2023 Illinois Compiled Statutes › Chapter 305 - PUBLIC AID › 305 ILCS 5/ - Illinois Public Aid Code. › Article V - Medical Assistance

(305 ILCS 5/Art. V heading)
ARTICLE V.  
		MEDICAL ASSISTANCE
(305 ILCS 5/5-1) (from Ch. 23, par. 5-1)
Sec. 5-1. Declaration of purpose. It is the purpose of this Article to
provide a program of essential
medical care and rehabilitative services for persons receiving basic
maintenance grants under this Code and for other persons who are unable,
because of inadequate resources, to meet their essential medical needs.
Preservation of health, alleviation of sickness, and correction of
disabling conditions for persons requiring maintenance support are
essential if they are to have an opportunity to become self-supporting or
to attain a greater capacity for self-care.  For persons who are medically
indigent but otherwise able to provide themselves with a livelihood, it is
of special importance to maintain their incentives for continued
independence and preserve their limited resources for ordinary maintenance
needs to prevent their total or substantial dependency.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-1.1) (from Ch. 23, par. 5-1.1)
Sec. 5-1.1. Definitions. The terms defined in this Section
shall have the meanings ascribed to them, except when the
context otherwise requires.
(a) "Nursing facility" means a facility, licensed by the Department of Public Health under the Nursing Home Care Act, that provides nursing facility services within the meaning of Title XIX of
the federal Social Security Act.
(b) "Intermediate care facility for persons with developmental disabilities" or "ICF/DD" means a facility, licensed by the Department of Public Health under the ID/DD Community Care Act, that is an intermediate care facility for the mentally retarded within the meaning of Title XIX
of the federal Social Security Act.
(c) "Standard services" means those services required for
the care of all patients in the facility and shall, as a
minimum, include the following:  (1) administration; (2)
dietary (standard); (3) housekeeping; (4) laundry and linen;
(5) maintenance of property and equipment, including utilities;
(6) medical records; (7) training of employees; (8) utilization
review; (9) activities services; (10) social services; (11)
disability services; and all other similar services required
by either the laws of the State of Illinois or one of its
political subdivisions or municipalities or by Title XIX of
the Social Security Act.
(d) "Patient services" means those which vary with the
number of personnel; professional and para-professional
skills of the personnel; specialized equipment, and reflect
the intensity of the medical and psycho-social needs of the
patients.  Patient services shall as a minimum include:
(1) physical services; (2) nursing services, including
restorative nursing; (3) medical direction and patient care
planning; (4) health related supportive and habilitative
services and all similar services required by either the
laws of the State of Illinois or one of its political
subdivisions or municipalities or by Title XIX of the
Social Security Act.
(e) "Ancillary services" means those services which
require a specific physician's order and defined as under
the medical assistance program as not being routine in
nature for skilled nursing facilities and ICF/DDs.
Such services generally must be authorized prior to delivery
and payment as provided for under the rules of the Department
of Healthcare and Family Services.
(f) "Capital" means the investment in a facility's assets
for both debt and non-debt funds.  Non-debt capital is the
difference between an adjusted replacement value of the assets
and the actual amount of debt capital.
(g) "Profit" means the amount which shall accrue to a
facility as a result of its revenues exceeding its expenses
as determined in accordance with generally accepted accounting
principles.
(h) "Non-institutional services" means those services provided under
paragraph (f) of Section 3 of the Rehabilitation of Persons with Disabilities Act and those services provided under Section 4.02 of the Illinois Act on the Aging.
(i) (Blank).
(j) "Institutionalized person" means an individual who is an inpatient
in an ICF/DD or nursing facility, or who is an inpatient in
a medical
institution receiving a level of care equivalent to that of an ICF/DD or nursing facility, or who is receiving services under
Section 1915(c) of the Social Security Act.
(k) "Institutionalized spouse" means an institutionalized person who is
expected to receive services at the same level of care for at least 30 days
and is married to a spouse who is not an institutionalized person.
(l) "Community spouse" is the spouse of an institutionalized spouse.
(m) "Health Benefits Service Package" means, subject to federal approval, benefits covered by the medical assistance program as determined by the Department by rule for individuals eligible for medical assistance under  paragraph 18 of Section 5-2 of this Code.
(n) "Federal poverty level" means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services.  These guidelines set poverty levels by family size.
(Source: P.A. 98-104, eff. 7-22-13; 99-143, eff. 7-27-15.)
(305 ILCS 5/5-1.2)
Sec. 5-1.2. Recipient eligibility verification.
(a) The Illinois Department shall initiate a statewide system by which
providers and sites of medical care can electronically verify recipient
eligibility for aid under this Article.
High-volume providers and sites of medical care, as defined by the Illinois
Department by rule, shall be required to participate in the eligibility
verification system.
Every non-high-volume provider and site of medical
care shall be afforded the opportunity to participate in the eligibility
verification system.
The Illinois Department shall provide by rule for
implementation of the system, which may be accomplished in phases over time and
by geographic region, recipient classification, and provider type.
The system shall initially be implemented in, but not limited to, the
following zip codes in Cook County: 60601, 60602, 60603, 60604, 60605, 60606,
60607, 60608, 60609, 60612, and 60616.  The system shall be implemented within
6
months after approval by the federal government.  The Illinois Department shall
report to the General Assembly by December 31, 1994 on the status of the
Illinois Department's application to the federal government for approval of
this system.
The recipient eligibility verification system may be coordinated with the
Electronic Benefits Transfer system established by Section 11-3.1 of this Code
and compatible with any of the methods for the delivery of medical care and
services authorized by this Article.
The system shall make available to providers the history of claims for
medical services submitted to the Illinois Department for those services
provided to the recipient.  The Illinois Department shall develop safeguards to
protect each recipient's health information from misuse or unauthorized
disclosure.
(b) The Illinois Department shall conduct a demonstration project in at
least 2 geographic locations for the purpose of assessing the effectiveness of
a recipient photo identification card in reducing abuses in the provision of
services under this Article.  In order to receive medical care, recipients
included in this demonstration project must present a Medicaid card and photo
identification card.  The Illinois Department shall apply for any federal
waivers or approvals necessary to conduct this demonstration project.  The
demonstration project shall become operational (i) 12 months after the
effective
date of this amendatory Act of 1994 or (ii) after the Illinois Department's
receipt
of all necessary federal waivers and approvals, whichever occurs later, and
shall operate for 12 months.
(c)  Effective October 1, 2007, all changes in status of Medicaid recipients
residing in Illinois nursing facilities after initial eligibility for
Medicaid has been established shall be reported to the Department, using an
Internet-based electronic data interchange system, by the nursing facilities,
except for those changes made by personnel of the Department.  Changes reported
using the Internet-based electronic data interchange system shall be deemed
valid and shall be used as the basis for future Medicaid payments unless
Department approval of the transaction is required, or until such time as
any review or audit conducted by the State establishes that the
information is incorrect.
(Source: P.A. 95-458, eff. 8-27-07.)
(305 ILCS 5/5-1.3)
Sec. 5-1.3. Payer of last resort. To the extent permissible under federal law, the State may pay for medical services only after payment from all other sources of payment have been exhausted, or after the Department has determined that pursuit of such payment is economically unfeasible.  Applicants for, and recipients of, medical assistance under this Code shall disclose to the State all insurance coverage they have.  To the extent permissible under federal law, the State shall require vendors of medical services to bill third-party payers for services that may be covered by those third-party payers prior to submission of a request for payment to the State.  The Department shall, to the extent permissible under federal law, reject a request for payment of a medical service that should first have been submitted to a third-party payer.
(Source: P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-1.4)
Sec. 5-1.4. Moratorium on eligibility expansions. Beginning on January 25, 2011 (the effective date of Public Act 96-1501), there shall be a 4-year moratorium on the expansion of eligibility through increasing financial eligibility standards, or through increasing income disregards, or through the creation of new programs which would add new categories of eligible individuals under the medical assistance program in addition to those categories covered on January 1, 2011 or above the level of any subsequent reduction in eligibility. This moratorium shall not apply to expansions required as a federal condition of State participation in the medical assistance program or to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds.  If the State of Illinois finds that the State has borne a cost related to such an expansion, the unit of local government shall reimburse the State. All federal funds associated with an expansion funded by a unit of local government shall be returned to the local government entity funding the expansion, pursuant to an intergovernmental agreement between the Department of Healthcare and Family Services and the local government entity. Within 10 calendar days of the effective date of this amendatory Act of the 97th General Assembly, the Department of Healthcare and Family Services shall formally advise the Centers for Medicare and Medicaid Services  of the passage of this amendatory Act of the 97th General Assembly.  The State is prohibited from submitting additional waiver requests that expand or allow for an increase in the classes of persons eligible for medical assistance under this Article to the federal government for its consideration beginning on the 20th calendar day following the effective date of this amendatory Act of the 97th General Assembly until January 25, 2015. This moratorium shall not apply to those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) and 42 U.S.C. 1396a(a)(10)(A)(i)(IX).
(Source: P.A. 97-687, eff. 6-14-12; 98-104, eff. 7-22-13.)
(305 ILCS 5/5-1.5)
Sec. 5-1.5. COVID-19 public health emergency. Notwithstanding any other provision of  Articles V, XI, and XII of this Code, the Department may take necessary actions to address the COVID-19 public health emergency to the extent such actions are required, approved, or authorized by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services. Such actions may continue throughout the public health emergency and for up to 12 months after the period ends, and may include, but are not limited to: accepting an applicant's or recipient's attestation of income, incurred medical expenses, residency, and insured status when electronic verification is not available; eliminating resource tests for some eligibility determinations; suspending  redeterminations; suspending changes that would adversely affect an applicant's or recipient's eligibility; phone or verbal approval by an applicant to submit an application in lieu of applicant signature; allowing adult presumptive eligibility; allowing presumptive eligibility for children, pregnant women, and adults as often as twice per calendar year; paying for additional services delivered by telehealth; and suspending premium and co-payment requirements.
The Department's authority under this Section shall extend to encompass, incorporate, or effectuate the terms, items, conditions, and other provisions approved, authorized, or required by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, and shall not extend beyond the time of the COVID-19 public health emergency and up to 12 months after the period expires.
Any individual determined eligible for medical assistance under this Code as of or during the COVID-19 public health emergency may be treated as eligible for such medical assistance benefits during the COVID-19 public health emergency, and up to 12 months after the period expires, regardless of whether federally required or whether the individual's eligibility may be State or federally funded, unless the individual requests a voluntary termination of eligibility or ceases to be a resident. This paragraph shall not restrict any determination of medical need or appropriateness for any particular service and shall not require continued coverage of any particular service that may be no longer necessary, appropriate, or otherwise authorized for an individual. Nothing shall prevent the Department from determining and properly establishing an individual's eligibility under a different category of eligibility.
(Source: P.A. 101-649, eff. 7-7-20; 102-43, eff. 7-6-21.)
(305 ILCS 5/5-1.6)
Sec. 5-1.6. Continuous eligibility; ex parte redeterminations.
(a) By July 1, 2022, the Department of Healthcare and Family Services shall seek a State Plan amendment or any federal waivers necessary to make changes to the medical assistance program. The Department shall apply for federal approval to implement 12 months of continuous eligibility for adults participating in the medical assistance program. The Department shall secure federal financial participation in accordance with this Section for expenditures made by the Department in State Fiscal Year 2023 and every State fiscal year thereafter.
(b) By July 1, 2022, the Department of Healthcare and Family Services shall seek a State Plan amendment or any federal waivers or approvals necessary to make changes to the medical assistance redetermination process for people without any income at the time of redetermination. These changes shall seek to allow all people without income to be considered for ex parte redetermination. If there is no non-income related disqualifying information for medical assistance recipients without any income, then a person without any income shall be redetermined ex parte. Within 60 days after receiving federal approval or guidance, the Department of Healthcare and Family Services and the Department of Human Services shall make necessary technical and rule changes to implement  changes to the redetermination process. The percentage of medical assistance recipients whose eligibility is renewed through the ex parte redetermination process shall be reported monthly by the Department of Healthcare and Family Services on its website in accordance with subsection (d) of Section 11-5.1 of this Code as well as shared in all Medicaid Advisory Committee meetings and Medicaid Advisory Committee Public Education Subcommittee meetings.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
Sec. 5-2. Classes of persons eligible. Medical assistance under this
Article shall be available to any of the following classes of persons in
respect to whom a plan for coverage has been submitted to the Governor
by the Illinois Department and approved by him. If changes made in this Section 5-2 require federal approval, they shall not take effect until such approval has been received:
1. Recipients of basic maintenance grants under     Articles III and IV.
2. Beginning January 1, 2014, persons otherwise     eligible for basic maintenance under Article III, excluding any eligibility requirements that are inconsistent with any federal law or federal regulation, as interpreted by the U.S. Department of Health and Human Services, but who fail to qualify thereunder on the basis of need, and who have insufficient income and resources to meet the costs of necessary medical care, including, but not limited to, the following:
(a) All persons otherwise eligible for basic         maintenance under Article III but who fail to qualify under that Article on the basis of need and who meet either of the following requirements:
(i) their income, as determined by the             Illinois Department in accordance with any federal requirements, is equal to or less than 100% of the federal poverty level; or
(ii) their income, after the deduction of             costs incurred for medical care and for other types of remedial care, is equal to or less than 100% of the federal poverty level.
(b) (Blank).
3. (Blank).
4. Persons not eligible under any of the preceding     paragraphs who fall sick, are injured, or die, not having sufficient money, property or other resources to meet the costs of necessary medical care or funeral and burial expenses.
5.(a) Beginning January 1, 2020, individuals during     pregnancy and during the 12-month period beginning on the last day of the pregnancy, together with their infants, whose income is at or below 200% of the federal poverty level. Until September 30, 2019, or sooner if the maintenance of effort requirements under the Patient Protection and Affordable Care Act are eliminated or may be waived before then, individuals during pregnancy and during the 12-month period beginning on the last day of the pregnancy, whose countable monthly income, after the deduction of costs incurred for medical care and for other types of remedial care as specified in administrative rule, is equal to or less than the Medical Assistance-No Grant(C) (MANG(C)) Income Standard in effect on April 1, 2013 as set forth in administrative rule.
(b) The plan for coverage shall provide ambulatory     prenatal care to pregnant individuals during a presumptive eligibility period and establish an income eligibility standard that is equal to 200% of the federal poverty level, provided that costs incurred for medical care are not taken into account in determining such income eligibility.
(c) The Illinois Department may conduct a     demonstration in at least one county that will provide medical assistance to pregnant individuals together with their infants and children up to one year of age, where the income eligibility standard is set up to 185% of the nonfarm income official poverty line, as defined by the federal Office of Management and Budget. The Illinois Department shall seek and obtain necessary authorization provided under federal law to implement such a demonstration.  Such demonstration may establish resource standards that are not more restrictive than those established under Article IV of this Code.
6. (a) Subject to federal approval, children younger     than age 19 when countable income is at or below 313% of the federal poverty level, as determined by the Department and in accordance with all applicable federal requirements. The Department is authorized to adopt emergency rules to implement the changes made to this paragraph by Public Act 102-43.  Until September 30, 2019, or sooner if the maintenance of effort requirements under the Patient Protection and Affordable Care Act are eliminated or may be waived before then, children younger than age 19 whose countable monthly income, after the deduction of costs incurred for medical care and for other types of remedial care as specified in administrative rule, is equal to or less than the Medical Assistance-No Grant(C) (MANG(C)) Income Standard in effect on April 1, 2013 as set forth in administrative rule.
(b)  Children and youth who are under temporary     custody or guardianship of the Department of Children and Family Services or who receive financial assistance in support of an adoption or guardianship placement from the Department of Children and Family Services.
7. (Blank).
8. As required under federal law, persons who are     eligible for Transitional Medical Assistance as a result of an increase in earnings or child or spousal support received.  The plan for coverage for this class of persons shall:
(a) extend the medical assistance coverage to the         extent required by federal law; and
(b) offer persons who have initially received 6         months of the coverage provided in paragraph (a) above, the option of receiving an additional 6 months of coverage, subject to the following:
(i) such coverage shall be pursuant to             provisions of the federal Social Security Act;
(ii) such coverage shall include all services             covered under Illinois' State Medicaid Plan;
(iii) no premium shall be charged for such             coverage; and
(iv) such coverage shall be suspended in the             event of a person's failure without good cause to file in a timely fashion reports required for this coverage under the Social Security Act and coverage shall be reinstated upon the filing of such reports if the person remains otherwise eligible.
9. Persons with acquired immunodeficiency syndrome     (AIDS) or with AIDS-related conditions with respect to whom there has been a determination that but for home or community-based services such individuals would require the level of care provided in an inpatient hospital, skilled nursing facility or intermediate care facility the cost of which is reimbursed under this Article.  Assistance shall be provided to such persons to the maximum extent permitted under Title XIX of the Federal Social Security Act.
10. Participants in the long-term care insurance     partnership program established under the Illinois Long-Term Care Partnership Program Act who meet the qualifications for protection of resources described in Section 15 of that Act.
11. Persons with disabilities who are employed and     eligible for Medicaid, pursuant to Section 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, subject to federal approval, persons with a medically improved disability who are employed and eligible for Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of the Social Security Act, as provided by the Illinois Department by rule. In establishing eligibility standards under this paragraph 11, the Department shall, subject to federal approval:
(a) set the income eligibility standard at not         lower than 350% of the federal poverty level;
(b) exempt retirement accounts that the person         cannot access without penalty before the age         of 59 1/2, and medical savings accounts established pursuant to 26 U.S.C. 220;
(c) allow non-exempt assets up to $25,000 as to         those assets accumulated during periods of eligibility under this paragraph 11; and
(d) continue to apply subparagraphs (b) and (c)         in determining the eligibility of the person under this Article even if the person loses eligibility under this paragraph 11.
12. Subject to federal approval, persons who are     eligible for medical assistance coverage under applicable provisions of the federal Social Security Act and the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000.  Those eligible persons are defined to include, but not be limited to, the following persons:
(1) persons who have been screened for breast or         cervical cancer under the U.S. Centers for Disease Control and Prevention Breast and Cervical Cancer Program established under Title XV of the federal Public Health Service Act in accordance with the requirements of Section 1504 of that Act as administered by the Illinois Department of Public Health; and
(2) persons whose screenings under the above         program were funded in whole or in part by funds appropriated to the Illinois Department of Public Health for breast or cervical cancer screening.
"Medical assistance" under this paragraph 12 shall be     identical to the benefits provided under the State's approved plan under Title XIX of the Social Security Act.  The Department must request federal approval of the coverage under this paragraph 12 within 30 days after July 3, 2001 (the effective date of Public Act 92-47).
In addition to the persons who are eligible for     medical assistance pursuant to subparagraphs (1) and (2) of this paragraph 12, and to be paid from funds appropriated to the Department for its medical programs, any uninsured person as defined by the Department in rules residing in Illinois who is younger than 65 years of age, who has been screened for breast and cervical cancer in accordance with standards and procedures adopted by the Department of Public Health for screening, and who is referred to the Department by the Department of Public Health as being in need of treatment for breast or cervical cancer is eligible for medical assistance benefits that are consistent with the benefits provided to those persons described in subparagraphs (1) and (2). Medical assistance coverage for the persons who are eligible under the preceding sentence is not dependent on federal approval, but  federal moneys may be used to pay for services provided under that coverage upon federal approval.
13. Subject to appropriation and to federal approval,     persons living with HIV/AIDS who are not otherwise eligible under this Article and who qualify for services covered under Section 5-5.04 as provided by the Illinois Department by rule.
14.    Subject to the availability of funds for this     purpose, the Department may provide coverage under this Article to persons who reside in Illinois who are not eligible under any of the preceding paragraphs and who meet the income guidelines of paragraph 2(a) of this Section and (i) have an application for asylum pending before the federal Department of Homeland Security or on appeal before a court of competent jurisdiction and are represented either by counsel or by an advocate accredited by the federal Department of Homeland Security and employed by a not-for-profit organization in regard to that application or appeal, or (ii) are receiving services through a federally funded torture treatment center. Medical coverage under this paragraph 14 may be provided for up to 24 continuous months from the initial eligibility date so long as an individual continues to satisfy the criteria of this paragraph 14. If an individual has an appeal pending regarding an application for asylum before the Department of Homeland Security, eligibility under this paragraph 14 may be extended until a final decision is rendered on the appeal. The Department may adopt rules governing the implementation of this paragraph 14.
15. Family Care Eligibility.
(a) On and after July 1, 2012, a parent or other         caretaker relative who is 19 years of age or  older when countable income is at or below 133% of the federal poverty level. A person may not spend down to become eligible under this paragraph 15.
(b) Eligibility shall be reviewed annually.
(c) (Blank).
(d) (Blank).
(e) (Blank).
(f) (Blank).
(g) (Blank).
(h) (Blank).
(i) Following termination of an individual's          coverage under this paragraph 15, the individual must be determined eligible before the person can be re-enrolled.
16. Subject to appropriation, uninsured persons who     are not otherwise eligible under this Section who have been certified and referred by the Department of Public Health as having been screened and found to need diagnostic evaluation or treatment, or both diagnostic evaluation and treatment, for prostate or testicular cancer.  For the purposes of this paragraph 16, uninsured persons are those who do not have creditable coverage, as defined under the Health Insurance Portability and Accountability Act, or have otherwise exhausted any insurance benefits they may have had, for prostate or testicular cancer diagnostic evaluation or treatment, or both diagnostic evaluation and treatment.  To be eligible, a person must furnish a Social Security number.  A person's assets are exempt from consideration in determining eligibility under this paragraph 16.  Such persons shall be eligible for medical assistance under this paragraph 16 for so long as they need treatment for the cancer.  A person shall be considered to need treatment if, in the opinion of the person's treating physician, the person requires therapy directed toward cure or palliation of prostate or testicular cancer, including recurrent metastatic cancer that is a known or presumed complication of prostate or testicular cancer and complications resulting from the treatment modalities themselves.  Persons who require only routine monitoring services are not considered to need treatment.  "Medical assistance" under this paragraph 16 shall be identical to the benefits provided under the State's approved plan under Title XIX of the Social Security Act.  Notwithstanding any other provision of law, the Department (i) does not have a claim against the estate of a deceased recipient of services under this paragraph 16 and (ii) does not have a lien against any homestead property or other legal or equitable real property interest owned by a recipient of services under this paragraph 16.
17.  Persons who, pursuant to a waiver approved by     the Secretary of the U.S. Department of Health and Human Services, are eligible for medical assistance under Title XIX or XXI of the federal Social Security Act.  Notwithstanding any other provision of this Code and consistent with the terms of the approved waiver, the Illinois Department, may by rule:
(a)         Limit the geographic areas in which         the waiver program operates.
(b) Determine the scope, quantity, duration, and         quality, and the rate and method of reimbursement, of the medical services to be provided, which may differ from those for other classes of persons eligible for assistance under this Article.
(c)         Restrict the persons' freedom in         choice of providers.
18. Beginning  January 1, 2014, persons aged 19 or     older, but younger than 65, who are not otherwise eligible for medical assistance under this Section 5-2, who qualify for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) and applicable federal regulations, and who have income at or below 133% of the federal poverty level plus 5% for the applicable family size as determined pursuant to 42 U.S.C. 1396a(e)(14) and applicable federal regulations.  Persons eligible for medical assistance under this paragraph 18 shall receive coverage for the Health Benefits Service Package as that term is defined in subsection (m) of Section 5-1.1 of this Code. If Illinois' federal medical assistance percentage (FMAP) is reduced below 90% for persons eligible for medical assistance under this paragraph 18, eligibility under this paragraph 18 shall cease no later than the end of the third month following the month in which the reduction in FMAP takes effect.
19. Beginning January 1, 2014, as required under 42     U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18 and younger than age 26 who are not otherwise eligible for medical assistance under paragraphs (1) through (17) of this Section who (i) were in foster care under the responsibility of the State on the date of attaining age 18 or on the date of attaining age 21 when a court has continued wardship for good cause as provided in Section 2-31 of the Juvenile Court Act of 1987 and (ii) received medical assistance under the Illinois Title XIX State Plan or waiver of such plan while in foster care.
20. Beginning January 1, 2018, persons who are     foreign-born victims of human trafficking, torture, or other serious crimes as defined in Section 2-19 of this Code and their  derivative family members if such persons: (i)  reside in Illinois; (ii) are not eligible under any of the preceding paragraphs;  (iii) meet the income guidelines of subparagraph (a) of paragraph 2; and (iv) meet the nonfinancial eligibility requirements of Sections 16-2, 16-3, and 16-5 of this Code. The Department may extend medical assistance for persons who are foreign-born victims of human trafficking, torture, or other serious crimes whose medical assistance would be terminated pursuant to subsection (b) of Section 16-5 if the Department determines that the person, during the year of initial eligibility (1)  experienced a health crisis, (2) has been unable, after reasonable attempts, to obtain necessary information from a third party, or (3) has other extenuating circumstances that prevented the person from completing his or her application for status. The Department may adopt any rules necessary to implement the provisions of this paragraph.
21. Persons who are not otherwise eligible for     medical assistance under this Section who may qualify for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the duration of any federal or State declared emergency due to COVID-19.  Medical assistance to persons eligible for medical assistance solely pursuant to this paragraph 21 shall be limited to any in vitro diagnostic product (and the administration of such product) described in 42 U.S.C. 1396d(a)(3)(B) on or after March 18, 2020, any visit described in 42 U.S.C. 1396o(a)(2)(G), or any other medical assistance that may be federally authorized for this class of persons.  The Department may also cover treatment of COVID-19 for this class of persons, or any similar category of uninsured individuals, to the extent authorized under a federally approved 1115 Waiver or other federal authority.  Notwithstanding the provisions of Section 1-11 of this Code, due to the nature of the COVID-19 public health emergency, the Department may cover and provide the medical assistance described in this paragraph 21 to noncitizens who would otherwise meet the eligibility requirements for the class of persons described in this paragraph 21 for the duration of the State emergency period.
In implementing the provisions of Public Act 96-20, the Department is authorized to adopt only those rules necessary, including emergency rules. Nothing in Public Act 96-20 permits the Department to adopt rules or issue a decision that expands eligibility for the FamilyCare Program to a person whose income exceeds 185% of the Federal Poverty Level as determined from time to time by the U.S. Department of Health and Human Services, unless the Department is provided with express statutory authority.
The eligibility of any such person for medical assistance under this
Article is not affected by the payment of any grant under the Senior
Citizens and Persons with Disabilities Property Tax Relief Act or any distributions or items of income described under
subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
The Department shall by rule establish the amounts of
assets to be disregarded in determining eligibility for medical assistance,
which shall at a minimum equal the amounts to be disregarded under the
Federal Supplemental Security Income Program.  The amount of assets of a
single person to be disregarded
shall not be less than $2,000, and the amount of assets of a married couple
to be disregarded shall not be less than $3,000.
To the extent permitted under federal law, any person found guilty of a
second violation of Article VIIIA
shall be ineligible for medical assistance under this Article, as provided
in Section 8A-8.
The eligibility of any person for medical assistance under this Article
shall not be affected by the receipt by the person of donations or benefits
from fundraisers held for the person in cases of serious illness,
as long as neither the person nor members of the person's family
have actual control over the donations or benefits or the disbursement
of the donations or benefits.
Notwithstanding any other provision of this Code, if the United States Supreme Court holds Title II, Subtitle A, Section 2001(a) of Public Law 111-148 to be unconstitutional, or if a holding of Public Law 111-148 makes Medicaid eligibility allowed under Section 2001(a) inoperable, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after June 14, 2012 (the effective date of Public Act 97-687), and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible.
Notwithstanding any other provision of this Code, if an Act of Congress that becomes a Public Law eliminates Section 2001(a) of Public Law 111-148, the State or a unit of local government shall be prohibited from enrolling individuals in the Medical Assistance Program as the result of federal approval of a State Medicaid waiver on or after June 14, 2012 (the effective date of Public Act 97-687), and any individuals enrolled in the Medical Assistance Program pursuant to eligibility permitted as a result of such a State Medicaid waiver shall become immediately ineligible.
Effective October 1, 2013, the determination of eligibility of persons who qualify under paragraphs 5, 6, 8, 15, 17, and 18 of this Section shall comply with the requirements of 42 U.S.C. 1396a(e)(14) and applicable federal regulations.
The Department of Healthcare and Family Services, the Department of Human Services, and the Illinois health insurance marketplace shall work cooperatively to assist persons who would otherwise lose health benefits as a result of changes made under Public Act 98-104 to transition to other health insurance coverage.
(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; 102-43, eff. 7-6-21; 102-558, eff. 8-20-21; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-2a)
Sec. 5-2a. Medicaid State Plan; eligibility determination status. The Department shall conduct an analysis and deliver a report to the General Assembly by January 1, 2012 to evaluate the feasibility of changing Illinois' Medicaid State Plan from 209(b) status to the federal 1634 eligibility  determination status for applicable individuals as provided in the Social Security Act. The report shall include a review of the current standard used by the Department, anticipated fiscal implications of converting to 1634 status, anticipated changes in caseloads resulting from a change to 1634 status, and any additional information deemed relevant by the Department to evaluate the feasibility of converting to 1634 status.
(Source: P.A. 97-173, eff. 7-22-11.)
(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.
(Source: P.A. 103-102, eff. 1-1-24.)
(305 ILCS 5/5-2.01)
Sec. 5-2.01. Medicaid accountability through transparency program.
(a) Internet-based transparency program. The Director of the Department of Healthcare and Family Services shall be authorized to implement a program under which the Director shall make available through the Department's public Internet website  information on medical claims reimbursed under the State's medical assistance program insofar as such information has been de-identified in accordance with regulations promulgated pursuant to the Illinois Health Insurance Portability and Accountability Act. In implementing the program, the Director shall ensure the following:
(1) The information made so available shall be in a     format that is easily accessible, useable, and understandable to the public, including individuals interested in improving the quality of care provided to individuals eligible for items and services under this Article, researchers, health care providers, and individuals interested in reducing the prevalence of waste and fraud under this Article.
(2) The information made so available shall be as     current as deemed practical by the Director and shall be updated at least once per calendar quarter.
(3) The information made so available shall be     aggregated to a level to ensure patient confidentiality, but shall, to the extent feasible, allow for posting of information by provider or vendor name and county, number of individuals served, total patient visits, payment for bills submitted, average cost for bills submitted, adjustments to payments, and total amounts paid.
(4) The Director periodically solicits comments from     a sampling of individuals who access the information through the program on how to best improve the utility of the program.
(b) Use of contractor. For purposes of implementing the program under subsection (a) of this Section and ensuring the information made available through the program is periodically updated, the Director may select and enter into a contract with a public or private entity meeting the criteria and qualifications the Director determines appropriate.
(c) Annual Reports. Not later than 12 months after the effective date of this amendatory Act of the 96th General Assembly and annually thereafter, the Director shall submit to the General Assembly a report on the status of the program authorized under subsection (a).  The report shall include details including, but not limited to, the estimated or actual costs of developing and maintaining the reporting system, the actual or potential benefit or adverse consequences associated with the system, and, if applicable, the extent to which information made available through the program is accessed and the extent to which comments received under paragraph (4) of subsection (a) of this Section were used to improve the utility of the program.
(Source: P.A. 96-941, eff. 6-25-10.)
(305 ILCS 5/5-2.03)
Sec. 5-2.03. Presumptive eligibility. Beginning on the effective date of this amendatory Act of the 96th General Assembly and except where federal law requires presumptive eligibility, no adult may be presumed eligible for medical assistance under this Code and the Department may not cover any service rendered to an adult unless the adult has completed an application for benefits, all required verifications have been received, and the Department or its designee has found the adult eligible for the date on which that service was provided. Nothing in this Section shall apply to pregnant women or to persons enrolled under the medical assistance program due to expansions approved by the federal government that are financed entirely by units of local government and federal matching funds.
(Source: P.A. 96-1501, eff. 1-25-11; 97-687, eff. 6-14-12.)
(305 ILCS 5/5-2.05)
Sec. 5-2.05. Children with disabilities.
(a) The Department of Healthcare and Family Services, in conjunction with the Department of Human Services,
						
