
case mix index for the determination quarter multiplied by
the hospital's total number of category of service 29 paid
EAPGs for the determination quarter.
(13) For long term acute care hospitals the amount of


$495 multiplied by the hospital's total number of
inpatient days for the determination quarter.
(14) For psychiatric hospitals the amount of $210
multiplied by the hospital's total number of inpatient
days for category of service 21 for the determination
quarter.
(15) For psychiatric hospitals the amount of $250
multiplied by the hospital's total number of outpatient
claims for category of service 27 and 28 for the
determination quarter.
(16) For rehabilitation hospitals the amount of $410
multiplied by the hospital's total number of inpatient
days for category of service 22 for the determination
quarter.
(17) For rehabilitation hospitals the amount of $100
multiplied by the hospital's total number of outpatient
claims for category of service 29 for the determination
quarter.
(18) Effective for the Payout Quarter beginning
January 1, 2023, for the directed payments to hospitals
required under this subsection, the Department shall
establish the amounts that shall be used to calculate such
directed payments using the methodologies specified in
this paragraph. The Department shall use a single, uniform
rate, adjusted for acuity as specified in paragraphs (1)
through (12), for all categories of inpatient services


provided by each class of hospitals and a single uniform
rate, adjusted for acuity as specified in paragraphs (1)
through (12), for all categories of outpatient services
provided by each class of hospitals. The Department shall
establish such amounts so that the total amount of
payments to each hospital under this Section in calendar
year 2023 is projected to be substantially similar to the
total amount of such payments received by the hospital
under this Section in calendar year 2021, adjusted for
increased funding provided for fixed pool directed
payments under subsection (g) in calendar year 2022,
assuming that the volume and acuity of claims are held
constant. The Department shall publish the directed
payment amounts to be established under this subsection on
its website by November 15, 2022.
(19) Each hospital shall be paid 1/3 of their
quarterly inpatient and outpatient directed payment in
each of the 3 months of the Payout Quarter, in accordance
with directions provided to each MCO by the Department.
(20) Each MCO shall pay each hospital the Monthly
Directed Payment amount as identified by the Department on
its quarterly determination report.
Notwithstanding any other provision of this subsection, if
the Department determines that the actual total hospital
utilization data that is used to calculate the fixed rate
directed payments is substantially different than anticipated


when the rates in this subsection were initially determined
for unforeseeable circumstances (such as the COVID-19 pandemic
or some other public health emergency), the Department may
adjust the rates specified in this subsection so that the
total directed payments approximate the total spending amount
anticipated when the rates were initially established.
Definitions. As used in this subsection:
(A) "Payout Quarter" means each calendar quarter,
beginning July 1, 2020.
(B) "Determination Quarter" means each calendar
quarter which ends 3 months prior to the first day of
each Payout Quarter.
(C) "Case mix index" means a hospital specific
calculation. For inpatient claims the case mix index
is calculated each quarter by summing the relative
weight of all inpatient Diagnosis-Related Group (DRG)
claims for a category of service in the applicable
Determination Quarter and dividing the sum by the
number of sum total of all inpatient DRG admissions
for the category of service for the associated claims.
The case mix index for outpatient claims is calculated
each quarter by summing the relative weight of all
paid EAPGs in the applicable Determination Quarter and
dividing the sum by the sum total of paid EAPGs for the
associated claims.
(i) Beginning January 1, 2021, the rates for directed


payments shall be recalculated in order to spend the
additional funds for directed payments that result from
reduction in the amount of pass-through payments allowed under
federal regulations. The additional funds for directed
payments shall be allocated proportionally to each class of
hospitals based on that class' proportion of services.
(1) Beginning January 1, 2024, the fixed pool directed
payment amounts and the associated annual initial rates
referenced in paragraph (6) of subsection (f) for each
hospital class shall be uniformly increased by a ratio of
not less than, the ratio of the total pass-through
reduction amount pursuant to paragraph (4) of subsection
(j), for the hospitals comprising the hospital fixed pool
directed payment class for the next calendar year, to the
total inpatient and outpatient directed payments for the
hospitals comprising the hospital fixed pool directed
payment class paid during the preceding calendar year.
(2) Beginning January 1, 2024, the fixed rates for the
directed payments referenced in paragraph (18) of
subsection (h) for each hospital class shall be uniformly
increased by a ratio of not less than, the ratio of the
total pass-through reduction amount pursuant to paragraph
(4) of subsection (j), for the hospitals comprising the
hospital directed payment class for the next calendar
year, to the total inpatient and outpatient directed
payments for the hospitals comprising the hospital fixed


rate directed payment class paid during the preceding
calendar year.
(j) Pass-through payments.
(1) For the period July 1, 2020 through December 31,
2020, the Department shall assign quarterly pass-through
payments to each class of hospitals equal to one-fourth of
the following annual allocations:
(A) $390,487,095 to safety-net hospitals.
(B) $62,553,886 to critical access hospitals.
(C) $345,021,438 to high Medicaid hospitals.
(D) $551,429,071 to general acute care hospitals.
(E) $27,283,870 to long term acute care hospitals.
(F) $40,825,444 to freestanding psychiatric
hospitals.
(G) $9,652,108 to freestanding rehabilitation
hospitals.
(2) For the period of July 1, 2020 through December
31, 2020, the pass-through payments shall at a minimum
ensure hospitals receive a total amount of monthly
payments under this Section as received in calendar year
2019 in accordance with this Article and paragraph (1) of
subsection (d-5) of Section 14-12, exclusive of amounts
received through payments referenced in subsection (b).
(3) For the calendar year beginning January 1, 2023,
the Department shall establish the annual pass-through
allocation to each class of hospitals and the pass-through


payments to each hospital so that the total amount of
payments to each hospital under this Section in calendar
year 2023 is projected to be substantially similar to the
total amount of such payments received by the hospital
under this Section in calendar year 2021, adjusted for
increased funding provided for fixed pool directed
payments under subsection (g) in calendar year 2022,
assuming that the volume and acuity of claims are held
constant. The Department shall publish the pass-through
allocation to each class and the pass-through payments to
each hospital to be established under this subsection on
its website by November 15, 2022.
(4) For the calendar years beginning January 1, 2021
and January 1, 2022, each hospital's pass-through payment
amount shall be reduced proportionally to the reduction of
all pass-through payments required by federal regulations.
Beginning January 1, 2024, the Department shall reduce
total pass-through payments by the minimum amount
necessary to comply with federal regulations. Pass-through
payments to safety-net hospitals, as defined in Section
5-5e.1 of this Code, shall not be reduced until all
pass-through payments to other hospitals have been
eliminated. All other hospitals shall have their
pass-through payments reduced proportionally.
(k) At least 30 days prior to each calendar year, the
Department shall notify each hospital of changes to the


payment methodologies in this Section, including, but not
limited to, changes in the fixed rate directed payment rates,
the aggregate pass-through payment amount for all hospitals,
and the hospital's pass-through payment amount for the
upcoming calendar year.
(l) Notwithstanding any other provisions of this Section,
the Department may adopt rules to change the methodology for
directed and pass-through payments as set forth in this
Section, but only to the extent necessary to obtain federal
approval of a necessary State Plan amendment or Directed
Payment Preprint or to otherwise conform to federal law or
federal regulation.
(m) As used in this subsection, "managed care
organization" or "MCO" means an entity which contracts with
the Department to provide services where payment for medical
services is made on a capitated basis, excluding contracted
entities for dual eligible or Department of Children and
Family Services youth populations.
(n) In order to address the escalating infant mortality
rates among minority communities in Illinois, the State shall,
subject to appropriation, create a pool of funding of at least
$50,000,000 annually to be disbursed among safety-net
hospitals that maintain perinatal designation from the
Department of Public Health. The funding shall be used to
preserve or enhance OB/GYN services or other specialty
services at the receiving hospital, with the distribution of


funding to be established by rule and with consideration to
perinatal hospitals with safe birthing levels and quality
metrics for healthy mothers and babies.
(o) In order to address the growing challenges of
providing stable access to healthcare in rural Illinois,
including perinatal services, behavioral healthcare including
substance use disorder services (SUDs) and other specialty
services, and to expand access to telehealth services among
rural communities in Illinois, the Department of Healthcare
and Family Services shall administer a program to provide at
least $10,000,000 in financial support annually to critical
access hospitals for delivery of perinatal and OB/GYN
services, behavioral healthcare including SUDS, other
specialty services and telehealth services. The funding shall
be used to preserve or enhance perinatal and OB/GYN services,
behavioral healthcare including SUDS, other specialty
services, as well as the explanation of telehealth services by
the receiving hospital, with the distribution of funding to be
established by rule.
(p) For calendar year 2023, the final amounts, rates, and
payments under subsections (c), (d-2), (g), (h), and (j) shall
be established by the Department, so that the sum of the total
estimated annual payments under subsections (c), (d-2), (g),
(h), and (j) for each hospital class for calendar year 2023, is
no less than:
(1) $858,260,000 to safety-net hospitals.


(2) $86,200,000 to critical access hospitals.
(3) $1,765,000,000 to high Medicaid hospitals.
(4) $673,860,000 to general acute care hospitals.
(5) $48,330,000 to long term acute care hospitals.
(6) $89,110,000 to freestanding psychiatric hospitals.
(7) $24,300,000 to freestanding rehabilitation
hospitals.
(8) $32,570,000 to public hospitals.
(q) Hospital Pandemic Recovery Stabilization Payments. The
Department shall disburse a pool of $460,000,000 in stability
payments to hospitals prior to April 1, 2023. The allocation
of the pool shall be based on the hospital directed payment
classes and directed payments issued, during Calendar Year
2022 with added consideration to safety net hospitals, as
defined in subdivision (f)(1)(B) of this Section, and critical
access hospitals.
(Source: P.A. 102-4, eff. 4-27-21; 102-16, eff. 6-17-21;
102-886, eff. 5-17-22; 102-1115, eff. 1-9-23; 103-102, eff.
6-16-23; revised 9-21-23.)
ARTICLE 45.
Section 45-5. The Illinois Public Aid Code is amended by
adding Section 5-5.08a as follows:
(305 ILCS 5/5-5.08a new)


Sec. 5-5.08a. Renal dialysis; add-on payments for home
dialysis providers in skilled nursing facilities.
(a) Findings. The General Assembly finds the following:
(1) Home dialysis services provided on-site at skilled
nursing facilities are beneficial to nursing home
residents by permitting more time for other health and
wellness activities, and nullifying burdensome off-site
travel which carries various health care risks and
increased costs.
(2) Home dialysis for nursing home residents provides
an on-site venue for high-acuity residents to receive
dialysis services, effectively creating downstream care
opportunities for hospital patients in need of post-acute
care and dialysis, and reducing the total cost of dialysis
care.
(3) On-site home dialysis in nursing homes is costlier
for the provider than conventional outpatient dialysis, as
labor costs are greater per treatment and such patients
typically have higher acuities, necessitating more
medication and greater staff involvement to promote
patient compliance.
(b) Subject to federal approval, for dates of service
beginning on and after January 1, 2025, for home renal
dialysis provided to residents of skilled nursing facilities,
the Department shall reimburse a per-claim add-on payment to
certified home dialysis providers in accordance with this


Section. Certified home dialysis providers providing dialysis
services within a skilled nursing facility shall receive a
per-claim add-on payment of $95 per treatment. As used in this
Section, "certified home dialysis provider" means an end-stage
renal disease facility that (i) provides dialysis treatment or
dialysis training to caregivers or individuals with end-stage
renal disease and (ii) has been approved to provide dialysis
home training support services by the federal Centers for
Medicare and Medicaid Services.
ARTICLE 50.
Section 50-5. The Illinois Public Aid Code is amended by
changing Sections 5-5.07 and 14-13 as follows:
(305 ILCS 5/5-5.07)
Sec. 5-5.07. Inpatient psychiatric stay; DCFS per diem
rate. The Department of Children and Family Services shall pay
the DCFS per diem rate for inpatient psychiatric stay at a
free-standing psychiatric hospital or a hospital with a
pediatric or adolescent inpatient psychiatric unit effective
the 3rd day 11th day when a child is in the hospital beyond
medical necessity, and the parent or caregiver has denied the
child access to the home and has refused or failed to make
provisions for another living arrangement for the child or the
child's discharge is being delayed due to a pending inquiry or


investigation by the Department of Children and Family
Services. If any portion of a hospital stay is reimbursed
under this Section, the hospital stay shall not be eligible
for payment under the provisions of Section 14-13 of this
Code.
(Source: Reenacted by P.A. 101-15, eff. 6-14-19; reenacted by
P.A. 101-209, eff. 8-5-19; P.A. 101-655, eff. 3-12-21;
102-201, eff. 7-30-21; 102-558, eff. 8-20-21; 102-1037, eff.
6-2-22.)
(305 ILCS 5/14-13)
Sec. 14-13. Reimbursement for inpatient stays extended
beyond medical necessity.
(a) By October 1, 2019, the Department shall by rule
implement a methodology effective for dates of service July 1,
2019 and later to reimburse hospitals for inpatient stays
extended beyond medical necessity due to the inability of the
Department or the managed care organization in which a
recipient is enrolled or the hospital discharge planner to
find an appropriate placement after discharge from the
hospital. The Department shall evaluate the effectiveness of
the current reimbursement rate for inpatient hospital stays
beyond medical necessity.
(b) The methodology shall provide reasonable compensation
for the services provided attributable to the days of the
extended stay for which the prevailing rate methodology


provides no reimbursement. The Department may use a day
outlier program to satisfy this requirement. The reimbursement
rate shall be set at a level so as not to act as an incentive
to avoid transfer to the appropriate level of care needed or
placement, after discharge.
(c) The Department shall require managed care
organizations to adopt this methodology or an alternative
methodology that pays at least as much as the Department's
adopted methodology unless otherwise mutually agreed upon
contractual language is developed by the provider and the
managed care organization for a risk-based or innovative
payment methodology.
(d) Days beyond medical necessity shall not be eligible
for per diem add-on payments under the Medicaid High Volume
Adjustment (MHVA) or the Medicaid Percentage Adjustment (MPA)
programs.
(e) For services covered by the fee-for-service program,
reimbursement under this Section shall only be made for days
beyond medical necessity that occur after the hospital has
notified the Department of the need for post-discharge
placement. For services covered by a managed care
organization, hospitals shall notify the appropriate managed
care organization of an admission within 24 hours of
admission. For every 24-hour period beyond the initial 24
hours after admission that the hospital fails to notify the
managed care organization of the admission, reimbursement


under this subsection shall be reduced by one day.
(f) The Department of Children and Family Services shall
pay for all inpatient stays beginning on the 3rd day a child is
in the hospital beyond medical necessity, and the parent or
caregiver has denied the child access to the home and has
refused or failed to make provisions for another living
arrangement for the child or the child's discharge is being
delayed due to a pending inquiry or investigation by the
Department of Children and Family Services.
(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.)
ARTICLE 55.
Section 55-5. The Illinois Public Aid Code is amended by
adding Section 5-55 as follows:
(305 ILCS 5/5-55 new)
Sec. 5-55. Reimbursement for music therapy services.
Subject to federal approval, for dates of service beginning on
and after July 1, 2025, the Department shall reimburse music
therapy services provided by licensed professional music
therapists. To be eligible for reimbursement under this
Section, music therapy services must be provided by a licensed
professional music therapist authorized to practice under the
Music Therapy Licensing and Practice Act.


ARTICLE 60.
Section 60-5. The Illinois Public Aid Code is amended by
adding Section 5-60 as follows:
(305 ILCS 5/5-60 new)
Sec. 5-60. Optometric services; reimbursement rates.
Notwithstanding any other law or rule to the contrary and
subject to federal approval, for dates of service beginning on
and after January 1, 2025, the reimbursement rates for
optometric and optical services for determining refractive
state, fitting of spectacles, and fitting of bifocal
spectacles shall be increased by 35% above the rates in effect
on January 1, 2024.
ARTICLE 65.
Section 65-5. The Illinois Public Aid Code is amended by
changing Section 5-2.06 as follows:
(305 ILCS 5/5-2.06)
Sec. 5-2.06. Payment rates; Children's Community-Based
Health Care Centers. Beginning January 1, 2025 and subject to
federal approval 2020, the Department shall, for eligible
individuals, reimburse Children's Community-Based Health Care
Centers established in the Alternative Health Care Delivery


Act and providing nursing care for the purpose of
transitioning children from a hospital to home placement or
other appropriate setting and reuniting families for a maximum
of up to 120 days on a per diem basis at the lower of the
Children's Community-Based Health Care Center's usual and
customary charge to the public or at the Department rate of
$1,300 $950. Payments at the rate set forth in this Section are
exempt from the 2.7% rate reduction required under Section
5-5e.
(Source: P.A. 101-10, eff. 6-5-19.)
ARTICLE 70.
Section 70-5. The Illinois Public Aid Code is amended by
adding Section 5-5.24a as follows:
(305 ILCS 5/5-5.24a new)
Sec. 5-5.24a. Remote ultrasounds and remote fetal
nonstress tests; reimbursement.
(a) Subject to federal approval, for dates of service
beginning on and after January 1, 2025, the Department shall
reimburse for remote ultrasound procedures and remote fetal
nonstress tests when the patient is in a residence or other
off-site location from the patient's provider and the same
standard of care is met as would be present during an in-person
visit.


(b) Remote ultrasounds and remote fetal nonstress tests
are only eligible for reimbursement when the provider uses
digital technology:
(1) to collect medical and other forms of health data
from a patient and to electronically transmit that
information securely to a health care provider in a
different location for interpretation and recommendation;
(2) that is compliant with the federal Health
Insurance Portability and Accountability Act of 1996; and
(3) that is approved by the U.S. Food and Drug
Administration.
(c) A fetal nonstress test is only eligible for
reimbursement with a place of service modifier for at-home
monitoring with remote monitoring solutions that are cleared
by the U.S. Food and Drug Administration for on-label use for
monitoring fetal heart rate, maternal heart rate, and uterine
activity.
(d) The Department shall issue guidance to implement the
provisions of this Section.
ARTICLE 75.
Section 75-5. The Illinois Public Aid Code is amended by
changing Section 5-2b as follows:
(305 ILCS 5/5-2b)


Sec. 5-2b. Medically fragile and technology dependent
children eligibility and program; provider reimbursement
rates.
(a) Notwithstanding any other provision of law except as
provided in Section 5-30a, on and after September 1, 2012,
subject to federal approval, medical assistance under this
Article shall be available to children who qualify as persons
with a disability, as defined under the federal Supplemental
Security Income program and who are medically fragile and
technology dependent. The program shall allow eligible
children to receive the medical assistance provided under this
Article in the community and must maximize, to the fullest
extent permissible under federal law, federal reimbursement
and family cost-sharing, including co-pays, premiums, or any
other family contributions, except that the Department shall
be permitted to incentivize the utilization of selected
services through the use of cost-sharing adjustments. The
Department shall establish the policies, procedures,
standards, services, and criteria for this program by rule.
(b) Notwithstanding any other provision of this Code,
subject to federal approval, on and after January 1, 2024, the
reimbursement rates for nursing paid through Nursing and
Personal Care Services for non-waiver customers and to
providers of private duty nursing services for children
eligible for medical assistance under this Section shall be
20% higher than the reimbursement rates in effect for nursing


services on December 31, 2023.
(c) Notwithstanding any other provision of this Code,
subject to federal approval, on and after January 1, 2025, the
reimbursement rates for nursing paid through Nursing and
Personal Care Services for non-waiver customers and to
providers of private duty nursing services for children
eligible for medical assistance under this Section shall be 7%
higher than the reimbursement rates in effect for nursing
services on December 31, 2024.
(Source: P.A. 103-102, eff. 1-1-24.)
ARTICLE 80.
Section 80-5. The Illinois Public Aid Code is amended by
adding Section 5-52 as follows:
(305 ILCS 5/5-52 new)
Sec. 5-52. Custom prosthetic and orthotic devices;
reimbursement rates. Subject to federal approval, for dates of
service beginning on and after January 1, 2025, the Department
shall increase the current 2024 Medicaid rate by 7% under the
medical assistance program for custom prosthetic and orthotic
devices.
ARTICLE 85.


Section 85-5. The Illinois Public Aid Code is amended by
changing Section 5-4.2 as follows:
(305 ILCS 5/5-4.2)
Sec. 5-4.2. Ambulance services payments.
(a) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1993, the Illinois
Department shall reimburse ambulance service providers at
rates calculated in accordance with this Section. It is the
intent of the General Assembly to provide adequate
reimbursement for ambulance services so as to ensure adequate
access to services for recipients of aid under this Article
and to provide appropriate incentives to ambulance service
providers to provide services in an efficient and
cost-effective manner. Thus, it is the intent of the General
Assembly that the Illinois Department implement a
reimbursement system for ambulance services that, to the
extent practicable and subject to the availability of funds
appropriated by the General Assembly for this purpose, is
consistent with the payment principles of Medicare. To ensure
uniformity between the payment principles of Medicare and
Medicaid, the Illinois Department shall follow, to the extent
necessary and practicable and subject to the availability of
funds appropriated by the General Assembly for this purpose,
the statutes, laws, regulations, policies, procedures,
principles, definitions, guidelines, and manuals used to


determine the amounts paid to ambulance service providers
under Title XVIII of the Social Security Act (Medicare).
(b) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1996, the Illinois
Department shall reimburse ambulance service providers based
upon the actual distance traveled if a natural disaster,
weather conditions, road repairs, or traffic congestion
necessitates the use of a route other than the most direct
route.
(c) For purposes of this Section, "ambulance services"
includes medical transportation services provided by means of
an ambulance, air ambulance, medi-car, service car, or taxi.
(c-1) For purposes of this Section, "ground ambulance
service" means medical transportation services that are
described as ground ambulance services by the Centers for
Medicare and Medicaid Services and provided in a vehicle that
is licensed as an ambulance by the Illinois Department of
Public Health pursuant to the Emergency Medical Services (EMS)
Systems Act.
(c-2) For purposes of this Section, "ground ambulance
service provider" means a vehicle service provider as
described in the Emergency Medical Services (EMS) Systems Act
that operates licensed ambulances for the purpose of providing
emergency ambulance services, or non-emergency ambulance
services, or both. For purposes of this Section, this includes
both ambulance providers and ambulance suppliers as described


by the Centers for Medicare and Medicaid Services.
(c-3) For purposes of this Section, "medi-car" means
transportation services provided to a patient who is confined
to a wheelchair and requires the use of a hydraulic or electric
lift or ramp and wheelchair lockdown when the patient's
condition does not require medical observation, medical
supervision, medical equipment, the administration of
medications, or the administration of oxygen.
(c-4) For purposes of this Section, "service car" means
transportation services provided to a patient by a passenger
vehicle where that patient does not require the specialized
modes described in subsection (c-1) or (c-3).
(c-5) For purposes of this Section, "air ambulance
service" means medical transport by helicopter or airplane for
patients, as defined in 29 U.S.C. 1185f(c)(1), and any service
that is described as an air ambulance service by the federal
Centers for Medicare and Medicaid Services.
(d) This Section does not prohibit separate billing by
ambulance service providers for oxygen furnished while
providing advanced life support services.
(e) Beginning with services rendered on or after July 1,
2008, all providers of non-emergency medi-car and service car
transportation must certify that the driver and employee
attendant, as applicable, have completed a safety program
approved by the Department to protect both the patient and the
driver, prior to transporting a patient. The provider must


maintain this certification in its records. The provider shall
produce such documentation upon demand by the Department or
its representative. Failure to produce documentation of such
training shall result in recovery of any payments made by the
Department for services rendered by a non-certified driver or
employee attendant. Medi-car and service car providers must
maintain legible documentation in their records of the driver
and, as applicable, employee attendant that actually
transported the patient. Providers must recertify all drivers
and employee attendants every 3 years. If they meet the
established training components set forth by the Department,
providers of non-emergency medi-car and service car
transportation that are either directly or through an
affiliated company licensed by the Department of Public Health
shall be approved by the Department to have in-house safety
programs for training their own staff.
Notwithstanding the requirements above, any public
transportation provider of medi-car and service car
transportation that receives federal funding under 49 U.S.C.
5307 and 5311 need not certify its drivers and employee
attendants under this Section, since safety training is
already federally mandated.
(f) With respect to any policy or program administered by
the Department or its agent regarding approval of
non-emergency medical transportation by ground ambulance
service providers, including, but not limited to, the


Non-Emergency Transportation Services Prior Approval Program
(NETSPAP), the Department shall establish by rule a process by
which ground ambulance service providers of non-emergency
medical transportation may appeal any decision by the
Department or its agent for which no denial was received prior
to the time of transport that either (i) denies a request for
approval for payment of non-emergency transportation by means
of ground ambulance service or (ii) grants a request for
approval of non-emergency transportation by means of ground
ambulance service at a level of service that entitles the
ground ambulance service provider to a lower level of
compensation from the Department than the ground ambulance
service provider would have received as compensation for the
level of service requested. The rule shall be filed by
December 15, 2012 and shall provide that, for any decision
rendered by the Department or its agent on or after the date
the rule takes effect, the ground ambulance service provider
shall have 60 days from the date the decision is received to
file an appeal. The rule established by the Department shall
be, insofar as is practical, consistent with the Illinois
Administrative Procedure Act. The Director's decision on an
appeal under this Section shall be a final administrative
decision subject to review under the Administrative Review
Law.
(f-5) Beginning 90 days after July 20, 2012 (the effective
date of Public Act 97-842), (i) no denial of a request for


approval for payment of non-emergency transportation by means
of ground ambulance service, and (ii) no approval of
non-emergency transportation by means of ground ambulance
service at a level of service that entitles the ground
ambulance service provider to a lower level of compensation
from the Department than would have been received at the level
of service submitted by the ground ambulance service provider,
may be issued by the Department or its agent unless the
Department has submitted the criteria for determining the
appropriateness of the transport for first notice publication
in the Illinois Register pursuant to Section 5-40 of the
Illinois Administrative Procedure Act.
(f-6) Within 90 days after June 2, 2022 (the effective
date of Public Act 102-1037) this amendatory Act of the 102nd
General Assembly and subject to federal approval, the
Department shall file rules to allow for the approval of
ground ambulance services when the sole purpose of the
transport is for the navigation of stairs or the assisting or
lifting of a patient at a medical facility or during a medical
appointment in instances where the Department or a contracted
Medicaid managed care organization or their transportation
broker is unable to secure transportation through any other
transportation provider.
(f-7) For non-emergency ground ambulance claims properly
denied under Department policy at the time the claim is filed
due to failure to submit a valid Medical Certification for


Non-Emergency Ambulance on and after December 15, 2012 and
prior to January 1, 2021, the Department shall allot
$2,000,000 to a pool to reimburse such claims if the provider
proves medical necessity for the service by other means.
Providers must submit any such denied claims for which they
seek compensation to the Department no later than December 31,
2021 along with documentation of medical necessity. No later
than May 31, 2022, the Department shall determine for which
claims medical necessity was established. Such claims for
which medical necessity was established shall be paid at the
rate in effect at the time of the service, provided the
$2,000,000 is sufficient to pay at those rates. If the pool is
not sufficient, claims shall be paid at a uniform percentage
of the applicable rate such that the pool of $2,000,000 is
exhausted. The appeal process described in subsection (f)
shall not be applicable to the Department's determinations
made in accordance with this subsection.
(g) Whenever a patient covered by a medical assistance
program under this Code or by another medical program
administered by the Department, including a patient covered
under the State's Medicaid managed care program, is being
transported from a facility and requires non-emergency
transportation including ground ambulance, medi-car, or
service car transportation, a Physician Certification
Statement as described in this Section shall be required for
each patient. Facilities shall develop procedures for a


licensed medical professional to provide a written and signed
Physician Certification Statement. The Physician Certification
Statement shall specify the level of transportation services
needed and complete a medical certification establishing the
criteria for approval of non-emergency ambulance
transportation, as published by the Department of Healthcare
and Family Services, that is met by the patient. This
certification shall be completed prior to ordering the
transportation service and prior to patient discharge. The
Physician Certification Statement is not required prior to
transport if a delay in transport can be expected to
negatively affect the patient outcome. If the ground ambulance
provider, medi-car provider, or service car provider is unable
to obtain the required Physician Certification Statement
within 10 calendar days following the date of the service, the
ground ambulance provider, medi-car provider, or service car
provider must document its attempt to obtain the requested
certification and may then submit the claim for payment.
Acceptable documentation includes a signed return receipt from
the U.S. Postal Service, facsimile receipt, email receipt, or
other similar service that evidences that the ground ambulance
provider, medi-car provider, or service car provider attempted
to obtain the required Physician Certification Statement.
The medical certification specifying the level and type of
non-emergency transportation needed shall be in the form of
the Physician Certification Statement on a standardized form


prescribed by the Department of Healthcare and Family
Services. Within 75 days after July 27, 2018 (the effective
date of Public Act 100-646), the Department of Healthcare and
Family Services shall develop a standardized form of the
Physician Certification Statement specifying the level and
type of transportation services needed in consultation with
the Department of Public Health, Medicaid managed care
organizations, a statewide association representing ambulance
providers, a statewide association representing hospitals, 3
statewide associations representing nursing homes, and other
stakeholders. The Physician Certification Statement shall
include, but is not limited to, the criteria necessary to
demonstrate medical necessity for the level of transport
needed as required by (i) the Department of Healthcare and
Family Services and (ii) the federal Centers for Medicare and
Medicaid Services as outlined in the Centers for Medicare and
Medicaid Services' Medicare Benefit Policy Manual, Pub.
100-02, Chap. 10, Sec. 10.2.1, et seq. The use of the Physician
Certification Statement shall satisfy the obligations of
hospitals under Section 6.22 of the Hospital Licensing Act and
nursing homes under Section 2-217 of the Nursing Home Care
Act. Implementation and acceptance of the Physician
Certification Statement shall take place no later than 90 days
after the issuance of the Physician Certification Statement by
the Department of Healthcare and Family Services.
Pursuant to subsection (E) of Section 12-4.25 of this


Code, the Department is entitled to recover overpayments paid
to a provider or vendor, including, but not limited to, from
the discharging physician, the discharging facility, and the
ground ambulance service provider, in instances where a
non-emergency ground ambulance service is rendered as the
result of improper or false certification.
Beginning October 1, 2018, the Department of Healthcare
and Family Services shall collect data from Medicaid managed
care organizations and transportation brokers, including the
Department's NETSPAP broker, regarding denials and appeals
related to the missing or incomplete Physician Certification
Statement forms and overall compliance with this subsection.
The Department of Healthcare and Family Services shall publish
quarterly results on its website within 15 days following the
end of each quarter.
(h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(i) Subject to federal approval, on and after January 1,
2024 through June 30, 2026, the Department shall increase the
base rate of reimbursement for both base charges and mileage
charges for ground ambulance service providers not
participating in the Ground Emergency Medical Transportation
(GEMT) Program for medical transportation services provided by


means of a ground ambulance to a level not lower than 140% of
the base rate in effect as of January 1, 2023.
(j) For the purpose of understanding ground ambulance
transportation services cost structures and their impact on
the Medical Assistance Program, the Department shall engage
stakeholders, including, but not limited to, a statewide
association representing private ground ambulance service
providers in Illinois, to develop recommendations for a plan
for the regular collection of cost data for all ground
ambulance transportation providers reimbursed under the
Illinois Title XIX State Plan. Cost data obtained through this
process shall be used to inform on and to ensure the
effectiveness and efficiency of Illinois Medicaid rates. The
Department shall establish a process to limit public
availability of portions of the cost report data determined to
be proprietary. This process shall be concluded and
recommendations shall be provided no later than December 31,
2025 April 1, 2024.
(k) (j) Subject to federal approval, beginning on January
1, 2024, the Department shall increase the base rate of
reimbursement for both base charges and mileage charges for
medical transportation services provided by means of an air
ambulance to a level not lower than 50% of the Medicare
ambulance fee schedule rates, by designated Medicare locality,
in effect on January 1, 2023.
(Source: P.A. 102-364, eff. 1-1-22; 102-650, eff. 8-27-21;


102-813, eff. 5-13-22; 102-1037, eff. 6-2-22; 103-102, Article
70, Section 70-5, eff. 1-1-24; 103-102, Article 80, Section
80-5, eff. 1-1-24; revised 12-15-23.)
ARTICLE 90.
Section 90-5. The Illinois Public Aid Code is amended by
changing Section 5-5 as follows:
(305 ILCS 5/5-5)
Sec. 5-5. Medical services.  The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing
home, or elsewhere; (6) medical care, or any other type of
remedial care furnished by licensed practitioners; (7) home
health care services; (8) private duty nursing service; (9)
clinic services; (10) dental services, including prevention
and treatment of periodontal disease and dental caries disease
for pregnant individuals, provided by an individual licensed
to practice dentistry or dental surgery; for purposes of this


item (10), "dental services" means diagnostic, preventive, or
corrective procedures provided by or under the supervision of
a dentist in the practice of his or her profession; (11)
physical therapy and related services; (12) prescribed drugs,
dentures, and prosthetic devices; and eyeglasses prescribed by
a physician skilled in the diseases of the eye, or by an
optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative
services, including to ensure that the individual's need for
intervention or treatment of mental disorders or substance use
disorders or co-occurring mental health and substance use
disorders is determined using a uniform screening, assessment,
and evaluation process inclusive of criteria, for children and
adults; for purposes of this item (13), a uniform screening,
assessment, and evaluation process refers to a process that
includes an appropriate evaluation and, as warranted, a
referral; "uniform" does not mean the use of a singular
instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary;
(15) medical treatment of sexual assault survivors, as defined
in Section 1a of the Sexual Assault Survivors Emergency
Treatment Act, for injuries sustained as a result of the
sexual assault, including examinations and laboratory tests to
discover evidence which may be used in criminal proceedings
arising from the sexual assault; (16) the diagnosis and
treatment of sickle cell anemia; (16.5) services performed by


a chiropractic physician licensed under the Medical Practice
Act of 1987 and acting within the scope of his or her license,
including, but not limited to, chiropractic manipulative
treatment; and (17) any other medical care, and any other type
of remedial care recognized under the laws of this State. The
term "any other type of remedial care" shall include nursing
care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
Notwithstanding any other provision of this Code,
reproductive health care that is otherwise legal in Illinois
shall be covered under the medical assistance program for
persons who are otherwise eligible for medical assistance
under this Article.
Notwithstanding any other provision of this Section, all
tobacco cessation medications approved by the United States
Food and Drug Administration and all individual and group
tobacco cessation counseling services and telephone-based
counseling services and tobacco cessation medications provided
through the Illinois Tobacco Quitline shall be covered under


the medical assistance program for persons who are otherwise
eligible for assistance under this Article. The Department
shall comply with all federal requirements necessary to obtain
federal financial participation, as specified in 42 CFR
433.15(b)(7), for telephone-based counseling services provided
through the Illinois Tobacco Quitline, including, but not
limited to: (i) entering into a memorandum of understanding or
interagency agreement with the Department of Public Health, as
administrator of the Illinois Tobacco Quitline; and (ii)
developing a cost allocation plan for Medicaid-allowable
Illinois Tobacco Quitline services in accordance with 45 CFR
95.507. The Department shall submit the memorandum of
understanding or interagency agreement, the cost allocation
plan, and all other necessary documentation to the Centers for
Medicare and Medicaid Services for review and approval.
Coverage under this paragraph shall be contingent upon federal
approval.
Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
Upon receipt of federal approval of an amendment to the
Illinois Title XIX State Plan for this purpose, the Department


shall authorize the Chicago Public Schools (CPS) to procure a
vendor or vendors to manufacture eyeglasses for individuals
enrolled in a school within the CPS system. CPS shall ensure
that its vendor or vendors are enrolled as providers in the
medical assistance program and in any capitated Medicaid
managed care entity (MCE) serving individuals enrolled in a
school within the CPS system. Under any contract procured
under this provision, the vendor or vendors must serve only
individuals enrolled in a school within the CPS system. Claims
for services provided by CPS's vendor or vendors to recipients
of benefits in the medical assistance program under this Code,
the Children's Health Insurance Program, or the Covering ALL
KIDS Health Insurance Program shall be submitted to the
Department or the MCE in which the individual is enrolled for
payment and shall be reimbursed at the Department's or the
MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare
and Family Services may provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever


the person may select.
On and after July 1, 2018, the Department of Healthcare
and Family Services shall provide dental services to any adult
who is otherwise eligible for assistance under the medical
assistance program. As used in this paragraph, "dental
services" means diagnostic, preventative, restorative, or
corrective procedures, including procedures and services for
the prevention and treatment of periodontal disease and dental
caries disease, provided by an individual who is licensed to
practice dentistry or dental surgery or who is under the
supervision of a dentist in the practice of his or her
profession.
On and after July 1, 2018, targeted dental services, as
set forth in Exhibit D of the Consent Decree entered by the
United States District Court for the Northern District of
Illinois, Eastern Division, in the matter of Memisovski v.
Maram, Case No. 92 C 1982, that are provided to adults under
the medical assistance program shall be established at no less
than the rates set forth in the "New Rate" column in Exhibit D
of the Consent Decree for targeted dental services that are
provided to persons under the age of 18 under the medical
assistance program.
Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled


not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical
assistance program. A not-for-profit health clinic shall
include a public health clinic or Federally Qualified Health
Center or other enrolled provider, as determined by the
Department, through which dental services covered under this
Section are performed. The Department shall establish a
process for payment of claims for reimbursement for covered
dental services rendered under this provision.
Subject to appropriation and to federal approval, the
Department shall file administrative rules updating the
Handicapping Labio-Lingual Deviation orthodontic scoring tool
by January 1, 2025, or as soon as practicable.
On and after January 1, 2022, the Department of Healthcare
and Family Services shall administer and regulate a
school-based dental program that allows for the out-of-office
delivery of preventative dental services in a school setting
to children under 19 years of age. The Department shall
establish, by rule, guidelines for participation by providers
and set requirements for follow-up referral care based on the
requirements established in the Dental Office Reference Manual
published by the Department that establishes the requirements
for dentists participating in the All Kids Dental School
Program. Every effort shall be made by the Department when
developing the program requirements to consider the different
geographic differences of both urban and rural areas of the


State for initial treatment and necessary follow-up care. No
provider shall be charged a fee by any unit of local government
to participate in the school-based dental program administered
by the Department. Nothing in this paragraph shall be
construed to limit or preempt a home rule unit's or school
district's authority to establish, change, or administer a
school-based dental program in addition to, or independent of,
the school-based dental program administered by the
Department.
The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in
accordance with the classes of persons designated in Section
5-2.
The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for
individuals 35 years of age or older who are eligible for
medical assistance under this Article, as follows:
(A) A baseline mammogram for individuals 35 to 39


years of age.
(B) An annual mammogram for individuals 40 years of
age or older.
(C) A mammogram at the age and intervals considered
medically necessary by the individual's health care
provider for individuals under 40 years of age and having
a family history of breast cancer, prior personal history
of breast cancer, positive genetic testing, or other risk
factors.
(D) A comprehensive ultrasound screening and MRI of an
entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(F) A diagnostic mammogram when medically necessary,
as determined by a physician licensed to practice medicine
in all its branches, advanced practice registered nurse,
or physician assistant.
The Department shall not impose a deductible, coinsurance,
copayment, or any other cost-sharing requirement on the
coverage provided under this paragraph; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible


health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool.
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using
diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"Low-dose mammography" means the x-ray examination of the
breast using equipment dedicated specifically for mammography,
including the x-ray tube, filter, compression device, and
image receptor, with an average radiation exposure delivery of
less than one rad per breast for 2 views of an average size
breast. The term also includes digital mammography and
includes breast tomosynthesis.
"Breast tomosynthesis" means a radiologic procedure that
involves the acquisition of projection images over the
stationary breast to produce cross-sectional digital
three-dimensional images of the breast.


If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage for breast tomosynthesis outlined in this
paragraph, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this paragraph.
On and after January 1, 2016, the Department shall ensure
that all networks of care for adult clients of the Department
include access to at least one breast imaging Center of
Imaging Excellence as certified by the American College of
Radiology.
On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall
be reimbursed for screening and diagnostic mammography at the
same rate as the Medicare program's rates, including the
increased reimbursement for digital mammography and, after


January 1, 2023 (the effective date of Public Act 102-1018),
breast tomosynthesis.
The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards for mammography.
On and after January 1, 2017, providers participating in a
breast cancer treatment quality improvement program approved
by the Department shall be reimbursed for breast cancer
treatment at a rate that is no lower than 95% of the Medicare
program's rates for the data elements included in the breast
cancer treatment quality program.
The Department shall convene an expert panel, including
representatives of hospitals, free-standing breast cancer
treatment centers, breast cancer quality organizations, and
doctors, including breast surgeons, reconstructive breast
surgeons, oncologists, and primary care providers to establish
quality standards for breast cancer treatment.
Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities. By January 1, 2016, the
Department shall report to the General Assembly on the status
of the provision set forth in this paragraph.
The Department shall establish a methodology to remind


individuals who are age-appropriate for screening mammography,
but who have not received a mammogram within the previous 18
months, of the importance and benefit of screening
mammography. The Department shall work with experts in breast
cancer outreach and patient navigation to optimize these
reminders and shall establish a methodology for evaluating
their effectiveness and modifying the methodology based on the
evaluation.
The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot
program in areas of the State with the highest incidence of
mortality related to breast cancer. At least one pilot program
site shall be in the metropolitan Chicago area and at least one
site shall be outside the metropolitan Chicago area. On or
after July 1, 2016, the pilot program shall be expanded to
include one site in western Illinois, one site in southern
Illinois, one site in central Illinois, and 4 sites within
metropolitan Chicago. An evaluation of the pilot program shall
be carried out measuring health outcomes and cost of care for


those served by the pilot program compared to similarly
situated patients who are not served by the pilot program.
The Department shall require all networks of care to
develop a means either internally or by contract with experts
in navigation and community outreach to navigate cancer
patients to comprehensive care in a timely fashion. The
Department shall require all networks of care to include
access for patients diagnosed with cancer to at least one
academic commission on cancer-accredited cancer program as an
in-network covered benefit.
The Department shall provide coverage and reimbursement
for a human papillomavirus (HPV) vaccine that is approved for
marketing by the federal Food and Drug Administration for all
persons between the ages of 9 and 45. Subject to federal
approval, the Department shall provide coverage and
reimbursement for a human papillomavirus (HPV) vaccine for
persons of the age of 46 and above who have been diagnosed with
cervical dysplasia with a high risk of recurrence or
progression. The Department shall disallow any
preauthorization requirements for the administration of the
human papillomavirus (HPV) vaccine.
On or after July 1, 2022, individuals who are otherwise
eligible for medical assistance under this Article shall
receive coverage for perinatal depression screenings for the
12-month period beginning on the last day of their pregnancy.
Medical assistance coverage under this paragraph shall be


conditioned on the use of a screening instrument approved by
the Department.
Any medical or health care provider shall immediately
recommend, to any pregnant individual who is being provided
prenatal services and is suspected of having a substance use
disorder as defined in the Substance Use Disorder Act,
referral to a local substance use disorder treatment program
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department
of Human Services.
All medical providers providing medical assistance to
pregnant individuals under this Code shall receive information
from the Department on the availability of services under any
program providing case management services for addicted
individuals, including information on appropriate referrals
for other social services that may be needed by addicted
individuals in addition to treatment for addiction.
The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through
a public awareness campaign, may provide information
concerning treatment for alcoholism and drug abuse and


addiction, prenatal health care, and other pertinent programs
directed at reducing the number of drug-affected infants born
to recipients of medical assistance.
Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of the recipient's substance
abuse.
The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration
projects in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by
rule, shall develop qualifications for sponsors of
Partnerships. Nothing in this Section shall be construed to
require that the sponsor organization be a medical
organization.