						may offer, to children with developmental
disabilities or children with severe mental illness or severe emotional disorders who
otherwise would not qualify for medical assistance under this Article due to
family income, home-based and community-based services instead of institutional
placement, as allowed under paragraph 7 of Section 5-2.
(b) The Department of Healthcare and Family Services, in conjunction with the Department of
Human Services and the Division of Specialized Care for Children, University of
Illinois-Chicago, shall submit a bi-annual
						
report to the Governor and the General Assembly no
later than January 1 of every even-numbered year, beginning in 2008, regarding the status of existing services offered
under paragraph 7
of Section 5-2. This report shall include, but not be limited to, the following
information:
(1) The number of persons who currently receive these     services.
(2) The nature, scope, and cost of services.
(3) The comparative cost of providing those services     in a hospital, skilled nursing facility, or intermediate care facility.
(4) The funding sources for the provision of     services, including federal financial participation.
(5) The qualifications, skills, and availability of     caregivers for children receiving services.
(6) The number of children who have aged out of the     services offered under paragraph 7 of Section 5-2 during the 2 years immediately preceding the report.
(Source: P.A. 95-331, eff. 8-21-07; 95-622, eff. 9-17-07.)
(305 ILCS 5/5-2.06)
Sec. 5-2.06. Payment rates; Children's Community-Based Health Care Centers. Beginning January 1, 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 $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.)
(305 ILCS 5/5-2.07)
Sec. 5-2.07. Use of Medicaid spend-down. No later than July 1, 2007, subject to federal approval of a State Medicaid Plan amendment, which shall be sought by the Department of Healthcare and Family Services or its successor agency, persons described in item 2(a) of Section 5-2, who fail to qualify for basic maintenance under Article III of this Code on the basis of need because of excess income or assets, or both, may establish eligibility for medical assistance by paying the amount of their monthly spend-down under this Article (as described in 42 CFR 435.831) to the Department of Healthcare and Family Services or its successor agency or by having a third party pay that amount to the Department on their behalf. A person who uses Medicaid spend-down to qualify for medical assistance shall be provided up to 6 consecutive months to submit and have medical receipts and bills processed by the Department as evidence of payment of the person's monthly spend-down amount before becoming ineligible for medical assistance under this Section.
(Source: P.A. 102-74, eff. 7-9-21.)
(305 ILCS 5/5-2.08)
Sec. 5-2.08. Spousal caregiver demonstration.
(a) The Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall develop a demonstration project within the Home Services Program under which a spouse may be reimbursed for providing care to his or her spouse, who is eligible for services through the Home Services Program and who meets the criteria for this demonstration project. The demonstration project shall operate in selected counties and be limited to serving no more than 100 unduplicated persons in a State fiscal year.
The components of the demonstration project shall include the following:
(1) Authorization for a spouse to be reimbursed for     care provided to his or her otherwise eligible spouse through the Home Services Program.
(2) The development of specific criteria for the     provision of services under the demonstration project. Criteria applicable to a spousal caregiver shall include, but need not be limited to, (i) a limitation on the total hours of a spousal caregiver's outside employment plus hours of providing care to his or her eligible spouse to ensure that the complete plan of care is delivered to the eligible spouse and (ii) limitations on a spousal caregiver's participation in the demonstration project if the caregiver has a known history of spousal abuse, neglect, or exploitation.
(3) The determination of the personal care or similar     services for which payment may be made. Spousal caregivers shall be paid at the Personal Assistant level of care and pay rate. In those instances in which the eligible spouse requires specialized services (for example, services provided by a certified nursing assistant (CNA), licensed practical nurse (LPN), or registered nurse (RN)) and the spousal caregiver has the corresponding certification or licensure, the spousal caregiver shall be paid the higher rate for the specialized services only. The specialized services the eligible spouse is authorized to receive shall be defined and approved in the services plan.
(4) The method for determining that the amount of     personal care or similar services provided by the spouse is "extraordinary care" that exceeds the ordinary care that would be provided to a spouse without a disability.
(5) Limitations on the number of hours of personal     services that will be reimbursed.
(6) Utilization of the Determination of Need     evaluation and other comprehensive assessment tools as criteria for determining eligibility and developing service plans under the demonstration project.
(7) Determination of how or whether the provision of     personal care by the spouse is in the best interest of his or her spouse, who is an eligible participant in the demonstration project.
(8) Use of procedures that ensure that payments are     made for services rendered.
(9) Assurances that all other criteria of the     demonstration project are met.
(10) Measurement of participant experiences.
(11) Monthly in-home monitoring of the health and     safety of the eligible spouse.
(12) Documentation of the marital relationship for     participation in the demonstration project.
(13) Assurances that the eligible spouse is capable     of communicating his or her needs.
(14) Enrollment of an alternative care provider to     ensure that there is no disruption of care to the eligible spouse.
(15) Assurances that the spousal caregiver is     emotionally, physically, and cognitively able to provide the necessary care to the eligible spouse.
(b) By July 1, 2009, the Department of Human Services, in consultation with the Department of Healthcare and Family Services, shall begin development of the demonstration project.  The Department of Human Services shall provide an interim report on or before March 1, 2010 to the Governor and the General Assembly that includes the progress on the development of the demonstration project and implementation timelines of the demonstration project and the criteria for the demonstration project.
(c) The Department of Human Services shall report findings and recommendations by March 1, 2011 to the Governor and the General Assembly.  The report shall include an explanation of the manner in which each demonstration project component listed in paragraphs (1) through (10) of subsection (a) is addressed.  In addition, the report shall include (i) the estimated number of clients statewide who could utilize services and (ii) an analysis of the fiscal impact per client on the Department's new and existing costs under the Home Services Program.
(Source: P.A. 96-351, eff. 8-13-09.)
(305 ILCS 5/5-2.09)
Sec. 5-2.09. Enhanced federal medical assistance percentage. In accordance with Section 9817 of the American Rescue Plan Act of 2021 (Pub. L. 117-2) and corresponding federal guidance, the Department of Healthcare and Family Services shall take appropriate actions to claim an enhanced federal medical assistance percentage (FMAP) provided by Section 9817 of the American Rescue Plan Act of 2021 with respect to expenditures under the State medical assistance program for home and community-based services from April 1, 2021 through March 31, 2022.  The Department is authorized to use State funds equivalent to the amount of federal funds attributable to the increased federal medical assistance percentage under Section 9817 of the American Rescue Plan Act of 2021  to implement or supplement the implementation of activities to enhance, expand, or strengthen home and community based services under the State's medical assistance program to the extent permitted by and aligned with the goals of Section 9817 of the American Rescue Plan Act of 2021 through March 31, 2024 or any revised deadline established by the federal government. The use of such funds is subject to compliance with applicable federal requirements and federal approval, including the approval of any necessary State Plan Amendments, Waiver Amendments, or other federally required documents or assurances.
The Department may adopt rules as necessary, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(Source: P.A. 102-16, eff. 6-17-21.)
(305 ILCS 5/5-2.10)
Sec. 5-2.10. Increased accountability for nursing facilities. The Department shall develop a plan for the revitalization of nursing homes licensed under the Nursing Home Care Act and shall report to the Governor and the General Assembly on a recommended course of action, including, but not limited to, the following:
(1) significantly increasing federal funds by     streamlining and raising the nursing home provider assessment on occupied beds;
(2)improving payments through increased funding and     providing additional incentives for staffing, quality metrics and infection control measures; and
(3)transitioning the methodologies for reimbursement     of nursing services as provided under this Article to the Patient Driven Payment Model (PDPM) developed by the federal Centers for Medicare and Medicaid Services.
No later than September 30, 2021, the Department shall submit a report to the Governor and the General Assembly, which outlines the steps taken by the Department,  including discussions with interested stakeholders and industry representatives, and recommendations for further action by the General Assembly to provide for  accountability and to achieve the program objectives outlined in this Section, which shall require action by the General Assembly.
(Source: P.A. 102-16, eff. 6-17-21.)
(305 ILCS 5/5-2.1) (from Ch. 23, par. 5-2.1)
Sec. 5-2.1. 
		Property transfers.
(a) To the extent required under federal law, a person shall not make or
have made a voluntary or involuntary assignment or transfer of any legal or
equitable interests in real property or in personal property, whether vested,
contingent or inchoate, for less than fair market value. A person's interest in
real or personal property includes all income and assets to which the person is
entitled or to which the person would be entitled if the person had not taken
action to avoid receiving the interest.
(b) (Blank).
(c) (Blank).
(d) (Blank).
(e) (Blank).
(Source: P.A. 92-84, eff. 7-1-02.)
(305 ILCS 5/5-2.1a)
Sec. 5-2.1a. Treatment of trust amounts. To the extent required by
federal
law, the Department of Healthcare and Family Services shall provide by rule for the consideration of
trusts and similar legal instruments or devices established by a person in the
Illinois Department's determination of the person's eligibility for and the
amount of assistance provided under this Article.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5-2.1d)
Sec. 5-2.1d. Retroactive eligibility. An applicant for medical assistance may be eligible for up to 3 months prior to the date of application if the person would have been eligible for medical assistance at the time he or she received the services if he or she had applied, regardless of whether the individual is alive when the application for medical assistance is made.  In determining financial eligibility for medical assistance for retroactive months, the Department shall consider the amount of income and resources and exemptions available to a person as of the first day of each of the backdated months for which eligibility is sought.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-2.2) (from Ch. 23, par. 5-2.2)
Sec. 5-2.2. 
		Cooperation in establishing support obligation. 
		A
parent or other person having custody of the child or a spouse who fails or
refuses to comply with the requirements of Title XIX of the federal Social
Security Act, and the regulations duly promulgated thereunder, regarding
establishment and enforcement of the child or spousal support obligation
shall be ineligible for medical assistance and shall remain ineligible for
medical assistance for as long as the failure or refusal persists.
In addition to any other definition of failure or refusal to comply
with the requirements of Title XIX of the federal Social Security Act, in
the case of failure to attend court hearings, the parent or other person
can show cooperation by attending a court hearing or, if a court hearing
cannot be scheduled within 30 days following the court hearing that was
missed, by signing a statement that the parent or other person is now
willing to cooperate in the child support enforcement process and will
appear at any later scheduled court date.  The parent or other person can
show cooperation by signing such a statement only once.  If failure to
attend the court hearing or other failure to cooperate results in the case
being dismissed, such a statement may be signed after 2 months.
No denial or termination of medical assistance pursuant to this Section
shall commence during pregnancy of the parent or other person having
custody of the child or for 30 days after the termination of such pregnancy.
 The termination of medical assistance may commence thereafter if the
Illinois Department determines that the failure or refusal to comply with
this Section persists.  Postponement of denial or termination of medical
assistance during pregnancy under this paragraph shall be effective only to
the extent it does not conflict with federal law or regulation.
(Source: P.A. 85-1155.)
(305 ILCS 5/5-2.3)
Sec. 5-2.3. 
		Notice of rights concerning institutionalization. 
		The
Illinois Department shall prepare a notice to be given to every applicant for
and recipient of medical assistance under this Article when the applicant or
recipient, or the spouse of the applicant or recipient, or a person for whom
the applicant or recipient is the primary caretaker, becomes an
institutionalized person.  The notice shall fully and completely inform the
institutionalized person (and that person's spouse or primary caretaker, if
applicable) of each individual's rights and obligations under this Code with
respect to that institutionalization.
(Source: P.A. 88-162.)
(305 ILCS 5/5-2.4)
Sec. 5-2.4. (Repealed).
(Source: P.A. 95-248, eff. 8-17-07. Repealed by P.A. 97-48, eff. 6-28-11.)
(305 ILCS 5/5-3) (from Ch. 23, par. 5-3)
Sec. 5-3. Residence.  Any person who has established his residence
in this State and lives therein, including any person who is a migrant
worker, may qualify for medical assistance.  A person who, while
temporarily in this State, suffers  injury or illness endangering his
life and health and necessitating emergency care, may also qualify.
Temporary absence from the State shall not disqualify a person from
maintaining his eligibility under this Article.
As used in this Section, "migrant worker" means any person residing
temporarily and employed in Illinois who moves seasonally  from one
place to another for the purpose of employment in agricultural
activities, including the planting, raising, or harvesting of any
agricultural or horticultural commodities and the handling, packing, or
processing of such commodities on the farm where produced or at the
point of first processing, in animal husbandry, or in other activities connected
with the care of animals.  Dependents of such person shall be
considered eligible if they are living with the person during his or her
temporary residence and employment in Illinois.
In order to be eligible for medical assistance under this section,
each migrant worker shall show proof of citizenship or legal immigration status.
(Source: P.A. 102-1030, eff. 5-27-22; 103-154, eff. 6-30-23.)
(305 ILCS 5/5-4) (from Ch. 23, par. 5-4)
Sec. 5-4. Amount and nature of medical assistance.
(a) The amount and nature of
medical assistance shall be determined in accordance
with the standards, rules, and regulations of the Department of Healthcare and Family Services, with due regard to the requirements and conditions in each case,
including contributions available from legally responsible
relatives.  However, the amount and nature of such medical assistance shall
not be affected by the payment of any grant under the Senior Citizens and
Persons with Disabilities Property Tax Relief Act or any
distributions or items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois Income Tax
Act.
The amount and nature of medical assistance shall not be affected by the
receipt of donations or benefits from fundraisers in cases of serious
illness, as long as neither the person nor members of the person's family
have actual control over the donations or benefits or the disbursement of
the donations or benefits.
In determining the income and resources available to the institutionalized
spouse and to the community spouse, the Department of Healthcare and Family Services