The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and
the Illinois Health Finance Reform Act, except that:
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by
the Illinois Department, to persons in areas covered by
the Partnership may receive an additional surcharge for
such services.
(2) The Department may elect to consider and negotiate
financial incentives to encourage the development of
Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management
services above the level usually offered through the
medical assistance program.
Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois


Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that
provided services may be accessed from therapeutically
certified optometrists to the full extent of the Illinois
Optometric Practice Act of 1987 without discriminating between
service providers.
The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance
under this Article. Such records must be retained for a period
of not less than 6 years from the date of service or as
provided by applicable State law, whichever period is longer,
except that if an audit is initiated within the required
retention period then the records must be retained until the
audit is completed and every exception is resolved. The


Illinois Department shall require health care providers to
make available, when authorized by the patient, in writing,
the medical records in a timely fashion to other health care
providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of
medical services shall be required to maintain and retain
business and professional records sufficient to fully and
accurately document the nature, scope, details and receipt of
the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations
promulgated by the Illinois Department. The rules and
regulations shall require that proof of the receipt of
prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of
such medical services. No such claims for reimbursement shall
be approved for payment by the Illinois Department without
such proof of receipt, unless the Illinois Department shall
have put into effect and shall be operating a system of
post-payment audit and review which shall, on a sampling
basis, be deemed adequate by the Illinois Department to assure
that such drugs, dentures, prosthetic devices and eyeglasses
for which payment is being made are actually being received by
eligible recipients. Within 90 days after September 16, 1984
(the effective date of Public Act 83-1439), the Illinois
Department shall establish a current list of acquisition costs


for all prosthetic devices and any other items recognized as
medical equipment and supplies reimbursable under this Article
and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be
updated no less frequently than every 30 days as required by
Section 5-5.12.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after July 22, 2013
(the effective date of Public Act 98-104), establish
procedures to permit skilled care facilities licensed under
the Nursing Home Care Act to submit monthly billing claims for
reimbursement purposes. Following development of these
procedures, the Department shall, by July 1, 2016, test the
viability of the new system and implement any necessary
operational or structural changes to its information
technology platforms in order to allow for the direct
acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the
Illinois Department shall, within 365 days after August 15,
2014 (the effective date of Public Act 98-963), establish
procedures to permit ID/DD facilities licensed under the ID/DD
Community Care Act and MC/DD facilities licensed under the
MC/DD Act to submit monthly billing claims for reimbursement
purposes. Following development of these procedures, the
Department shall have an additional 365 days to test the
viability of the new system and to ensure that any necessary


operational or structural changes to its information
technology platforms are implemented.
The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or
liens for the Illinois Department.
Enrollment of a vendor shall be subject to a provisional
period and shall be conditional for one year. During the
period of conditional enrollment, the Department may terminate
the vendor's eligibility to participate in, or may disenroll
the vendor from, the medical assistance program without cause.
Unless otherwise specified, such termination of eligibility or
disenrollment is not subject to the Department's hearing


process. However, a disenrolled vendor may reapply without
penalty.
The Department has the discretion to limit the conditional
enrollment period for vendors based upon the category of risk
of the vendor.
Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during


the conditional enrollment period.
To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period
shall not begin until the date on the written notice from
the Illinois Department that the provider enrollment is
complete.
(2) In the case of errors attributable to the Illinois
Department or any of its claims processing intermediaries
which result in an inability to receive, process, or
adjudicate a claim, the 180-day period shall not begin
until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000
when local government funds finance federal participation
for claims payments.
For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be


filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
In the case of long term care facilities, within 120
calendar days of receipt by the facility of required
prescreening information, new admissions with associated
admission documents shall be submitted through the Medical
Electronic Data Interchange (MEDI) or the Recipient
Eligibility Verification (REV) System or shall be submitted
directly to the Department of Human Services using required
admission forms. Effective September 1, 2014, admission
documents, including all prescreening information, must be
submitted through MEDI or REV. Confirmation numbers assigned
to an accepted transaction shall be retained by a facility to
verify timely submittal. Once an admission transaction has
been completed, all resubmitted claims following prior
rejection are subject to receipt no later than 180 days after
the admission transaction has been completed.
Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal


agencies and departments shall provide the Illinois Department
access to confidential and other information and data
necessary to perform eligibility and payment verifications and
other Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter
into agreements with federal agencies and departments, under
which such agencies and departments shall share data necessary
for medical assistance program integrity functions and
oversight. The Illinois Department shall develop, in
cooperation with other State departments and agencies, and in
compliance with applicable federal laws and regulations,
appropriate and effective methods to share such data. At a
minimum, and to the extent necessary to provide data sharing,
the Illinois Department shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of


Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre-adjudicated, or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the
acquisition, repair and replacement of orthotic and prosthetic
devices and durable medical equipment. Such rules shall
provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients;
and (2) rental, lease, purchase or lease-purchase of durable
medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of


the recipient's needs, and the requirements and costs for
maintaining such equipment. Subject to prior approval, such
rules shall enable a recipient to temporarily acquire and use
alternative or substitute devices or equipment pending repairs
or replacements of any device or equipment previously
authorized for such recipient by the Department.
Notwithstanding any provision of Section 5-5f to the contrary,
the Department may, by rule, exempt certain replacement
wheelchair parts from prior approval and, for wheelchairs,
wheelchair parts, wheelchair accessories, and related seating
and positioning items, determine the wholesale price by
methods other than actual acquisition costs.
The Department shall require, by rule, all providers of
durable medical equipment to be accredited by an accreditation
organization approved by the federal Centers for Medicare and
Medicaid Services and recognized by the Department in order to
bill the Department for providing durable medical equipment to
recipients. No later than 15 months after the effective date
of the rule adopted pursuant to this paragraph, all providers
must meet the accreditation requirement.
In order to promote environmental responsibility, meet the
needs of recipients and enrollees, and achieve significant
cost savings, the Department, or a managed care organization
under contract with the Department, may provide recipients or
managed care enrollees who have a prescription or Certificate
of Medical Necessity access to refurbished durable medical


equipment under this Section (excluding prosthetic and
orthotic devices as defined in the Orthotics, Prosthetics, and
Pedorthics Practice Act and complex rehabilitation technology
products and associated services) through the State's
assistive technology program's reutilization program, using
staff with the Assistive Technology Professional (ATP)
Certification if the refurbished durable medical equipment:
(i) is available; (ii) is less expensive, including shipping
costs, than new durable medical equipment of the same type;
(iii) is able to withstand at least 3 years of use; (iv) is
cleaned, disinfected, sterilized, and safe in accordance with
federal Food and Drug Administration regulations and guidance
governing the reprocessing of medical devices in health care
settings; and (v) equally meets the needs of the recipient or
enrollee. The reutilization program shall confirm that the
recipient or enrollee is not already in receipt of the same or
similar equipment from another service provider, and that the
refurbished durable medical equipment equally meets the needs
of the recipient or enrollee. Nothing in this paragraph shall
be construed to limit recipient or enrollee choice to obtain
new durable medical equipment or place any additional prior
authorization conditions on enrollees of managed care
organizations.
The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to


effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the
State where they are not currently available or are
undeveloped; and (iii) notwithstanding any other provision of
law, subject to federal approval, on and after July 1, 2012, an
increase in the determination of need (DON) scores from 29 to
37 for applicants for institutional and home and
community-based long term care; if and only if federal
approval is not granted, the Department may, in conjunction
with other affected agencies, implement utilization controls
or changes in benefit packages to effectuate a similar savings
amount for this population; and (iv) no later than July 1,
2013, minimum level of care eligibility criteria for
institutional and home and community-based long term care; and
(v) no later than October 1, 2013, establish procedures to
permit long term care providers access to eligibility scores
for individuals with an admission date who are seeking or
receiving services from the long term care provider. In order
to select the minimum level of care eligibility criteria, the
Governor shall establish a workgroup that includes affected
agency representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for


community-based services in circumstances where federal
approval has been granted.
The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation
and programs for monitoring of utilization of health care
services and facilities, as it affects persons eligible for
medical assistance under this Code.
The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
Illinois Department.
The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The requirement for reporting to the General
Assembly shall be satisfied by filing copies of the report as
required by Section 3.1 of the General Assembly Organization


Act, and filing such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act.
Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate
of reimbursement for services or other payments in accordance
with Section 5-5e.
Because kidney transplantation can be an appropriate,
cost-effective alternative to renal dialysis when medically
necessary and notwithstanding the provisions of Section 1-11
of this Code, beginning October 1, 2014, the Department shall
cover kidney transplantation for noncitizens with end-stage
renal disease who are not eligible for comprehensive medical
benefits, who meet the residency requirements of Section 5-3
of this Code, and who would otherwise meet the financial
requirements of the appropriate class of eligible persons
under Section 5-2 of this Code. To qualify for coverage of
kidney transplantation, such person must be receiving


emergency renal dialysis services covered by the Department.
Providers under this Section shall be prior approved and
certified by the Department to perform kidney transplantation
and the services under this Section shall be limited to
services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the
contrary, on or after July 1, 2015, all FDA approved forms of
medication assisted treatment prescribed for the treatment of
alcohol dependence or treatment of opioid dependence shall be
covered under both fee-for-service fee for service and managed
care medical assistance programs for persons who are otherwise
eligible for medical assistance under this Article and shall
not be subject to any (1) utilization control, other than
those established under the American Society of Addiction
Medicine patient placement criteria, (2) prior authorization
mandate, or (3) lifetime restriction limit mandate.
On or after July 1, 2015, opioid antagonists prescribed
for the treatment of an opioid overdose, including the
medication product, administration devices, and any pharmacy
fees or hospital fees related to the dispensing, distribution,
and administration of the opioid antagonist, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
As used in this Section, "opioid antagonist" means a drug that
binds to opioid receptors and blocks or inhibits the effect of
opioids acting on those receptors, including, but not limited


to, naloxone hydrochloride or any other similarly acting drug
approved by the U.S. Food and Drug Administration. The
Department shall not impose a copayment on the coverage
provided for naloxone hydrochloride under the medical
assistance program.
Upon federal approval, the Department shall provide
coverage and reimbursement for all drugs that are approved for
marketing by the federal Food and Drug Administration and that
are recommended by the federal Public Health Service or the
United States Centers for Disease Control and Prevention for
pre-exposure prophylaxis and related pre-exposure prophylaxis
services, including, but not limited to, HIV and sexually
transmitted infection screening, treatment for sexually
transmitted infections, medical monitoring, assorted labs, and
counseling to reduce the likelihood of HIV infection among
individuals who are not infected with HIV but who are at high
risk of HIV infection.
A federally qualified health center, as defined in Section
1905(l)(2)(B) of the federal Social Security Act, shall be
reimbursed by the Department in accordance with the federally
qualified health center's encounter rate for services provided
to medical assistance recipients that are performed by a
dental hygienist, as defined under the Illinois Dental
Practice Act, working under the general supervision of a
dentist and employed by a federally qualified health center.
Within 90 days after October 8, 2021 (the effective date


of Public Act 102-665), the Department shall seek federal
approval of a State Plan amendment to expand coverage for
family planning services that includes presumptive eligibility
to individuals whose income is at or below 208% of the federal
poverty level. Coverage under this Section shall be effective
beginning no later than December 1, 2022.
Subject to approval by the federal Centers for Medicare
and Medicaid Services of a Title XIX State Plan amendment
electing the Program of All-Inclusive Care for the Elderly
(PACE) as a State Medicaid option, as provided for by Subtitle
I (commencing with Section 4801) of Title IV of the Balanced
Budget Act of 1997 (Public Law 105-33) and Part 460
(commencing with Section 460.2) of Subchapter E of Title 42 of
the Code of Federal Regulations, PACE program services shall
become a covered benefit of the medical assistance program,
subject to criteria established in accordance with all
applicable laws.
Notwithstanding any other provision of this Code,
community-based pediatric palliative care from a trained
interdisciplinary team shall be covered under the medical
assistance program as provided in Section 15 of the Pediatric
Palliative Care Act.
Notwithstanding any other provision of this Code, within
12 months after June 2, 2022 (the effective date of Public Act
102-1037) and subject to federal approval, acupuncture
services performed by an acupuncturist licensed under the


Acupuncture Practice Act who is acting within the scope of his
or her license shall be covered under the medical assistance
program. The Department shall apply for any federal waiver or
State Plan amendment, if required, to implement this
paragraph. The Department may adopt any rules, including
standards and criteria, necessary to implement this paragraph.
Notwithstanding any other provision of this Code, the
medical assistance program shall, subject to appropriation and
federal approval, reimburse hospitals for costs associated
with a newborn screening test for the presence of
metachromatic leukodystrophy, as required under the Newborn
Metabolic Screening Act, at a rate not less than the fee
charged by the Department of Public Health. The Department
shall seek federal approval before the implementation of the
newborn screening test fees by the Department of Public
Health.
Notwithstanding any other provision of this Code,
beginning on January 1, 2024, subject to federal approval,
cognitive assessment and care planning services provided to a
person who experiences signs or symptoms of cognitive
impairment, as defined by the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, shall be covered
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Code,
medically necessary reconstructive services that are intended


to restore physical appearance shall be covered under the
medical assistance program for persons who are otherwise
eligible for medical assistance under this Article. As used in
this paragraph, "reconstructive services" means treatments
performed on structures of the body damaged by trauma to
restore physical appearance.
(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
1-1-24; revised 12-15-23.)
ARTICLE 95.
Section 95-5. The Specialized Mental Health Rehabilitation
Act of 2013 is amended by changing Section 5-107 as follows:
(210 ILCS 49/5-107)
Sec. 5-107. Quality of life enhancement. Beginning on July
1, 2019, for improving the quality of life and the quality of
care, an additional payment shall be awarded to a facility for


their single occupancy rooms. This payment shall be in
addition to the rate for recovery and rehabilitation. The
additional rate for single room occupancy shall be no less
than $10 per day, per single room occupancy. The Department of
Healthcare and Family Services shall adjust payment to
Medicaid managed care entities to cover these costs. Beginning
July 1, 2022, for improving the quality of life and the quality
of care, a payment of no less than $5 per day, per single room
occupancy shall be added to the existing $10 additional per
day, per single room occupancy rate for a total of at least $15
per day, per single room occupancy. For improving the quality
of life and the quality of care, on January 1, 2024, a payment
of no less than $10.50 per day, per single room occupancy shall
be added to the existing $15 additional per day, per single
room occupancy rate for a total of at least $25.50 per day, per
single room occupancy. For improving the quality of life and
the quality of care, beginning on January 1, 2025, a payment of
no less than $10 per day, per single room occupancy shall be
added to the existing $25.50 additional per day, per single
room occupancy rate for a total of at least $35.50 per day, per
single room occupancy. Beginning July 1, 2022, for improving
the quality of life and the quality of care, an additional
payment shall be awarded to a facility for its dual-occupancy
rooms. This payment shall be in addition to the rate for
recovery and rehabilitation. The additional rate for
dual-occupancy rooms shall be no less than $10 per day, per


Medicaid-occupied bed, in each dual-occupancy room. Beginning
January 1, 2024, for improving the quality of life and the
quality of care, a payment of no less than $4.50 per day, per
dual-occupancy room shall be added to the existing $10
additional per day, per dual-occupancy room rate for a total
of at least $14.50, per Medicaid-occupied bed, in each
dual-occupancy room. Beginning January 1, 2025, for improving
the quality of life and the quality of care, a payment of no
less than $8.75 per day, per dual-occupancy room shall be
added to the existing $14.50 additional per day, per
dual-occupancy room rate for a total of at least $23.25, per
Medicaid-occupied bed, in each dual-occupancy room. The
Department of Healthcare and Family Services shall adjust
payment to Medicaid managed care entities to cover these
costs. As used in this Section, "dual-occupancy room" means a
room that contains 2 resident beds.
(Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24.)
ARTICLE 100.
Section 100-5. The Illinois Public Aid Code is amended by
changing Section 5-5.01a as follows:
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program.
(a) The Department shall establish and provide oversight


for a program of supportive living facilities that seek to
promote resident independence, dignity, respect, and
well-being in the most cost-effective manner.
A supportive living facility is (i) a free-standing
facility or (ii) a distinct physical and operational entity
within a mixed-use building that meets the criteria
established in subsection (d). A supportive living facility
integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents
their own separate, private, and distinct living units.
Sites for the operation of the program shall be selected
by the Department based upon criteria that may include the
need for services in a geographic area, the availability of
funding, and the site's ability to meet the standards.
(b) Beginning July 1, 2014, subject to federal approval,
the Medicaid rates for supportive living facilities shall be
equal to the supportive living facility Medicaid rate
effective on June 30, 2014 increased by 8.85%. Once the
assessment imposed at Article V-G of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act, the Department shall increase the Medicaid rates for
supportive living facilities effective on July 1, 2014 by
9.09%. The Department shall apply this increase retroactively
to coincide with the imposition of the assessment in Article
V-G of this Code in accordance with the approval for federal
financial participation by the Centers for Medicare and


Medicaid Services.
The Medicaid rates for supportive living facilities
effective on July 1, 2017 must be equal to the rates in effect
for supportive living facilities on June 30, 2017 increased by
2.8%.
The Medicaid rates for supportive living facilities
effective on July 1, 2018 must be equal to the rates in effect
for supportive living facilities on June 30, 2018.
Subject to federal approval, the Medicaid rates for
supportive living services on and after July 1, 2019 must be at
least 54.3% of the average total nursing facility services per
diem for the geographic areas defined by the Department while
maintaining the rate differential for dementia care and must
be updated whenever the total nursing facility service per
diems are updated. Beginning July 1, 2022, upon the
implementation of the Patient Driven Payment Model, Medicaid
rates for supportive living services must be at least 54.3% of
the average total nursing services per diem rate for the
geographic areas. For purposes of this provision, the average
total nursing services per diem rate shall include all add-ons
for nursing facilities for the geographic area provided for in
Section 5-5.2. The rate differential for dementia care must be
maintained in these rates and the rates shall be updated
whenever nursing facility per diem rates are updated.
Subject to federal approval, beginning January 1, 2024,
the dementia care rate for supportive living services must be


no less than the non-dementia care supportive living services
rate multiplied by 1.5.
(c) The Department may adopt rules to implement this
Section. Rules that establish or modify the services,
standards, and conditions for participation in the program
shall be adopted by the Department in consultation with the
Department on Aging, the Department of Rehabilitation
Services, and the Department of Mental Health and
Developmental Disabilities (or their successor agencies).
(d) Subject to federal approval by the Centers for
Medicare and Medicaid Services, the Department shall accept
for consideration of certification under the program any
application for a site or building where distinct parts of the
site or building are designated for purposes other than the
provision of supportive living services, but only if:
(1) those distinct parts of the site or building are
not designated for the purpose of providing assisted
living services as required under the Assisted Living and
Shared Housing Act;
(2) those distinct parts of the site or building are
completely separate from the part of the building used for
the provision of supportive living program services,
including separate entrances;
(3) those distinct parts of the site or building do
not share any common spaces with the part of the building
used for the provision of supportive living program


services; and
(4) those distinct parts of the site or building do
not share staffing with the part of the building used for
the provision of supportive living program services.
(e) Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good
standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois
Health Facilities Planning Act.
(f) Section 9817 of the American Rescue Plan Act of 2021
(Public Law 117-2) authorizes a 10% enhanced federal medical
assistance percentage for supportive living services for a
12-month period from April 1, 2021 through March 31, 2022.
Subject to federal approval, including the approval of any
necessary waiver amendments or other federally required
documents or assurances, for a 12-month period the Department
must pay a supplemental $26 per diem rate to all supportive
living facilities with the additional federal financial
participation funds that result from the enhanced federal
medical assistance percentage from April 1, 2021 through March
31, 2022. The Department may issue parameters around how the
supplemental payment should be spent, including quality
improvement activities. The Department may alter the form,
methods, or timeframes concerning the supplemental per diem
rate to comply with any subsequent changes to federal law,
changes made by guidance issued by the federal Centers for


Medicare and Medicaid Services, or other changes necessary to
receive the enhanced federal medical assistance percentage.
(g) All applications for the expansion of supportive
living dementia care settings involving sites not approved by
the Department by January 1, 2024 on the effective date of this
amendatory Act of the 103rd General Assembly may allow new
elderly non-dementia units in addition to new dementia care
units. The Department may approve such applications only if
the application has: (1) no more than one non-dementia care
unit for each dementia care unit and (2) the site is not
located within 4 miles of an existing supportive living
program site in Cook County (including the City of Chicago),
not located within 12 miles of an existing supportive living
program site in Alexander, Bond, Boone, Calhoun, Champaign,
Clinton, DeKalb, DuPage Fulton, Grundy, Henry, Jackson,
Jersey, Johnson, Kane, Kankakee, Kendall, Lake, Macon,
Macoupin, Madison, Marshall, McHenry, McLean, Menard, Mercer,
Monroe, Peoria, Piatt, Rock Island, Sangamon, Stark, St.
Clair, Tazewell, Vermilion, Will, Williamson, Winnebago, or
Woodford counties County, Kane County, Lake County, McHenry
County, or Will County, or not located within 25 miles of an
existing supportive living program site in any other county.
(Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)


ARTICLE 105.
Section 105-5. The Illinois Public Aid Code is amended by
changing Section 5-36 as follows:
(305 ILCS 5/5-36)
Sec. 5-36. Pharmacy benefits.
(a)(1) The Department may enter into a contract with a
third party on a fee-for-service reimbursement model for the
purpose of administering pharmacy benefits as provided in this
Section for members not enrolled in a Medicaid managed care
organization; however, these services shall be approved by the
Department. The Department shall ensure coordination of care
between the third-party administrator and managed care
organizations as a consideration in any contracts established
in accordance with this Section. Any managed care techniques,
principles, or administration of benefits utilized in
accordance with this subsection shall comply with State law.
(2) The following shall apply to contracts between
entities contracting relating to the Department's third-party
administrators and pharmacies:
(A) the Department shall approve any contract between
a third-party administrator and a pharmacy;
(B) the Department's third-party administrator shall
not change the terms of a contract between a third-party
administrator and a pharmacy without written approval by


the Department; and
(C) the Department's third-party administrator shall
not create, modify, implement, or indirectly establish any
fee on a pharmacy, pharmacist, or a recipient of medical
assistance without written approval by the Department.
(b) The provisions of this Section shall not apply to
outpatient pharmacy services provided by a health care
facility registered as a covered entity pursuant to 42 U.S.C.
256b or any pharmacy owned by or contracted with the covered
entity. A Medicaid managed care organization shall, either
directly or through a pharmacy benefit manager, administer and
reimburse outpatient pharmacy claims submitted by a health
care facility registered as a covered entity pursuant to 42
U.S.C. 256b, its owned pharmacies, and contracted pharmacies
in accordance with the contractual agreements the Medicaid
managed care organization or its pharmacy benefit manager has
with such facilities and pharmacies and in accordance with
subsection (h-5).
(b-5) Any pharmacy benefit manager that contracts with a
Medicaid managed care organization to administer and reimburse
pharmacy claims as provided in this Section must be registered
with the Director of Insurance in accordance with Section
513b2 of the Illinois Insurance Code.
(c) On at least an annual basis, the Director of the
Department of Healthcare and Family Services shall submit a
report beginning no later than one year after January 1, 2020


(the effective date of Public Act 101-452) that provides an
update on any contract, contract issues, formulary, dispensing
fees, and maximum allowable cost concerns regarding a
third-party administrator and managed care. The requirement
for reporting to the General Assembly shall be satisfied by
filing copies of the report with the Speaker, the Minority
Leader, and the Clerk of the House of Representatives and with
the President, the Minority Leader, and the Secretary of the
Senate. The Department shall take care that no proprietary
information is included in the report required under this
Section.
(d) A pharmacy benefit manager shall notify the Department
in writing of any activity, policy, or practice of the
pharmacy benefit manager that directly or indirectly presents
a conflict of interest that interferes with the discharge of
the pharmacy benefit manager's duty to a managed care
organization to exercise its contractual duties. "Conflict of
interest" shall be defined by rule by the Department.
(e) A pharmacy benefit manager shall, upon request,
disclose to the Department the following information:
(1) whether the pharmacy benefit manager has a
contract, agreement, or other arrangement with a
pharmaceutical manufacturer to exclusively dispense or
provide a drug to a managed care organization's enrollees,
and the aggregate amounts of consideration of economic
benefits collected or received pursuant to that


arrangement;
(2) the percentage of claims payments made by the
pharmacy benefit manager to pharmacies owned, managed, or
controlled by the pharmacy benefit manager or any of the
pharmacy benefit manager's management companies, parent
companies, subsidiary companies, or jointly held
companies;
(3) the aggregate amount of the fees or assessments
imposed on, or collected from, pharmacy providers; and
(4) the average annualized percentage of revenue
collected by the pharmacy benefit manager as a result of
each contract it has executed with a managed care
organization contracted by the Department to provide
medical assistance benefits which is not paid by the
pharmacy benefit manager to pharmacy providers and
pharmaceutical manufacturers or labelers or in order to
perform administrative functions pursuant to its contracts
with managed care organizations; .
(5) the total number of prescriptions dispensed under
each contract the pharmacy benefit manager has with a
managed care organization (MCO) contracted by the
Department to provide medical assistance benefits;
(6) the aggregate wholesale acquisition cost for drugs
that were dispensed to enrollees in each MCO with which
the pharmacy benefit manager has a contract by any
pharmacy owned, managed, or controlled by the pharmacy


benefit manager or any of the pharmacy benefit manager's
management companies, parent companies, subsidiary
companies, or jointly-held companies;
(7) the aggregate amount of administrative fees that
the pharmacy benefit manager received from all
pharmaceutical manufacturers for prescriptions dispensed
to MCO enrollees;
(8) for each MCO with which the pharmacy benefit
manager has a contract, the aggregate amount of payments
received by the pharmacy benefit manager from the MCO;
(9) for each MCO with which the pharmacy benefit
manager has a contract, the aggregate amount of
reimbursements the pharmacy benefit manager paid to
contracting pharmacies; and
(10) any other information considered necessary by the
Department.
(f) The information disclosed under subsection (e) shall
include all retail, mail order, specialty, and compounded
prescription products. All information made available to the
Department under subsection (e) is confidential and not
subject to disclosure under the Freedom of Information Act.
All information made available to the Department under
subsection (e) shall not be reported or distributed in any way
that compromises its competitive, proprietary, or financial
value. The information shall only be used by the Department to
assess the contract, agreement, or other arrangements made


between a pharmacy benefit manager and a pharmacy provider,
pharmaceutical manufacturer or labeler, managed care
organization, or other entity, as applicable.
(g) A pharmacy benefit manager shall disclose directly in
writing to a pharmacy provider or pharmacy services
administrative organization contracting with the pharmacy
benefit manager of any material change to a contract provision
that affects the terms of the reimbursement, the process for
verifying benefits and eligibility, dispute resolution,
procedures for verifying drugs included on the formulary, and
contract termination at least 30 days prior to the date of the
change to the provision. The terms of this subsection shall be
deemed met if the pharmacy benefit manager posts the
information on a website, viewable by the public. A pharmacy
service administration organization shall notify all contract
pharmacies of any material change, as described in this
subsection, within 2 days of notification. As used in this
Section, "pharmacy services administrative organization" means
an entity operating within the State that contracts with
independent pharmacies to conduct business on their behalf
with third-party payers. A pharmacy services administrative
organization may provide administrative services to pharmacies
and negotiate and enter into contracts with third-party payers
or pharmacy benefit managers on behalf of pharmacies.
(h) A pharmacy benefit manager shall not include the
following in a contract with a pharmacy provider:


(1) a provision prohibiting the provider from
informing a patient of a less costly alternative to a
prescribed medication; or
(2) a provision that prohibits the provider from
dispensing a particular amount of a prescribed medication,
if the pharmacy benefit manager allows that amount to be
dispensed through a pharmacy owned or controlled by the
pharmacy benefit manager, unless the prescription drug is
subject to restricted distribution by the United States
Food and Drug Administration or requires special handling,
provider coordination, or patient education that cannot be
provided by a retail pharmacy.
(h-5) Unless required by law, a Medicaid managed care
organization or pharmacy benefit manager administering or
managing benefits on behalf of a Medicaid managed care
organization shall not refuse to contract with a 340B entity
or 340B pharmacy for refusing to accept less favorable payment
terms or reimbursement methodologies when compared to
similarly situated non-340B entities and shall not include in
a contract with a 340B entity or 340B pharmacy a provision
that:
(1) imposes any fee, chargeback, or rate adjustment
that is not similarly imposed on similarly situated
pharmacies that are not 340B entities or 340B pharmacies;
(2) imposes any fee, chargeback, or rate adjustment
that exceeds the fee, chargeback, or rate adjustment that


is not similarly imposed on similarly situated pharmacies
that are not 340B entities or 340B pharmacies;
(3) prevents or interferes with an individual's choice
to receive a prescription drug from a 340B entity or 340B
pharmacy through any legally permissible means;
(4) excludes a 340B entity or 340B pharmacy from a
pharmacy network on the basis of whether the 340B entity
or 340B pharmacy participates in the 340B drug discount
program;
(5) prevents a 340B entity or 340B pharmacy from using
a drug purchased under the 340B drug discount program so
long as the drug recipient is a patient of the 340B entity;
nothing in this Section exempts a 340B pharmacy from
following the Department's preferred drug list or from any
prior approval requirements of the Department or the
Medicaid managed care organization that are imposed on the
drug for all pharmacies; or
(6) any other provision that discriminates against a
340B entity or 340B pharmacy by treating a 340B entity or
340B pharmacy differently than non-340B entities or
non-340B pharmacies for any reason relating to the
entity's participation in the 340B drug discount program.
A provision that violates this subsection in any contract
between a Medicaid managed care organization or its pharmacy
benefit manager and a 340B entity entered into, amended, or
renewed after July 1, 2022 shall be void and unenforceable.


In this subsection (h-5):
"340B entity" means a covered entity as defined in 42
U.S.C. 256b(a)(4) authorized to participate in the 340B drug
discount program.
"340B pharmacy" means any pharmacy used to dispense 340B
drugs for a covered entity, whether entity-owned or external.
(i) Nothing in this Section shall be construed to prohibit
a pharmacy benefit manager from requiring the same
reimbursement and terms and conditions for a pharmacy provider
as for a pharmacy owned, controlled, or otherwise associated
with the pharmacy benefit manager.
(j) A pharmacy benefit manager shall establish and
implement a process for the resolution of disputes arising out
of this Section, which shall be approved by the Department.
(k) The Department shall adopt rules establishing
reasonable dispensing fees for fee-for-service payments in
accordance with guidance or guidelines from the federal
Centers for Medicare and Medicaid Services.
(Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21;
102-778, eff. 7-1-22.)
ARTICLE 110.
Section 110-5. The Specialized Mental Health
Rehabilitation Act of 2013 is amended by adding Section 5-113
as follows:


(210 ILCS 49/5-113 new)
Sec. 5-113. Specialized mental health rehabilitation
facility; one payment. Notwithstanding any other provision of
this Act to the contrary, beginning January 1, 2025, there
shall be a separate per diem add-on paid solely and
exclusively to facilities licensed under this Act that are
licensed for only single occupancy rooms and have reduced
their licensed capacity. No facility licensed under this Act
shall be eligible for these payments if the facility contains
any rooms that house more than a single occupant and have
failed to reduce the facilities' licensed capacity.
The payment shall be a per diem add-on payment. For
facilities with less than 100 licensed beds, the add-on
payment shall result in a rate not less than $240 per day. For
facilities with 100 licensed beds to 130 licensed beds, the
add-on payment shall result in a rate not less than $230 per
day. For facilities with more than 130 licensed beds, the
add-on payment shall result in a rate of not less than $220 per
day. All add-on rates shall be based upon the new licensed
capacity.
Any additional payments in effect after January 1, 2025
under Section 5-107 shall be paid in addition to the amounts
listed in this Section. Facilities receiving payments under
this Section shall receive payment as prescribed under Section
5-101.


ARTICLE 115.
Section 115-5. The Illinois Public Aid Code is amended by
adding Section 5-53 as follows:
(305 ILCS 5/5-53 new)
Sec. 5-53. Coverage for self-measure blood pressure
monitoring services. Subject to federal approval and
notwithstanding any other provision of this Code, for services
on and after January 1, 2025, the following self-measure blood
pressure monitoring services shall be covered and reimbursed
under the medical assistance program for persons who are
otherwise eligible for medical assistance under this Article:
(1) patient education and training services on the
set-up and use of a self-measure blood pressure
measurement device validated for clinical accuracy and
device calibration; and
(2) separate self-measurement readings and the
collection of data reports by the patient or caregiver to
the health care provider in order to communicate blood
pressure readings and create or modify treatment plans.
ARTICLE 120.
(305 ILCS 5/15-6 rep.)


Section 120-5. The Illinois Public Aid Code is amended by
repealing Section 15-6.
Article 125.
Section 125-5. The State Finance Act is amended by
changing Section 5.797 as follows:
(30 ILCS 105/5.797)
Sec. 5.797. The Electronic Health Record Incentive Fund.
This Section is repealed on January 1, 2025.
(Source: P.A. 97-169, eff. 7-22-11; 97-813, eff. 7-13-12.)
Section 125-10. The Illinois Public Aid Code is amended by
changing Section 12-10.6a as follows:
(305 ILCS 5/12-10.6a)
Sec. 12-10.6a. The Electronic Health Record Incentive
Fund.
(a) The Electronic Health Record Incentive Fund is a
special fund created in the State treasury. All federal moneys
received by the Department of Healthcare and Family Services
for payments to qualifying health care providers to encourage
the adoption and use of certified electronic health records
technology pursuant to paragraph 1903(t)(1) of the Social
Security Act, shall be deposited into the Fund.


(b) Disbursements from the Fund shall be made at the
direction of the Director of Healthcare and Family Services to
qualifying health care providers, in amounts established under
applicable federal regulation (42 CFR 495 et seq.), in order
to encourage the adoption and use of certified electronic
health records technology.
(c) On January 1, 2025, or as soon thereafter as
practical, the State Comptroller shall direct and the State
Treasurer shall transfer the remaining balance from the
Electronic Health Record Incentive Fund into the Public Aid
Recoveries Trust Fund. Upon completion of the transfer, the
Electronic Health Record Incentive Fund is dissolved, and any
future deposits due to that Fund and any outstanding
obligations or liabilities of that Fund shall pass to the
Public Aid Recoveries Trust Fund.
(Source: P.A. 97-169, eff. 7-22-11.)
Article 130.
(30 ILCS 105/5.836 rep.)
Section 130-5. The State Finance Act is amended by
repealing Section 5.836.
(305 ILCS 5/5-31 rep.)
(305 ILCS 5/5-32 rep.)
Section 130-10. The Illinois Public Aid Code is amended by


repealing Sections 5-31 and 5-32.
Article 135.
Section 135-5. The State Finance Act is amended by
changing Section 5.481 as follows:
(30 ILCS 105/5.481)
Sec. 5.481. The Juvenile Rehabilitation Services Medicaid
Matching Fund. This Section is repealed on January 1, 2026.
(Source: P.A. 90-587, eff. 7-1-98.)
Section 135-10. The Illinois Public Aid Code is amended by
changing Sections 12-9 and 12-10.4 as follows:
(305 ILCS 5/12-9) (from Ch. 23, par. 12-9)
Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
Public Aid Recoveries Trust Fund shall consist of (1)
recoveries by the Department of Healthcare and Family Services
(formerly Illinois Department of Public Aid) authorized by
this Code in respect to applicants or recipients under
Articles III, IV, V, and VI, including recoveries made by the
Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid) from the estates of
deceased recipients, (2) recoveries made by the Department of
Healthcare and Family Services (formerly Illinois Department


of Public Aid) in respect to applicants and recipients under
the Children's Health Insurance Program Act, and the Covering
ALL KIDS Health Insurance Act, (2.5) recoveries made by the
Department of Healthcare and Family Services in connection
with the imposition of an administrative penalty as provided
under Section 12-4.45, (3) federal funds received on behalf of
and earned by State universities, other State agencies or
departments, and local governmental entities for services
provided to applicants or recipients covered under this Code,
the Children's Health Insurance Program Act, and the Covering
ALL KIDS Health Insurance Act, (3.5) federal financial
participation revenue related to eligible disbursements made
by the Department of Healthcare and Family Services from
appropriations required by this Section, and (4) all other
moneys received to the Fund, including interest thereon. The
Fund shall be held as a special fund in the State Treasury.
Disbursements from this Fund shall be only (1) for the
reimbursement of claims collected by the Department of
Healthcare and Family Services (formerly Illinois Department
of Public Aid) through error or mistake, (2) for payment to
persons or agencies designated as payees or co-payees on any
instrument, whether or not negotiable, delivered to the
Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid) as a recovery under this
Section, such payment to be in proportion to the respective
interests of the payees in the amount so collected, (3) for


payments to the Department of Human Services for collections
made by the Department of Healthcare and Family Services
(formerly Illinois Department of Public Aid) on behalf of the
Department of Human Services under this Code, the Children's
Health Insurance Program Act, and the Covering ALL KIDS Health
Insurance Act, (4) for payment of administrative expenses
incurred in performing the activities authorized under this
Code, the Children's Health Insurance Program Act, and the
Covering ALL KIDS Health Insurance Act, (5) for payment of
fees to persons or agencies in the performance of activities
pursuant to the collection of monies owed the State that are
collected under this Code, the Children's Health Insurance
Program Act, and the Covering ALL KIDS Health Insurance Act,
(6) for payments of any amounts which are reimbursable to the
federal government which are required to be paid by State
warrant by either the State or federal government, and (7) for
payments to State universities, other State agencies or
departments, and local governmental entities of federal funds
for services provided to applicants or recipients covered
under this Code, the Children's Health Insurance Program Act,
and the Covering ALL KIDS Health Insurance Act. Disbursements
from this Fund for purposes of items (4) and (5) of this
paragraph shall be subject to appropriations from the Fund to
the Department of Healthcare and Family Services (formerly
Illinois Department of Public Aid).
The balance in this Fund after payment therefrom of any


amounts reimbursable to the federal government, and minus the
amount reasonably anticipated to be needed to make the
disbursements authorized by this Section during the current
and following 3 calendar months, shall be certified by the
Director of Healthcare and Family Services and transferred by
the State Comptroller to the Drug Rebate Fund or the
Healthcare Provider Relief Fund in the State Treasury, as
appropriate, on at least an annual basis by June 30th of each
fiscal year. The Director of Healthcare and Family Services
may certify and the State Comptroller shall transfer to the
Drug Rebate Fund or the Healthcare Provider Relief Fund
amounts on a more frequent basis.
On July 1, 1999, the State Comptroller shall transfer the
sum of $5,000,000 from the Public Aid Recoveries Trust Fund
(formerly the Public Assistance Recoveries Trust Fund) into
the DHS Recoveries Trust Fund.
(Source: P.A. 97-647, eff. 1-1-12; 97-689, eff. 6-14-12;
98-130, eff. 8-2-13; 98-651, eff. 6-16-14.)
(305 ILCS 5/12-10.4)
Sec. 12-10.4. Juvenile Rehabilitation Services Medicaid
Matching Fund.  There is created in the State Treasury the
Juvenile Rehabilitation Services Medicaid Matching Fund.
Deposits to this Fund shall consist of all moneys received
from the federal government for behavioral health services
secured by counties pursuant to an agreement with the


Department of Healthcare and Family Services with respect to
Title XIX of the Social Security Act or under the Children's
Health Insurance Program pursuant to the Children's Health
Insurance Program Act and Title XXI of the Social Security Act
for minors who are committed to mental health facilities by
the Illinois court system and for residential placements
secured by the Department of Juvenile Justice for minors as a
condition of their aftercare release.
Disbursements from the Fund shall be made, subject to
appropriation, by the Department of Healthcare and Family
Services for grants to the Department of Juvenile Justice and
those counties which secure behavioral health services ordered
by the courts and which have an interagency agreement with the
Department and submit detailed bills according to standards
determined by the Department.
On January 1, 2026, or as soon thereafter as practical,
the State Comptroller shall direct and the State Treasurer
shall transfer the remaining balance from the Juvenile
Rehabilitation Services Medicaid Matching Fund into the Public
Aid Recoveries Trust Fund. Upon completion of the transfer,
the Juvenile Rehabilitation Services Medicaid Matching Fund is
dissolved, and any future deposits due to that Fund and any
outstanding obligations or liabilities of that Fund shall pass
to the Public Aid Recoveries Trust Fund.
(Source: P.A. 98-558, eff. 1-1-14.)


Article 140.
(30 ILCS 105/5.856 rep.)
Section 140-5. The State Finance Act is amended by
repealing Section 5.856.
(305 ILCS 5/Art. V-G rep.)
Section 140-10. The Illinois Public Aid Code is amended by
repealing Article V-G.
Article 145.
Section 145-5. The State Finance Act is amended by
changing Sections 5.409 and 6z-40 as follows:
(30 ILCS 105/5.409)
Sec. 5.409. The Provider Inquiry Trust Fund. This Section
is repealed on January 1, 2025.
(Source: P.A. 89-21, eff. 7-1-95.)
(30 ILCS 105/6z-40)
Sec. 6z-40. Provider Inquiry Trust Fund. The Provider
Inquiry Trust Fund is created as a special fund in the State
treasury. Payments into the fund shall consist of fees or
other moneys owed by providers of services or their agents,
including other State agencies, for access to and utilization


of Illinois Department of Healthcare and Family Services
Public Aid eligibility files to verify eligibility of clients,
bills for services, or other similar, related uses.
Disbursements from the fund shall consist of payments to the
Department of Innovation and Technology Central Management
Services for communication and statistical services and for
payments for administrative expenses incurred by the Illinois
Department of Healthcare and Family Services Public Aid in the
operation of the fund.
On January 1, 2025, or as soon thereafter as practical,
the State Comptroller shall direct and the State Treasurer
shall transfer the remaining balance from the Provider Inquiry
Trust Fund into the Healthcare Provider Relief Fund. Upon
completion of the transfer, the Provider Inquiry Trust Fund is
dissolved, and any future deposits due to that Fund and any
outstanding obligations or liabilities of that Fund shall pass
to the Healthcare Provider Relief Fund.
(Source: P.A. 94-91, eff. 7-1-05.)
ARTICLE 150.
Section 150-5. The Illinois Public Aid Code is amended by
changing Section 5-30.1 and by adding Section 5-30.18 as
follows:
(305 ILCS 5/5-30.1)