shall follow the procedures established by federal law. If an institutionalized spouse or community spouse refuses to comply with the requirements of Title XIX of the federal Social Security Act and the regulations duly promulgated thereunder by failing to provide the total value of assets, including income and resources, to the extent either the institutionalized spouse or community spouse has an ownership interest in them pursuant to 42 U.S.C. 1396r-5, such refusal may result in the institutionalized spouse being denied eligibility and continuing to remain ineligible for the medical assistance program based on failure to cooperate.
Subject to federal approval, beginning January 1, 2023, the community spouse resource allowance shall be established and maintained as follows: a base amount of $109,560 plus an additional amount of $2,784 added to the base amount each year for a period of 10 years commencing with calendar year 2024 through calendar year 2034. In addition to the base amount and the additional amount shall be any increase each year from the prior year to the maximum resource allowance permitted under Section 1924(f)(2)(A)(ii)(II) of the Social Security Act. Subject to federal approval, beginning January 1, 2034 the community spouse resource allowance shall be established and maintained at the maximum amount permitted under Section 1924(f)(2)(A)(ii)(II) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing. Subject to federal approval, beginning January 1, 2023 the monthly maintenance allowance for the community spouse shall be
established and maintained at the maximum amount permitted pursuant to Section
1924(d)(3)(C) of the Social Security Act, as now or hereafter amended, or an amount set after a fair hearing, whichever is greater.  Subject
to the approval of the Secretary of the United States Department of Health and
Human Services, the provisions of this Section shall be extended to persons who
but for the provision of home or community-based services under Section
4.02 of the Illinois Act on the Aging, would require the level of care provided
in an institution, as is provided for in federal law.
(b) Spousal support for institutionalized spouses receiving medical assistance.
(i) The Department may seek support for an     institutionalized spouse, who has assigned his or her right of support from his or her spouse to the State, from the resources and income available to the community spouse.
(ii) The Department may bring an action in the     circuit court to establish support orders or itself establish administrative support orders by any means and procedures authorized in this Code, as applicable, except that the standard and regulations for determining ability to support in Section 10-3 shall not limit the amount of support that may be ordered.
(iii) Proceedings may be initiated to obtain support,     or for the recovery of aid granted during the period such support was not provided, or both, for the obtainment of support and the recovery of the aid provided. Proceedings for the recovery of aid may be taken separately or they may be consolidated with actions to obtain support. Such proceedings may be brought in the name of the person or persons requiring support or may be brought in the name of the Department, as the case requires.
(iv) The orders for the payment of moneys for the     support of the person shall be just and equitable and may direct payment thereof for such period or periods of time as the circumstances require, including support for a period before the date the order for support is entered. In no event shall the orders reduce the community spouse resource allowance below the level established in subsection (a) of this Section or an amount set after a fair hearing, whichever is greater, or reduce the monthly maintenance allowance for the community spouse below the level permitted pursuant to subsection (a) of this Section.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-4.1) (from Ch. 23, par. 5-4.1)
Sec. 5-4.1. Co-payments. The Department may by rule provide that recipients under any Article of this Code shall pay a federally approved fee as a co-payment for services. No 
co-payment requirement can exist
for renal dialysis, radiation therapy, cancer chemotherapy, or insulin, and
other products necessary on a recurring basis, the absence of which would
be life threatening, or where co-payment expenditures for required services
and/or medications for chronic diseases that the Illinois Department shall
by rule designate shall cause an extensive financial burden on the
recipient, and provided no co-payment shall exist for emergency room
encounters which are for medical emergencies. The Department shall seek approval of a State plan amendment that allows pharmacies to refuse to dispense drugs in circumstances where the recipient does not pay the required co-payment. Co-payments may not exceed $10 for emergency room use for a non-emergency situation as defined by the Department by rule and subject to federal approval.
(Source: P.A. 101-209, eff. 8-5-19.)
(305 ILCS 5/5-4.2)
(Text of Section from P.A. 102-1037)
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, 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).
(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 the effective date of 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) On and after July 1, 2018, the Department shall increase the base rate of reimbursement for both base charges and mileage charges for ground ambulance service providers for medical transportation services provided by means of a ground ambulance to a level not lower than 112% of the base rate in effect as of June 30, 2018.
(Source: P.A. 101-81, eff. 7-12-19; 101-649, eff. 7-7-20; 102-364, eff. 1-1-22; 102-650, eff. 8-27-21; 102-813, eff. 5-13-22; 102-1037, eff. 6-2-22.)
(Text of Section from P.A. 103-102, Article 70, Section 70-5)
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 the effective date of 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) On and after July 1, 2018, the Department shall increase the base rate of reimbursement for both base charges and mileage charges for ground ambulance service providers for medical transportation services provided by means of a ground ambulance to a level not lower than 112% of the base rate in effect as of June 30, 2018.
(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.)
(Text of Section from P.A. 103-102, Article 80, Section 80-5)
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, 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).
(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 the effective date of 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 April 1, 2024.
(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 80, Section 80-5, eff. 1-1-24.)
(305 ILCS 5/5-4.20)
Sec. 5-4.20. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.21)
Sec. 5-4.21. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.22)
Sec. 5-4.22. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.23)
Sec. 5-4.23. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.24)
Sec. 5-4.24. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.25)
Sec. 5-4.25. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.26)
Sec. 5-4.26. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.27)
Sec. 5-4.27. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.28)
Sec. 5-4.28. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.29)
Sec. 5-4.29. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.30)
Sec. 5-4.30. (Repealed).
(Source: P.A. 88-380. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.31)
Sec. 5-4.31. (Repealed).
(Source: P.A. 90-372, eff. 7-1-98. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.32)
Sec. 5-4.32. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.33)
Sec. 5-4.33. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.34)
Sec. 5-4.34. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.35)
Sec. 5-4.35. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.36)
Sec. 5-4.36. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.37)
Sec. 5-4.37. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.38)
Sec. 5-4.38. (Repealed).
(Source: P.A. 87-13. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-4.39)
Sec. 5-4.39. (Repealed).
(Source: P.A. 87-861. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
(Text of Section from P.A. 103-102, Article 15, Section 15-5)
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.
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 and 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 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, 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.
(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.)
(Text of Section from P.A. 103-102, Article 95, Section 95-15)
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.
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 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.
(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 95, Section 95-15, eff. 1-1-24.)
(Text of Section from P.A. 103-123)
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.
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 and 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 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, 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; 103-123, eff. 1-1-24.)
(Text of Section from P.A. 103-154)
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.
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 and 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 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.
(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; 103-154, eff. 6-30-23.)
(Text of Section from P.A. 103-368)
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.
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 and 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 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.
(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; 103-368, eff. 1-1-24.)
(305 ILCS 5/5-5.01) (from Ch. 23, par. 5-5.01)
Sec. 5-5.01. The Department of Healthcare and Family Services may establish and implement
a pilot project for determining the feasibility of authorizing medical
assistance payments for the costs of diagnosis and treatment of Alzheimer's
disease.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-5.01a)
(Text of Section from P.A. 103-102, Article 20, Section 20-5)
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.
(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.)
(Text of Section from P.A. 103-102, Article 100, Section 100-5)
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.
(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 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 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.
(Source: P.A. 102-43, eff. 7-6-21; 102-699, eff. 4-19-22; 103-102, Article 100, Section 100-5, eff. 1-1-24.)
(305 ILCS 5/5-5.01b)
Sec. 5-5.01b. Certified Nursing Assistant Intern Program.
(a) The Department shall establish or approve  a Certified Nursing Assistant Intern Program to address the increasing need for trained health care workers for the supporting living facilities program established under Section 5-5.01a. Upon successful completion of the classroom education and on-the-job training requirements of the Program under this Section, an individual may provide, at a facility certified under this Act, the patient and resident care services determined under the Program and may perform the procedures listed under subsection (d).
(b) In order to qualify as a certified nursing assistant intern, an individual shall successfully complete at least 8 hours of classroom education on the services and procedures listed under subsection (d). The classroom education shall be:
(1) taken within the facility where the certified     nursing assistant intern will be employed;
(2) proctored by either an advanced practice     registered nurse or a registered nurse who holds a bachelor's degree in nursing, has a minimum of 3 years of continuous experience in geriatric care, or is certified as a nursing assistant instructor; and
(3) satisfied by the successful completion of an     approved 8-hour online training course or in-person group training.
(c) In order to qualify as a certified nursing assistant intern, an individual shall successfully complete at least 24 hours of on-the-job training in the services and procedures determined under the Program and listed under subsection (d), as follows:
(1) The training program instructor shall be either     an advanced practice registered nurse or a registered nurse who holds a bachelor's degree in nursing, has a minimum of 3 years of continuous experience in geriatric care, or is certified as a nursing assistant instructor.
(2) The training program instructor shall ensure that     the student meets the competencies determined under the Program and those listed under subsection (d). The instructor shall document the successful completion or failure of the competencies and any remediation that may allow for the successful completion of the competencies.
(3) All on-the-job training shall be under the direct     observation of either an advanced practice registered nurse or a registered nurse who holds a bachelor's degree in nursing, has a minimum of 3 years of continuous experience in geriatric care, or is certified as a nursing assistant instructor.
(4) All on-the-job training shall be conducted at a     facility that is licensed by the State of Illinois and that is the facility where the certified nursing assistant intern will be working.
(d) A certified nursing assistant intern shall receive classroom and on-the-job training on how to provide the patient or resident care services and procedures, as determined under the Program, that are required of a certified nursing assistant's performance skills, including, but not limited to, all of the following:
(1) Successful completion and maintenance of active     certification in both first aid and the American Red Cross' courses on cardiopulmonary resuscitation.
(2) Infection control and in-service training     required at the facility.
(3) Washing a resident's hands.
(4) Performing oral hygiene on a resident.
(5) Shaving a resident with an electric razor.
(6) Giving a resident a partial bath.
(7) Making a bed that is occupied.
(8) Dressing a resident.
(9) Transferring a resident to a wheelchair using a     gait belt or transfer belt.
(10) Ambulating a resident with a gait belt or     transfer belt.
(11) Feeding a resident.
(12) Calculating a resident's intake and output.
(13) Placing a resident in a side-lying position.
(14) The Heimlich maneuver.
(e) A certified nursing assistant intern may not perform any of the following on a resident:
(1) Shaving with a nonelectric razor.
(2) Nail care.
(3) Perineal care.
(4) Transfer using a mechanical lift.
(5) Passive range of motion.
(f) A certified nursing assistant intern may only provide the patient or resident care services and perform the procedures that he or she is deemed qualified to perform that are listed under subsection (d).  A certified nursing assistant intern may not provide the procedures excluded under subsection (e).
(g) A certified nursing assistant intern shall report to a facility's charge nurse or nursing supervisor and may only be assigned duties authorized in this Section by a supervising nurse.
(h) A facility shall notify its certified and licensed staff members, in writing, that a certified nursing assistant intern may only provide the services and perform the procedures listed under subsection (d). The notification shall detail which duties may be delegated to a certified nursing assistant intern.
(i) If a facility learns that a certified nursing assistant intern is performing work outside of the scope of the Program's training, the facility shall:
(1) stop the certified nursing assistant intern from     performing the work;
(2) inspect the work and correct mistakes, if the     work performed was done improperly;
(3) assign the work to the appropriate personnel; and
(4) ensure that a thorough assessment of any resident     involved in the work performed is completed by a registered nurse.
(j) The Program is subject to the Health Care Worker Background Check Act and the Health Care Worker Background Check Code under 77 Ill. Adm. Code 955. Program participants and personnel shall be included on the Health Care Worker Registry.
(k) A Program participant who has completed the training required under paragraph (5) of subsection (a) of Section 3-206 of the Nursing Home Care Act, has completed the Program from April 21, 2020 through September 18, 2020, and has shown competency in all of the performance skills listed under subsection (d) shall be considered a certified nursing assistant intern.
(l) The requirement under subsection (b) of Section 395.400 of Title 77 of the Illinois Administrative Code that a student must pass a BNATP written competency examination within 12 months after the completion of the BNATP does not apply to a certified nursing assistant intern under this Section. However, upon a Program participant's enrollment in a certified nursing assistant course, the requirement under subsection (b) of Section 395.400 of Title 77 of the Illinois Administrative Code that a student pass a BNATP written competency examination within 12 months after completion of the BNATP program applies.
(m) A certified nursing assistant intern shall enroll in a certified nursing assistant program within 6 months after completing his or her certified nursing assistant intern training under the Program. The individual may continue to work as a certified nursing assistant intern during his or her certified nursing assistant training. If the scope of work for a nurse assistant in training pursuant to 77 Ill. Adm. Code 300.660 is broader in scope than the work permitted to be performed by a certified nursing assistant intern, then the certified nursing assistant intern enrolled in certified nursing assistant training may perform the work allowed under 77. Ill. Adm. Code 300.660. The individual shall receive one hour of credit for every hour employed as a certified nursing assistant intern or as a temporary nurse assistant, not to exceed 30 hours of credit, subject to the approval of an accredited certified nursing assistant training    program.
(n) A facility that seeks to train and employ a certified nursing assistant intern at the facility must:
(1) not have received a substantiated citation, that     the facility has the right to the appeal, for a violation that has caused severe harm to or the death of a resident within the 2 years prior to employing a certified nursing assistant intern; and
(2) establish a certified nursing assistant intern     mentoring program within the facility for the purposes of increasing education and retention, which must include an experienced certified nurse assistant who has at least 3 years of active employment and is employed by the facility.
(o) A facility that does not meet the requirements of subsection (n) shall cease its new employment training, education, or onboarding of any employee under the Program. The facility may resume its new employment training, education, or onboarding of an employee under the Program once the Department determines that the facility is in compliance with subsection (n).
(p) To study the effectiveness of the Program, the Department shall collect data from participating facilities and publish a report on the extent to which the Program brought individuals into continuing employment as certified nursing assistants in long-term care. Data collected from facilities shall include, but shall not be limited to, the number of certified nursing assistants employed, the number of persons who began participation in the Program, the number of persons who successfully completed the Program, and the number of persons who continue employment in a long-term care service or facility. The report shall be published no later than 6 months after the Program end date determined under subsection (r).  A facility participating in the Program shall, twice annually, submit data under this subsection in a manner and time determined by the Department. Failure to submit data under this subsection shall result in suspension of the facility's Program.
(q) The Department may adopt emergency rules in accordance with Section 5-45.32 of the Illinois Administrative Procedure Act.
(r) The Program shall end upon  the termination of the Secretary of Health and Human Services' public health emergency declaration for COVID-19 or 3 years after the date that the Program becomes operational, whichever occurs later.
(s) This Section is inoperative 18 months after the Program end date determined under subsection (r).
(Source: P.A. 102-1037, eff. 6-2-22; 103-154, eff. 6-30-23.)
(305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)
Sec. 5-5.02. Hospital reimbursements.
(a) Reimbursement to hospitals; July 1, 1992 through September 30, 1992.
Notwithstanding any other provisions of this Code or the Illinois
Department's Rules promulgated under the Illinois Administrative Procedure
Act, reimbursement to hospitals for services provided during the period
July 1, 1992 through September 30, 1992, shall be as follows:
(1) For inpatient hospital services rendered, or if     applicable, for inpatient hospital discharges occurring, on or after July 1, 1992 and on or before September 30, 1992, the Illinois Department shall reimburse hospitals for inpatient services under the reimbursement methodologies in effect for each hospital, and at the inpatient payment rate calculated for each hospital, as of June 30, 1992.  For purposes of this paragraph, "reimbursement methodologies" means all reimbursement methodologies that pertain to the provision of inpatient hospital services, including, but not limited to, any adjustments for disproportionate share, targeted access, critical care access and uncompensated care, as defined by the Illinois Department on June 30, 1992.
(2) For the purpose of calculating the inpatient     payment rate for each hospital eligible to receive quarterly adjustment payments for targeted access and critical care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period July 1, 1992 through September 30, 1992, shall be 25% of the annual adjustment payments calculated for each eligible hospital, as of June 30, 1992.  The Illinois Department shall determine by rule the adjustment payments for targeted access and critical care beginning October 1, 1992.
(3) For the purpose of calculating the inpatient     payment rate for each hospital eligible to receive quarterly adjustment payments for uncompensated care, as defined by the Illinois Department on June 30, 1992, the adjustment payment for the period August 1, 1992 through September 30, 1992, shall be one-sixth of the total uncompensated care adjustment payments calculated for each eligible hospital for the uncompensated care rate year, as defined by the Illinois Department, ending on July 31, 1992.  The Illinois Department shall determine by rule the adjustment payments for uncompensated care beginning October 1, 1992.
(b) Inpatient payments.  For inpatient services provided on or after October
1, 1993, in addition to rates paid for hospital inpatient services pursuant to
the Illinois Health Finance Reform Act, as now or hereafter amended, or the
Illinois Department's prospective reimbursement methodology, or any other
methodology used by the Illinois Department for inpatient services, the
Illinois Department shall make adjustment payments, in an amount calculated
pursuant to the methodology described in paragraph (c) of this Section, to
hospitals that the Illinois Department determines satisfy any one of the
following requirements:
(1) Hospitals that are described in Section 1923 of     the federal Social Security Act, as now or hereafter amended, except that for rate year 2015 and after a hospital described in Section 1923(b)(1)(B) of the federal Social Security Act and qualified for the payments described in subsection (c) of this Section for rate year 2014 provided the hospital continues to meet the description in Section 1923(b)(1)(B) in the current determination year;  or
(2) Illinois hospitals that have a Medicaid inpatient     utilization rate which is at least one-half a standard deviation above the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department; or
(3) Illinois hospitals that on July 1, 1991 had a     Medicaid inpatient utilization rate, as defined in paragraph (h) of this Section, that was at least the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Illinois Department and which were located in a planning area with one-third or fewer excess beds as determined by the Health Facilities and Services Review Board, and that, as of June 30, 1992, were located in a federally designated Health Manpower Shortage Area; or
(4) Illinois hospitals that:
(A) have a Medicaid inpatient utilization rate         that is at least equal to the mean Medicaid inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department; and
(B) also have a Medicaid obstetrical inpatient         utilization rate that is at least one standard deviation above the mean Medicaid obstetrical inpatient utilization rate for all hospitals in Illinois receiving Medicaid payments from the Department for obstetrical services; or
(5) Any children's hospital, which means a hospital     devoted exclusively to caring for children.  A hospital which includes a facility devoted exclusively to caring for children shall be considered a children's hospital to the degree that the hospital's Medicaid care is provided to children if either (i) the facility devoted exclusively to caring for children is separately licensed as a hospital by a municipality prior to February 28, 2013; (ii) the hospital has been designated by the State as a Level III perinatal care facility, has a Medicaid Inpatient Utilization rate greater than 55% for the rate year 2003 disproportionate share determination, and has more than 10,000 qualified children days as defined by the Department in rulemaking; (iii) the hospital has been designated as a Perinatal Level III center by the State as of December 1, 2017, is a Pediatric Critical Care Center designated by the State as of December 1, 2017 and has a 2017 Medicaid inpatient utilization rate equal to or greater than 45%; or (iv) the hospital has been designated as a Perinatal Level II center by the State as of December 1, 2017, has a 2017 Medicaid Inpatient Utilization Rate greater than 70%, and has at least 10 pediatric beds as listed on the IDPH 2015 calendar year hospital profile; or
(6) A hospital that reopens a previously closed     hospital facility within 4 calendar years of the hospital facility's closure, if the previously closed hospital facility qualified for payments under paragraph (c) at the time of closure, until utilization data for the new facility is available for the Medicaid inpatient utilization rate calculation. For purposes of this clause, a "closed hospital facility" shall include hospitals that have been terminated from participation in the medical assistance program in accordance with Section 12-4.25 of this Code.
(c) Inpatient adjustment payments.  The adjustment payments required by
paragraph (b) shall be calculated based upon the hospital's Medicaid
inpatient utilization rate as follows:
(1) hospitals with a Medicaid inpatient utilization     rate below the mean shall receive a per day adjustment payment equal to $25;
(2) hospitals with a Medicaid inpatient utilization     rate that is equal to or greater than the mean Medicaid inpatient utilization rate but less than one standard deviation above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $25 plus $1 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds the mean Medicaid inpatient utilization rate;