Sec. 5-30.1. Managed care protections.
(a) As used in this Section:
"Managed care organization" or "MCO" means any entity
which contracts with the Department to provide services where
payment for medical services is made on a capitated basis.
"Emergency services" means health care items and services,
including inpatient and outpatient hospital services,
furnished or required to evaluate and stabilize an emergency
medical condition. "Emergency services" include inpatient
stabilization services furnished during the inpatient
stabilization period. "Emergency services" do not include
post-stabilization medical services. include:
(1) emergency services, as defined by Section 10 of
the Managed Care Reform and Patient Rights Act;
(2) emergency medical screening examinations, as
defined by Section 10 of the Managed Care Reform and
Patient Rights Act;
(3) post-stabilization medical services, as defined by
Section 10 of the Managed Care Reform and Patient Rights
Act; and
(4) emergency medical conditions, as defined by
Section 10 of the Managed Care Reform and Patient Rights
Act.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
regardless of the final diagnosis given, such that a prudent


layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy;
(2) serious impairment to bodily functions;
(3) serious dysfunction of any bodily organ or part;
(4) inadequately controlled pain; or
(5) with respect to a pregnant woman who is having
contractions:
(A) inadequate time to complete a safe transfer to
another hospital before delivery; or
(B) a transfer to another hospital may pose a
threat to the health or safety of the woman or unborn
child.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed
to practice medicine in all its branches or, to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Health care services" mean any medical or behavioral
health services covered under the medical assistance program
that are subject to review under a service authorization


program.
"Inpatient stabilization period" means the initial 72
hours of inpatient stabilization services, beginning from the
date and time of the order for inpatient admission to the
hospital.
"Inpatient stabilization services" mean emergency services
furnished in the inpatient setting at a hospital pursuant to
an order for inpatient admission by a physician or other
qualified practitioner who has admitting privileges at the
hospital, as permitted by State law, to stabilize an emergency
medical condition following an emergency medical screening
examination.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a
hospital by a provider that is qualified to furnish such
services and determined to be medically necessary by the
provider and directly related to the emergency medical
condition following stabilization.
"Provider" means a facility or individual who is actively
enrolled in the medical assistance program and licensed or
otherwise authorized to order, prescribe, refer, or render
health care services in this State.
"Service authorization determination" means a decision
made by a service authorization program in advance of,
concurrent to, or after the provision of a health care service
to approve, change the level of care, partially deny, deny, or


otherwise limit coverage and reimbursement for a health care
service upon review of a service authorization request.
"Service authorization program" means any utilization
review, utilization management, peer review, quality review,
or other medical management activity conducted by an MCO, or
its contracted utilization review organization, including, but
not limited to, prior authorization, prior approval,
pre-certification, concurrent review, retrospective review, or
certification of admission, of health care services provided
in the inpatient or outpatient hospital setting.
"Service authorization request" means a request by a
provider to a service authorization program to determine
whether a health care service meets the reimbursement
eligibility requirements for medically necessary, clinically
appropriate care, resulting in the issuance of a service
authorization determination.
"Utilization review organization" or "URO" means an MCO's
utilization review department or a peer review organization or
quality improvement organization that contracts with an MCO to
administer a service authorization program and make service
authorization determinations.
(b) As provided by Section 5-16.12, managed care
organizations are subject to the provisions of the Managed
Care Reform and Patient Rights Act.
(c) An MCO shall pay any provider of emergency services,
including for inpatient stabilization services provided during


the inpatient stabilization period, that does not have in
effect a contract with the contracted Medicaid MCO. The
default rate of reimbursement shall be the rate paid under
Illinois Medicaid fee-for-service program methodology,
including all policy adjusters, including but not limited to
Medicaid High Volume Adjustments, Medicaid Percentage
Adjustments, Outpatient High Volume Adjustments, and all
outlier add-on adjustments to the extent such adjustments are
incorporated in the development of the applicable MCO
capitated rates.
(d) (Blank). An MCO shall pay for all post-stabilization
services as a covered service in any of the following
situations:
(1) the MCO authorized such services;
(2) such services were administered to maintain the
enrollee's stabilized condition within one hour after a
request to the MCO for authorization of further
post-stabilization services;
(3) the MCO did not respond to a request to authorize
such services within one hour;
(4) the MCO could not be contacted; or
(5) the MCO and the treating provider, if the treating
provider is a non-affiliated provider, could not reach an
agreement concerning the enrollee's care and an affiliated
provider was unavailable for a consultation, in which case
the MCO must pay for such services rendered by the


treating non-affiliated provider until an affiliated
provider was reached and either concurred with the
treating non-affiliated provider's plan of care or assumed
responsibility for the enrollee's care. Such payment shall
be made at the default rate of reimbursement paid under
Illinois Medicaid fee-for-service program methodology,
including all policy adjusters, including but not limited
to Medicaid High Volume Adjustments, Medicaid Percentage
Adjustments, Outpatient High Volume Adjustments and all
outlier add-on adjustments to the extent that such
adjustments are incorporated in the development of the
applicable MCO capitated rates.
(e) Notwithstanding any other provision of law, the The
following requirements apply to MCOs in determining payment
for all emergency services, including inpatient stabilization
services provided during the inpatient stabilization period:
(1) The MCO MCOs shall not impose any service
authorization program requirements for prior approval of
emergency services, including, but not limited to, prior
authorization, prior approval, pre-certification,
certification of admission, concurrent review, or
retrospective review.
(A) Notification period: Hospitals shall notify
the enrollee's Medicaid MCO within 48 hours of the
date and time the order for inpatient admission is
written. Notification shall be limited to advising the


MCO that the patient has been admitted to a hospital
inpatient level of care.
(B) If the admitting hospital complies with the
notification provisions of subparagraph (A), the
Medicaid MCO may not initiate concurrent review before
the end of the inpatient stabilization period. If the
admitting hospital does not comply with the
notification requirements in subparagraph (A), the
Medicaid MCO may initiate concurrent review for the
continuation of the stay beginning at the end of the
48-hour notification period.
(C) Coverage for services provided during the
48-hour notification period may not be retrospectively
denied.
(2) The MCO shall cover emergency services provided to
enrollees who are temporarily away from their residence
and outside the contracting area to the extent that the
enrollees would be entitled to the emergency services if
they still were within the contracting area.
(3) The MCO shall have no obligation to cover
emergency medical services provided on an emergency basis
that are not covered services under the contract between
the MCO and the Department.
(4) The MCO shall not condition coverage for emergency
services on the treating provider notifying the MCO of the
enrollee's emergency medical screening examination and


treatment within 10 days after presentation for emergency
services.
(5) The determination of the attending emergency
physician, or the practitioner responsible for the
enrollee's care at the hospital the provider actually
treating the enrollee, of whether an enrollee requires
inpatient stabilization services, can be stabilized in the
outpatient setting, or is sufficiently stabilized for
discharge or transfer to another setting facility, shall
be binding on the MCO. The MCO shall cover and reimburse
providers for emergency services as billed by the provider
for all enrollees whether the emergency services are
provided by an affiliated or non-affiliated provider,
except in cases of fraud. The MCO shall reimburse
inpatient stabilization services provided during the
inpatient stabilization period and billed as inpatient
level of care based on the appropriate inpatient
reimbursement methodology.
(6) The MCO's financial responsibility for
post-stabilization medical care services it has not
pre-approved ends when:
(A) a plan physician with privileges at the
treating hospital assumes responsibility for the
enrollee's care;
(B) a plan physician assumes responsibility for
the enrollee's care through transfer;


(C) a contracting entity representative and the
treating physician reach an agreement concerning the
enrollee's care; or
(D) the enrollee is discharged.
(e-5) An MCO shall pay for all post-stabilization medical
services as a covered service in any of the following
situations:
(1) the MCO or its URO authorized such services;
(2) such services were administered to maintain the
enrollee's stabilized condition within one hour after a
request to the MCO for authorization of further
post-stabilization services;
(3) the MCO or its URO did not respond to a request to
authorize such services within one hour;
(4) the MCO or its URO could not be contacted; or
(5) the MCO or its URO and the treating provider, if
the treating provider is a non-affiliated provider, could
not reach an agreement concerning the enrollee's care and
an affiliated provider was unavailable for a consultation,
in which case the MCO must pay for such services rendered
by the treating non-affiliated provider until an
affiliated provider was reached and either concurred with
the treating non-affiliated provider's plan of care or
assumed responsibility for the enrollee's care. Such
payment shall be made at the default rate of reimbursement
paid under the State's Medicaid fee-for-service program


methodology, including all policy adjusters, including,
but not limited to, Medicaid High Volume Adjustments,
Medicaid Percentage Adjustments, Outpatient High Volume
Adjustments, and all outlier add-on adjustments to the
extent that such adjustments are incorporated in the
development of the applicable MCO capitated rates.
(f) Network adequacy and transparency.
(1) The Department shall:
(A) ensure that an adequate provider network is in
place, taking into consideration health professional
shortage areas and medically underserved areas;
(B) publicly release an explanation of its process
for analyzing network adequacy;
(C) periodically ensure that an MCO continues to
have an adequate network in place;
(D) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet
provider directory requirements under Section 5-30.3;
(E) require MCOs to ensure that any
Medicaid-certified provider under contract with an MCO
and previously submitted on a roster on the date of
service is paid for any medically necessary,
Medicaid-covered, and authorized service rendered to
any of the MCO's enrollees, regardless of inclusion on
the MCO's published and publicly available directory
of available providers; and


(F) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet each of
the requirements under subsection (d-5) of Section 10
of the Network Adequacy and Transparency Act; with
necessary exceptions to the MCO's network to ensure
that admission and treatment with a provider or at a
treatment facility in accordance with the network
adequacy standards in paragraph (3) of subsection
(d-5) of Section 10 of the Network Adequacy and
Transparency Act is limited to providers or facilities
that are Medicaid certified.
(2) Each MCO shall confirm its receipt of information
submitted specific to physician or dentist additions or
physician or dentist deletions from the MCO's provider
network within 3 days after receiving all required
information from contracted physicians or dentists, and
electronic physician and dental directories must be
updated consistent with current rules as published by the
Centers for Medicare and Medicaid Services or its
successor agency.
(g) Timely payment of claims.
(1) The MCO shall pay a claim within 30 days of
receiving a claim that contains all the essential
information needed to adjudicate the claim.
(2) The MCO shall notify the billing party of its
inability to adjudicate a claim within 30 days of


receiving that claim.
(3) The MCO shall pay a penalty that is at least equal
to the timely payment interest penalty imposed under
Section 368a of the Illinois Insurance Code for any claims
not timely paid.
(A) When an MCO is required to pay a timely payment
interest penalty to a provider, the MCO must calculate
and pay the timely payment interest penalty that is
due to the provider within 30 days after the payment of
the claim. In no event shall a provider be required to
request or apply for payment of any owed timely
payment interest penalties.
(B) Such payments shall be reported separately
from the claim payment for services rendered to the
MCO's enrollee and clearly identified as interest
payments.
(4)(A) The Department shall require MCOs to expedite
payments to providers identified on the Department's
expedited provider list, determined in accordance with 89
Ill. Adm. Code 140.71(b), on a schedule at least as
frequently as the providers are paid under the
Department's fee-for-service expedited provider schedule.
(B) Compliance with the expedited provider requirement
may be satisfied by an MCO through the use of a Periodic
Interim Payment (PIP) program that has been mutually
agreed to and documented between the MCO and the provider,


if the PIP program ensures that any expedited provider
receives regular and periodic payments based on prior
period payment experience from that MCO. Total payments
under the PIP program may be reconciled against future PIP
payments on a schedule mutually agreed to between the MCO
and the provider.
(C) The Department shall share at least monthly its
expedited provider list and the frequency with which it
pays providers on the expedited list.
(g-5) Recognizing that the rapid transformation of the
Illinois Medicaid program may have unintended operational
challenges for both payers and providers:
(1) in no instance shall a medically necessary covered
service rendered in good faith, based upon eligibility
information documented by the provider, be denied coverage
or diminished in payment amount if the eligibility or
coverage information available at the time the service was
rendered is later found to be inaccurate in the assignment
of coverage responsibility between MCOs or the
fee-for-service system, except for instances when an
individual is deemed to have not been eligible for
coverage under the Illinois Medicaid program; and
(2) the Department shall, by December 31, 2016, adopt
rules establishing policies that shall be included in the
Medicaid managed care policy and procedures manual
addressing payment resolutions in situations in which a


provider renders services based upon information obtained
after verifying a patient's eligibility and coverage plan
through either the Department's current enrollment system
or a system operated by the coverage plan identified by
the patient presenting for services:
(A) such medically necessary covered services
shall be considered rendered in good faith;
(B) such policies and procedures shall be
developed in consultation with industry
representatives of the Medicaid managed care health
plans and representatives of provider associations
representing the majority of providers within the
identified provider industry; and
(C) such rules shall be published for a review and
comment period of no less than 30 days on the
Department's website with final rules remaining
available on the Department's website.
The rules on payment resolutions shall include, but
not be limited to:
(A) the extension of the timely filing period;
(B) retroactive prior authorizations; and
(C) guaranteed minimum payment rate of no less
than the current, as of the date of service,
fee-for-service rate, plus all applicable add-ons,
when the resulting service relationship is out of
network.


The rules shall be applicable for both MCO coverage
and fee-for-service coverage.
If the fee-for-service system is ultimately determined to
have been responsible for coverage on the date of service, the
Department shall provide for an extended period for claims
submission outside the standard timely filing requirements.
(g-6) MCO Performance Metrics Report.
(1) The Department shall publish, on at least a
quarterly basis, each MCO's operational performance,
including, but not limited to, the following categories of
metrics:
(A) claims payment, including timeliness and
accuracy;
(B) prior authorizations;
(C) grievance and appeals;
(D) utilization statistics;
(E) provider disputes;
(F) provider credentialing; and
(G) member and provider customer service.
(2) The Department shall ensure that the metrics
report is accessible to providers online by January 1,
2017.
(3) The metrics shall be developed in consultation
with industry representatives of the Medicaid managed care
health plans and representatives of associations
representing the majority of providers within the


identified industry.
(4) Metrics shall be defined and incorporated into the
applicable Managed Care Policy Manual issued by the
Department.
(g-7) MCO claims processing and performance analysis. In
order to monitor MCO payments to hospital providers, pursuant
to Public Act 100-580, the Department shall post an analysis
of MCO claims processing and payment performance on its
website every 6 months. Such analysis shall include a review
and evaluation of a representative sample of hospital claims
that are rejected and denied for clean and unclean claims and
the top 5 reasons for such actions and timeliness of claims
adjudication, which identifies the percentage of claims
adjudicated within 30, 60, 90, and over 90 days, and the dollar
amounts associated with those claims.
(g-8) Dispute resolution process. The Department shall
maintain a provider complaint portal through which a provider
can submit to the Department unresolved disputes with an MCO.
An unresolved dispute means an MCO's decision that denies in
whole or in part a claim for reimbursement to a provider for
health care services rendered by the provider to an enrollee
of the MCO with which the provider disagrees. Disputes shall
not be submitted to the portal until the provider has availed
itself of the MCO's internal dispute resolution process.
Disputes that are submitted to the MCO internal dispute
resolution process may be submitted to the Department of


Healthcare and Family Services' complaint portal no sooner
than 30 days after submitting to the MCO's internal process
and not later than 30 days after the unsatisfactory resolution
of the internal MCO process or 60 days after submitting the
dispute to the MCO internal process. Multiple claim disputes
involving the same MCO may be submitted in one complaint,
regardless of whether the claims are for different enrollees,
when the specific reason for non-payment of the claims
involves a common question of fact or policy. Within 10
business days of receipt of a complaint, the Department shall
present such disputes to the appropriate MCO, which shall then
have 30 days to issue its written proposal to resolve the
dispute. The Department may grant one 30-day extension of this
time frame to one of the parties to resolve the dispute. If the
dispute remains unresolved at the end of this time frame or the
provider is not satisfied with the MCO's written proposal to
resolve the dispute, the provider may, within 30 days, request
the Department to review the dispute and make a final
determination. Within 30 days of the request for Department
review of the dispute, both the provider and the MCO shall
present all relevant information to the Department for
resolution and make individuals with knowledge of the issues
available to the Department for further inquiry if needed.
Within 30 days of receiving the relevant information on the
dispute, or the lapse of the period for submitting such
information, the Department shall issue a written decision on


the dispute based on contractual terms between the provider
and the MCO, contractual terms between the MCO and the
Department of Healthcare and Family Services and applicable
Medicaid policy. The decision of the Department shall be
final. By January 1, 2020, the Department shall establish by
rule further details of this dispute resolution process.
Disputes between MCOs and providers presented to the
Department for resolution are not contested cases, as defined
in Section 1-30 of the Illinois Administrative Procedure Act,
conferring any right to an administrative hearing.
(g-9)(1) The Department shall publish annually on its
website a report on the calculation of each managed care
organization's medical loss ratio showing the following:
(A) Premium revenue, with appropriate adjustments.
(B) Benefit expense, setting forth the aggregate
amount spent for the following:
(i) Direct paid claims.
(ii) Subcapitation payments.
(iii) Other claim payments.
(iv) Direct reserves.
(v) Gross recoveries.
(vi) Expenses for activities that improve health
care quality as allowed by the Department.
(2) The medical loss ratio shall be calculated consistent
with federal law and regulation following a claims runout
period determined by the Department.


(g-10)(1) "Liability effective date" means the date on
which an MCO becomes responsible for payment for medically
necessary and covered services rendered by a provider to one
of its enrollees in accordance with the contract terms between
the MCO and the provider. The liability effective date shall
be the later of:
(A) The execution date of a network participation
contract agreement.
(B) The date the provider or its representative
submits to the MCO the complete and accurate standardized
roster form for the provider in the format approved by the
Department.
(C) The provider effective date contained within the
Department's provider enrollment subsystem within the
Illinois Medicaid Program Advanced Cloud Technology
(IMPACT) System.
(2) The standardized roster form may be submitted to the
MCO at the same time that the provider submits an enrollment
application to the Department through IMPACT.
(3) By October 1, 2019, the Department shall require all
MCOs to update their provider directory with information for
new practitioners of existing contracted providers within 30
days of receipt of a complete and accurate standardized roster
template in the format approved by the Department provided
that the provider is effective in the Department's provider
enrollment subsystem within the IMPACT system. Such provider


directory shall be readily accessible for purposes of
selecting an approved health care provider and comply with all
other federal and State requirements.
(g-11) The Department shall work with relevant
stakeholders on the development of operational guidelines to
enhance and improve operational performance of Illinois'
Medicaid managed care program, including, but not limited to,
improving provider billing practices, reducing claim
rejections and inappropriate payment denials, and
standardizing processes, procedures, definitions, and response
timelines, with the goal of reducing provider and MCO
administrative burdens and conflict. The Department shall
include a report on the progress of these program improvements
and other topics in its Fiscal Year 2020 annual report to the
General Assembly.
(g-12) Notwithstanding any other provision of law, if the
Department or an MCO requires submission of a claim for
payment in a non-electronic format, a provider shall always be
afforded a period of no less than 90 business days, as a
correction period, following any notification of rejection by
either the Department or the MCO to correct errors or
omissions in the original submission.
Under no circumstances, either by an MCO or under the
State's fee-for-service system, shall a provider be denied
payment for failure to comply with any timely submission
requirements under this Code or under any existing contract,


unless the non-electronic format claim submission occurs after
the initial 180 days following the latest date of service on
the claim, or after the 90 business days correction period
following notification to the provider of rejection or denial
of payment.
(g-13) Utilization Review Standardization and
Transparency.
(1) To ensure greater standardization and transparency
related to service authorization determinations, for all
individuals covered under the medical assistance program,
including both the fee-for-service and managed care
programs, the Department shall, in consultation with the
MCOs, a statewide association representing the MCOs, a
statewide association representing the majority of
Illinois hospitals, a statewide association representing
physicians, or any other interested parties deemed
appropriate by the Department, adopt administrative rules
consistent with this subsection, in accordance with the
Illinois Administrative Procedure Act.
(2) Prior to July 1, 2025, the Department shall in
accordance with the Illinois Administrative Procedure Act
adopt rules which govern MCO practices for dates of
services on and after July 1, 2025, as follows:
(A) guidelines related to the publication of MCO
authorization policies;
(B) procedures that, due to medical complexity,


must be reimbursed under the applicable inpatient
methodology, when provided in the inpatient setting
and billed as an inpatient service;
(C) standardization of administrative forms used
in the member appeal process;
(D) limitations on second or subsequent medical
necessity review of a health care service already
authorized by the MCO or URO under a service
authorization program;
(E) standardization of peer-to-peer processes and
timelines;
(F) defined criteria for urgent and standard
post-acute care service authorization requests; and
(G) standardized criteria for service
authorization programs for authorization of admission
to a long-term acute care hospital.
(3) The Department shall expand the scope of the
quality and compliance audits conducted by its contracted
external quality review organization to include, but not
be limited to:
(A) an analysis of the Medicaid MCO's compliance
with nationally recognized clinical decision
guidelines;
(B) an analysis that compares and contrasts the
Medicaid MCO's service authorization determination
outcomes to the outcomes of each other MCO plan and the


State's fee-for-service program model to evaluate
whether service authorization determinations are being
made consistently by all Medicaid MCOs to ensure that
all individuals are being treated in accordance with
equitable standards of care;
(C) an analysis, for each Medicaid MCO, of the
number of service authorization requests, including
requests for concurrent review and certification of
admissions, received, initially denied, overturned
through any post-denial process including, but not
limited to, enrollee or provider appeal, peer-to-peer
review, or the provider dispute resolution process,
denied but approved for a lower or different level of
care, and the number denied on final determination;
and
(D) provide a written report to the General
Assembly, detailing the items listed in this
subsection and any other metrics deemed necessary by
the Department, by the second April, following the
effective date of this amendatory Act of the 103rd
General Assembly, and each April thereafter. The
Department shall make this report available within 30
days of delivery to the General Assembly, on its
public facing website.
(h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already


designated by the Department as of June 1, 2014 for the
individuals whose eligibility for medical assistance is not
the seniors or people with disabilities population until the
Department provides an opportunity for accountable care
entities and MCOs to participate in such newly designated
counties.
(h-5) Leading indicator data sharing. By January 1, 2024,
the Department shall obtain input from the Department of Human
Services, the Department of Juvenile Justice, the Department
of Children and Family Services, the State Board of Education,
managed care organizations, providers, and clinical experts to
identify and analyze key indicators from assessments and data
sets available to the Department that can be shared with
managed care organizations and similar care coordination
entities contracted with the Department as leading indicators
for elevated behavioral health crisis risk for children. To
the extent permitted by State and federal law, the identified
leading indicators shall be shared with managed care
organizations and similar care coordination entities
contracted with the Department within 6 months of
identification for the purpose of improving care coordination
with the early detection of elevated risk. Leading indicators
shall be reassessed annually with stakeholder input.
(i) The requirements of this Section apply to contracts
with accountable care entities and MCOs entered into, amended,
or renewed after June 16, 2014 (the effective date of Public


Act 98-651).
(j) Health care information released to managed care
organizations. A health care provider shall release to a
Medicaid managed care organization, upon request, and subject
to the Health Insurance Portability and Accountability Act of
1996 and any other law applicable to the release of health
information, the health care information of the MCO's
enrollee, if the enrollee has completed and signed a general
release form that grants to the health care provider
permission to release the recipient's health care information
to the recipient's insurance carrier.
(k) The Department of Healthcare and Family Services,
managed care organizations, a statewide organization
representing hospitals, and a statewide organization
representing safety-net hospitals shall explore ways to
support billing departments in safety-net hospitals.
(l) The requirements of this Section added by Public Act
102-4 shall apply to services provided on or after the first
day of the month that begins 60 days after April 27, 2021 (the
effective date of Public Act 102-4).
(m) Except where otherwise expressly specified, the
requirements of this Section added by this amendatory Act of
the 103rd General Assembly shall apply to services provided on
or after July 1, 2025.
(Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21;
102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff.


5-13-22; 103-546, eff. 8-11-23.)
(305 ILCS 5/5-30.18 new)
Sec. 5-30.18. Service authorization program performance.
(a) Definitions. As used in this Section:
"Gold Card provider" means a provider identified by each
Medicaid Managed Care Organization (MCO) as qualified under
the guidelines outlined by the Department in accordance with
subsection (c) and thereby granted a service authorization
exemption when ordering a health care service.
"Health care service" means any medical or behavioral
health service covered under the medical assistance program
that is rendered in the inpatient or outpatient hospital
setting, including hospital-based clinics, and subject to
review under a service authorization program.
"Provider" means an individual actively enrolled in the
medical assistance program and licensed or otherwise
authorized to order, prescribe, refer, or render health care
services in this State, and, as determined by the Department,
may also include hospitals that submit service authorization
requests.
"Service authorization exemption" means an exception
granted by a Medicaid MCO to a provider under which all service
authorization requests for covered health care services,
excluding pharmacy services and durable medical equipment, are
automatically deemed to be medically necessary, clinically


appropriate, and approved for reimbursement as ordered.
"Service authorization program" means any utilization
review, utilization management, peer review, quality review,
or other medical management activity conducted in advance of,
concurrent to, or after the provision of a health care service
by a Medicaid MCO, either directly or through a contracted
utilization review organization (URO), including, but not
limited to, prior authorization, pre-certification,
certification of admission, concurrent review, and
retrospective review of health care services.
"Service authorization request" means a request by a
provider to a service authorization program to determine
whether a health care service that is otherwise covered under
the medical assistance program meets the reimbursement
requirements established by the Medicaid MCO, or its
contracted URO, for medically necessary, clinically
appropriate care and to issue a service authorization
determination.
"Utilization review organization" or "URO" means a managed
care organization or other entity that has established or
administers one or more service authorization programs.
(b) In consultation with the Medicaid MCOs, a statewide
association representing managed care organizations, a
statewide association representing the majority of Illinois
hospitals, and a statewide association representing
physicians, the Department shall in accordance with the


Illinois Administrative Procedure Act, adopt administrative
rules, consistent with this Section, to require each Medicaid
MCO to identify Gold Card providers with such identification
initially being effective for health care services provided on
and after July 1, 2025.
(c) The Department shall adopt rules, in accordance with
the Illinois Administrative Procedure Act, to implement this
Section that include, but are not limited to, the following
provisions:
(1) Require each Medicaid MCO to provide a service
authorization exemption to a provider if the provider has
submitted at least 50 service authorization requests to
its service authorization program in the preceding
calendar year and the service authorization program
approved at least 90% of all service authorization
requests, regardless of the type of health care services
requested.
(2) Require that service authorization exemptions be
limited to services provided in an inpatient or outpatient
hospital setting inclusive of hospital-based clinics.
Service authorization exemptions under this Section shall
not pertain to pharmacy services and durable medical
equipment and supplies.
(3) The service authorization exemption shall be valid
for at least one year, shall be made by each Medicaid MCO
or its URO, and shall be binding on the Medicaid MCO and


its URO.
(4) The provider shall be required to continue to
document medically necessary, clinically appropriate care
and submit such documentation to the Medicaid MCO for the
purpose of continuous performance monitoring. If a
provider fails to maintain the 90% service authorization
standard, as determined on no more frequent a basis than
bi-annually, the provider's service authorization
exemption is subject to temporary or permanent suspension.
(5) Require that each Medicaid MCO publish on its
provider portal a list of all providers that have
qualified for a service authorization exemption or
indicate that a provider has qualified for a service
authorization exemption on its provider-facing provider
roster.
(6) Require that no later than December 1 of each
calendar year, each Medicaid MCO shall provide written
notification to all providers who qualify for a service
authorization exemption, for the subsequent calendar year.
(7) Require that each Medicaid MCO or its URO use the
policies and guidelines published by the Department to
evaluate whether a provider meets the criteria to qualify
for a service authorization exemption and the conditions
under which a service authorization exemption may be
rescinded, including review of the provider's service
authorization determinations during the preceding calendar


year.
(8) Require each Medicaid MCO to provide the
Department a list of all providers who were denied a
service authorization exemption or had a previously
granted service authorization exemption suspended, with
such denials being subject to an annual audit conducted by
an independent third-party URO to ensure their
appropriateness.
(A) The independent third-party URO shall issue a
written report consistent with this paragraph.
(B) The independent third-party URO shall not be
owned by, affiliated with, or employed by any Medicaid
MCO or its contracted URO, nor shall it have any
financial interest in the Medicaid MCO's service
authorization exemption program.
(d) Each Medicaid MCO must have a standard method to
accept and process professional claims and facility claims, as
billed by the provider, for a health care service that is
rendered, prescribed, or ordered by a provider granted a
service authorization exemption, except in cases of fraud.
(e) A service authorization program shall not deny,
partially deny, reduce the level of care, or otherwise limit
reimbursement to the rendering or supervising provider,
including the rendering facility, for health care services
ordered by a provider who qualifies for a service
authorization exemption, except in cases of fraud.


(f) This Section is repealed on December 31, 2030.
ARTICLE 155.
Section 155-5. The Community-Integrated Living
Arrangements Licensure and Certification Act is amended by
adding Section 13.3 as follows:
(210 ILCS 135/13.3 new)
Sec. 13.3. Community-integrated living arrangement per
diem reimbursement. As used in this Section, "medical absence"
means a situation in which a resident is temporarily absent
from a community-integrated living arrangement to receive
medical treatment or for other reasons that have been
recommended by third-party medical personnel, including, but
not limited to, hospitalizations, placements in short-term
stabilization homes or State-operated facilities, stays in
nursing facilities, rehabilitation in long-term care
facilities, or other absences for legitimate medical reasons.
Beginning January 1, 2025, the Department's Division of
Developmental Disabilities shall provide 100% of the per diem
reimbursement to a 24-hour community-integrated living
arrangement provider for up to 20 days for any resident
requiring a medical absence. During the medical absence, the
provider shall hold the bed for the resident. After the
medical absence, the resident shall return to the


community-integrated living arrangement when the resident is
medically able to return in order for the provider to receive
the full per diem reimbursement for the absent days. The per
diem reimbursement shall be in addition to the existing
occupancy factor policy set by the Division of Developmental
Disabilities.
ARTICLE 160.
Section 160-5. The Illinois Public Aid Code is amended by
adding Section 5-5.12f as follows:
(305 ILCS 5/5-5.12f new)
Sec. 5-5.12f. Prescription drugs for mental illness; no
utilization or prior approval mandates.
(a) Notwithstanding any other provision of this Code to
the contrary, except as otherwise provided in subsection (b),
for the purpose of removing barriers to the timely treatment
of serious mental illnesses, prior authorization mandates and
utilization management controls shall not be imposed under the
fee-for-service and managed care medical assistance programs
on any FDA-approved prescription drug that is recognized by a
generally accepted standard medical reference as effective in
the treatment of conditions specified in the most recent
Diagnostic and Statistical Manual of Mental Disorders
published by the American Psychiatric Association if a


preferred or non-preferred drug is prescribed to an adult
patient to treat serious mental illness and one of the
following applies:
(1) the patient has changed providers, including, but
not limited to, a change from an inpatient to an
outpatient provider, and is stable on the drug that has
been previously prescribed, and received prior
authorization, if required;
(2) the patient has changed insurance coverage and is
stable on the drug that has been previously prescribed and
received prior authorization under the previous source of
coverage; or
(3) subject to federal law on maximum dosage limits
and safety edits adopted by the Department's Drug and
Therapeutics Board, including those safety edits and
limits needed to comply with federal requirements
contained in 42 CFR 456.703, the patient has previously
been prescribed and obtained prior authorization for the
drug and the prescription modifies the dosage, dosage
frequency, or both, of the drug as part of the same
treatment for which the drug was previously prescribed.
(b) The following safety edits shall be permitted for
prescription drugs covered under this Section:
(1) clinically appropriate drug utilization review
(DUR) edits, including, but not limited to, drug-to-drug,
drug-age, and drug-dose;


(2) generic drug substitution if a generic drug is
available for the prescribed medication in the same dosage
and formulation; and
(3) any utilization management control that is
necessary for the Department to comply with any current
consent decrees or federal waivers.
(c) As used in this Section, "serious mental illness"
means any one or more of the following diagnoses and
International Classification of Diseases, Tenth Revision,
Clinical Modification (ICD-10-CM) codes listed by the
Department of Human Services' Division of Mental Health, as
amended, on its official website:
(1) Delusional Disorder (F22)
(2) Brief Psychotic Disorder (F23)
(3) Schizophreniform Disorder (F20.81)
(4) Schizophrenia (F20.9)
(5) Schizoaffective Disorder (F25.x)
(6) Catatonia Associated with Another Mental Disorder
(Catatonia Specifier) (F06.1)
(7) Other Specified Schizophrenia Spectrum and Other
Psychotic Disorder (F28)
(8) Unspecified Schizophrenia Spectrum and Other
Psychotic Disorder (F29)
(9) Bipolar I Disorder (F31.xx)
(10) Bipolar II Disorder (F31.81)
(11) Cyclothymic Disorder (F34.0)


(12) Unspecified Bipolar and Related Disorder (F31.9)
(13) Disruptive Mood Dysregulation Disorder (F34.8)
(14) Major Depressive Disorder Single episode (F32.xx)
(15) Major Depressive Disorder, Recurrent episode
(F33.xx)
(16) Obsessive-Compulsive Disorder (F42)
(17) Posttraumatic Stress Disorder (F43.10)
(18) Anorexia Nervosa (F50.0x)
(19) Bulimia Nervosa (F50.2)
(20) Postpartum Depression (F53.0)
(21) Puerperal Psychosis (F53.1)
(22) Factitious Disorder Imposed on Another (F68.A)
(d) Notwithstanding any other provision of law, nothing in
this Section shall not be construed to conflict with Section
1927(a)(1) and (b)(1)(A) of the federal Social Security Act
and any implementing regulations and agreements.
ARTICLE 165.
Section 165-5. The Illinois Public Aid Code is amended by
changing Section 5-5.01a as follows:
(305 ILCS 5/5-5.01a)
Sec. 5-5.01a. Supportive living facilities program.
(a) The Department shall establish and provide oversight
for a program of supportive living facilities that seek to


promote resident independence, dignity, respect, and
well-being in the most cost-effective manner.
A supportive living facility is (i) a free-standing
facility or (ii) a distinct physical and operational entity
within a mixed-use building that meets the criteria
established in subsection (d). A supportive living facility
integrates housing with health, personal care, and supportive
services and is a designated setting that offers residents
their own separate, private, and distinct living units.
Sites for the operation of the program shall be selected
by the Department based upon criteria that may include the
need for services in a geographic area, the availability of
funding, and the site's ability to meet the standards.
(b) Beginning July 1, 2014, subject to federal approval,
the Medicaid rates for supportive living facilities shall be
equal to the supportive living facility Medicaid rate
effective on June 30, 2014 increased by 8.85%. Once the
assessment imposed at Article V-G of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act, the Department shall increase the Medicaid rates for
supportive living facilities effective on July 1, 2014 by
9.09%. The Department shall apply this increase retroactively
to coincide with the imposition of the assessment in Article
V-G of this Code in accordance with the approval for federal
financial participation by the Centers for Medicare and
Medicaid Services.


The Medicaid rates for supportive living facilities
effective on July 1, 2017 must be equal to the rates in effect
for supportive living facilities on June 30, 2017 increased by
2.8%.
The Medicaid rates for supportive living facilities
effective on July 1, 2018 must be equal to the rates in effect
for supportive living facilities on June 30, 2018.
Subject to federal approval, the Medicaid rates for
supportive living services on and after July 1, 2019 must be at
least 54.3% of the average total nursing facility services per
diem for the geographic areas defined by the Department while
maintaining the rate differential for dementia care and must
be updated whenever the total nursing facility service per
diems are updated. Beginning July 1, 2022, upon the
implementation of the Patient Driven Payment Model, Medicaid
rates for supportive living services must be at least 54.3% of
the average total nursing services per diem rate for the
geographic areas. For purposes of this provision, the average
total nursing services per diem rate shall include all add-ons
for nursing facilities for the geographic area provided for in
Section 5-5.2. The rate differential for dementia care must be
maintained in these rates and the rates shall be updated
whenever nursing facility per diem rates are updated.
Subject to federal approval, beginning January 1, 2024,
the dementia care rate for supportive living services must be
no less than the non-dementia care supportive living services


rate multiplied by 1.5.
(c) The Department may adopt rules to implement this
Section. Rules that establish or modify the services,
standards, and conditions for participation in the program
shall be adopted by the Department in consultation with the
Department on Aging, the Department of Rehabilitation
Services, and the Department of Mental Health and
Developmental Disabilities (or their successor agencies).
(d) Subject to federal approval by the Centers for
Medicare and Medicaid Services, the Department shall accept
for consideration of certification under the program any
application for a site or building where distinct parts of the
site or building are designated for purposes other than the
provision of supportive living services, but only if:
(1) those distinct parts of the site or building are
not designated for the purpose of providing assisted
living services as required under the Assisted Living and
Shared Housing Act;
(2) those distinct parts of the site or building are
completely separate from the part of the building used for
the provision of supportive living program services,
including separate entrances;
(3) those distinct parts of the site or building do
not share any common spaces with the part of the building
used for the provision of supportive living program
services; and


(4) those distinct parts of the site or building do
not share staffing with the part of the building used for
the provision of supportive living program services.
(e) Facilities or distinct parts of facilities which are
selected as supportive living facilities and are in good
standing with the Department's rules are exempt from the
provisions of the Nursing Home Care Act and the Illinois
Health Facilities Planning Act.
(f) Section 9817 of the American Rescue Plan Act of 2021
(Public Law 117-2) authorizes a 10% enhanced federal medical
assistance percentage for supportive living services for a
12-month period from April 1, 2021 through March 31, 2022.
Subject to federal approval, including the approval of any
necessary waiver amendments or other federally required
documents or assurances, for a 12-month period the Department
must pay a supplemental $26 per diem rate to all supportive
living facilities with the additional federal financial
participation funds that result from the enhanced federal
medical assistance percentage from April 1, 2021 through March
31, 2022. The Department may issue parameters around how the
supplemental payment should be spent, including quality
improvement activities. The Department may alter the form,
methods, or timeframes concerning the supplemental per diem
rate to comply with any subsequent changes to federal law,
changes made by guidance issued by the federal Centers for
Medicare and Medicaid Services, or other changes necessary to


receive the enhanced federal medical assistance percentage.
(g) All applications for the expansion of supportive
living dementia care settings involving sites not approved by
the Department on January 1, 2024 (the effective date of
Public Act 103-102) this amendatory Act of the 103rd General
Assembly may allow new elderly non-dementia units in addition
to new dementia care units. The Department may approve such
applications only if the application has: (1) no more than one
non-dementia care unit for each dementia care unit and (2) the
site is not located within 4 miles of an existing supportive
living program site in Cook County (including the City of
Chicago), not located within 12 miles of an existing
supportive living program site in DuPage County, Kane County,
Lake County, McHenry County, or Will County, or not located
within 25 miles of an existing supportive living program site
in any other county.
(h) As stated in the supportive living program home and
community-based service waiver approved by the federal Centers
for Medicare and Medicaid Services, and beginning July 1,
2025, the Department must maintain the rate add-on implemented
on January 1, 2023 for the provision of 2 meals per day at no
less than $6.15 per day.
(Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22;
103-102, Article 20, Section 20-5, eff. 1-1-24; 103-102,
Article 100, Section 100-5, eff. 1-1-24; revised 12-15-23.)


ARTICLE 170.
Section 170-5. The Illinois Public Aid Code is amended by
adding Section 5-2.06a as follows:
(305 ILCS 5/5-2.06a new)
Sec. 5-2.06a. Medically fragile children; reimbursement
for legally responsible family caregivers. By January 1, 2025,
the Department of Healthcare and Family Services shall apply
for a Home and Community-Based Services State Plan amendment
and any federal waiver necessary to reimburse legally
responsible family caregivers as providers of personal care or
home health aide services under the Illinois Title XIX State
Plan Home and Community-Based Services benefit and the home
and community-based services waiver program authorized under
Section 1915(c) of the Social Security Act for persons who are
medically fragile and technology dependent. To be eligible for
reimbursement under this Section, a legally responsible family
caregiver must be a certified nursing assistant or certified
nurse aide and must provide services to a medically fragile
relative who is receiving in-home shift nursing services
coordinated by the University of Illinois at Chicago, Division
of Specialized Care for Children. Upon federal approval of the
State Plan amendment and waiver, the Department shall
promulgate rules that define who qualifies for reimbursement
as a legally responsible family caregiver, specify which


personal care and home health aide services are eligible for
reimbursement if the provider is a legally responsible family
caregiver, establish oversight policies to ensure legally
responsible family caregivers meet and comply with licensing
and program requirements, and adopt any other policies or
procedures necessary to implement this Section.
ARTICLE 175.
Section 175-5. The Illinois Public Aid Code is amended by
changing Section 5-5.5 as follows:
(305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5)
Sec. 5-5.5. Elements of Payment Rate.
(a) The Department of Healthcare and Family Services shall
develop a prospective method for determining payment rates for
nursing facility and ICF/DD services in nursing facilities
composed of the following cost elements:
(1) Standard Services, with the cost of this component
being determined by taking into account the actual costs
to the facilities of these services subject to cost
ceilings to be defined in the Department's rules.
(2) Resident Services, with the cost of this component
being determined by taking into account the actual costs,
needs and utilization of these services, as derived from
an assessment of the resident needs in the nursing


facilities.
(3) Ancillary Services, with the payment rate being
developed for each individual type of service. Payment
shall be made only when authorized under procedures
developed by the Department of Healthcare and Family
Services.
(4) Nurse's Aide Training, with the cost of this
component being determined by taking into account the
actual cost to the facilities of such training.
(5) Real Estate Taxes, with the cost of this component
being determined by taking into account the figures
contained in the most currently available cost reports
(with no imposition of maximums) updated to the midpoint
of the current rate year for long term care services
rendered between July 1, 1984 and June 30, 1985, and with
the cost of this component being determined by taking into
account the actual 1983 taxes for which the nursing homes
were assessed (with no imposition of maximums) updated to
the midpoint of the current rate year for long term care
services rendered between July 1, 1985 and June 30, 1986.
(b) In developing a prospective method for determining
payment rates for nursing facility and ICF/DD services in
nursing facilities and ICF/DDs, the Department of Healthcare
and Family Services shall consider the following cost
elements:
(1) Reasonable capital cost determined by utilizing


incurred interest rate and the current value of the
investment, including land, utilizing composite rates, or
by utilizing such other reasonable cost related methods
determined by the Department. However, beginning with the
rate reimbursement period effective July 1, 1987, the
Department shall be prohibited from establishing,
including, and implementing any depreciation factor in
calculating the capital cost element.
(2) Profit, with the actual amount being produced and
accruing to the providers in the form of a return on their
total investment, on the basis of their ability to
economically and efficiently deliver a type of service.
The method of payment may assure the opportunity for a
profit, but shall not guarantee or establish a specific
amount as a cost.
(c) The Illinois Department may implement the amendatory
changes to this Section made by this amendatory Act of 1991
through the use of emergency rules in accordance with the
provisions of Section 5.02 of the Illinois Administrative
Procedure Act. For purposes of the Illinois Administrative
Procedure Act, the adoption of rules to implement the
amendatory changes to this Section made by this amendatory Act
of 1991 shall be deemed an emergency and necessary for the
public interest, safety and welfare.
(d) No later than January 1, 2001, the Department of
Public Aid shall file with the Joint Committee on


Administrative Rules, pursuant to the Illinois Administrative
Procedure Act, a proposed rule, or a proposed amendment to an
existing rule, regarding payment for appropriate services,
including assessment, care planning, discharge planning, and
treatment provided by nursing facilities to residents who have
a serious mental illness.
(e) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(f) Beginning January 1, 2025, the real estate tax
component of the payment rate shall be updated using the most
recent property tax bill on file with the Department for
facilities licensed under the Nursing Home Care Act and
facilities licensed under the Specialized Mental Health
Rehabilitation Act of 2013. The per diem rate shall be
computed by dividing the real estate tax costs reported in the
cost report inflated to the midpoint of the rate year by the
total number of patient days reported in the same cost report.
Computation of the real estate tax component shall be based on
capital days.
(Source: P.A. 96-1123, eff. 1-1-11; 96-1530, eff. 2-16-11;
97-689, eff. 6-14-12.)
ARTICLE 180.