(3) hospitals with a Medicaid inpatient utilization     rate that is equal to or greater than one standard deviation above the mean Medicaid inpatient utilization rate but less than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $40 plus $7 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds one standard deviation above the mean Medicaid inpatient utilization rate;
(4) hospitals with a Medicaid inpatient utilization     rate that is equal to or greater than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a per day adjustment payment equal to the sum of $90 plus $2 for each one percent that the hospital's Medicaid inpatient utilization rate exceeds 1.5 standard deviations above the mean Medicaid inpatient utilization rate; and
(5) hospitals qualifying under clause (6) of     paragraph (b) shall have the rate assigned to the previously closed hospital facility at the date of closure, until utilization data for the new facility is available for the Medicaid inpatient utilization rate calculation.
(d) Supplemental adjustment payments.  In addition to the adjustment
payments described in paragraph (c), hospitals as defined in clauses
(1) through (6) of paragraph (b), excluding county hospitals (as defined in
subsection (c) of Section 15-1 of this Code) and a hospital organized under the
University of Illinois Hospital Act, shall be paid supplemental inpatient
adjustment payments of $60 per day.  For purposes of Title XIX of the federal
Social Security Act, these supplemental adjustment payments shall not be
classified as adjustment payments to disproportionate share hospitals.
(e) The inpatient adjustment payments described in paragraphs (c) and (d)
shall be increased on October 1, 1993 and annually thereafter by a percentage
equal to the lesser of (i) the increase in the DRI hospital cost index for the
most recent 12 month period for which data are available, or (ii) the
percentage increase in the statewide average hospital payment rate over the
previous year's statewide average hospital payment rate.  The sum of the
inpatient adjustment payments under paragraphs (c) and (d) to a hospital, other
than a county hospital (as defined in subsection (c) of Section 15-1 of this
Code) or a hospital organized under the University of Illinois Hospital Act,
however, shall not exceed $275 per day; that limit shall be increased on
October 1, 1993 and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most recent 12-month
period for which data are available or (ii) the percentage increase in the
statewide average hospital payment rate over the previous year's statewide
average hospital payment rate.
(f) Children's hospital inpatient adjustment payments.  For children's
hospitals, as defined in clause (5) of paragraph (b), the adjustment payments
required pursuant to paragraphs (c) and (d) shall be multiplied by 2.0.
(g) County hospital inpatient adjustment payments.  For county hospitals,
as defined in subsection (c) of Section 15-1 of this Code, there shall be an
adjustment payment as determined by rules issued by the Illinois Department.
(h) For the purposes of this Section the following terms shall be defined
as follows:
(1) "Medicaid inpatient utilization rate" means a     fraction, the numerator of which is the number of a hospital's inpatient days provided in a given 12-month period to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act, and the denominator of which is the total number of the hospital's inpatient days in that same period.
(2) "Mean Medicaid inpatient utilization rate" means     the total number of Medicaid inpatient days provided by all Illinois Medicaid-participating hospitals divided by the total number of inpatient days provided by those same hospitals.
(3) "Medicaid obstetrical inpatient utilization rate"     means the ratio of Medicaid obstetrical inpatient days to total Medicaid inpatient days for all Illinois hospitals receiving Medicaid payments from the Illinois Department.
(i) Inpatient adjustment payment limit.  In order to meet the limits
of Public Law 102-234 and Public Law 103-66, the
Illinois Department shall by rule adjust
disproportionate share adjustment payments.
(j) University of Illinois Hospital inpatient adjustment payments.  For
hospitals organized under the University of Illinois Hospital Act, there shall
be an adjustment payment as determined by rules adopted by the Illinois
Department.
(k) The Illinois Department may by rule establish criteria for and develop
methodologies for adjustment payments to hospitals participating under this
Article.
(l) 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.
(m) The Department shall establish a cost-based reimbursement methodology for determining payments to hospitals for approved graduate medical education (GME) programs for dates of service on and after July 1, 2018.
(1) As used in this subsection, "hospitals" means the     University of Illinois Hospital as defined in the University of Illinois Hospital Act and a county hospital in a county of over 3,000,000 inhabitants.
(2) An amendment to the Illinois Title XIX State Plan     defining GME shall maximize reimbursement, shall not be limited to the education programs or special patient care payments allowed under Medicare, and shall include:
(A) inpatient days;
(B) outpatient days;
(C) direct costs;
(D) indirect costs;
(E) managed care days;
(F) all stages of medical training and education         including students, interns, residents, and fellows with no caps on the number of persons who may qualify; and
(G)  patient care payments related to the         complexities of treating Medicaid enrollees including clinical and social determinants of health.
(3) The Department shall make all GME payments     directly to hospitals including such costs in support of clients enrolled in Medicaid managed care entities.
(4) The Department shall promptly take all actions     necessary for reimbursement to be effective for dates of service on and after July 1, 2018 including publishing all appropriate public notices, amendments to the Illinois Title XIX State Plan, and adoption of administrative rules if necessary.
(5) As used in this subsection, "managed care days"     means costs associated with services rendered to enrollees of Medicaid managed care entities. "Medicaid managed care entities" means any entity which contracts with the Department to provide services paid for on a capitated basis. "Medicaid managed care entities" includes a managed care organization and a managed care community network.
(6) All payments under this Section are contingent     upon federal approval of changes to the Illinois Title XIX State Plan, if that approval is required.
(7) The Department may adopt rules necessary to     implement Public Act 100-581 through the use of emergency rulemaking in accordance with subsection (aa) of Section 5-45 of the Illinois Administrative Procedure Act. For purposes of that Act, the General Assembly finds that the adoption of rules to implement Public Act 100-581 is deemed an emergency and necessary for the public interest, safety, and welfare. (Source: P.A. 101-81, eff. 7-12-19; 102-682, eff. 12-10-21; 102-886, eff. 5-17-22.)
(305 ILCS 5/5-5.03)
Sec. 5-5.03. 
		Trauma center adjustment.
(a) For inpatient admissions on or after October 1, 1992 for trauma
injuries as defined in the Emergency Medical Services (EMS) Systems Act, in
addition to any other payments made under this Code, the Illinois Department
shall make adjustment payments, in an amount calculated under subsection (b) of
this Section, to hospitals located in the State of Illinois that are recognized
as Level I trauma centers (adult or pediatric) and to certain Level II trauma
centers as determined by the Illinois Department.
(b) Trauma center adjustment calculation.
(1) The funds used to make trauma center adjustment     payments to qualifying trauma centers shall consist of:
(A) At least 50% of the amount of moneys         deposited each State fiscal year into the Trauma Center Fund created in the State treasury; and
(B) All federal matching funds received by the         Illinois Department as a result of expenditures made by the Illinois Department as required by this Section.
(2) The trauma center adjustment payments shall be     made to qualifying trauma centers on a quarterly basis.  In determining the payment methodology for trauma center adjustment payments, the Illinois Department shall divide the available funds from the Trauma Center Fund for each quarter by the total number of the Medicaid trauma admissions as determined by the Illinois Department for the same quarter of the Trauma Center base year.  The result of that calculation shall be the amount of the quarterly trauma center adjustment payment to be paid to qualifying trauma centers.
(3) Disbursements from the Trauma Center Fund shall     be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.
(4) Trauma center adjustment payments shall not be     treated as payments for hospital services under Title XIX of the Social Security Act for purposes of the calculation of the intergovernmental transfer provided for in Section 15-3(a) of the Code.
(c) Definitions.  As used in this Section, unless the context requires
otherwise:
"Trauma center adjustment year" means, beginning October 1, 1992, the 12
month period beginning on October 1 of the year and ending September 30 of
the following year.
"Trauma center base year" means State Fiscal Year 1991 for trauma center
adjustment payments calculated for the October 1, 1992 trauma center
adjustment year, State Fiscal Year 1992 for trauma center adjustment payments
calculated for the October 1, 1993 trauma center adjustment year, and so on
for each succeeding State Fiscal Year for trauma center adjustment payments
calculated for the trauma center adjustment year beginning October 1 of
that State Fiscal Year.
(Source: P.A. 87-1229.)
(305 ILCS 5/5-5.04)
Sec. 5-5.04. Persons living with HIV/AIDS. The Department of Public Aid may seek federal approval to expand access to health care for persons living with HIV/AIDS.  Implementation of this Section is subject to appropriation.
(Source: P.A. 94-629, eff. 1-1-06.)
(305 ILCS 5/5-5.4k)
Sec. 5-5.4k. Payments for long-acting injectable medications for mental health or substance use disorders. Notwithstanding any other provision of this Code, effective for dates of service on and after January 1, 2022, the medical assistance program shall separately reimburse at the prevailing fee schedule, for long-acting injectable medications administered for mental health or substance use disorder in the hospital inpatient setting, and which are compliant with the prior authorization requirements of this Section. The Department, in consultation with a statewide association representing a majority of hospitals and Managed Care Organizations  shall implement, by rule, reimbursement policy and prior authorization criteria for the use of long-acting injectable medications administered in the hospital inpatient setting for the treatment of mental health disorders.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-5.05)
Sec. 5-5.05. Hospitals; psychiatric services.
(a) On and after January 1, 2024, the inpatient, per diem rate to be paid to a hospital for inpatient psychiatric services shall be not less than 90% of the per diem rate established in accordance with paragraph (b-5) of this Section, subject to the provisions of Section 14-12.5.
(b) For purposes of this Section, "hospital" means a hospital with a distinct part unit for psychiatric services.
For purposes of this Section, "inpatient psychiatric services" means those services provided to patients who are in need of short-term acute inpatient hospitalization for active treatment of an emotional or mental disorder.
(b-5)    Notwithstanding any other provision of this Section, the inpatient, per diem rate to be paid to all safety-net hospitals for inpatient psychiatric services on and after January 1, 2021 shall be at least $630, subject to the provisions of Section 14-12.5.
(b-10) Notwithstanding any other provision of this Section, effective with dates of service on and after January 1, 2022, any general acute care hospital with more than 9,500 inpatient psychiatric Medicaid days in any calendar year shall be paid the inpatient per diem rate of no less than $630, subject to the provisions of Section 14-12.5.
(c) No rules shall be promulgated to implement this Section. For purposes of this Section, "rules" is given the meaning contained in Section 1-70 of the Illinois Administrative Procedure Act.
(d) (Blank).
(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.
(Source: P.A. 102-4, eff. 4-27-21; 102-674, eff. 11-30-21; 103-102, eff. 6-16-23.)
(305 ILCS 5/5-5.05a)
Sec. 5-5.05a. Reimbursement rates; community mental health centers. Notwithstanding the provisions of any other law,
reimbursement rates, including enhanced payment rates and rate
add-ons, for psychiatric and behavioral health services
provided in or by community mental health centers licensed or
certified by the Department of Human Services shall not be
lower than the rates for such services in effect on November 1,
2017. The Department of Healthcare and Family Services shall
apply for any waiver or State Plan amendment, if required, to
implement the reimbursement rates established in this Section.
Implementation of the reimbursement rates shall be contingent
on federal approval.
(Source: P.A. 100-587, eff. 6-4-18.)
(305 ILCS 5/5-5.05b)
Sec. 5-5.05b. Access to psychiatric treatment. Effective July 1, 2019, or as soon thereafter as practical and subject to federal approval, the Department shall allocate an amount of up to $40,000,000 to enhance access psychiatric treatment, including both reimbursement rates to individual physicians board certified in psychiatry as well as community mental health centers and other relevant providers.
(Source: P.A. 101-10, eff. 6-5-19.)
(305 ILCS 5/5-5.05c)
Sec. 5-5.05c. Access to physician services. The Department shall increase rates of reimbursement for physician services to as close to 60% of Medicare rates in effect as of January 1, 2020 utilizing the rates of Illinois Locality 99 facility rates.
(Source: P.A. 101-650, eff. 7-7-20.)
(305 ILCS 5/5-5.05d)
Sec. 5-5.05d. Academic detailing for behavioral health providers. The Department shall develop, in collaboration with associations representing behavioral health providers, a program designed to provide behavioral health providers and providers in academic medical settings who need assistance in caring for patients with severe mental illness or a developmental disability under the medical assistance program with academic detailing and clinical consultation over the phone from a qualified provider on how to best care for the patient. The Department shall include the phone number on its website and notify providers that the service is available.  The Department may create an in-person option if adequate staff is available. To the extent practicable, the Department shall build upon this service to address worker shortages and the availability of specialty services.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.05e)
Sec. 5-5.05e. Tracking availability of beds for withdrawal management services. The Department of Human Services shall track, or contract with an organization to track, the availability of beds for withdrawal management services that are licensed by the Department and are available to medical assistance beneficiaries. The Department of Human Services shall update the tracking daily and publish the availability of beds online or in another public format.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.05f)
Sec. 5-5.05f. Medicaid coverage for peer recovery support services. On or before January 1, 2023, the Department shall seek approval from the federal Centers for Medicare and Medicaid Services to cover peer recovery support services under the medical assistance program when rendered by certified peer support specialists for the purposes of supporting the recovery of individuals receiving substance use disorder treatment. As used in this Section, "certified peer support specialist" means an individual who:
(1) is a self-identified current or former recipient     of substance use disorder services who has the ability to support other individuals diagnosed with a substance use disorder;
(2) is affiliated with a substance use prevention and     recovery provider agency that is licensed by the Department of Human Services' Division of Substance Use Prevention and Recovery; and
(A) is certified in accordance with applicable         State law to provide peer recovery support services in substance use disorder settings; or
(B) is certified as qualified to furnish peer         support services under a certification process consistent with the National Practice Guidelines for Peer Supporters and inclusive of the core competencies identified by the Substance Abuse and Mental Health Services Administration in the Core Competencies for Peer Workers in Behavioral Health Services.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.05g)
Sec. 5-5.05g. Alignment of substance use prevention and recovery and mental health policy. The Department and the Department of Human Services shall collaborate to review coverage and billing requirements for substance use prevention and recovery and mental health services with the goal of identifying disparities and streamlining coverage and billing requirements to reduce the administrative burden for providers and medical assistance beneficiaries.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.06)
Sec. 5-5.06. Dental home initiative. The Department, in cooperation with the dental community and other affected organizations such as Head Start, shall work to develop and promote the concept of a dental home for children covered under this Article.  Included in this dental home outreach should be an effort to ensure an ongoing relationship between the patient and the dentist with an effort to provide comprehensive, coordinated, oral health care so that all children covered under this Article have access to preventative and restorative oral health care.
(Source: P.A. 97-283, eff. 8-9-11.)
(305 ILCS 5/5-5.06a)
Sec. 5-5.06a. Increased funding for dental services. Beginning January 1, 2022, the amount allocated to fund rates for dental services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $10,000,000.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-5.06b)
Sec. 5-5.06b. Dental services. On and after July 1, 2021, dental services provided to adults and children under the medical assistance program may be established and paid at no less than the rates published by the Department and effective January 1, 2020 for all local health departments as the fee schedule for children and adult recipients but shall include the following dental procedures and amounts: D0140 $19.12, D0150 $24.84, D0220 $6.61, D0230 $4.48, D0272 $11.09, D0274 $19.94, D1110 $48.38, D2140 $36.40, D2150 $56.82, D2391 $36.40, D2392 $56.82, D5110 $444.09, D5120 $444.09, D7140 $46.16, D7210 $67.73.
(Source: P.A. 102-16, eff. 6-17-21.)
(305 ILCS 5/5-5.06c)
Sec. 5-5.06c. Access to prenatal and postpartum care. To ensure access to high quality prenatal and postpartum care and to promote continuity of care for pregnant individuals, the Department shall increase the rate for prenatal and postpartum visits to no less than the rate for an adult well visit, including any applicable add-ons, beginning on January 1, 2023. Bundled rates that include prenatal or postpartum visits shall incorporate this increased rate, beginning on January 1, 2023.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.06d)
Sec. 5-5.06d. External cephalic version rate. To encourage provider use of external cephalic versions and decrease the rates of caesarean sections in Illinois, the Department shall evaluate the rate for external cephalic versions and increase the rate by an amount determined by the Department to promote safer birthing options for pregnant individuals, beginning on January 1, 2023.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-5.06e)
Sec. 5-5.06e. Increased funding for dental services. Beginning January 1, 2023, the amount allocated to fund rates for dental services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $10,000,000.
(Source: P.A. 102-1037, eff. 6-2-22.)
(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 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 5/5-5.08)
Sec. 5-5.08. Dialysis center funding. Notwithstanding any other provision of law, the add-on Medicaid payments to hospitals and freestanding chronic dialysis centers established under 89 Illinois Administrative Code 148.140(g)(4) for dates of service July 1, 2013 through June 30, 2015 is restored and in effect for dates of  service on and after July 1, 2015 with no end date for such payments.
(Source: P.A. 100-23, eff. 7-6-17.)
(305 ILCS 5/5-5.1) (from Ch. 23, par. 5-5.1)
Sec. 5-5.1. Grouping of facilities. The Department of Healthcare and Family Services shall, for purposes of payment, provide for
groupings of nursing facilities.  Factors to be considered
in grouping facilities may include, but are not limited to,
size, age, patient mix, percentage of Medicaid funded residents, or geographical area.
The groupings developed under this Section shall be
considered in determining reasonable cost reimbursement
formulas.  However, this Section shall not preclude the
Department from recognizing and evaluating the cost of
capital on a facility-by-facility basis.
A resident of a nursing facility whose application for long term care benefits is awaiting final action shall be included in the calculation as a Medicaid funded resident.
(Source: P.A. 99-684, eff. 1-1-17.)
(305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)
(Text of Section from P.A. 102-1118)
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 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 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.
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 $14.88. Facilities with at least 80% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $14.88, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $23.80. Facilities with at least 92% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $23.80, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $29.75. Facilities with at least 100% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $29.75, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $35.70. Facilities with at least 110% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $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. 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.
(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%.
(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. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19; 102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23.)
(Text of Section from P.A. 103-102, Article 40, Section 40-5)
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 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 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.
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 $14.88. Facilities with at least 80% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $14.88, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $23.80. Facilities with at least 92% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $23.80, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $29.75. Facilities with at least 100% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $29.75, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $35.70. Facilities with at least 110% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $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. 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.
(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.)
(Text of Section from P.A. 103-102, Article 50, Section 50-5)
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 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 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.
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 $14.88. Facilities with at least 80% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $14.88, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $23.80. Facilities with at least 92% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $23.80, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $29.75. Facilities with at least 100% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $29.75, increasing by equivalent steps for each whole percentage point until the facilities reach a per diem add-on of $35.70. Facilities with at least 110% of the staffing indicated by the STRIVE study shall be paid a per diem add-on of $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. 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%.
(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 50, Section 50-5, eff. 1-1-24.)
(305 ILCS 5/5-5.3) (from Ch. 23, par. 5-5.3)
Sec. 5-5.3. Conditions of Payment - Prospective Rates -
Accounting Principles.  This amendatory Act establishes certain
conditions for the Department of Healthcare and Family Services in instituting
rates for the care of recipients of medical assistance in
 nursing facilities and ICF/DDs.
 Such conditions shall assure a method under which the payment
for nursing facility and ICF/DD services provided
to recipients under the Medical Assistance Program shall be
on a reasonable cost related basis, which is prospectively
determined at least annually by the Department of Public Aid (now Healthcare and Family Services).
The annually established payment rate shall take effect on July 1 in 1984
and subsequent years.  There shall be no rate increase during calendar year
1983 and the first six months of calendar year 1984.
The determination of the payment shall be made on the
basis of generally accepted accounting principles that
shall take into account the actual costs to the facility
of providing nursing facility and ICF/DD services
to recipients under the medical assistance program.
The resultant total rate for a specified type of service
shall be an amount which shall have been determined to be
adequate to reimburse  allowable costs of a facility that
is economically and efficiently operated.  The Department
shall establish an effective date for each facility or group
of facilities after which rates shall be paid on a reasonable
cost related basis which shall be no sooner than the effective
date of this amendatory Act of 1977.
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.
(Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)
Sec. 5-5.4. Standards of Payment - Department of Healthcare and Family Services.
The Department of Healthcare and Family Services shall develop standards of payment of
nursing facility and ICF/DD services in facilities providing such services
under this Article which:
(1) Provide for the determination of a facility's payment
for nursing facility or ICF/DD services on a prospective basis.
The amount of the payment rate for all nursing facilities certified by the
Department of Public Health under the ID/DD Community Care Act or the Nursing Home Care Act as Intermediate
Care for the Developmentally Disabled facilities, Long Term Care for Under Age
22 facilities, Skilled Nursing facilities, or Intermediate Care facilities
under the
medical assistance program shall be prospectively established annually on the
basis of historical, financial, and statistical data reflecting actual costs
from prior years, which shall be applied to the current rate year and updated
for inflation, except that the capital cost element for newly constructed
facilities shall be based upon projected budgets.  The annually established
payment rate shall take effect on July 1 in 1984 and subsequent years.  No rate
increase and no
update for inflation shall be provided on or after July 1, 1994, unless specifically provided for in this
Section.
The changes made by Public Act 93-841