Section 180-5. The Illinois Public Aid Code is amended by
changing Section 5-5.2 as follows:
(305 ILCS 5/5-5.2)
Sec. 5-5.2. Payment.
(a) All nursing facilities that are grouped pursuant to
Section 5-5.1 of this Act shall receive the same rate of
payment for similar services.
(b) It shall be a matter of State policy that the Illinois
Department shall utilize a uniform billing cycle throughout
the State for the long-term care providers.
(c) (Blank).
(c-1) Notwithstanding any other provisions of this Code,
the methodologies for reimbursement of nursing services as
provided under this Article shall no longer be applicable for
bills payable for nursing services rendered on or after a new
reimbursement system based on the Patient Driven Payment Model
(PDPM) has been fully operationalized, which shall take effect
for services provided on or after the implementation of the
PDPM reimbursement system begins. For the purposes of Public
Act 102-1035 this amendatory Act of the 102nd General
Assembly, the implementation date of the PDPM reimbursement
system and all related provisions shall be July 1, 2022 if the
following conditions are met: (i) the Centers for Medicare and
Medicaid Services has approved corresponding changes in the


reimbursement system and bed assessment; and (ii) the
Department has filed rules to implement these changes no later
than June 1, 2022. Failure of the Department to file rules to
implement the changes provided in Public Act 102-1035 this
amendatory Act of the 102nd General Assembly no later than
June 1, 2022 shall result in the implementation date being
delayed to October 1, 2022.
(d) The new nursing services reimbursement methodology
utilizing the Patient Driven Payment Model, which shall be
referred to as the PDPM reimbursement system, taking effect
July 1, 2022, upon federal approval by the Centers for
Medicare and Medicaid Services, shall be based on the
following:
(1) The methodology shall be resident-centered,
facility-specific, cost-based, and based on guidance from
the Centers for Medicare and Medicaid Services.
(2) Costs shall be annually rebased and case mix index
quarterly updated. The nursing services methodology will
be assigned to the Medicaid enrolled residents on record
as of 30 days prior to the beginning of the rate period in
the Department's Medicaid Management Information System
(MMIS) as present on the last day of the second quarter
preceding the rate period based upon the Assessment
Reference Date of the Minimum Data Set (MDS).
(3) Regional wage adjustors based on the Health
Service Areas (HSA) groupings and adjusters in effect on


April 30, 2012 shall be included, except no adjuster shall
be lower than 1.06.
(4) PDPM nursing case mix indices in effect on March
1, 2022 shall be assigned to each resident class at no less
than 0.7858 of the Centers for Medicare and Medicaid
Services PDPM unadjusted case mix values, in effect on
March 1, 2022.
(5) The pool of funds available for distribution by
case mix and the base facility rate shall be determined
using the formula contained in subsection (d-1).
(6) The Department shall establish a variable per diem
staffing add-on in accordance with the most recent
available federal staffing report, currently the Payroll
Based Journal, for the same period of time, and if
applicable adjusted for acuity using the same quarter's
MDS. The Department shall rely on Payroll Based Journals
provided to the Department of Public Health to make a
determination of non-submission. If the Department is
notified by a facility of missing or inaccurate Payroll
Based Journal data or an incorrect calculation of
staffing, the Department must make a correction as soon as
the error is verified for the applicable quarter.
Beginning October 1, 2024, the staffing percentage
used in the calculation of the per diem staffing add-on
shall be its PDPM STRIVE Staffing Ratio which equals: its
Reported Total Nurse Staffing Hours Per Resident Per Day


as published in the most recent federal staffing report
(the Provider Information File), divided by the facility's
PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
Staffing Target is equal to .82 times the facility's
Illinois Adjusted Facility Case-Mix Hours Per Resident Per
Day. A facility's Illinois Adjusted Facility Case Mix
Hours Per Resident Per Day is equal to its Case-Mix Total
Nurse Staffing Hours Per Resident Per Day (as published in
the most recent federal staffing report) times 3.662
(which reflects the national resident days-weighted mean
Reported Total Nurse Staffing Hours Per Resident Per Day
as calculated using the January 2024 federal Provider
Information Files), divided by the national resident
days-weighted mean Reported Total Nurse Staffing Hours Per
Resident Per Day calculated using the most recent federal
Provider Information File.
(6.5) Beginning July 1, 2024, the paid per diem
staffing add-on shall be the paid per diem staffing add-on
in effect April 1, 2024. For dates beginning October 1,
2024 and through September 30, 2025, the denominator for
the staffing percentage shall be the lesser of the
facility's PDPM STRIVE Staffing Target and:
(A) For the quarter beginning October 1, 2024, the
sum of 20% of the facility's PDPM STRIVE Staffing
Target and 80% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in


the January 2024 federal staffing report).
(B) For the quarter beginning January 1, 2025, the
sum of 40% of the facility's PDPM STRIVE Staffing
Target and 60% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in
the January 2024 federal staffing report).
(C) For the quarter beginning March 1, 2025, the
sum of 60% of the facility's PDPM STRIVE Staffing
Target and 40% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in
the January 2024 federal staffing report).
(D) For the quarter beginning July 1, 2025, the
sum of 80% of the facility's PDPM STRIVE Staffing
Target and 20% of the facility's Case-Mix Total Nurse
Staffing Hours Per Resident Per Day (as published in
the January 2024 federal staffing report).
Facilities with at least 70% of the staffing
indicated by the STRIVE study shall be paid a per diem
add-on of $9, increasing by equivalent steps for each
whole percentage point until the facilities reach a per
diem of $16.52 $14.88. Facilities with at least 80% of the
staffing indicated by the STRIVE study shall be paid a per
diem add-on of $16.52 $14.88, increasing by equivalent
steps for each whole percentage point until the facilities
reach a per diem add-on of $25.77 $23.80. Facilities with
at least 92% of the staffing indicated by the STRIVE study


shall be paid a per diem add-on of $25.77 $23.80,
increasing by equivalent steps for each whole percentage
point until the facilities reach a per diem add-on of
$30.98 $29.75. Facilities with at least 100% of the
staffing indicated by the STRIVE study shall be paid a per
diem add-on of $30.98 $29.75, increasing by equivalent
steps for each whole percentage point until the facilities
reach a per diem add-on of $36.44 $35.70. Facilities with
at least 110% of the staffing indicated by the STRIVE
study shall be paid a per diem add-on of $36.44 $35.70,
increasing by equivalent steps for each whole percentage
point until the facilities reach a per diem add-on of
$38.68. Facilities with at least 125% or higher of the
staffing indicated by the STRIVE study shall be paid a per
diem add-on of $38.68. No Beginning April 1, 2023, no
nursing facility's variable staffing per diem add-on shall
be reduced by more than 5% in 2 consecutive quarters. For
the quarters beginning July 1, 2022 and October 1, 2022,
no facility's variable per diem staffing add-on shall be
calculated at a rate lower than 85% of the staffing
indicated by the STRIVE study. No facility below 70% of
the staffing indicated by the STRIVE study shall receive a
variable per diem staffing add-on after December 31, 2022.
(7) For dates of services beginning July 1, 2022, the
PDPM nursing component per diem for each nursing facility
shall be the product of the facility's (i) statewide PDPM


nursing base per diem rate, $92.25, adjusted for the
facility average PDPM case mix index calculated quarterly
and (ii) the regional wage adjuster, and then add the
Medicaid access adjustment as defined in (e-3) of this
Section. Transition rates for services provided between
July 1, 2022 and October 1, 2023 shall be the greater of
the PDPM nursing component per diem or:
(A) for the quarter beginning July 1, 2022, the
RUG-IV nursing component per diem;
(B) for the quarter beginning October 1, 2022, the
sum of the RUG-IV nursing component per diem
multiplied by 0.80 and the PDPM nursing component per
diem multiplied by 0.20;
(C) for the quarter beginning January 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.60 and the PDPM nursing component per
diem multiplied by 0.40;
(D) for the quarter beginning April 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.40 and the PDPM nursing component per
diem multiplied by 0.60;
(E) for the quarter beginning July 1, 2023, the
sum of the RUG-IV nursing component per diem
multiplied by 0.20 and the PDPM nursing component per
diem multiplied by 0.80; or
(F) for the quarter beginning October 1, 2023 and


each subsequent quarter, the transition rate shall end
and a nursing facility shall be paid 100% of the PDPM
nursing component per diem.
(d-1) Calculation of base year Statewide RUG-IV nursing
base per diem rate.
(1) Base rate spending pool shall be:
(A) The base year resident days which are
calculated by multiplying the number of Medicaid
residents in each nursing home as indicated in the MDS
data defined in paragraph (4) by 365.
(B) Each facility's nursing component per diem in
effect on July 1, 2012 shall be multiplied by
subsection (A).
(C) Thirteen million is added to the product of
subparagraph (A) and subparagraph (B) to adjust for
the exclusion of nursing homes defined in paragraph
(5).
(2) For each nursing home with Medicaid residents as
indicated by the MDS data defined in paragraph (4),
weighted days adjusted for case mix and regional wage
adjustment shall be calculated. For each home this
calculation is the product of:
(A) Base year resident days as calculated in
subparagraph (A) of paragraph (1).
(B) The nursing home's regional wage adjustor
based on the Health Service Areas (HSA) groupings and


adjustors in effect on April 30, 2012.
(C) Facility weighted case mix which is the number
of Medicaid residents as indicated by the MDS data
defined in paragraph (4) multiplied by the associated
case weight for the RUG-IV 48 grouper model using
standard RUG-IV procedures for index maximization.
(D) The sum of the products calculated for each
nursing home in subparagraphs (A) through (C) above
shall be the base year case mix, rate adjusted
weighted days.
(3) The Statewide RUG-IV nursing base per diem rate:
(A) on January 1, 2014 shall be the quotient of the
paragraph (1) divided by the sum calculated under
subparagraph (D) of paragraph (2);
(B) on and after July 1, 2014 and until July 1,
2022, shall be the amount calculated under
subparagraph (A) of this paragraph (3) plus $1.76; and
(C) beginning July 1, 2022 and thereafter, $7
shall be added to the amount calculated under
subparagraph (B) of this paragraph (3) of this
Section.
(4) Minimum Data Set (MDS) comprehensive assessments
for Medicaid residents on the last day of the quarter used
to establish the base rate.
(5) Nursing facilities designated as of July 1, 2012
by the Department as "Institutions for Mental Disease"


shall be excluded from all calculations under this
subsection. The data from these facilities shall not be
used in the computations described in paragraphs (1)
through (4) above to establish the base rate.
(e) Beginning July 1, 2014, the Department shall allocate
funding in the amount up to $10,000,000 for per diem add-ons to
the RUGS methodology for dates of service on and after July 1,
2014:
(1) $0.63 for each resident who scores in I4200
Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
(2) $2.67 for each resident who scores either a "1" or
"2" in any items S1200A through S1200I and also scores in
RUG groups PA1, PA2, BA1, or BA2.
(e-1) (Blank).
(e-2) For dates of services beginning January 1, 2014 and
ending September 30, 2023, the RUG-IV nursing component per
diem for a nursing home shall be the product of the statewide
RUG-IV nursing base per diem rate, the facility average case
mix index, and the regional wage adjustor. For dates of
service beginning July 1, 2022 and ending September 30, 2023,
the Medicaid access adjustment described in subsection (e-3)
shall be added to the product.
(e-3) A Medicaid Access Adjustment of $4 adjusted for the
facility average PDPM case mix index calculated quarterly
shall be added to the statewide PDPM nursing per diem for all
facilities with annual Medicaid bed days of at least 70% of all


occupied bed days adjusted quarterly. For each new calendar
year and for the 6-month period beginning July 1, 2022, the
percentage of a facility's occupied bed days comprised of
Medicaid bed days shall be determined by the Department
quarterly. For dates of service beginning January 1, 2023, the
Medicaid Access Adjustment shall be increased to $4.75. This
subsection shall be inoperative on and after January 1, 2028.
(e-4) Subject to federal approval, on and after January 1,
2024, the Department shall increase the rate add-on at
paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
for ventilator services from $208 per day to $481 per day.
Payment is subject to the criteria and requirements under 89
Ill. Adm. Code 147.335.
(f) (Blank).
(g) Notwithstanding any other provision of this Code, on
and after July 1, 2012, for facilities not designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease", rates effective May 1, 2011 shall be
adjusted as follows:
(1) (Blank);
(2) (Blank);
(3) Facility rates for the capital and support
components shall be reduced by 1.7%.
(h) Notwithstanding any other provision of this Code, on
and after July 1, 2012, nursing facilities designated by the
Department of Healthcare and Family Services as "Institutions


for Mental Disease" and "Institutions for Mental Disease" that
are facilities licensed under the Specialized Mental Health
Rehabilitation Act of 2013 shall have the nursing,
socio-developmental, capital, and support components of their
reimbursement rate effective May 1, 2011 reduced in total by
2.7%.
(i) On and after July 1, 2014, the reimbursement rates for
the support component of the nursing facility rate for
facilities licensed under the Nursing Home Care Act as skilled
or intermediate care facilities shall be the rate in effect on
June 30, 2014 increased by 8.17%.
(i-1) Subject to federal approval, on and after January 1,
2024, the reimbursement rates for the support component of the
nursing facility rate for facilities licensed under the
Nursing Home Care Act as skilled or intermediate care
facilities shall be the rate in effect on June 30, 2023
increased by 12%.
(j) Notwithstanding any other provision of law, subject to
federal approval, effective July 1, 2019, sufficient funds
shall be allocated for changes to rates for facilities
licensed under the Nursing Home Care Act as skilled nursing
facilities or intermediate care facilities for dates of
services on and after July 1, 2019: (i) to establish, through
June 30, 2022 a per diem add-on to the direct care per diem
rate not to exceed $70,000,000 annually in the aggregate
taking into account federal matching funds for the purpose of


addressing the facility's unique staffing needs, adjusted
quarterly and distributed by a weighted formula based on
Medicaid bed days on the last day of the second quarter
preceding the quarter for which the rate is being adjusted.
Beginning July 1, 2022, the annual $70,000,000 described in
the preceding sentence shall be dedicated to the variable per
diem add-on for staffing under paragraph (6) of subsection
(d); and (ii) in an amount not to exceed $170,000,000 annually
in the aggregate taking into account federal matching funds to
permit the support component of the nursing facility rate to
be updated as follows:
(1) 80%, or $136,000,000, of the funds shall be used
to update each facility's rate in effect on June 30, 2019
using the most recent cost reports on file, which have had
a limited review conducted by the Department of Healthcare
and Family Services and will not hold up enacting the rate
increase, with the Department of Healthcare and Family
Services.
(2) After completing the calculation in paragraph (1),
any facility whose rate is less than the rate in effect on
June 30, 2019 shall have its rate restored to the rate in
effect on June 30, 2019 from the 20% of the funds set
aside.
(3) The remainder of the 20%, or $34,000,000, shall be
used to increase each facility's rate by an equal
percentage.


(k) During the first quarter of State Fiscal Year 2020,
the Department of Healthcare of Family Services must convene a
technical advisory group consisting of members of all trade
associations representing Illinois skilled nursing providers
to discuss changes necessary with federal implementation of
Medicare's Patient-Driven Payment Model. Implementation of
Medicare's Patient-Driven Payment Model shall, by September 1,
2020, end the collection of the MDS data that is necessary to
maintain the current RUG-IV Medicaid payment methodology. The
technical advisory group must consider a revised reimbursement
methodology that takes into account transparency,
accountability, actual staffing as reported under the
federally required Payroll Based Journal system, changes to
the minimum wage, adequacy in coverage of the cost of care, and
a quality component that rewards quality improvements.
(l) The Department shall establish per diem add-on
payments to improve the quality of care delivered by
facilities, including:
(1) Incentive payments determined by facility
performance on specified quality measures in an initial
amount of $70,000,000. Nothing in this subsection shall be
construed to limit the quality of care payments in the
aggregate statewide to $70,000,000, and, if quality of
care has improved across nursing facilities, the
Department shall adjust those add-on payments accordingly.
The quality payment methodology described in this


subsection must be used for at least State Fiscal Year
2023. Beginning with the quarter starting July 1, 2023,
the Department may add, remove, or change quality metrics
and make associated changes to the quality payment
methodology as outlined in subparagraph (E). Facilities
designated by the Centers for Medicare and Medicaid
Services as a special focus facility or a hospital-based
nursing home do not qualify for quality payments.
(A) Each quality pool must be distributed by
assigning a quality weighted score for each nursing
home which is calculated by multiplying the nursing
home's quality base period Medicaid days by the
nursing home's star rating weight in that period.
(B) Star rating weights are assigned based on the
nursing home's star rating for the LTS quality star
rating. As used in this subparagraph, "LTS quality
star rating" means the long-term stay quality rating
for each nursing facility, as assigned by the Centers
for Medicare and Medicaid Services under the Five-Star
Quality Rating System. The rating is a number ranging
from 0 (lowest) to 5 (highest).
(i) Zero-star or one-star rating has a weight
of 0.
(ii) Two-star rating has a weight of 0.75.
(iii) Three-star rating has a weight of 1.5.
(iv) Four-star rating has a weight of 2.5.


(v) Five-star rating has a weight of 3.5.
(C) Each nursing home's quality weight score is
divided by the sum of all quality weight scores for
qualifying nursing homes to determine the proportion
of the quality pool to be paid to the nursing home.
(D) The quality pool is no less than $70,000,000
annually or $17,500,000 per quarter. The Department
shall publish on its website the estimated payments
and the associated weights for each facility 45 days
prior to when the initial payments for the quarter are
to be paid. The Department shall assign each facility
the most recent and applicable quarter's STAR value
unless the facility notifies the Department within 15
days of an issue and the facility provides reasonable
evidence demonstrating its timely compliance with
federal data submission requirements for the quarter
of record. If such evidence cannot be provided to the
Department, the STAR rating assigned to the facility
shall be reduced by one from the prior quarter.
(E) The Department shall review quality metrics
used for payment of the quality pool and make
recommendations for any associated changes to the
methodology for distributing quality pool payments in
consultation with associations representing long-term
care providers, consumer advocates, organizations
representing workers of long-term care facilities, and


payors. The Department may establish, by rule, changes
to the methodology for distributing quality pool
payments.
(F) The Department shall disburse quality pool
payments from the Long-Term Care Provider Fund on a
monthly basis in amounts proportional to the total
quality pool payment determined for the quarter.
(G) The Department shall publish any changes in
the methodology for distributing quality pool payments
prior to the beginning of the measurement period or
quality base period for any metric added to the
distribution's methodology.
(2) Payments based on CNA tenure, promotion, and CNA
training for the purpose of increasing CNA compensation.
It is the intent of this subsection that payments made in
accordance with this paragraph be directly incorporated
into increased compensation for CNAs. As used in this
paragraph, "CNA" means a certified nursing assistant as
that term is described in Section 3-206 of the Nursing
Home Care Act, Section 3-206 of the ID/DD Community Care
Act, and Section 3-206 of the MC/DD Act. The Department
shall establish, by rule, payments to nursing facilities
equal to Medicaid's share of the tenure wage increments
specified in this paragraph for all reported CNA employee
hours compensated according to a posted schedule
consisting of increments at least as large as those


specified in this paragraph. The increments are as
follows: an additional $1.50 per hour for CNAs with at
least one and less than 2 years' experience plus another
$1 per hour for each additional year of experience up to a
maximum of $6.50 for CNAs with at least 6 years of
experience. For purposes of this paragraph, Medicaid's
share shall be the ratio determined by paid Medicaid bed
days divided by total bed days for the applicable time
period used in the calculation. In addition, and additive
to any tenure increments paid as specified in this
paragraph, the Department shall establish, by rule,
payments supporting Medicaid's share of the
promotion-based wage increments for CNA employee hours
compensated for that promotion with at least a $1.50
hourly increase. Medicaid's share shall be established as
it is for the tenure increments described in this
paragraph. Qualifying promotions shall be defined by the
Department in rules for an expected 10-15% subset of CNAs
assigned intermediate, specialized, or added roles such as
CNA trainers, CNA scheduling "captains", and CNA
specialists for resident conditions like dementia or
memory care or behavioral health.
(m) The Department shall work with nursing facility
industry representatives to design policies and procedures to
permit facilities to address the integrity of data from
federal reporting sites used by the Department in setting


facility rates.
(Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
Section 50-5, eff. 1-1-24; revised 12-15-23.)
ARTICLE 185.
Section 185-5. The Illinois Public Aid Code is amended by
changing Section 5-5a.1 as follows:
(305 ILCS 5/5-5a.1)
Sec. 5-5a.1. Telehealth services for persons with
intellectual and developmental disabilities.  The Department
shall file an amendment to the Home and Community-Based
Services Waiver Program for Adults with Developmental
Disabilities authorized under Section 1915(c) of the Social
Security Act to incorporate telehealth services administered
by a provider of telehealth services that demonstrates
knowledge and experience in providing medical and emergency
services for persons with intellectual and developmental
disabilities. For dates of service on and after January 1,
2025, the Department shall pay negotiated, agreed upon
administrative fees associated with implementing telehealth
services for persons with intellectual and developmental
disabilities who are receiving Community Integrated Living


Arrangement residential services under the Home and
Community-Based Services Waiver Program for Adults with
Developmental Disabilities. The implementation of telehealth
services shall not impede the choice of any individual
receiving waiver-funded services through the Home and
Community-Based Services Waiver Program for Adults with
Developmental Disabilities to receive in-person health care
services at any time. The Department shall ensure individuals
enrolled in the waiver, or their guardians, request to opt-in
to these services. For individuals who opt in, this service
shall be included in the individual's person-centered plan.
The use of telehealth services shall not be used for the
convenience of staff at any time nor shall it replace primary
care physician services. The Department shall pay
administrative fees associated with implementing telehealth
services for all persons with intellectual and developmental
disabilities who are receiving services under the Home and
Community-Based Services Waiver Program for Adults with
Developmental Disabilities.
(Source: P.A. 103-102, eff. 7-1-23.)
ARTICLE 190.
Section 190-5. The Pharmacy Practice Act is amended by
changing Sections 3 and 9.6 as follows:


(225 ILCS 85/3)
(Section scheduled to be repealed on January 1, 2028)
Sec. 3. Definitions. For the purpose of this Act, except
where otherwise limited therein:
(a) "Pharmacy" or "drugstore" means and includes every
store, shop, pharmacy department, or other place where
pharmacist care is provided by a pharmacist (1) where drugs,
medicines, or poisons are dispensed, sold or offered for sale
at retail, or displayed for sale at retail; or (2) where
prescriptions of physicians, dentists, advanced practice
registered nurses, physician assistants, veterinarians,
podiatric physicians, or optometrists, within the limits of
their licenses, are compounded, filled, or dispensed; or (3)
which has upon it or displayed within it, or affixed to or used
in connection with it, a sign bearing the word or words
"Pharmacist", "Druggist", "Pharmacy", "Pharmaceutical Care",
"Apothecary", "Drugstore", "Medicine Store", "Prescriptions",
"Drugs", "Dispensary", "Medicines", or any word or words of
similar or like import, either in the English language or any
other language; or (4) where the characteristic prescription
sign (Rx) or similar design is exhibited; or (5) any store, or
shop, or other place with respect to which any of the above
words, objects, signs or designs are used in any
advertisement.
(b) "Drugs" means and includes (1) articles recognized in
the official United States Pharmacopoeia/National Formulary