extending the duration of the prohibition against a rate increase or update for inflation are effective retroactive to July 1, 2004.
For facilities licensed by the Department of Public Health under the Nursing
Home Care Act as Intermediate Care for the Developmentally Disabled facilities
or Long Term Care for Under Age 22 facilities, the rates taking effect on July
1, 1998 shall include an increase of 3%.  For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as Skilled Nursing
facilities or Intermediate Care facilities, the rates taking effect on July 1,
1998 shall include an increase of 3% plus $1.10 per resident-day, as defined by
the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2006 shall include an increase of 3%.
For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January  1, 2009 shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive staff. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities the rates taking effect within 30 days after July 6, 2017 (the effective date of Public Act 100-23) shall include an increase sufficient to provide a $0.75 per hour wage increase for non-executive staff. The Department shall adopt rules, including emergency rules under subsection (y) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act  as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, the rates taking effect within 30 days after June 5, 2019 (the effective date of Public Act 101-10) shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive  front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff. The Department shall adopt rules, including emergency rules under subsection (bb) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on July 1, 1999 shall include an increase of 1.6% plus $3.00 per
resident-day, as defined by the Department.  For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as Skilled Nursing
facilities or Intermediate Care facilities, the rates taking effect on July 1,
1999 shall include an increase of 1.6% and, for services provided on or after
October 1, 1999, shall be increased by $4.00 per resident-day, as defined by
the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on July 1, 2000 shall include an increase of 2.5% per resident-day,
as defined by the Department.  For facilities licensed by the Department of
Public Health under the Nursing Home Care Act as Skilled Nursing facilities or
Intermediate Care facilities, the rates taking effect on July 1, 2000 shall
include an increase of 2.5% per resident-day, as defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as skilled nursing facilities or intermediate care
facilities, a new payment methodology must be implemented for the nursing
component of the rate effective July 1, 2003. The Department of Public Aid
(now Healthcare and Family Services) shall develop the new payment methodology using the Minimum Data Set
(MDS) as the instrument to collect information concerning nursing home
resident condition necessary to compute the rate. The Department
shall develop the new payment methodology to meet the unique needs of
Illinois nursing home residents while remaining subject to the appropriations
provided by the General Assembly.
A transition period from the payment methodology in effect on June 30, 2003
to the payment methodology in effect on July 1, 2003 shall be provided for a
period not exceeding 3 years and 184 days after implementation of the new payment
methodology as follows:
(A) For a facility that would receive a lower nursing     component rate per patient day under the new system than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be held at the level in effect on the date immediately preceding the date that the Department implements the new payment methodology until a higher nursing component rate of reimbursement is achieved by that facility.
(B) For a facility that would receive a higher     nursing component rate per patient day under the payment methodology in effect on July 1, 2003 than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be adjusted.
(C) Notwithstanding paragraphs (A) and (B), the     nursing component rate per patient day for the facility shall be adjusted subject to appropriations provided by the General Assembly.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on March 1, 2001 shall include a statewide increase of 7.85%, as
defined by the Department.
Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the
Nursing Home Care Act as skilled nursing facilities or intermediate care
facilities, except facilities participating in the Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, the numerator of the ratio used by the Department of Healthcare and Family Services to compute the rate payable under this Section using the Minimum Data Set (MDS) methodology shall incorporate the following annual amounts as the additional funds appropriated to the Department specifically to pay for rates based on the MDS nursing component methodology in excess of the funding in effect on December 31, 2006:
(i) For rates taking effect January 1, 2007,     $60,000,000.
(ii) For rates taking effect January 1, 2008,     $110,000,000.
(iii) For rates taking effect January 1, 2009,     $194,000,000.
(iv) For rates taking effect April 1, 2011, or the     first day of the month that begins at least 45 days after February 16, 2011 (the effective date of Public Act 96-1530), $416,500,000 or an amount as may be necessary to complete the transition to the MDS methodology for the nursing component of the rate. Increased payments under this item (iv) are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.
Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the support component of the rates taking effect on January 1, 2008 shall be computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on April 1, 2002 shall include a statewide increase of 2.0%, as
defined by the Department.
This increase terminates on July 1, 2002;
beginning July 1, 2002 these rates are reduced to the level of the rates
in effect on March 31, 2002, as defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as skilled nursing facilities or intermediate care
facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports
on file with the Department of Public Aid no later than April 1, 2000,
updated for inflation to January 1, 2001.  For rates effective July 1, 2001
only, rates shall be the greater of the rate computed for July 1, 2001
or the rate effective on June 30, 2001.
Notwithstanding any other provision of this Section, for facilities
licensed by the Department of Public Health under the Nursing Home Care Act
as skilled nursing facilities or intermediate care facilities, the Illinois
Department shall determine by rule the rates taking effect on July 1, 2002,
which shall be 5.9% less than the rates in effect on June 30, 2002.
Notwithstanding any other provision of this Section, for facilities
licensed by the Department of Public Health under the Nursing Home Care Act as
skilled nursing
facilities or intermediate care facilities, if the payment methodologies required under Section 5A-12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take
effect only upon approval and
implementation of the payment methodologies required under Section 5A-12.
Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004.
Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January  1, 2009, the per diem support component of the rates effective on January 1, 2008, computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006, shall be increased to the amount that would have been derived using standard Department of Healthcare and Family Services methods, procedures, and inflators.
Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as intermediate care facilities that are federally defined as Institutions for Mental Disease, or facilities licensed by the Department of Public Health under the Specialized Mental Health Rehabilitation Act of 2013, a socio-development component rate equal to 6.6% of the facility's nursing component rate as of January 1, 2006 shall be established and paid effective July 1, 2006. The socio-development component of the rate shall be increased by a factor of 2.53 on the first day of the month that begins at least 45 days after January 11, 2008 (the effective date of Public Act 95-707). As of August 1, 2008, the socio-development component rate shall be equal to 6.6% of the facility's nursing component rate as of January 1, 2006, multiplied by a factor of 3.53. For services provided on or after April 1, 2011, or the first day of the month that begins at least 45 days after February 16, 2011 (the effective date of Public Act 96-1530), whichever is later, the Illinois Department may by rule adjust these socio-development component rates, and may use different adjustment methodologies for those facilities participating, and those not participating, in the Illinois Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, but in no case may such rates be diminished below those in effect on August 1, 2008.
For facilities
licensed
by the
Department of Public Health under the Nursing Home Care Act as Intermediate
Care for
the Developmentally Disabled facilities or as long-term care facilities for
residents under 22 years of age, the rates taking effect on July 1,
2003 shall
include a statewide increase of 4%, as defined by the Department.
For facilities licensed by the Department of Public Health under the
Nursing Home Care Act as Intermediate Care for the Developmentally Disabled
facilities or Long Term Care for Under Age 22 facilities, the rates taking
effect on the first day of the month that begins at least 45 days after January 11, 2008 (the effective date of Public Act 95-707) shall include a statewide increase of 2.5%, as
defined by the Department.
Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2005, facility rates shall be increased by the difference between (i) a facility's per diem property, liability, and malpractice insurance costs as reported in the cost report filed with the Department of Public Aid and used to establish rates effective July 1, 2001 and (ii) those same costs as reported in the facility's 2002 cost report.  These costs shall be passed through to the facility without caps or limitations, except for adjustments required under normal auditing procedures.
Rates established effective each July 1 shall govern payment
for services rendered throughout that fiscal year, except that rates
established on July 1, 1996 shall be increased by 6.8% for services
provided on or after January 1, 1997.  Such rates will be based
upon the rates calculated for the year beginning July 1, 1990, and for
subsequent years thereafter until June 30, 2001 shall be based on the
facility cost reports
for the facility fiscal year ending at any point in time during the previous
calendar year, updated to the midpoint of the rate year.  The cost report
shall be on file with the Department no later than April 1 of the current
rate year.  Should the cost report not be on file by April 1, the Department
shall base the rate on the latest cost report filed by each skilled care
facility and intermediate care facility, updated to the midpoint of the
current rate year.  In determining rates for services rendered on and after
July 1, 1985, fixed time shall not be computed at less than zero.  The
Department shall not make any alterations of regulations which would reduce
any component of the Medicaid rate to a level below what that component would
have been utilizing in the rate effective on July 1, 1984.
(2) Shall take into account the actual costs incurred by facilities
in providing services for recipients of skilled nursing and intermediate
care services under the medical assistance program.
(3) Shall take into account the medical and psycho-social
characteristics and needs of the patients.
(4) Shall take into account the actual costs incurred by facilities in
meeting licensing and certification standards imposed and prescribed by the
State of Illinois, any of its political subdivisions or municipalities and by
the U.S. Department of Health and Human Services pursuant to Title XIX of the
Social Security Act.
The Department of Healthcare and Family Services

shall develop precise standards for
payments to reimburse nursing facilities for any utilization of
appropriate rehabilitative personnel for the provision of rehabilitative
services which is authorized by federal regulations, including
reimbursement for services provided by qualified therapists or qualified
assistants, and which is in accordance with accepted professional
practices.  Reimbursement also may be made for utilization of other
supportive personnel under appropriate supervision.
The Department shall develop enhanced payments to offset the additional costs incurred by a

      facility serving exceptional need residents and shall allocate at least $4,000,000 of the funds

      collected from the assessment established by Section 5B-2 of this Code for such payments. For

      the purpose of this Section, "exceptional needs" means, but need not be limited to, ventilator care and traumatic brain injury care. The enhanced payments for exceptional need residents under this paragraph  are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.
Beginning January 1, 2014 the methodologies for reimbursement of nursing facility services as provided under this Section 5-5.4 shall no longer be applicable for services provided on or after January 1, 2014.
No payment increase under this Section for the MDS methodology, exceptional care residents, or the socio-development component rate established by Public Act 96-1530 of the 96th General Assembly and funded by the assessment imposed under Section 5B-2 of this Code shall be due and payable until after the Department notifies the long-term care providers, in writing, that the payment methodologies to long-term care providers required under this Section have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and the waivers under 42 CFR 433.68 for the assessment imposed by this Section, if necessary, have been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. Upon notification to the Department of approval of the payment methodologies required under this Section and the waivers granted under 42 CFR 433.68, all increased payments otherwise due under this Section prior to the date of notification shall be due and payable within 90 days of the date federal approval is received.
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.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect for services delivered on or after August 1, 2019 shall be increased by 3.5% over the rates in effect on June 30, 2019.  The Department shall adopt rules, including emergency rules under subsection (ii) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect on the latter of the approval date of the State Plan Amendment for these facilities or the Waiver Amendment for the home and community-based services settings shall include an increase sufficient to provide a $0.26 per hour wage increase to the base wage for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of
this Section, including wage increases for direct care staff.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, the rates taking effect for the services delivered on or after July 1, 2020 shall include an increase sufficient to provide a $1.00 per hour wage increase for non-executive staff. For services delivered on or after January 1, 2021, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, shall include an increase sufficient to provide a $0.50 per hour increase for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after July 1, 2021, shall include an increase sufficient to provide a $0.50 per hour increase for aides in the rate methodology.  For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after January 1, 2022 shall include an increase sufficient to provide a $1.00 per hour increase for aides in the rate methodology.  In addition, for residential services delivered on or after January 1, 2022 such rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD facilities and under the MC/DD Act as MC/DD facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for services delivered on or after January 1, 2023, shall include a $1.00 per hour wage increase for all direct support personnel and all other frontline personnel who are not subject to the Bureau of Labor Statistics' average wage increases, who work in residential and community day services settings, with at least $0.50 of those funds to be provided as a direct increase to all aide base wages, with the remaining $0.50 to be used flexibly for base wage increases to the rate methodology for aides. In addition, for residential services delivered on or after January 1, 2023 the rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as determined by the Department. Also, for services delivered on or after January 1, 2023, the rates will include adjustments to employment-related expenses as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD facilities and under the MC/DD Act as MC/DD facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for services delivered on or after January 1, 2024 shall include a $2.50 per hour wage increase for all direct support personnel and all other frontline personnel who are not subject to the Bureau of Labor Statistics' average wage increases and who work in residential and community day services settings. At least $1.25 of the per hour wage increase shall be provided as a direct increase to all aide base wages, and the remaining $1.25 of the per hour wage increase shall be used flexibly for base wage increases to the rate methodology for aides. In addition, for residential services delivered on or after January 1, 2024, the rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as determined by the Department. Also, for services delivered on or after January 1, 2024, the rates will include adjustments to employment-related expenses as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(Source: P.A. 102-16, eff. 6-17-21; 102-699, eff. 4-19-22; 103-8, eff. 6-7-23.)
(305 ILCS 5/5-5.4a)
Sec. 5-5.4a. (Repealed).
(Source: P.A. 96-1530, eff. 2-16-11. Repealed by P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4b)
Sec. 5-5.4b. 
		Publicly owned or publicly operated nursing facilities. 
		The
Illinois
Department may by rule establish alternative reimbursement methodologies for
nursing facilities that are owned or operated by a county, a township,
a municipality, a hospital district, or any other local government in
Illinois.
(Source: P.A. 93-20, eff. 6-20-03.)
(305 ILCS 5/5-5.4c)
Sec. 5-5.4c. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4d)
Sec. 5-5.4d. MDS payment methodology; quarterly rate adjustments.
(a) On and after July 1, 2009, and until April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be calculated and adjusted quarterly.  The Department of Healthcare and Family Services may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section.  For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare.
(b) On April 1, 2011, the nursing component of the nursing facility medical assistance rate computed under the Minimum Data Set (MDS) payment methodology shall be frozen to allow the Department of Healthcare and Family Services to develop a rate methodology based on a federally mandated long term care data collection system. The rates in effect prior to and through the quarter ending March 31, 2011, shall continue to be subject to follow-up audits and retroactive rate adjustments pursuant to administrative rules of the Department for reviews of accuracy and resident assessment information. The reimbursement methodology for a Class I Institution for Mental Diseases shall also be frozen pending review of a federally mandated long term care data collection system.
(Source: P.A. 96-743, eff. 8-25-09; 96-959, eff. 7-1-10.)
(305 ILCS 5/5-5.4e)
Sec. 5-5.4e. Nursing facilities; ventilator rates. On and after October 1, 2009, the Department of Healthcare and Family Services shall adopt rules to provide medical assistance reimbursement under this Article for the care of persons on ventilators in skilled nursing facilities licensed under the Nursing Home Care Act and certified to participate under the medical assistance program.  Accordingly, necessary amendments to the rules implementing the Minimum Data Set (MDS) payment methodology shall also be made to provide a separate per diem ventilator rate based on days of service.  The Department may adopt rules necessary to implement this amendatory Act of the 96th General Assembly through the use of emergency rulemaking in accordance with Section 5-45 of the Illinois Administrative Procedure Act, except that the 24-month limitation on the adoption of emergency rules under Section 5-45 and the provisions of Sections 5-115 and 5-125 of that Act do not apply to rules adopted under this Section.  For purposes of that Act, the General Assembly finds that the adoption of rules to implement this amendatory Act of the 96th General Assembly is deemed an emergency and necessary for the public interest, safety, and welfare.
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.
(Source: P.A. 96-743, eff. 8-25-09; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.4f)
Sec. 5-5.4f. Intermediate care facilities for persons with developmental disabilities quality workforce initiative.
(a) Legislative intent. Individuals with developmental disabilities who live in community-based settings rely on direct support staff for a variety of supports and services essential to the ability to reach their full potential.   A stable, well-trained direct support workforce is critical to the well-being of these individuals.  State and national studies have documented high rates of turnover among direct support workers and confirmed that improvements in wages can help reduce turnover and develop a more stable and committed workforce. This Section would increase the wages and benefits for direct care workers supporting individuals with developmental disabilities and provide accountability by ensuring that additional resources go directly to these workers.
(b)  Reimbursement. Notwithstanding any provision of Section 5-5.4, in order to attract and retain a stable, qualified, and healthy workforce, beginning July 1, 2010, the Department of Healthcare and Family Services may reimburse an individual intermediate care facility for persons with developmental disabilities for spending incurred to provide improved wages and benefits to its employees serving the individuals residing in the facility. Reimbursement shall be based upon patient days reported in the facility's most recent cost report. Subject to available appropriations, this reimbursement shall be made according to the following criteria:
(1)  The Department shall reimburse the facility to     compensate for spending on improved wages and benefits for its eligible employees. Eligible employees include employees engaged in direct care work.
(2)   In order to qualify for reimbursement under     this Section, a facility must submit to the Department, before January 1 of each year, documentation of a written, legally binding commitment to increase spending for the purpose of providing improved wages and benefits to its eligible employees during the next year. The commitment must be binding as to both existing and future staff. The commitment must include a method of enforcing the commitment that is available to the employees or their representative and is expeditious, uses a neutral decision-maker, and is economical for the employees. The Department must also receive documentation of the facility's provision of written notice of the commitment and the availability of the enforcement mechanism to the employees or their representative.
(3)  Reimbursement shall be based on the amount of     increased spending to be incurred by the facility for improving wages and benefits that exceeds the spending reported in the cost report currently used by the Department. Reimbursement shall be calculated as follows: the per diem equivalent of the quarterly difference between the cost to provide improved wages and benefits for covered eligible employees as identified in the legally binding commitment and the previous period cost of wages and benefits as reported in the cost report currently used by the Department, subject to the limitations identified in paragraph (2) of this subsection.  In no event shall the per diem increase be in excess of $5.00 for any 12 month period for an intermediate care facility for persons with developmental disabilities with more than 16 beds, or in excess of $6.00 for any 12 month period for an intermediate care facility for persons with developmental disabilities with 16 beds or less.
(4)  Any intermediate care facility for persons with     developmental disabilities is eligible to receive reimbursement under this Section. A facility's eligibility to receive reimbursement shall continue as long as the facility maintains eligibility under paragraph (2) of this subsection and the reimbursement program continues to exist.
(c) Audit. Reimbursement under this Section is subject to audit by the Department and shall be reduced or eliminated in the case of any facility that does not honor its commitment to increase spending to improve the wages and benefits of its employees or that decreases such spending.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-5.4g)
Sec. 5-5.4g. Minimum Data Set (MDS) Compliance Review; preliminary findings. The Department shall establish by rule a procedure for sharing preliminary Minimum Data Set (MDS) Compliance Review findings with nursing facilities prior to completion of the on-site review.  The procedure shall include, but not be limited to, notification to a nursing facility of specific areas of missing documentation required under 89 Ill. Adm. Code 147.75 and the federally mandated resident assessment instrument as specified in 42 CFR 483.20 likely to be determined deficient upon conclusion of the Department's quality assurance review process.   Prior to the conclusion of the on-site review, the facility shall be given the opportunity to address the specific areas of missing documentation. A facility disputing any rate change may submit an appeal request pursuant to provisions established at 89 Ill. Adm. Code 140.830.  An appeal hearing may be requested if the facility believes that the basis for reducing the facility's MDS rate was in error. The facility may not offer any additional documentation during the appeal hearing, but may identify documentation provided during the on-site review that may support a specific area of documentation deemed deficient by the Department.
(Source: P.A. 96-1317, eff. 7-27-10; 97-333, eff. 8-12-11.)
(305 ILCS 5/5-5.4h)
Sec. 5-5.4h. Medicaid reimbursement for medically complex for the developmentally disabled facilities licensed under the MC/DD Act.
(a) Facilities licensed as medically complex for the developmentally disabled facilities that serve severely and chronically ill patients shall have a specific reimbursement system designed to recognize the characteristics and needs of the patients they serve.
(b) For dates of services starting July 1, 2013 and until a new reimbursement system is designed, medically complex for the developmentally disabled facilities that meet the following criteria:
(1) serve exceptional care patients; and
(2) have 30% or more of their patients receiving     ventilator care;shall receive Medicaid reimbursement on a 30-day expedited schedule.
(c) Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting July 1, 2014 through March 31, 2019, medically complex for the developmentally disabled facilities which meet the criteria in subsection (b) of this Section shall receive a per diem rate for clinically complex residents of $304. Clinically complex residents on a ventilator shall receive a per diem rate of $669. Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting April 1, 2019, medically complex for the developmentally disabled facilities must be reimbursed an exceptional care per diem rate, instead of the base rate, for services to residents with complex or extensive medical needs. Exceptional care per diem rates must be paid for the conditions or services specified under subsection (f) at the following per diem rates: Tier 1 $326, Tier 2 $546, and Tier 3 $735. Subject to federal approval, on and after January 1, 2024, each tier rate shall be increased 6% over the amount in effect on the effective date of this amendatory Act of the 103rd General Assembly. Any reimbursement increases applied to the base rate to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to each tier of exceptional care per diem rates for medically complex for the developmentally disabled facilities.
(d) For residents on a ventilator pursuant to subsection (c) or subsection (f), facilities shall have a policy documenting their method of routine assessment of a resident's weaning potential with interventions implemented noted in the resident's medical record.
(e) For services provided prior to April 1, 2019 and for the purposes of this Section, a resident is considered clinically complex if the resident requires at least one of the following medical services:
(1) Tracheostomy care with dependence on mechanical     ventilation for a minimum of 6 hours each day.
(2) Tracheostomy care requiring suctioning at least     every 6 hours, room air mist or oxygen as needed, and dependence on one of the treatment procedures listed under paragraph (4) excluding the procedure listed in subparagraph (A) of paragraph (4).
(3) Total parenteral nutrition or other intravenous     nutritional support and one of the treatment procedures listed under paragraph (4).
(4) The following treatment procedures apply to the     conditions in paragraphs (2) and (3) of this subsection:
(A) Intermittent suctioning at least every 8         hours and room air mist or oxygen as needed.
(B) Continuous intravenous therapy including         administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent via a peripheral or central line, without  continuous infusion.
(C) Peritoneal dialysis treatments requiring at         least 4 exchanges every 24 hours.
(D) Tube feeding via nasogastric or gastrostomy         tube.
(E) Other medical technologies required         continuously, which in the opinion of the attending physician require the services of a professional nurse.
(f) Complex or extensive medical needs for exceptional care reimbursement. The conditions and services used for the purposes of this Section have the same meanings as ascribed to those conditions and services under the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) and specified in the most recent manual. Instead of submitting minimum data set assessments to the Department, medically complex for the developmentally disabled facilities must document within each resident's medical record the conditions or services using the minimum data set documentation standards and requirements to qualify for exceptional care reimbursement.
(1) Tier 1 reimbursement is for residents who are     receiving at least 51% of their caloric intake via a feeding tube.
(2) Tier 2 reimbursement is for residents who are     receiving tracheostomy care without a ventilator.
(3) Tier 3 reimbursement is for residents who are     receiving tracheostomy care and ventilator care.
(g) For dates of services starting April 1, 2019, reimbursement calculations and direct payment for services provided by medically complex for the developmentally disabled facilities are the responsibility of the Department of Healthcare and Family Services instead of the Department of Human Services. Appropriations for medically complex for the developmentally disabled facilities must be shifted from the Department of Human Services to the Department of Healthcare and Family Services. Nothing in this Section prohibits the Department of Healthcare and Family Services from paying more than the rates specified in this Section. The rates in this Section must be interpreted as a minimum amount. Any reimbursement increases applied to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to medically complex for the developmentally disabled facilities.
(h) The Department of Healthcare and Family Services shall pay the rates in effect on March 31, 2019 until the changes made to this Section by this amendatory Act of the 100th General Assembly have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
(i) The Department of Healthcare and Family Services may adopt rules as allowed by the Illinois Administrative Procedure Act to implement this Section; however, the requirements of this Section must be implemented by the Department of Healthcare and Family Services even if the Department of Healthcare and Family Services has not adopted rules by the implementation date of April 1, 2019.
(Source: P.A. 103-102, eff. 1-1-24.)
(305 ILCS 5/5-5.4i)
Sec. 5-5.4i. Rates and reimbursements.
(a) Within 30 days after July 6, 2017 (the effective date of Public Act 100-23), the Department shall increase rates and reimbursements to fund a minimum of a $0.75 per hour wage increase for front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff working in community-based provider organizations serving individuals with developmental disabilities. The Department shall adopt rules, including emergency rules under subsection (y) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(b) Within 30 days after June 4, 2018 (the effective date of Public Act 100-587), the Department shall increase rates and reimbursements to fund a minimum of a $0.50 per hour wage increase for front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff working in community-based provider organizations serving individuals with developmental disabilities. The Department shall adopt rules, including emergency rules under subsection (bb) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.
(c) Within 30 days after the effective date of this amendatory Act of the 101st General Assembly, subject to federal approval, the Department shall increase rates and reimbursements in effect on June 30, 2019 for community-based providers for persons with Developmental Disabilities by 3.5%. The Department shall adopt rules, including emergency rules under subsection (ii) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.
(Source: P.A. 100-23, eff. 7-6-17; 100-587, eff. 6-4-18; 101-10, eff. 6-5-19.)
(305 ILCS 5/5-5.4j)
Sec. 5-5.4j. ID/DD targeted Medicaid rate enhancement. Within 30 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall increase the Medicaid per diem rate by $21.15 for facilities with more than 16 beds licensed by the Department of Public Health under the ID/DD Community Care Act located in the Department of Public Health's Planning Area 7-B.
(Source: P.A. 100-587, eff. 6-4-18.)
(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.
(Source: P.A. 96-1123, eff. 1-1-11; 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.5a) (from Ch. 23, par. 5-5.5a)
Sec. 5-5.5a. Kosher kitchen and food service.
(a) The Department of Healthcare and Family Services may develop in its rate structure for
 nursing facilities an accommodation
for fully kosher kitchen and food service operations, rabbinically
approved or certified on an annual basis for a facility in which the only
kitchen or all kitchens are fully kosher (a fully kosher facility).
Beginning in the fiscal year after the fiscal year when this amendatory Act
of 1990 becomes effective, the rate structure may provide for an additional
payment to such facility not to exceed 50 cents per resident per day if 60%
or more of the residents in the facility request kosher foods or food
products prepared in accordance with Jewish religious dietary requirements
for religious purposes in a fully kosher facility.  Based upon food cost
reports of the Illinois Department of Agriculture regarding kosher and
non-kosher food available in the various regions of the State, this rate
structure may be periodically adjusted by the Department but may not exceed
the maximum authorized under this subsection (a).
(b) The Department shall by rule determine how a facility with a fully
kosher kitchen and food service may be determined to be eligible and apply
for the rate accommodation specified in subsection (a).
(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.6) (from Ch. 23, par. 5-5.6)
Sec. 5-5.6. 
		Federal Requirements. 
		All reimbursement
rates established pursuant to this Act must be consistent
with the criteria for nursing facility reimbursement
established by the Federal government for approval of
matching funds under Title XIX of the Federal
Social Security Act.
(Source: P.A. 80-1142.)
(305 ILCS 5/5-5.6a)
Sec. 5-5.6a. (Repealed).
(Source: P.A. 85-1440. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.6b) (from Ch. 23, par. 5-5.6b)
Sec. 5-5.6b. Prohibition against double payment. If any resident of a
 nursing facility or ICF/DD is admitted to such
facility on the basis that the charges for such resident's care will be
paid from private funds, and the source of payment for such care thereafter
changes from private funds to payments under this Article, the facility
shall, upon receiving the first such payment under this Article, notify the
Illinois Department of such source of private funds for such recipient and
repay to the source of private funds any amounts received from such source
as payment for care for which payment also was made under this Article.
Private funds shall not include third party resources such as
insurance or Medicare benefits or payments made by responsible relatives.
(Source: P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.7) (from Ch. 23, par. 5-5.7)
Sec. 5-5.7. Cost reports - audits. The Department of Healthcare and Family Services shall
work with the Department of Public Health to use cost report information
currently being collected under provisions of the Nursing Home Care
Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, and the MC/DD Act.  The Department of Healthcare and Family Services may, in conjunction with the Department of Public Health,
develop in accordance with generally accepted accounting principles a
uniform chart of accounts which each facility providing services under the
medical assistance program shall adopt, after a reasonable period.
Facilities licensed under the Nursing Home Care Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act
and providers of adult developmental training services certified by the
Department of Human Services pursuant to
Section 15.2 of the Mental Health and Developmental Disabilities Administrative
Act which provide
services to clients eligible for
medical assistance under this Article are responsible for submitting the
required annual cost report to the Department of Healthcare and Family Services.
The Department of Healthcare and Family Services

shall audit the financial and statistical
records of each provider participating in the medical assistance program
as a nursing facility, a specialized mental health rehabilitation facility, or an ICF/DD over a 3 year period,
beginning with the close of the first cost reporting year.  Following the
end of this 3-year term, audits of the financial and statistical records
will be performed each year in at least 20% of the facilities participating
in the medical assistance program with at least 10% being selected on a
random sample basis, and the remainder selected on the basis of exceptional
profiles.  All audits shall be conducted in accordance with generally accepted
auditing standards.
The Department of Healthcare and Family Services

shall establish prospective payment rates
for categories or levels of services within each licensure class, in order to more appropriately recognize the
individual needs of patients in nursing facilities.
The Department of Healthcare and Family Services