(USP/NF), or any supplement thereto and being intended for and
having for their main use the diagnosis, cure, mitigation,
treatment or prevention of disease in man or other animals, as
approved by the United States Food and Drug Administration,
but does not include devices or their components, parts, or
accessories; and (2) all other articles intended for and
having for their main use the diagnosis, cure, mitigation,
treatment or prevention of disease in man or other animals, as
approved by the United States Food and Drug Administration,
but does not include devices or their components, parts, or
accessories; and (3) articles (other than food) having for
their main use and intended to affect the structure or any
function of the body of man or other animals; and (4) articles
having for their main use and intended for use as a component
or any articles specified in clause (1), (2) or (3); but does
not include devices or their components, parts or accessories.
(c) "Medicines" means and includes all drugs intended for
human or veterinary use approved by the United States Food and
Drug Administration.
(d) "Practice of pharmacy" means:
(1) the interpretation and the provision of assistance
in the monitoring, evaluation, and implementation of
prescription drug orders;
(2) the dispensing of prescription drug orders;
(3) participation in drug and device selection;
(4) drug administration limited to the administration


of oral, topical, injectable, and inhalation as follows:
(A) in the context of patient education on the
proper use or delivery of medications;
(B) vaccination of patients 7 years of age and
older pursuant to a valid prescription or standing
order, by a physician licensed to practice medicine in
all its branches, except for vaccinations covered by
paragraph (15), upon completion of appropriate
training, including how to address contraindications
and adverse reactions set forth by rule, with
notification to the patient's physician and
appropriate record retention, or pursuant to hospital
pharmacy and therapeutics committee policies and
procedures. Eligible vaccines are those listed on the
U.S. Centers for Disease Control and Prevention (CDC)
Recommended Immunization Schedule, the CDC's Health
Information for International Travel, or the U.S. Food
and Drug Administration's Vaccines Licensed and
Authorized for Use in the United States. As applicable
to the State's Medicaid program and other payers,
vaccines ordered and administered in accordance with
this subsection shall be covered and reimbursed at no
less than the rate that the vaccine is reimbursed when
ordered and administered by a physician;
(B-5) following the initial administration of
long-acting or extended-release form opioid


antagonists by a physician licensed to practice
medicine in all its branches, administration of
injections of long-acting or extended-release form
opioid antagonists for the treatment of substance use
disorder, pursuant to a valid prescription by a
physician licensed to practice medicine in all its
branches, upon completion of appropriate training,
including how to address contraindications and adverse
reactions, including, but not limited to, respiratory
depression and the performance of cardiopulmonary
resuscitation, set forth by rule, with notification to
the patient's physician and appropriate record
retention, or pursuant to hospital pharmacy and
therapeutics committee policies and procedures;
(C) administration of injections of
alpha-hydroxyprogesterone caproate, pursuant to a
valid prescription, by a physician licensed to
practice medicine in all its branches, upon completion
of appropriate training, including how to address
contraindications and adverse reactions set forth by
rule, with notification to the patient's physician and
appropriate record retention, or pursuant to hospital
pharmacy and therapeutics committee policies and
procedures; and
(D) administration of injections of long-term
antipsychotic medications pursuant to a valid


prescription by a physician licensed to practice
medicine in all its branches, upon completion of
appropriate training conducted by an Accreditation
Council of Pharmaceutical Education accredited
provider, including how to address contraindications
and adverse reactions set forth by rule, with
notification to the patient's physician and
appropriate record retention, or pursuant to hospital
pharmacy and therapeutics committee policies and
procedures.
(5) (blank);
(6) drug regimen review;
(7) drug or drug-related research;
(8) the provision of patient counseling;
(9) the practice of telepharmacy;
(10) the provision of those acts or services necessary
to provide pharmacist care;
(11) medication therapy management;
(12) the responsibility for compounding and labeling
of drugs and devices (except labeling by a manufacturer,
repackager, or distributor of non-prescription drugs and
commercially packaged legend drugs and devices), proper
and safe storage of drugs and devices, and maintenance of
required records;
(13) the assessment and consultation of patients and
dispensing of hormonal contraceptives;


(14) the initiation, dispensing, or administration of
drugs, laboratory tests, assessments, referrals, and
consultations for human immunodeficiency virus
pre-exposure prophylaxis and human immunodeficiency virus
post-exposure prophylaxis under Section 43.5;
(15) vaccination of patients 7 years of age and older
for COVID-19 or influenza subcutaneously, intramuscularly,
or orally as authorized, approved, or licensed by the
United States Food and Drug Administration, pursuant to
the following conditions:
(A) the vaccine must be authorized or licensed by
the United States Food and Drug Administration;
(B) the vaccine must be ordered and administered
according to the Advisory Committee on Immunization
Practices standard immunization schedule;
(C) the pharmacist must complete a course of
training accredited by the Accreditation Council on
Pharmacy Education or a similar health authority or
professional body approved by the Division of
Professional Regulation;
(D) the pharmacist must have a current certificate
in basic cardiopulmonary resuscitation;
(E) the pharmacist must complete, during each
State licensing period, a minimum of 2 hours of
immunization-related continuing pharmacy education
approved by the Accreditation Council on Pharmacy


Education;
(F) the pharmacist must comply with recordkeeping
and reporting requirements of the jurisdiction in
which the pharmacist administers vaccines, including
informing the patient's primary-care provider, when
available, and complying with requirements whereby the
person administering a vaccine must review the vaccine
registry or other vaccination records prior to
administering the vaccine; and
(G) the pharmacist must inform the pharmacist's
patients who are less than 18 years old, as well as the
adult caregiver accompanying the child, of the
importance of a well-child visit with a pediatrician
or other licensed primary-care provider and must refer
patients as appropriate;
(16) the ordering and administration of COVID-19
therapeutics subcutaneously, intramuscularly, or orally
with notification to the patient's physician and
appropriate record retention or pursuant to hospital
pharmacy and therapeutics committee policies and
procedures. Eligible therapeutics are those approved,
authorized, or licensed by the United States Food and Drug
Administration and must be administered subcutaneously,
intramuscularly, or orally in accordance with that
approval, authorization, or licensing; and
(17) the ordering and administration of point of care


tests, and screenings, and treatments for (i) influenza,
(ii) SARS-CoV-2 SARS-COV 2, (iii) Group A Streptococcus,
(iv) respiratory syncytial virus, (v) adult-stage head
louse, and (vi) (iii) health conditions identified by a
statewide public health emergency, as defined in the
Illinois Emergency Management Agency Act, with
notification to the patient's physician, if any, and
appropriate record retention or pursuant to hospital
pharmacy and therapeutics committee policies and
procedures. Eligible tests and screenings are those
approved, authorized, or licensed by the United States
Food and Drug Administration and must be administered in
accordance with that approval, authorization, or
licensing.
A pharmacist who orders or administers tests or
screenings for health conditions described in this
paragraph may use a test that may guide clinical
decision-making for the health condition that is waived
under the federal Clinical Laboratory Improvement
Amendments of 1988 and regulations promulgated thereunder
or any established screening procedure that is established
under a statewide protocol.
A pharmacist may delegate the administrative and
technical tasks of performing a test for the health
conditions described in this paragraph to a registered
pharmacy technician or student pharmacist acting under the


supervision of the pharmacist.
The testing, screening, and treatment ordered under
this paragraph by a pharmacist shall not be denied
reimbursement under health benefit plans that are within
the scope of the pharmacist's license and shall be covered
as if the services or procedures were performed by a
physician, an advanced practice registered nurse, or a
physician assistant.
A pharmacy benefit manager, health carrier, health
benefit plan, or third-party payor shall not discriminate
against a pharmacy or a pharmacist with respect to
participation referral, reimbursement of a covered
service, or indemnification if a pharmacist is acting
within the scope of the pharmacist's license and the
pharmacy is operating in compliance with all applicable
laws and rules.
A pharmacist who performs any of the acts defined as the
practice of pharmacy in this State must be actively licensed
as a pharmacist under this Act.
(e) "Prescription" means and includes any written, oral,
facsimile, or electronically transmitted order for drugs or
medical devices, issued by a physician licensed to practice
medicine in all its branches, dentist, veterinarian, podiatric
physician, or optometrist, within the limits of his or her
license, by a physician assistant in accordance with
subsection (f) of Section 4, or by an advanced practice


registered nurse in accordance with subsection (g) of Section
4, containing the following: (1) name of the patient; (2) date
when prescription was issued; (3) name and strength of drug or
description of the medical device prescribed; and (4)
quantity; (5) directions for use; (6) prescriber's name,
address, and signature; and (7) DEA registration number where
required, for controlled substances. The prescription may, but
is not required to, list the illness, disease, or condition
for which the drug or device is being prescribed. DEA
registration numbers shall not be required on inpatient drug
orders. A prescription for medication other than controlled
substances shall be valid for up to 15 months from the date
issued for the purpose of refills, unless the prescription
states otherwise.
(f) "Person" means and includes a natural person,
partnership, association, corporation, government entity, or
any other legal entity.
(g) "Department" means the Department of Financial and
Professional Regulation.
(h) "Board of Pharmacy" or "Board" means the State Board
of Pharmacy of the Department of Financial and Professional
Regulation.
(i) "Secretary" means the Secretary of Financial and
Professional Regulation.
(j) "Drug product selection" means the interchange for a
prescribed pharmaceutical product in accordance with Section


25 of this Act and Section 3.14 of the Illinois Food, Drug and
Cosmetic Act.
(k) "Inpatient drug order" means an order issued by an
authorized prescriber for a resident or patient of a facility
licensed under the Nursing Home Care Act, the ID/DD Community
Care Act, the MC/DD Act, the Specialized Mental Health
Rehabilitation Act of 2013, the Hospital Licensing Act, or the
University of Illinois Hospital Act, or a facility which is
operated by the Department of Human Services (as successor to
the Department of Mental Health and Developmental
Disabilities) or the Department of Corrections.
(k-5) "Pharmacist" means an individual health care
professional and provider currently licensed by this State to
engage in the practice of pharmacy.
(l) "Pharmacist in charge" means the licensed pharmacist
whose name appears on a pharmacy license and who is
responsible for all aspects of the operation related to the
practice of pharmacy.
(m) "Dispense" or "dispensing" means the interpretation,
evaluation, and implementation of a prescription drug order,
including the preparation and delivery of a drug or device to a
patient or patient's agent in a suitable container
appropriately labeled for subsequent administration to or use
by a patient in accordance with applicable State and federal
laws and regulations. "Dispense" or "dispensing" does not mean
the physical delivery to a patient or a patient's


representative in a home or institution by a designee of a
pharmacist or by common carrier. "Dispense" or "dispensing"
also does not mean the physical delivery of a drug or medical
device to a patient or patient's representative by a
pharmacist's designee within a pharmacy or drugstore while the
pharmacist is on duty and the pharmacy is open.
(n) "Nonresident pharmacy" means a pharmacy that is
located in a state, commonwealth, or territory of the United
States, other than Illinois, that delivers, dispenses, or
distributes, through the United States Postal Service,
commercially acceptable parcel delivery service, or other
common carrier, to Illinois residents, any substance which
requires a prescription.
(o) "Compounding" means the preparation and mixing of
components, excluding flavorings, (1) as the result of a
prescriber's prescription drug order or initiative based on
the prescriber-patient-pharmacist relationship in the course
of professional practice or (2) for the purpose of, or
incident to, research, teaching, or chemical analysis and not
for sale or dispensing. "Compounding" includes the preparation
of drugs or devices in anticipation of receiving prescription
drug orders based on routine, regularly observed dispensing
patterns. Commercially available products may be compounded
for dispensing to individual patients only if all of the
following conditions are met: (i) the commercial product is
not reasonably available from normal distribution channels in


a timely manner to meet the patient's needs and (ii) the
prescribing practitioner has requested that the drug be
compounded.
(p) (Blank).
(q) (Blank).
(r) "Patient counseling" means the communication between a
pharmacist or a student pharmacist under the supervision of a
pharmacist and a patient or the patient's representative about
the patient's medication or device for the purpose of
optimizing proper use of prescription medications or devices.
"Patient counseling" may include without limitation (1)
obtaining a medication history; (2) acquiring a patient's
allergies and health conditions; (3) facilitation of the
patient's understanding of the intended use of the medication;
(4) proper directions for use; (5) significant potential
adverse events; (6) potential food-drug interactions; and (7)
the need to be compliant with the medication therapy. A
pharmacy technician may only participate in the following
aspects of patient counseling under the supervision of a
pharmacist: (1) obtaining medication history; (2) providing
the offer for counseling by a pharmacist or student
pharmacist; and (3) acquiring a patient's allergies and health
conditions.
(s) "Patient profiles" or "patient drug therapy record"
means the obtaining, recording, and maintenance of patient
prescription information, including prescriptions for


controlled substances, and personal information.
(t) (Blank).
(u) "Medical device" or "device" means an instrument,
apparatus, implement, machine, contrivance, implant, in vitro
reagent, or other similar or related article, including any
component part or accessory, required under federal law to
bear the label "Caution: Federal law requires dispensing by or
on the order of a physician". A seller of goods and services
who, only for the purpose of retail sales, compounds, sells,
rents, or leases medical devices shall not, by reasons
thereof, be required to be a licensed pharmacy.
(v) "Unique identifier" means an electronic signature,
handwritten signature or initials, thumb print, or other
acceptable biometric or electronic identification process as
approved by the Department.
(w) "Current usual and customary retail price" means the
price that a pharmacy charges to a non-third-party payor.
(x) "Automated pharmacy system" means a mechanical system
located within the confines of the pharmacy or remote location
that performs operations or activities, other than compounding
or administration, relative to storage, packaging, dispensing,
or distribution of medication, and which collects, controls,
and maintains all transaction information.
(y) "Drug regimen review" means and includes the
evaluation of prescription drug orders and patient records for
(1) known allergies; (2) drug or potential therapy


contraindications; (3) reasonable dose, duration of use, and
route of administration, taking into consideration factors
such as age, gender, and contraindications; (4) reasonable
directions for use; (5) potential or actual adverse drug
reactions; (6) drug-drug interactions; (7) drug-food
interactions; (8) drug-disease contraindications; (9)
therapeutic duplication; (10) patient laboratory values when
authorized and available; (11) proper utilization (including
over or under utilization) and optimum therapeutic outcomes;
and (12) abuse and misuse.
(z) "Electronically transmitted prescription" means a
prescription that is created, recorded, or stored by
electronic means; issued and validated with an electronic
signature; and transmitted by electronic means directly from
the prescriber to a pharmacy. An electronic prescription is
not an image of a physical prescription that is transferred by
electronic means from computer to computer, facsimile to
facsimile, or facsimile to computer.
(aa) "Medication therapy management services" means a
distinct service or group of services offered by licensed
pharmacists, physicians licensed to practice medicine in all
its branches, advanced practice registered nurses authorized
in a written agreement with a physician licensed to practice
medicine in all its branches, or physician assistants
authorized in guidelines by a supervising physician that
optimize therapeutic outcomes for individual patients through


improved medication use. In a retail or other non-hospital
pharmacy, medication therapy management services shall consist
of the evaluation of prescription drug orders and patient
medication records to resolve conflicts with the following:
(1) known allergies;
(2) drug or potential therapy contraindications;
(3) reasonable dose, duration of use, and route of
administration, taking into consideration factors such as
age, gender, and contraindications;
(4) reasonable directions for use;
(5) potential or actual adverse drug reactions;
(6) drug-drug interactions;
(7) drug-food interactions;
(8) drug-disease contraindications;
(9) identification of therapeutic duplication;
(10) patient laboratory values when authorized and
available;
(11) proper utilization (including over or under
utilization) and optimum therapeutic outcomes; and
(12) drug abuse and misuse.
"Medication therapy management services" includes the
following:
(1) documenting the services delivered and
communicating the information provided to patients'
prescribers within an appropriate time frame, not to
exceed 48 hours;


(2) providing patient counseling designed to enhance a
patient's understanding and the appropriate use of his or
her medications; and
(3) providing information, support services, and
resources designed to enhance a patient's adherence with
his or her prescribed therapeutic regimens.
"Medication therapy management services" may also include
patient care functions authorized by a physician licensed to
practice medicine in all its branches for his or her
identified patient or groups of patients under specified
conditions or limitations in a standing order from the
physician.
"Medication therapy management services" in a licensed
hospital may also include the following:
(1) reviewing assessments of the patient's health
status; and
(2) following protocols of a hospital pharmacy and
therapeutics committee with respect to the fulfillment of
medication orders.
(bb) "Pharmacist care" means the provision by a pharmacist
of medication therapy management services, with or without the
dispensing of drugs or devices, intended to achieve outcomes
that improve patient health, quality of life, and comfort and
enhance patient safety.
(cc) "Protected health information" means individually
identifiable health information that, except as otherwise


provided, is:
(1) transmitted by electronic media;
(2) maintained in any medium set forth in the
definition of "electronic media" in the federal Health
Insurance Portability and Accountability Act; or
(3) transmitted or maintained in any other form or
medium.
"Protected health information" does not include
individually identifiable health information found in:
(1) education records covered by the federal Family
Educational Right and Privacy Act; or
(2) employment records held by a licensee in its role
as an employer.
(dd) "Standing order" means a specific order for a patient
or group of patients issued by a physician licensed to
practice medicine in all its branches in Illinois.
(ee) "Address of record" means the designated address
recorded by the Department in the applicant's application file
or licensee's license file maintained by the Department's
licensure maintenance unit.
(ff) "Home pharmacy" means the location of a pharmacy's
primary operations.
(gg) "Email address of record" means the designated email
address recorded by the Department in the applicant's
application file or the licensee's license file, as maintained
by the Department's licensure maintenance unit.


(Source: P.A. 102-16, eff. 6-17-21; 102-103, eff. 1-1-22;
102-558, eff. 8-20-21; 102-813, eff. 5-13-22; 102-1051, eff.
1-1-23; 103-1, eff. 4-27-23.)
(225 ILCS 85/9.6)
Sec. 9.6. Administration of vaccines and therapeutics by
registered pharmacy technicians and student pharmacists.
(a) Under the supervision of an appropriately trained
pharmacist, a registered pharmacy technician or student
pharmacist may administer COVID-19, SARS-CoV-2, respiratory
syncytial virus, and influenza vaccines subcutaneously,
intramuscularly, or orally as authorized, approved, or
licensed by the United States Food and Drug Administration,
subject to the following conditions:
(1) the vaccination must be ordered by the supervising
pharmacist;
(2) the supervising pharmacist must be readily and
immediately available to the immunizing pharmacy
technician or student pharmacist;
(3) the pharmacy technician or student pharmacist must
complete a practical training program that is approved by
the Accreditation Council for Pharmacy Education and that
includes hands-on injection technique training and
training in the recognition and treatment of emergency
reactions to vaccines;
(4) the pharmacy technician or student pharmacist must


have a current certificate in basic cardiopulmonary
resuscitation;
(5) the pharmacy technician or student pharmacist must
complete, during the relevant licensing period, a minimum
of 2 hours of immunization-related continuing pharmacy
education that is approved by the Accreditation Council
for Pharmacy Education;
(6) the supervising pharmacist must comply with all
relevant recordkeeping and reporting requirements;
(7) the supervising pharmacist must be responsible for
complying with requirements related to reporting adverse
events;
(8) the supervising pharmacist must review the vaccine
registry or other vaccination records prior to ordering
the vaccination to be administered by the pharmacy
technician or student pharmacist;
(9) the pharmacy technician or student pharmacist
must, if the patient is 18 years of age or younger, inform
the patient and the adult caregiver accompanying the
patient of the importance of a well-child visit with a
pediatrician or other licensed primary-care provider and
must refer patients as appropriate;
(10) in the case of a COVID-19 vaccine, the
vaccination must be ordered and administered according to
the Advisory Committee on Immunization Practices' COVID-19
vaccine recommendations;


(11) in the case of a COVID-19 vaccine, the
supervising pharmacist must comply with any applicable
requirements or conditions of use as set forth in the
Centers for Disease Control and Prevention COVID-19
vaccination provider agreement and any other federal
requirements that apply to the administration of COVID-19
vaccines being administered; and
(12) the registered pharmacy technician or student
pharmacist and the supervising pharmacist must comply with
all other requirements of this Act and the rules adopted
thereunder pertaining to the administration of drugs.
(b) Under the supervision of an appropriately trained
pharmacist, a registered pharmacy technician or student
pharmacist may administer COVID-19 therapeutics
subcutaneously, intramuscularly, or orally as authorized,
approved, or licensed by the United States Food and Drug
Administration, subject to the following conditions:
(1) the COVID-19 therapeutic must be authorized,
approved or licensed by the United States Food and Drug
Administration;
(2) the COVID-19 therapeutic must be administered
subcutaneously, intramuscularly, or orally in accordance
with the United States Food and Drug Administration
approval, authorization, or licensing;
(3) a pharmacy technician or student pharmacist
practicing pursuant to this Section must complete a


practical training program that is approved by the
Accreditation Council for Pharmacy Education and that
includes hands-on injection technique training, clinical
evaluation of indications and contraindications of
COVID-19 therapeutics training, training in the
recognition and treatment of emergency reactions to
COVID-19 therapeutics, and any additional training
required in the United States Food and Drug Administration
approval, authorization, or licensing;
(4) the pharmacy technician or student pharmacist must
have a current certificate in basic cardiopulmonary
resuscitation;
(5) the pharmacy technician or student pharmacist must
comply with any applicable requirements or conditions of
use that apply to the administration of COVID-19
therapeutics;
(6) the supervising pharmacist must comply with all
relevant recordkeeping and reporting requirements;
(7) the supervising pharmacist must be readily and
immediately available to the pharmacy technician or
student pharmacist; and
(8) the registered pharmacy technician or student
pharmacist and the supervising pharmacist must comply with
all other requirements of this Act and the rules adopted
thereunder pertaining to the administration of drugs.
(Source: P.A. 103-1, eff. 4-27-23.)


ARTICLE 999.