shall provide, during the process of
establishing the payment rate for nursing facility, specialized mental health rehabilitation facility, or ICF/DD
services, or when a substantial change in rates is proposed, an opportunity
for public review and comment on the proposed rates prior to their becoming
effective.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
(305 ILCS 5/5-5.7a)
Sec. 5-5.7a. Pandemic related stability payments for health care providers. Notwithstanding other provisions of law, and in accordance with the Illinois Emergency Management Agency, the Department of Healthcare and Family Services shall develop a process to distribute pandemic related stability payments, from federal sources dedicated for such purposes, to health care providers that are providing care to recipients under the Medical Assistance Program. For provider types serving residents who are recipients of medical assistance under this Code and are funded by other State agencies, the Department will coordinate the distribution process of the pandemic related stability payments. Federal sources dedicated to pandemic related payments include, but are not limited to, funds distributed to the State of Illinois from the Coronavirus Relief Fund pursuant to the Coronavirus Aid, Relief, and Economic Security Act ("CARES Act") and from the Coronavirus State Fiscal Recovery Fund pursuant to Section 9901 of the American Rescue Plan Act of 2021, that are appropriated to the Department during Fiscal Years 2020, 2021, and 2022 for purposes permitted by those federal laws and related federal guidance.
(1) Pandemic related stability payments for these     providers shall be separate and apart from any rate methodology otherwise defined in this Code to the extent permitted in accordance with Section 5001 of the CARES Act and Section 9901 of the American Rescue Plan Act of 2021 and any related federal guidance.
(2) Payments made from moneys received from the     Coronavirus Relief Fund shall be used exclusively for expenses incurred by the providers that are eligible for reimbursement from the Coronavirus Relief Fund in accordance with Section 5001 of the CARES Act and related federal guidance. Payments made from moneys received from the Coronavirus State Fiscal Recovery Fund shall be used exclusively for purposes permitted by Section 9901 of the American Rescue Plan Act of 2021 and related federal guidance.
(3) All providers receiving pandemic related     stability payments shall attest in a format to be created by the Department and be able to demonstrate that their expenses are pandemic related, were not part of their annual budgets established before March 1, 2020.
(4) Pandemic related stability payments will be     distributed based on a schedule and framework to be established by the Department with recognition of the pandemic related acuity of the situation for each provider, taking into account the factors including, but not limited to, the following:
(A) the impact of the pandemic on patients         served, impact on staff, and shortages of the personal protective equipment necessary for infection control efforts for all providers;
(B) COVID-19 positivity rates among staff, or         patients, or both;
(C) pandemic related workforce challenges and         costs associated with temporary wage increases associated with pandemic related hazard pay programs, or costs associated with which providers do not have enough staff to adequately provide care and protection to the residents and other staff;
(D) providers with significant reductions in         utilization that result in corresponding reductions in revenue as a result of the pandemic, including, but not limited to, the cancellation or postponement of elective procedures and visits;
(E) pandemic related payments received directly         by the providers through other federal resources;
(F) current efforts to respond to and provide         services to communities disproportionately impacted by the COVID-19 public health emergency, including low-income and socially vulnerable communities that have seen the most severe health impacts and exacerbated health inequities along racial, ethnic, and socioeconomic lines; and
(G) provider needs for capital improvements to         existing facilities, including upgrades to HVAC and ventilation systems and capital improvements for enhancing infection control or reducing crowding, which may include bed-buybacks.
(5)  Pandemic related stability payments made from     moneys received from the Coronavirus Relief Fund will be distributed to providers based on a methodology to be administered by the Department with amounts determined by a calculation of total federal pandemic related funds appropriated by the Illinois General Assembly for this purpose. Providers receiving the pandemic related stability payments will attest to their increased costs, declining revenues, and receipt of additional pandemic related funds directly from the federal government.
(6) Of the payments provided for by this Section made     from moneys received from the Coronavirus Relief Fund, a minimum of 30% shall be allotted for health care providers that serve the ZIP codes located in the most disproportionately impacted areas of Illinois, based on positive COVID-19 cases based on data collected by the Department of Public Health and provided to the Department of Healthcare and Family Services.
(7) From funds appropriated, directly or indirectly,     from moneys received by the State from the Coronavirus State Fiscal Recovery Fund for Fiscal Years 2021 and 2022, the Department shall expend such funds only for purposes permitted by Section 9901 of the American Rescue Plan Act of 2021 and related federal guidance.  Such expenditures may include, but are not limited to: payments to providers for costs incurred due to the COVID-19 public health emergency; unreimbursed costs for testing and treatment of uninsured Illinois residents; costs of COVID-19 mitigation and prevention; medical expenses related to aftercare or extended care for COVID-19 patients with longer term symptoms and effects; costs of behavioral health care; costs of public health and safety staff; and expenditures permitted in order to address (i) disparities in public health outcomes, (ii) nursing and other essential health care workforce investments, (iii) exacerbation of pre-existing disparities, and  (iv) promoting healthy childhood environments.
(8) From funds appropriated, directly or indirectly,     from moneys received by the State from the Coronavirus State Fiscal Recovery Fund for Fiscal Years 2022 and 2023, the Department shall establish a program for making payments to long term care service providers and facilities, for purposes related to financial support for workers in the long term care industry, but only as permitted by either the CARES Act or Section 9901 of the American Rescue Plan Act of 2021 and related federal guidance, including, but not limited to the following: monthly amounts of $25,000,000 per month for July 2021, August 2021, and September 2021 where at least 50% of the funds in July shall be passed directly to front line workers and an additional 12.5% more in each of the next 2 months; financial support programs for providers enhancing direct care staff recruitment efforts through the payment of education expenses; and financial support programs for providers offering enhanced and expanded training for all levels of the long term care healthcare workforce to achieve better patient outcomes, such as training on infection control, proper personal protective equipment, best practices in quality of care, and culturally competent patient communications. The Department shall have the authority to audit and potentially recoup funds not utilized as outlined and attested.
(8.5) From funds appropriated, directly or     indirectly, from moneys received by the State from the Coronavirus State Fiscal Recovery Fund, the Department shall establish a grant program to provide premium pay and retention incentives to front line workers at facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities.
(A)   Awards pursuant to this program shall         comply with the requirements of Section 9901 of the American Rescue Plan Act of 2021 and all related federal guidance. Awards shall be scaled based on a process determined by the Department. The amount awarded to each recipient shall not exceed $3.17 per nursing hour. Awards shall be for eligible expenditures incurred no earlier than May 1, 2022 and no later than June 30, 2023.
(B)   Financial assistance under this paragraph         (8.5) shall be expended for:
(i) premium pay for eligible workers, which             must be in addition to any wages or remuneration the eligible worker has already received and shall be subject to the other requirements and limitations set forth in the American Rescue Plan Act of 2021 and related federal guidance; and
(ii) retention incentives paid to eligible
workers that are necessary for the facility to respond to the impacts of the public health emergency.
(C)   Upon receipt of funds, recipients shall         distribute funds such that eligible workers receive an amount up to $13 per hour but no more than $25,000 for the duration of the program. Recipients shall provide a written certification to the Department acknowledging compliance with this paragraph.
(D)   No portion of these funds shall be spent on         volunteer or temporary staff, and these funds shall not be used to make retroactive premium payments before the effective date of this amendatory Act of the 102nd General Assembly.
(E)   The Department shall require each recipient         under this paragraph  to submit appropriate documentation acknowledging compliance with State and federal law. For purposes of this paragraph, "eligible worker" means a permanent staff member, regardless of union affiliation, of a facility licensed by the Department of Public Health under the Nursing Home Care Act as a skilled nursing facility or intermediate care facility engaged in "essential work", as defined by Section 9901 of the American Rescue Plan Act of 2021 and related federal guidance, and (1) whose total pay is below 150% of the average annual wage for all occupations in the worker's county of residence, as defined by the Bureau of Labor Statistics Occupational Employment and Wage Statistics, or (2) is not exempt from the federal Fair Labor Standards Act overtime provisions.
(9) From funds appropriated, directly or indirectly,     from moneys received by the State from the Coronavirus State Fiscal Recovery Fund for Fiscal Years 2022 through 2024 the Department shall establish programs for making payments to facilities licensed under the Nursing Home Care Act and facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013. To the extent permitted by Section 9901 of the American Rescue Plan Act of 2021 and related federal guidance, the programs shall provide:
(A) Payments for making permanent improvements to         resident rooms in order to improve resident outcomes and infection control. Funds may be used to reduce bed capacity and room occupancy.  To be eligible for funding, a facility must submit an application to the Department as prescribed by the Department and as published on its website. A facility may need to receive approval from the Health Facilities and Services Review Board for the permanent improvements or the removal of the beds before it can receive payment under this paragraph.
(B)   Payments to reimburse facilities licensed         by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities for eligible expenses related to the public health impacts of the COVID-19 public health emergency, including, but not limited to, costs related to COVID-19 testing for residents, COVID-19 prevention and treatment equipment, medical supplies, and personal protective equipment.
(i)   Awards made pursuant to this program             shall comply with the requirements of Section 9901 of the American Rescue Plan Act of 2021 and all related federal guidance. The amount awarded to each recipient shall not exceed $1.71 per nursing hour. Permissible expenditures must be made no earlier than May 1, 2022 and no later than June 30, 2023.
(ii)   Financial assistance pursuant to this             paragraph shall not be expended for premium pay.
(iii)   The Department shall require each             recipient under this paragraph to submit appropriate documentation acknowledging compliance with State and federal law. (Source: P.A. 102-16, eff. 6-17-21; 102-687, eff. 12-17-21; 102-699, eff. 4-19-22; 103-8, eff. 6-7-23.)
(305 ILCS 5/5-5.7b)
Sec. 5-5.7b. Pandemic related stability payments to ambulance service providers in response to COVID-19.
(a)    Definitions. As used in this Section:
"Ambulance Services Industry" means the industry that is comprised of "Qualifying Ground Ambulance Service Providers", as defined in this Section.
"Qualifying Ground Ambulance Service Provider" means a "vehicle service provider," as that term is defined in Section 3.85 of the Emergency Medical Services (EMS) Systems Act, which operates licensed ambulances for the purpose of providing emergency, non-emergency ambulance services, or both emergency and non-emergency ambulance services. The term "Qualifying Ground Ambulance Service Provider" is limited to ambulance and EMS agencies that are privately held  and nonprofit organizations headquartered within the State and licensed by the Department of Public Health as of March 12, 2020.
"Eligible worker" means a staff member of a Qualifying Ground Ambulance Service Provider engaged in "essential work", as defined by Section 9901 of the ARPA and related federal guidance, and (1) whose total pay is below 150% of the average annual wage for all occupations in the worker's county of residence, as defined by the BLS Occupational Employment and Wage Statistics or (2) is not exempt from the federal Fair Labor Standards Act overtime provisions.
(b)   Purpose. The Department may receive federal funds under the authority of legislation passed in response to the Coronavirus epidemic, including, but not limited to, the American Rescue Plan Act of 2021, P.L. 117-2 (the "ARPA"). Upon receipt or availability of such State or federal funds, and subject to appropriations for their use, the Department shall establish and administer programs for purposes allowable under Section 9901 of the ARPA to provide financial assistance to Qualifying Ground Ambulance Service Providers for premium pay for eligible workers, to provide reimbursement for eligible expenditures, and to provide support following the negative economic impact of the COVID-19 public health emergency on the Ambulance Services Industry. Financial assistance may include, but is not limited to, grants, expense reimbursements, or subsidies.
(b-1)   By December 31, 2022, the Department shall obtain appropriate documentation from Qualifying Ground Ambulance Service Providers to ascertain an accurate count of the number of licensed vehicles available to serve enrollees in the State's medical assistance programs, which shall be known as the "total eligible vehicles".   By February 28, 2023, Qualifying Ground Ambulance Service Providers  shall be initially notified of their eligible award, which shall be the product of (i) the total amount of funds allocated under this Section and (ii) a quotient, the numerator of which is the number of licensed ground ambulance vehicles of an individual Qualifying Ground Ambulance Service Provider and the denominator of which is the total eligible vehicles. After March 31, 2024, any unobligated funds shall be reallocated pro rata to the remaining Qualifying Ground Ambulance Service Providers that are able to prove up eligible expenses in excess of their initial award amount until all such appropriated funds are exhausted.
Providers shall indicate to the Department what portion of their award they wish to allocate under the purposes outlined under paragraphs (d), (e), or (f), if applicable, of this Section.
(c)   Non-Emergency Service Certification. To be eligible for funding under this Section, a Qualifying Ground Ambulance Service Provider that provides non-emergency services to institutional residents must certify whether or not it is able to provide non-emergency ambulance services to individuals enrolled in the State's Medical Assistance Program and residing in non-institutional settings for at least one year following the receipt of funding pursuant to this amendatory Act of the 102nd General Assembly.  Certification indicating that a provider has such an ability does not mean that a provider is required to accept any or all requested transports.
(d)   Premium Pay Initiative. Subject to paragraph (c) of this Section, the Department shall establish a Premium Pay Initiative to distribute awards to each Qualifying Ground Ambulance Service Provider for the purpose of providing premium pay to eligible workers.
(1)   Financial assistance pursuant to this paragraph     (d) shall be scaled based on a process determined by the Department. The amount awarded to each Qualifying Ground Ambulance Service Provider shall be up to $13 per hour for each eligible worker employed.
(2)   The financial assistance awarded shall only be     expended for premium pay for eligible workers, which must be in addition to any wages or remuneration the eligible worker has already received and shall be subject to the other requirements and limitations set forth in the ARPA and related federal guidance.
(3)   Upon receipt of funds, the Qualifying Ground     Ambulance Service Provider shall distribute funds such that an eligible worker receives an amount up to $13 per hour but no more than $25,000 for the duration of the program. The Qualifying Ground Ambulance Service Provider shall provide a written certification to the Department acknowledging compliance with this paragraph (d).
(4)  No portion of these funds shall be spent on     volunteer staff.
(5)   These funds shall not be used to make     retroactive premium payments prior to the effective date of this amendatory Act of the 102nd General Assembly.
(6)   The Department shall require each Qualifying     Ground Ambulance Service Provider that receives funds under this paragraph (d) to submit appropriate documentation acknowledging compliance with State and federal law on an annual basis.
(e)   COVID-19 Response Support Initiative. Subject to paragraph (c) of this Section and based on an application filed by a Qualifying Ground Ambulance Service Provider, the Department shall establish the Ground Ambulance COVID-19 Response Support Initiative. The purpose of the award shall be to reimburse Qualifying Ground Ambulance Service Providers for eligible expenses under Section 9901 of the ARPA related to the public health impacts of the COVID-19 public health emergency, including, but not limited to: (i) costs incurred due to the COVID-19 public health emergency; (ii) costs related to vaccination programs, including vaccine incentives; (iii) costs related to COVID-19 testing; (iv) costs related to COVID-19 prevention and treatment equipment; (v) expenses for medical supplies; (vi) expenses for personal protective equipment; (vii) costs related to isolation and quarantine; (viii) costs for ventilation system installation and improvement; (ix) costs related to other emergency response equipment, such as ground ambulances, ventilators, cardiac monitoring equipment, defibrillation equipment, pacing equipment, ambulance stretchers, and radio equipment; and (x) other emergency medical response expenses.
(1)   The award shall be for eligible obligated     expenditures incurred no earlier than May 1, 2022 and no later than June 30, 2024. Expenditures under this paragraph must be incurred by June 30, 2025.
(2)   Funds awarded under this paragraph (e) shall     not be expended for premium pay to eligible workers.
(3)   The Department shall require each Qualifying     Ground Ambulance Service Provider that receives funds under this paragraph (e) to submit appropriate documentation acknowledging compliance with State and federal law on an annual basis. For purchases of medical equipment or other capital expenditures, the Qualifying Ground Ambulance Service Provider shall include documentation that describes the harm or need to be addressed by the expenditures and how that capital expenditure is appropriate to address that identified harm or need.
(f)     Ambulance Industry Recovery Program. If the Department designates the Ambulance Services Industry as an "impacted industry", as defined by the ARPA and related federal guidance, the Department shall establish the Ambulance Industry Recovery Grant Program, to provide aid to Qualifying Ground Ambulance Service Providers that experienced staffing losses due to the COVID-19 public health emergency.
(1)      Funds awarded under this paragraph (f) shall     not be expended for premium pay to eligible workers.
(2)     Each Qualifying Ground Ambulance Service     Provider that receives funds under this paragraph (f) shall comply with paragraph (c) of this Section.
(3)   The Department shall require each Qualifying     Ground Ambulance Service Provider that receives funds under this paragraph (f) to submit appropriate documentation acknowledging compliance with State and federal law on an annual basis.
(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23.)
(305 ILCS 5/5-5.8) (from Ch. 23, par. 5-5.8)
Sec. 5-5.8. Report on nursing home reimbursement. The Illinois
Department shall report annually to the General Assembly, no later than the
first Monday in April of 1982, and each year thereafter, in regard to:
(a) the rate structure used by the Illinois     Department to reimburse nursing facilities;
(b) changes in the rate structure for reimbursing     nursing facilities;
(c) the administrative and program costs of     reimbursing nursing facilities;
(d) the availability of beds in nursing facilities     for public aid recipients;
(e) the number of closings of nursing facilities, and     the reasons for those closings; and
(f) for years beginning 2025 and thereafter, drawing     on all available information that evaluates, to the extent possible, nursing facility costs and revenue, including a focus on the period of initial implementation of the payments and programs authorized in this Act.
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.
(Source: P.A. 102-1035, eff. 5-31-22.)
(305 ILCS 5/5-5.8a)
Sec. 5-5.8a. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 96-1123, eff. 1-1-11.)
(305 ILCS 5/5-5.8b) (from Ch. 23, par. 5-5.8b)
Sec. 5-5.8b. Payment to Campus Facilities. There is hereby established
a separate payment category for campus facilities.  A "campus facility" is
defined as an entity which consists of a long term care facility (or group
of facilities if the facilities are on the same contiguous parcel of real
estate) which meets all of the following criteria as of May 1,
1987:  the
entity provides care for both children and adults; residents of the entity
reside in three or more separate buildings with congregate and small group
living arrangements on a single campus; the entity provides three or more
separate licensed levels of care; the entity (or a part of the entity) is
enrolled with the Department of Healthcare and Family Services as a provider of long term care
services and receives payments from that Department; the
entity (or a part of the entity) receives funding from the Department of
 Human
Services; and the entity (or a part of
the entity) holds a current license as a child care institution issued by
the Department of Children and Family Services.
The Department of Healthcare and Family Services, the Department of Human Services, and the Department of Children and Family
Services shall develop jointly a rate methodology or methodologies for
campus facilities.  Such methodology or methodologies may establish a
single rate to be paid by all the agencies, or a separate rate to be paid
by each agency, or separate components to be paid to
different parts of the campus facility.  All campus facilities shall
receive the same rate of payment for similar services.  Any methodology
developed pursuant to this section shall take into account the actual costs
to the facility of providing services to residents, and shall be adequate
to reimburse the allowable costs of a campus facility which is economically
and efficiently operated.  Any methodology shall be established on the
basis of historical, financial, and statistical data submitted by campus
facilities, and shall take into account the actual costs incurred by campus
facilities in providing services, and in meeting licensing and
certification standards imposed and prescribed by the State of Illinois,
any of its political subdivisions or municipalities and by the United
States Department of Health and Human Services.  Rates may be established
on a prospective or retrospective basis.  Any methodology shall provide
reimbursement for appropriate payment elements, including the following:
standard services, patient services, real estate taxes, and capital costs.
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.
(Source: P.A. 96-1530, eff. 2-16-11; 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.09)
Sec. 5-5.09. Mental health professionals; veterans.
(a) The General Assembly is proud of and grateful to members of all branches of the United States Armed Forces.  The General Assembly recognizes that returning veterans may have unique and specific needs that are better understood and addressed by persons with military exposure.   The Department of Healthcare and Family Services shall seek federal approval of an amendment to the Illinois Title XIX State Plan for the purpose of allowing a person who has completed a psychiatric training certification program from any branch of the United States Armed Forces and who has at least one year of experience in a mental health setting to be recognized as a mental health professional.
(b) Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department of Healthcare and Family Services, in collaboration with all necessary partners including the Department of Human Services, shall adopt within 180 days after the date upon which federal approval is received any necessary rules that would allow a person who has completed a psychiatric training certification program from any branch of the United States Armed Forces and who has at least one year of experience in a mental health setting to be recognized as a mental health professional for purposes of programs authorized or funded by the Department of Healthcare and Family Services under the standards of practice as authorized by the Department.
(Source: P.A. 100-908, eff. 1-1-19.)
(305 ILCS 5/5-5.10)
Sec. 5-5.10. Value-based purchasing.
(a) The Department of Healthcare and Family Services, and, as appropriate, divisions within the Department of Human Services, shall confer with stakeholders to discuss development of alternative value-based payment models that move away from fee-for-service and reward health outcomes and improved quality and provide flexibility in how providers meet the needs of the individuals they serve.  Stakeholders include providers, managed care organizations, and community-based and advocacy organizations. The approaches explored may be different for different types of services.
(b) The Department of Healthcare and Family Services  and the Department of Human Services shall initiate discussions with mental health providers, substance abuse providers, managed care organizations, advocacy groups for individuals with behavioral health issues, and others, as appropriate, no later than July 1, 2019.  A model for value-based purchasing for behavioral health providers shall be presented to the General Assembly by January 31, 2020. In developing this model, the Department of Healthcare and Family Services shall develop projections of the funding necessary for the model.
(Source: P.A. 101-209, eff. 8-5-19.)
(305 ILCS 5/5-5.11)
Sec. 5-5.11. (Repealed).
(Source: P.A. 83-748. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
Sec. 5-5.12. Pharmacy payments.
(a) Every request submitted by a pharmacy for reimbursement under this
Article for prescription drugs provided to a recipient of aid under this
Article shall include the name of the prescriber or an acceptable
identification number as established by the Department.
(b) Pharmacies providing prescription drugs under
this Article shall be reimbursed at a rate which shall include
a professional dispensing fee as determined by the Illinois
Department, plus the current acquisition cost of the prescription
drug dispensed. The Illinois Department shall update its
information on the acquisition costs of all prescription drugs
no less frequently than every 30 days. However, the Illinois
Department may set the rate of reimbursement for the acquisition
cost, by rule, at a percentage of the current average wholesale
acquisition cost.
(c) (Blank).
(d) The Department shall review utilization of narcotic medications in the medical assistance program and impose utilization controls that protect against abuse.
(e) When making determinations as to which drugs shall be  on a prior approval list, the Department shall include as part of the analysis for this determination, the degree to which a drug may affect individuals in different ways based on factors including the gender of the person taking the medication.
(f) The Department shall cooperate with the Department of Public Health and the Department of Human Services Division of Mental Health in identifying psychotropic medications that, when given in a particular form, manner, duration, or frequency (including "as needed") in a dosage, or in conjunction with other psychotropic medications to a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act or the MC/DD Act, may constitute a chemical restraint or an "unnecessary drug" as defined by the Nursing Home Care Act or Titles XVIII and XIX of the Social Security Act and the implementing rules and regulations.  The Department shall require prior approval for any such medication prescribed for a nursing home resident or to a resident of a facility licensed under the ID/DD Community Care Act or the MC/DD Act, that appears to be a chemical restraint or an unnecessary drug.  The Department shall consult with the Department of Human Services Division of Mental Health in developing a protocol and criteria for deciding whether to grant such prior approval.
(g) The Department may by rule provide for reimbursement of the dispensing of a 90-day supply of a generic or brand name, non-narcotic maintenance medication in circumstances where it is cost effective.
(g-5) On and after July 1, 2012, the Department may require the dispensing of drugs to nursing home residents be in a 7-day supply or other amount less than a 31-day supply. The Department shall pay only one dispensing fee per 31-day supply.
(h) Effective July 1, 2011, the Department shall discontinue coverage of select over-the-counter drugs, including analgesics and cough and cold  and allergy medications.
(h-5) On and after July 1, 2012, the Department shall impose utilization controls, including, but not limited to, prior approval on specialty drugs, oncolytic drugs, drugs for the treatment of HIV or AIDS, immunosuppressant drugs, and biological products in order to maximize savings on these drugs. The Department may adjust payment methodologies for non-pharmacy billed drugs in order to incentivize the selection of lower-cost drugs. For drugs for the treatment of AIDS, the Department shall take into consideration the potential for non-adherence by certain populations, and shall develop protocols with organizations or providers primarily serving those with HIV/AIDS, as long as such measures intend to maintain cost neutrality with other utilization management controls such as prior approval.
For hemophilia, the Department shall develop a program of utilization review and control which may include, in the discretion of the Department, prior approvals. The Department may impose special standards on providers that dispense blood factors which shall include, in the discretion of the Department, staff training and education; patient outreach and education; case management; in-home patient assessments; assay management; maintenance of stock; emergency dispensing timeframes; data collection and reporting; dispensing of supplies related to blood factor infusions; cold chain management and packaging practices; care coordination; product recalls; and emergency clinical consultation. The Department may require patients to receive a comprehensive examination annually at an appropriate provider in order to be eligible to continue to receive blood factor.
(i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(j) On and after July 1, 2012, the Department shall impose limitations on prescription drugs such that the Department shall not provide reimbursement for more than 4 prescriptions, including 3 brand name prescriptions, for distinct drugs in a 30-day period, unless prior approval is received for all prescriptions in excess of the 4-prescription limit. Drugs in the following therapeutic classes shall not be subject to prior approval as a result of the 4-prescription limit:  immunosuppressant drugs, oncolytic drugs, anti-retroviral drugs, and, on or after July 1, 2014, antipsychotic drugs. On or after July 1, 2014, the Department may exempt children with complex medical needs enrolled in a care coordination entity contracted with the Department to solely coordinate care for such children, if the Department determines that the entity has a comprehensive drug reconciliation program.
(k)    No medication therapy management program implemented by the Department shall be contrary to the provisions of the Pharmacy Practice Act.
(l)    Any provider enrolled with the Department that bills the Department for outpatient drugs and is eligible to enroll in the federal Drug Pricing Program under Section 340B of the federal Public Health Service Act shall enroll in that program. No entity participating in the  federal Drug Pricing Program under Section 340B of the federal Public Health Service Act may exclude fee-for-service Medicaid from their participation in that program, however, entities defined in Section 1905(l)(2)(B) of the Social Security Act are excluded from this requirement. This subsection does not apply to outpatient drugs billed to Medicaid managed care organizations.
(Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)
(305 ILCS 5/5-5.12a)
Sec. 5-5.12a. 
		Title XIX waiver; pharmacy assistance program. 
		The
Illinois Department may seek a waiver of otherwise applicable requirements
of Title XIX of the federal Social Security Act in order to claim federal
financial participation for a pharmacy assistance program for persons aged
65 and over with income levels at or less than 250% of the federal poverty
level.  The Illinois Department may provide by rule for all other requirements
of the program, including cost sharing, as permitted by an approved waiver and
without regard to any provision of this Code to the contrary.  The benefits may
be no more restrictive than the Pharmacy Assistance Program in effect on May
31, 2001.  Benefits provided under the waiver are subject to appropriation.
The Illinois Department may not implement the waiver until cost neutrality is
demonstrated for the State relative to the final Pharmacy Assistance Program
appropriation for the fiscal year beginning July 1, 2001.  Implementation of
the waiver shall terminate on June 30, 2007.
(Source: P.A. 92-10, eff. 6-11-01.)
(305 ILCS 5/5-5.12b)
Sec. 5-5.12b. Critical access care pharmacy program.
(a) As used in this Section:
"Critical access care pharmacy" means an Illinois-based brick and mortar pharmacy that is located in a county with fewer than 50,000 residents  and that owns fewer than 10 pharmacies.
"Critical access care pharmacy program payment" means the number of individual prescriptions a critical access care pharmacy fills during that quarter multiplied by the lesser of the individual payment amount or the dispensing reimbursement rate made by the Department under the medical assistance program as of April 1, 2018.
"Individual payment amount" means the dividend of 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter.
(b) Subject to appropriations, the Department shall establish a critical access care pharmacy program to ensure the sustainability of critical access pharmacies throughout the State of Illinois.
(c) The critical access care pharmacy program shall not exceed $10,000,000 annually and individual payment amounts per prescription shall not exceed the dispensing rate that the Department would have reimbursed under the Medical Assistance Program as of April 1, 2018.
(d) Quarterly, the Department shall determine the number of prescriptions filled by critical access care pharmacies reimbursed by Medicaid managed care organizations utilizing encounter data available to the Department.  The Department shall determine the individual payment amount per prescription by dividing 1/4 of the annual amount appropriated for the critical access care pharmacy program by the number of prescriptions filled by all critical access care pharmacies reimbursed by Medicaid managed care organizations that quarter. If the individual payment amount per prescription as calculated using quarterly prescription amounts exceeds the reimbursement rate under the medical assistance program as of April 1, 2018, then the individual payment amount per prescription shall be the dispensing reimbursement rate under the medical assistance program as of April 1, 2018.
(e) Quarterly, the Department shall distribute to critical access care pharmacies a critical access care pharmacy program payment. The first payment shall be calculated utilizing the encounter data from the last quarter of State fiscal year 2018.
(f) The Department may adopt rules permitting an Illinois-based brick and mortar pharmacy that owns fewer than 10 pharmacies to receive critical access care pharmacy program payments in the same manner as a critical access care pharmacy, regardless of whether the pharmacy is located in a county with a population of less than 50,000.
(Source: P.A. 100-587, eff. 6-4-18.)
(305 ILCS 5/5-5.12c)
Sec. 5-5.12c. Managed care organization uniform electronic prior authorization form; prescription benefits.
(a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.
(b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, a managed care organization that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits.
(c) On or before July 1, 2020, the Department of Healthcare and Family Services shall develop a uniform electronic prior authorization form that shall be used by managed care organizations.  Notwithstanding any other provision of law to the contrary, on and after July 1, 2021, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits, and every managed care organization shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits.
(d)  The Department of Healthcare and Family Services shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director of Healthcare and Family Services:  2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents managed care organizations, from at least one public meeting.
(e) The Department of Healthcare and Family Services, in development of the uniform electronic prior authorization form, shall take into consideration the following:
(1) existing prior authorization forms established by     the federal Centers for Medicare and Medicaid Services and the Department of Healthcare and Family Services; and
(2) national standards pertaining to electronic prior     authorization.
(f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, a managed care organization fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours, then the prior authorization request shall be deemed to have been granted.
(Source: P.A. 101-463, eff. 1-1-20.)
(305 ILCS 5/5-5.12d)
Sec. 5-5.12d. Coverage for patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis provided by a pharmacist.
(a) Subject to approval by the federal Centers for Medicare and Medicaid Services, the medical assistance program, including both the fee-for-service and managed care medical assistance programs established under this Article, shall cover patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation.
(b) The Department shall establish a fee schedule for patient care services provided by a pharmacist under Sections 43 and 43.5 of the Pharmacy Practice Act and shall be covered and reimbursed at no less than 85% of the rate that the services are reimbursed when provided by a physician.
(c) The rate of reimbursement for patient care services provided by a pharmacist for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation shall be at 85% of the fee schedule for physician services by the medical assistance program.
(d) A pharmacist must be enrolled in the medical assistance program as an ordering and referring provider prior to providing patient care services for hormonal contraceptives, human immunodeficiency virus pre-exposure prophylaxis, and human immunodeficiency virus post-exposure prophylaxis assessment and consultation that is submitted by a pharmacy or pharmacist provider for reimbursement pursuant to this Section.
(e) The Department shall apply for any necessary federal waivers or approvals to implement this Section by January 1, 2023.
(f) This Section does not restrict or prohibit any services currently provided by pharmacists as authorized by law, including, but not limited to, pharmacist services provided under this Code or authorized under the Illinois Title XIX State Plan.
(g) The Department shall submit to the Joint Committee on Administrative Rules administrative rules for this Section as soon as practicable but no later than 6 months after federal approval is received.
(Source: P.A. 102-103, eff. 1-1-22; 102-813, eff. 5-13-22; 102-1051, eff. 1-1-23.)
(305 ILCS 5/5-5.12e)
Sec. 5-5.12e. Managed care organization prior authorization of health care services.
(a)   As used in this Section, "health care service" has the meaning given to that term in the Prior Authorization Reform Act.
(b)   Notwithstanding any other provision of law to the contrary, all managed care organizations shall comply with the requirements of the Prior Authorization Reform Act.
(Source: P.A. 102-409, eff. 1-1-22; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-5.13) (from Ch. 23, par. 5-5.13)
Sec. 5-5.13. 
		
		The Illinois Department shall establish procedures for the
expedited review, for purposes of inclusion in the Illinois Public Aid
formulary, of any drug for the treatment of acquired immunodeficiency syndrome
(AIDS) which the federal Food and Drug Administration has indicated is subject
to a treatment investigational new drug application.
(Source: P.A. 88-85.)
(305 ILCS 5/5-5.14)
Sec. 5-5.14. 
		(Repealed).
(Source: Repealed by P.A. 88-85.)
(305 ILCS 5/5-5.14.5)
Sec. 5-5.14.5. Treatment; substance use disorder and mental health. The Department shall consult with stakeholders and General Assembly members for input on a plan to develop enhanced Medicaid rates for substance use disorder treatment and mental health treatment in underserved communities. The Department shall present the plan to General Assembly members within 3 months of the effective date of this amendatory Act of the 101st General Assembly, which will specifically address ensuring access to treatment in provider deserts. Within 4 months of the effective date of this amendatory Act of the 101st General Assembly, the Department shall submit a State plan amendment to create medical assistance enhanced rates to enhance access to those to community mental health services and substance abuse services for underserved communities.

Subject to federal approval, the Department shall create medical assistance enhanced rates for community mental health services and substance abuse providers for underserved communities to enhance access to those communities.
(Source: P.A. 101-10, eff. 6-5-19.)
(305 ILCS 5/5-5.15)
Sec. 5-5.15. (Repealed).
(Source: P.A. 83-1509. Repealed by P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-5.16) (from Ch. 23, par. 5-5.16)
Sec. 5-5.16. 
		(Repealed).
(Source: P.A. 90-372, eff. 7-1-98.  Repealed internally, eff. 7-1-98.)
(305 ILCS 5/5-5.17) (from Ch. 23, par. 5-5.17)
Sec. 5-5.17. Separate reimbursement rate. The Illinois Department may
by rule establish a separate reimbursement rate to be paid to long term
care facilities for adult developmental training services as defined in
Section 15.2 of the Mental Health and Developmental Disabilities Administrative
Act which are provided to 
residents of such facilities who have intellectual disabilities and who receive aid under this Article.  Any such
reimbursement shall be based upon cost reports submitted by the providers
of such services and shall be paid by the long term care facility to the
provider within such time as the Illinois Department shall prescribe by
rule, but in no case less than 3 business days after receipt of the
reimbursement by such facility from the Illinois Department.  The Illinois
Department may impose a penalty upon a facility which does not make payment
to the provider of adult developmental training services within the time so
prescribed, up to the amount of payment not made to the provider.
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.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-5.18)
Sec. 5-5.18. 
		Diagnosis accompanying request for reimbursement. 
		Every
request submitted by a physician for reimbursement under this Article for
services provided to a recipient of aid under this Article shall include the
physician's diagnosis of the recipient's illness or other condition requiring
those services.  The diagnosis shall be either written out or expressed in a
code approved by the Illinois Department.
(Source: P.A. 88-554, eff. 7-26-94.)
(305 ILCS 5/5-5.19)
Sec. 5-5.19. 
		Reimbursement request records. 
		The Illinois Department shall
file all requests for reimbursement for medical services provided under this
Article
according to both (i) the name of the service provider and (ii) the name of the
recipient of aid under this Article to whom the medical services were
provided.
(Source: P.A. 88-554, eff. 7-26-94.)
(305 ILCS 5/5-5.20)
Sec. 5-5.20. Clinic payments. For services provided by federally
qualified health centers as defined in Section 1905 (l)(2)(B) of the federal
Social Security Act, on or after April 1, 1989, and as long as required by
federal law, the Illinois Department shall
reimburse those health centers for those services according to a prospective
cost-reimbursement methodology.
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.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-5.21)
Sec. 5-5.21. (Repealed).
(Source: P.A. 89-415, eff. 1-1-96. Repealed by P.A. 96-1530, eff. 2-16-11.)
(305 ILCS 5/5-5.22)
Sec. 5-5.22. (Repealed).
(Source: P.A. 92-725, eff. 7-25-02. Repealed by P.A. 94-838, eff. 6-6-06.)
(305 ILCS 5/5-5.23)
Sec. 5-5.23. Children's mental health services.
(a) The Department of Healthcare and Family Services, by rule, shall require the screening and
assessment of
a child prior to any Medicaid-funded admission to an inpatient hospital for
psychiatric
services to be funded by Medicaid. The screening and assessment shall include a
determination of the appropriateness and availability of out-patient support
services
for necessary treatment. The Department, by rule, shall establish methods and
standards of payment for the screening, assessment, and necessary alternative
support
services.
(b) The Department of Healthcare and Family Services, to the extent allowable under federal law,
shall secure federal financial participation for Individual Care Grant
expenditures made
by the Department of Healthcare and Family Services for the Medicaid optional service
authorized under
Section 1905(h) of the federal Social Security Act, pursuant to the provisions
of Section
7.1 of the Mental Health and Developmental Disabilities Administrative Act. The
Department of Healthcare and Family Services may exercise the
authority under this Section as is necessary to administer
Individual Care Grants as authorized under Section 7.1 of the
Mental Health and Developmental Disabilities Administrative
Act.
(c) The Department of Healthcare and Family Services shall work collaboratively with the Department of Children and Family
Services and the Division of Mental Health of the Department of
Human Services to implement subsections (a) and (b).
(d) 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.
(e)  All rights, powers, duties, and responsibilities currently exercised by the Department of Human Services related to the Individual Care Grant program are transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services to be completed and implemented within 6 months after the effective date of this amendatory Act of the 99th General Assembly. For the purposes of the Successor Agency Act, the Department of Healthcare and Family Services is declared to be the successor agency of the Department of Human Services, but only with respect to the functions of the Department of Human Services that are transferred to the Department of Healthcare and Family Services under this amendatory Act of the 99th General Assembly.
(1) Each act done by the Department of Healthcare and     Family Services in exercise of the transferred powers, duties, rights, and responsibilities shall have the same legal effect as if done by the Department of Human Services or its offices.
(2)  Any rules of the Department of Human Services     that relate to the functions and programs transferred by this amendatory Act of the 99th General Assembly that are in full force on the effective date of this amendatory Act of the 99th General Assembly shall become the rules of the Department of Healthcare and Family Services. All rules transferred under this amendatory Act of the 99th General Assembly are hereby amended such that the term "Department" shall be defined as the Department of Healthcare and Family Services and all references to the "Secretary" shall be changed to the "Director of Healthcare and Family Services or his or her designee".  As soon as practicable hereafter, the Department of Healthcare and Family Services shall revise and clarify the rules to reflect the transfer of rights, powers, duties, and responsibilities affected by this amendatory Act of the 99th General Assembly, using the procedures for recodification of rules available under the Illinois Administrative Procedure Act, except that existing title, part, and section numbering for the affected rules may be retained. The Department of Healthcare and Family Services, consistent with its authority to do so as granted by this amendatory Act of the 99th General Assembly, shall propose and adopt any other rules under the Illinois Administrative Procedure Act as necessary to administer the Individual Care Grant program. These rules may include, but are not limited to, the application process and eligibility requirements for recipients.
(3)  All unexpended appropriations and balances and     other funds available for use in connection with any functions of the Individual Care Grant program shall be transferred for the use of the Department of Healthcare and Family Services to operate the Individual Care Grant program. Unexpended balances shall be expended only for the purpose for which the appropriation was originally made. The Department of Healthcare and Family Services shall exercise all rights, powers, duties, and responsibilities for operation of the Individual Care Grant program.
(4)  Existing personnel and positions of the     Department of Human Services pertaining to the administration of the Individual Care Grant program shall be transferred to the Department of Healthcare and Family Services with the transfer and transition of the Individual Care Grant program to the Department of Healthcare and Family Services. The status and rights of Department of Human Services employees engaged in the performance of the functions of the Individual Care Grant program shall not be affected by this amendatory Act of the 99th General Assembly. The rights of the employees, the State of Illinois, and its agencies under the Personnel Code and applicable collective bargaining agreements or under any pension, retirement, or annuity plan shall not be affected by this amendatory Act of the 99th General Assembly. All transferred employees who are members of collective bargaining units shall retain their seniority, continuous service, salary, and accrued benefits.
(5) All books, records, papers, documents, property     (real and personal), contracts, and pending business pertaining to the powers, duties, rights, and responsibilities related to the functions of the Individual Care Grant program, including, but not limited to, material in electronic or magnetic format and necessary computer hardware and software, shall be delivered to the Department of Healthcare and Family Services; provided, however, that the delivery of this information shall not violate any applicable confidentiality constraints.
(6) Whenever reports or notices are now required to     be made or given or papers or documents furnished or served by any person to or upon the Department of Human Services in connection with any of the functions transferred by this amendatory Act of the 99th General Assembly, the same shall be made, given, furnished, or served in the same manner to or upon the Department of Healthcare and Family Services.
(7) This amendatory Act of the 99th General Assembly     shall not affect any act done, ratified, or canceled or any right occurring or established or any action or proceeding had or commenced in an administrative, civil, or criminal cause regarding the Department of Human Services before the effective date of this amendatory Act of the 99th General Assembly; and those actions or proceedings may be defended, prosecuted, and continued by the Department of Human Services.
(f) (Blank).
(g)  Family Support Program.  The Department of Healthcare and Family Services shall restructure the Family Support Program, formerly known as the Individual Care Grant program, to enable early treatment of youth, emerging adults, and transition-age adults with a serious mental illness or serious emotional disturbance.
(1) As used in this subsection and in subsections (h)     through (s):
(A) "Youth" means a person under the age of 18.
(B) "Emerging adult" means a person who is 18         through 20 years of age.
(C) "Transition-age adult" means a person who is         21 through 25 years of age.
(2) The Department shall amend 89 Ill. Adm. Code 139     in accordance with this Section and consistent with the timelines outlined in this Section.
(3) Implementation of any amended requirements shall     be completed within 8 months of the adoption of any amendment to 89 Ill. Adm. Code 139 that is consistent with the provisions of this Section.
(4) To align the Family Support Program with the     Medicaid system of care, the services available to a youth, emerging adult, or transition-age adult through the Family Support Program shall include all Medicaid community-based mental health treatment services and all Family Support Program services included under 89 Ill. Adm. Code 139. No person receiving services through the Family Support Program or the Specialized Family Support Program shall become a Medicaid enrollee unless Medicaid eligibility criteria are met and the person is enrolled in Medicaid. No part of this Section creates an entitlement to services through the Family Support Program, the Specialized Family Support Program, or the Medicaid program.
(5) The Family Support Program shall align with the     following system of care principles:
(A) Treatment and support services shall be based         on the results of an integrated behavioral health assessment and treatment plan using an instrument approved by the Department of Healthcare and Family Services.
(B) Strong interagency collaboration between all         State agencies the parent or legal guardian is involved with for services, including the Department of Healthcare and Family Services, the Department of Human Services, the Department of Children and Family Services, the Department of Juvenile Justice, and the Illinois State Board of Education.
(C) Individualized, strengths-based practices and         trauma-informed treatment approaches.
(D) For a youth, full participation of the parent         or legal guardian at all levels of treatment through a process that is family-centered and youth-focused.  The process shall include consideration of the services and supports the parent, legal guardian, or caregiver requires for family stabilization, and shall connect such person or persons to services based on available insurance coverage.
(h) Eligibility for the Family Support Program. Eligibility criteria established under 89 Ill.
Adm. Code 139 for the Family Support Program shall include the following:
(1) Individuals applying to the program must be under     the age of 26.
(2) Requirements for parental or legal guardian     involvement are applicable to  youth and  to emerging adults or transition-age adults who have a guardian appointed under Article XIa of the Probate Act.
(3) Youth, emerging adults, and transition-age adults     are eligible for services under the Family Support Program upon their third inpatient admission to a hospital or similar treatment facility for the primary purpose of psychiatric treatment within the most recent 12 months and are hospitalized for the purpose of psychiatric treatment.
(4) School participation for emerging adults applying     for services under the Family Support Program may be waived by request of the individual at the sole discretion of the Department of Healthcare and Family Services.
(5) School participation is not applicable to     transition-age adults.
(i) Notification of Family Support Program and Specialized Family Support Program services.
(1) Within 12 months after the effective date of this     amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services, with meaningful stakeholder input through a working group of psychiatric hospitals, Family Support Program providers, family support organizations, the Community and Residential Services Authority, a statewide association representing a majority of hospitals, a statewide association representing physicians, and foster care alumni advocates, shall establish a clear process by which a youth's or emerging adult's parents, guardian, or caregiver, or the emerging adult or transition-age adult, is identified, notified, and educated about the Family Support Program and the Specialized Family Support Program upon a first psychiatric inpatient hospital admission, and any following psychiatric inpatient admissions.  Notification and education may take place through a Family Support Program coordinator, a mobile crisis response provider, a Comprehensive Community Based Youth Services provider, the Community and Residential Services Authority, or any other designated provider or coordinator identified by the Department of Healthcare and Family Services. In developing this process, the Department of Healthcare and Family Services and the working group shall take into account the unique needs of emerging adults and transition-age adults without parental involvement who are eligible for services under the Family Support Program.   The Department of Healthcare and Family Services and the working group shall ensure the appropriate provider or coordinator is required to assist individuals and their parents, guardians, or caregivers, as applicable, in the completion of the application or referral process for the Family Support Program or the Specialized Family Support Program.
(2) Upon a youth's, emerging adult's or     transition-age adult's second psychiatric inpatient hospital admission, prior to hospital discharge, the hospital must, if it is aware of the patient's prior psychiatric inpatient hospital admission, ensure that the youth's parents, guardian, or caregiver, or the emerging adult or transition-age adult, has been notified of the Family Support Program and the Specialized Family Support Program.
(3) Psychiatric lockout as last resort.
(A) Prior to referring any youth to the         Department of Children and Family Services for the filing of a petition in accordance with subparagraph (c) of paragraph (1) of Section 2-4 of the Juvenile Court Act of 1987 alleging that the youth is dependent because the youth was left in a psychiatric hospital beyond medical necessity, the hospital shall  attempt to contact the youth and the youth's parents, guardian, or caregiver about the Family Support Program and the Specialized Family Support Program and shall assist with connections to the designated Family Support Program coordinator in the service area by providing educational materials developed by the Department of Healthcare and Family Services.  Once this process has begun, any such youth shall be considered a youth for whom an application for the Family Support Program is pending with the Department of Healthcare and Family Services or an active application for the Family Support Program was being reviewed by the Department for the purposes of subsection (a) of Section 2-4b of the Juvenile Court Act of 1987, or for the purposes of subsection (a) of Section 5-711 of the Juvenile Court Act of 1987.
(B) No state agency or hospital shall coach a         parent or guardian of a youth in a psychiatric hospital inpatient unit to lock out or otherwise relinquish custody of a youth to the Department of Children and Family Services for the sole purpose of obtaining necessary mental health treatment for the youth.  In the absence of abuse or neglect, a psychiatric lockout or custody relinquishment to the Department of Children and Family Services shall only be considered as the option of last resort. Nothing in this Section shall prohibit discussion of medical treatment options or a referral to legal counsel.
(4) Development of new Family Support Program     services.
(A) Development of specialized therapeutic         residential treatment for youth and emerging adults with high-acuity mental health conditions.  Through a working group led by the Department of Healthcare and Family Services that includes the Department of Children and Family Services and residential treatment providers for youth and emerging adults, the Department of Healthcare and Family Services, within 12 months after the effective date of this amendatory Act of the 101st General Assembly, shall develop a plan for the development of specialized therapeutic residential treatment beds similar to a qualified residential treatment program, as defined in the federal Family First Prevention Services Act, for youth in the Family Support Program with high-acuity mental health needs.  The Department of Healthcare and Family Services and the Department of Children and Family Services shall work together to maximize federal funding through Medicaid and Title IV-E of the Social Security Act in the development and implementation of this plan.
(B) Using the Department of Children and Family         Services' beyond medical necessity data over the last 5 years and any other relevant, available data, the  Department of Healthcare and Family Services shall assess the estimated number of these specialized high-acuity residential treatment beds that are needed in each region of the State based on the number of youth remaining in psychiatric hospitals beyond medical necessity and the number of youth placed out-of-state who need this level of care.  The  Department of Healthcare and Family Services shall report the results of this assessment to the General Assembly by no later than December 31, 2020.
(C) Development of an age-appropriate therapeutic         residential treatment model for emerging adults and transition-age adults.  Within 30 months after the effective date of this amendatory Act of the 101st General Assembly, the  Department of Healthcare and Family Services, in partnership with the Department of Human Services' Division of Mental Health and with significant and meaningful stakeholder input through a working group of providers and other stakeholders, shall develop a supportive housing model for emerging adults and transition-age adults receiving services through the Family Support Program who need residential treatment and support to enable recovery.  Such a model shall be age-appropriate and shall allow the residential component of the model to be in a community-based setting combined with intensive community-based mental health services.
(j) Workgroup to develop a plan for improving access to substance use treatment.   The Department of Healthcare and Family Services and the Department of Human Services' Division of Substance Use Prevention and Recovery shall co-lead a working group that includes Family Support Program providers, family support organizations, and other stakeholders over a 12-month period beginning in the first quarter of calendar year 2020 to develop a plan for increasing access to substance use treatment services for youth, emerging adults, and transition-age adults who are eligible for Family Support Program services.
(k) Appropriation. Implementation of this Section shall be limited by the State's annual appropriation to the Family Support Program.  Spending within the Family Support Program appropriation shall be further limited for the new Family Support Program services to be developed accordingly:
(1) Targeted use of specialized therapeutic     residential treatment for youth and emerging adults with high-acuity mental health conditions through appropriation limitation. No more than 12% of all annual Family Support Program funds shall be spent on this level of care in any given state fiscal year.
(2) Targeted use of residential treatment model     established for emerging adults and transition-age adults through appropriation limitation.  No more than one-quarter of all annual Family Support Program funds shall be spent on this level of care in any given state fiscal year.
(l) Exhausting third party insurance coverage first.
(A) A parent, legal guardian, emerging adult, or     transition-age adult with private insurance coverage shall work with the Department of Healthcare and Family Services, or its designee, to identify insurance coverage for any and all benefits covered by their plan. If insurance cost-sharing by any method for treatment is cost-prohibitive for the parent, legal guardian, emerging adult, or transition-age adult, Family Support Program funds may be applied as a payer of last resort toward insurance cost-sharing for purposes of using private insurance coverage to the fullest extent for the recommended treatment.  If the Department, or its agent, has a concern relating to the parent's, legal guardian's, emerging adult's, or transition-age adult's insurer's compliance with Illinois or federal insurance requirements relating to the coverage of mental health or substance use disorders, it shall refer all relevant information to the applicable regulatory authority.
(B) The Department of Healthcare and Family Services     shall use Medicaid funds first for an individual who has Medicaid coverage if the treatment or service recommended using an integrated behavioral health assessment and treatment plan (using the instrument approved by the Department of Healthcare and Family Services) is covered by Medicaid.
(C) If private or public insurance coverage does not     cover the needed treatment or service, Family Support Program funds shall be used to cover the services offered through the Family Support Program.
(m) Service authorization.  A youth, emerging adult, or transition-age adult enrolled in the Family Support Program or the Specialized Family Support Program shall be eligible to receive a mental health treatment service covered by the applicable program if the medical necessity criteria established by the Department of Healthcare and Family Services are met.
(n) Streamlined application.  The Department of Healthcare and Family Services shall revise the Family Support Program applications and the application process to reflect the changes made to this Section by this amendatory Act of the 101st General Assembly within 8 months after the adoption of any amendments to 89 Ill.
Adm. Code 139.
(o) Study of reimbursement policies during planned and unplanned absences of youth and emerging adults in Family Support Program residential treatment settings.  The Department of Healthcare and Family Services shall undertake a study of those standards of the Department of Children and Family Services and other states for reimbursement of residential treatment during planned and unplanned absences to determine if reimbursing residential providers for such unplanned absences positively impacts the availability of residential treatment for youth and emerging adults. The Department of Healthcare and Family Services shall begin the study on July 1, 2019 and shall report its findings and the results of the study to the General Assembly, along with any recommendations for or against adopting a similar policy, by December 31, 2020.
(p) Public awareness and educational campaign for all relevant providers. The Department of Healthcare and Family Services shall engage in a public awareness campaign to educate hospitals with psychiatric units, crisis response providers such as Screening, Assessment and Support Services providers and Comprehensive Community Based Youth Services agencies, schools, and other community institutions and providers across Illinois on the changes made by this amendatory Act of the 101st General Assembly to the Family Support Program.  The Department of Healthcare and Family Services shall produce written materials geared for the appropriate target audience, develop webinars, and conduct outreach visits over a 12-month period beginning after  implementation of the changes made to this Section by this amendatory Act of the 101st General Assembly.
(q) Maximizing federal matching funds for the Family Support Program and the Specialized Family Support Program. The Department of Healthcare and Family Services, as the sole Medicaid State agency, shall seek approval from the federal Centers for Medicare and Medicaid Services within 12 months after the effective date of this amendatory Act of the 101st General Assembly to draw additional federal Medicaid matching funds for individuals served under the Family Support Program or the Specialized Family Support Program who are not covered by the Department's medical assistance programs.  The Department of Children and Family Services, as the State agency responsible for administering federal funds pursuant to Title IV-E of the Social Security Act, shall submit a State Plan to the federal government within 12 months after the effective date of this amendatory Act of the 101st General Assembly to maximize the use of federal Title IV-E prevention funds through the federal Family First Prevention Services Act, to provide mental health and substance use disorder treatment services and supports, including, but not limited to, the provision of short-term crisis and transition beds post-hospitalization for youth who are at imminent risk of entering Illinois' youth welfare system solely due to the inability to access mental health or substance use treatment services.
(r) Outcomes and data reported annually to the General Assembly.  Beginning in 2021, the Department of Healthcare and Family Services shall submit an annual report to the General Assembly that includes the following information with respect to the time period covered by the report:
(1) The number and ages of youth, emerging adults,     and transition-age adults who requested services under the Family Support Program and the Specialized Family Support Program and the services received.
(2) The number and ages of youth, emerging adults,     and transition-age adults who requested services under the Specialized Family Support Program who were eligible for services based on the number of hospitalizations.
(3) The number and ages of youth, emerging adults,     and transition-age adults who applied for Family Support Program or Specialized Family Support Program services but did not receive any services.
(s) Rulemaking authority.  Unless a timeline is otherwise specified in a subsection, if amendments to 89 Ill. Adm. Code 139 are needed for implementation of this Section, such amendments shall be filed by the Department of Healthcare and Family Services within one year after the effective date of this amendatory Act of the 101st General Assembly.
(Source: P.A. 101-461, eff. 1-1-20; 101-616, eff. 12-20-19.)
(305 ILCS 5/5-5.24)
Sec. 5-5.24.  Prenatal and perinatal care.
(a) The Department of
Healthcare and Family Services may provide reimbursement under this Article for all prenatal and
perinatal health care services that are provided for the purpose of preventing
low-birthweight infants, reducing the need for neonatal intensive care hospital
services, and promoting perinatal and maternal health.  These services may include
comprehensive risk assessments for pregnant individuals, individuals with infants, and
infants, lactation counseling, nutrition counseling, childbirth support,
psychosocial counseling, treatment and prevention of periodontal disease, language translation, nurse home visitation, and
other support
services
that have been proven to improve birth and maternal health outcomes.
The Department
shall
maximize the use of preventive prenatal and perinatal health care services
consistent with
federal statutes, rules, and regulations.
The Department of Public Aid (now Department of Healthcare and Family Services)
shall develop a plan for prenatal and perinatal preventive
health care and
shall present the plan to the General Assembly by January 1, 2004.
On or before January 1, 2006 and
every 2 years
thereafter, the Department shall report to the General Assembly concerning the
effectiveness of prenatal and perinatal health care services reimbursed under
this Section
in preventing low-birthweight infants and reducing the need for neonatal
intensive care
hospital services.  Each such report shall include an evaluation of how the
ratio of
expenditures for treating
low-birthweight infants compared with the investment in promoting healthy
births and
infants in local community areas throughout Illinois relates to healthy infant
development
in those areas.
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.
(b)(1) As used in this subsection:
"Affiliated provider" means a provider who is enrolled in the medical assistance program and has an active contract with a managed care organization.
"Non-affiliated provider" means a provider who is enrolled in the medical assistance program but does not have a contract with an MCO.
"Preventive prenatal and perinatal health care services" means services described in subsection (a) including the following non-emergent diagnostic and ancillary services:
(i) Diagnostic labs and imaging, including level II     ultrasounds.
(ii) RhoGAM injections.
(iii) Injectable 17-alpha-hydroxyprogesterone     caproate (commonly called 17P).
(iv) Intrapartum (labor and delivery) services.
(v) Any other outpatient or inpatient service     relating to pregnancy or the 12 months following childbirth or fetal loss.
(2) In order to maximize the accessibility of preventive prenatal and perinatal health care services, the Department of Healthcare and Family Services shall amend its managed care contracts such that an MCO must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid under the Illinois Medicaid fee-for-service program methodology for such services, 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, unless a different rate was agreed upon by the health plan and the non-affiliated provider.
(3) In cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the requirements under paragraph (2) shall not apply if the services were not emergency services, as defined in Section 5-30.1, and:
(A) the non-affiliated provider is a perinatal     hospital and has, within the 12 months preceding the date of service, rejected a contract that was offered in good faith by the health plan as determined by the Department; or
(B) the health plan has terminated a contract with     the non-affiliated provider for cause, and the Department has not deemed the termination to have been without merit. The Department may deem that a determination for cause has merit if:
(i) an institutional provider has repeatedly         failed to conduct discharge planning; or
(ii) the provider's conduct adversely and         substantially impacts the health of Medicaid patients; or
(iii) the provider's conduct constitutes fraud,         waste, or abuse; or
(iv) the provider's conduct violates the code of         ethics governing his or her profession.(Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23.)
(305 ILCS 5/5-5.25)
Sec. 5-5.25. Access to behavioral health, medical, and epilepsy treatment services.
(a) The General Assembly finds that providing access to behavioral health, medical, and epilepsy treatment services in a timely manner will improve the quality of life for persons suffering from illness and will contain health care costs by avoiding the need for more costly inpatient hospitalization.
(b) The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in
Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth. The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. The Department, by rule, shall establish: (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.
(c) The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services' Division of Alcoholism and Substance Abuse.
(d) 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.
(Source: P.A. 101-81, eff. 7-12-19; 102-207, eff. 7-30-21.)
(305 ILCS 5/5-5.26)
Sec. 5-5.26. Multiple sclerosis; home services; waiver. The Department of Healthcare and Family Services shall apply for a waiver of federal law and regulations to the extent necessary to claim federal financial participation for medical assistance for services provided under the Department of Human Services' Home Services Program for persons with multiple sclerosis who are (i) over 60 years of age, and (ii) have assets not exceeding $17,500. In determining whether a person's assets meet this requirement, the Department must disregard retirement assets up to a total of $500,000 and disregard all life insurance assets.
(Source: P.A. 95-744, eff. 7-18-08.)
(305 ILCS 5/5-5.27)
Sec. 5-5.27. Coverage for clinical trials.
(a) The medical assistance program shall provide coverage for routine care costs that are incurred in the course of an approved clinical trial if the medical assistance program would provide coverage for the same routine care costs not incurred in a clinical trial. "Routine care cost" shall be defined by the Department by rule.
(b) The coverage that must be provided under this Section is subject to the terms, conditions, restrictions, exclusions, and limitations that apply generally under the medical assistance program, including terms, conditions, restrictions, exclusions, or limitations that apply to health care services rendered by participating providers and nonparticipating providers.
(c) Implementation of this Section shall be contingent upon federal approval. Upon receipt of federal approval, if required, the Department shall adopt any rules necessary to implement this Section.
(d) As used in this Section:
"Approved clinical trial" means a phase I, II, III, or IV clinical trial involving the prevention, detection, or treatment of cancer or any other life-threatening disease or condition if one or more of the following conditions apply:
(1) the Department makes a determination that the     study or investigation is an approved clinical trial;
(2) the study or investigation is conducted under an     investigational new drug application or an investigational device exemption reviewed by the federal Food and Drug Administration;
(3) the study or investigation is a drug trial that     is exempt from having an investigational new drug application or an investigational device exemption from the federal Food and Drug Administration; or
(4) the study or investigation is approved or funded     (which may include funding through in-kind contributions) by:
(A) the National Institutes of Health;
(B) the Centers for Disease Control and         Prevention;
(C) the Agency for Healthcare Research and         Quality;
(D) the Patient-Centered Outcomes Research         Institute;
(E) the federal Centers for Medicare and Medicaid         Services;
(F) a cooperative group or center of any of the         entities described in subparagraphs (A) through (E) or the United States Department of Defense or the United States Department of Veterans Affairs;
(G) a qualified non-governmental research entity         identified in the guidelines issued by the National Institutes of Health for center support grants; or
(H) the United States Department of Veterans         Affairs, the United States Department of Defense, or the United States Department of Energy, provided that review and approval of the study or investigation occurs through a system of peer review that is comparable to the peer review of studies performed by the National Institutes of Health, including an unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
"Care method" means the use of a particular drug or device in a particular manner.
"Life-threatening disease or condition" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.
(Source: P.A. 101-649, eff. 7-7-20.)
(305 ILCS 5/5-5a) (from Ch. 23, par. 5-5a)
Sec. 5-5a. Waiver for home and community-based services. The Department
shall apply for a waiver from the United States Health Care Financing
Administration to allow payment for home and community-based services under
this Article.
The Department, in cooperation with the Department on Aging, the Department
of Human Services and any other relevant State, local or
federal
government agency, may establish a nursing home pre-screening program to
determine whether the applicant, eligible for medical assistance under this
Article, may use home and community-based services as a reasonable,
lower-cost alternative form of care.  For the purpose of this Section,
"home and community-based services" may include, but are not limited to,
those services provided under subsection (f) of Section 3 of the Rehabilitation of Persons with Disabilities Act and Section 4 of the Illinois Act on the Aging.
(Source: P.A. 99-143, eff. 7-27-15.)
(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. 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.)
(305 ILCS 5/5-5b) (from Ch. 23, par. 5-5b)
Sec. 5-5b. 
		Payment Reductions.
(a) Notwithstanding any other Section in this Code establishing a
methodology for determining payment rates or dispensing fees for
non-institutional services provided under this Code, the Illinois
Department is authorized to reduce those payment rates or dispensing fees
with due regard for and subject to budgetary limitations to the extent
permitted by federal law.
(b) The Illinois Department may implement this Section as added 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 this Section as added by
this amendatory Act of 1991 shall be deemed an emergency
and necessary for the public interest, safety and welfare.
(Source: P.A. 87-14.)
(305 ILCS 5/5-5b.1)
Sec. 5-5b.1. Reimbursement rates; Fiscal Year 2015 reductions.
(a) Except as provided in subsection (b), notwithstanding any other provision of this Code to the contrary, and subject to rescission if not federally approved, providers of the following services shall have their reimbursement rates or dispensing fees reduced for the remainder of State fiscal year 2015 by an amount equivalent to a 2.25% reduction in appropriations from the General Revenue Fund for the medical assistance program for the full fiscal year:
(1) Nursing facility services delivered by a nursing     facility licensed under the Nursing Home Care Act.
(2) Home health services.
(3) Services delivered by a facility designated as a     Children's Habilitation Center.
(4) Services delivered by a supportive living     facility as defined in Section 5-5.01a.
(5) Services delivered by a specialized mental health     rehabilitation facility licensed under the Specialized Mental Health Rehabilitation Act of 2013.
(6) Ambulance services.
(7) Pharmacy services.
(8) Services delivered by a federally qualified     health center as defined in Section 1905 (l)(2)(B) of the federal Social Security Act.
(9) Services delivered by a Managed Care Entity, with     the exception of the rate paid to Managed Care Entities for services attributed to hospitals.
(10) Services for the treatment of hemophilia.
(11) Primary care physician services.
(12) Dental services.
(13) Optometric services.
(14) Podiatry services.
(15) Hospice care, including routine home care,     continuous home care, inpatient respite care, and general inpatient care.
(16) Laboratory services or services provided by     independent laboratories.
(17) Durable medical equipment and supplies.
(18) Renal dialysis services.
(19) Birth Center Services.
(20) Emergency services other than those offered by     or in a hospital.
(b) No provider shall be exempt from the rate reductions authorized under this Section, except that, rates or payments, or the portion thereof, paid to a provider that is operated by a unit of local government that provides the non-federal share of such services shall not be reduced as provided in this Section.
(c) To the extent practical and subject to rescission if not federally approved, the reductions required under this Section must be applied uniformly among and within each group, class, subgroup, or category of providers listed in this Section.
(d) In order to provide for the expeditious and timely implementation of the provisions of this Section, emergency rules to implement any provision of this Section may be adopted by the Department in accordance with subsection (s) of Section 5-45 of the Illinois Administrative Procedure Act.
(Source: P.A. 99-2, eff. 3-26-15.)
(305 ILCS 5/5-5c)
Sec.  5-5c. 
		
		Waiver for home and community-based services for traumatic
brain injury (TBI) patients.  The Department shall apply for a waiver from the
United States Health Care Financing Administration to allow payment for home
and community-based services under this Article for traumatic brain injury
patients.
The Department shall submit a Home and Community-Based
Services TBI
Waiver request to the United States Health Care Financing
Administration by January 1, 1998.  The waiver shall be requested pursuant to
Section
1915(c) of the Social Security Act.  The Department shall request a waiver of
Section 1902(a)(10)(B) of the Social Security Act in order to target home and
community-based services to individuals with a traumatic brain injury meeting
the Medicaid eligibility criteria set forth in appendices to the Prototype
Waiver request.
Under the waiver, the  Department,  in  cooperation  with  the
Department of Human Services and any other relevant State, local, or federal
government agency, may establish a nursing facility pre-screening program to
determine whether an applicant who is eligible for medical assistance under
this Article and has a traumatic brain injury may use home and community-based
services as a reasonable, lower-cost alternative form of care.  If a waiver
request has not been submitted by
January 1,
1998 the Department shall submit the TBI Prototype Waiver request to the
United States Health Care Financing Administration.
(Source: P.A. 90-335, eff. 8-8-97.)
(305 ILCS 5/5-5d)
Sec. 5-5d. Enhanced transition and follow-up services. The Department of Healthcare and Family Services shall apply for any necessary waivers pursuant to Section 1915(c) of the Social Security Act to facilitate the transition from one residential setting to another and follow-up services. Nothing in this Section shall be construed as limiting current similar programs by the Department of Human Services or the Department on Aging.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-5e)
Sec. 5-5e. Adjusted rates of reimbursement.
(a) Rates or payments for services in effect on June 30, 2012 shall be adjusted and
services shall be affected as required by any other provision of Public Act 97-689. In addition, the Department shall do the following:
(1) Delink the per diem rate paid for supportive     living facility services from the per diem rate paid for nursing facility services, effective for services provided on or after May 1, 2011 and before July 1, 2019.
(2) Cease payment for bed reserves in nursing     facilities and specialized mental health rehabilitation facilities; for purposes of therapeutic home visits for  individuals scoring as TBI on the MDS 3.0, beginning June 1, 2015, the Department shall approve payments for bed reserves in nursing facilities and specialized mental health rehabilitation facilities that have at least a 90% occupancy level and at least 80% of their residents are Medicaid eligible. Payment shall be at a daily rate of 75% of an individual's current Medicaid per diem and shall not exceed 10 days in a calendar month.
(2.5) Cease payment for bed reserves for purposes of     inpatient hospitalizations to intermediate care facilities for persons with developmental disabilities, except in the instance of residents who are under 21 years of age.
(3) Cease payment of the $10 per day add-on payment     to nursing facilities for certain residents with developmental disabilities.
(b) After the application of subsection (a), notwithstanding any other provision of this
Code to the contrary and to the extent permitted by federal law, on and after July 1,
2012, the rates of reimbursement for services and other payments provided under this
Code shall further be reduced as follows:
(1) Rates or payments for physician services, dental     services, or community health center services reimbursed through an encounter rate, and services provided under the Medicaid Rehabilitation Option of the Illinois Title XIX State Plan shall not be further reduced, except as provided in Section 5-5b.1.
(2) Rates or payments, or the portion thereof, paid     to a provider that is operated by a  unit of local government or State University that provides the non-federal share of such services shall not be further reduced, except as provided in Section 5-5b.1.
(3) Rates or payments for hospital services delivered     by a hospital defined as a Safety-Net Hospital under Section 5-5e.1 of this Code shall not be further reduced, except as provided in Section 5-5b.1.
(4) Rates or payments for hospital services delivered     by a Critical Access Hospital, which is an Illinois hospital designated as a critical care hospital by the Department of Public Health in accordance with 42 CFR 485, Subpart F, shall not be further reduced, except as provided in Section 5-5b.1.
(5) Rates or payments for Nursing Facility Services     shall only be further adjusted pursuant to Section 5-5.2 of this Code.
(6) Rates or payments for services delivered by long     term care facilities licensed under the ID/DD Community Care Act or the MC/DD Act  and developmental training services shall not be further reduced.
(7) Rates or payments for services provided under     capitation rates shall be adjusted taking into consideration the rates reduction and covered services required by Public Act 97-689.
(8) For hospitals not previously described in this     subsection, the rates or payments for hospital services provided before July 1, 2021, shall be further reduced by 3.5%, except for payments authorized under Section 5A-12.4 of this Code. For hospital services provided on or after July 1, 2021, all rates for hospital services previously reduced pursuant to Public Act 97-689 shall be increased to reflect the discontinuation of any hospital rate reductions authorized in this paragraph (8).
(9) For all other rates or payments for services     delivered by providers not specifically referenced in paragraphs (1) through (7), rates or payments shall be further reduced by 2.7%.
(c) Any assessment imposed by this Code shall continue and nothing in this Section shall be construed to cause it to cease.
(d) Notwithstanding any other provision of this Code to the contrary, subject to federal approval under Title XIX of the Social Security Act, for dates of service on and after July 1, 2014, rates or payments for services provided for the purpose of transitioning children from a hospital to home placement or other appropriate setting by a children's community-based health care center authorized under the Alternative Health Care Delivery Act shall be $683 per day.
(e) (Blank).
(f) (Blank).
(Source: P.A. 101-10, eff. 6-5-19; 101-649, eff. 7-7-20; 102-16, eff. 6-17-21; 102-687, eff. 12-17-21.)
(305 ILCS 5/5-5e.1)
Sec. 5-5e.1. Safety-Net Hospitals.
(a) A Safety-Net Hospital is an Illinois hospital that:
(1) is licensed by the Department of Public Health as     a general acute care or pediatric hospital; and
(2) is a disproportionate share hospital, as     described in Section 1923 of the federal Social Security Act, as determined by the Department; and
(3) meets one of the following:
(A) has a MIUR of at least 40% and a charity         percent of at least 4%; or
(B) has a MIUR of at least 50%.
(b) Definitions. As used in this Section:
(1) "Charity percent" means the ratio of (i) the     hospital's charity charges for services provided to individuals without health insurance or another source of third party coverage to (ii) the Illinois total hospital charges, each as reported on the hospital's OBRA form.
(2) "MIUR" means Medicaid Inpatient Utilization Rate     and is defined as a fraction, the numerator of which is the number of a hospital's inpatient days provided in the hospital's fiscal year ending 3 years prior to the rate year, to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act, 42 USC 1396a et seq., excluding those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of Section 5-2 of this Article,  and the denominator of which is the total number of the hospital's inpatient days in that same period, excluding those persons eligible for medical assistance pursuant to 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of Section 5-2 of this Article.
(3) "OBRA form" means form HFS-3834, OBRA '93 data     collection form, for the rate year.
(4) "Rate year" means the 12-month period beginning     on October 1.
(c) Beginning July 1, 2012 and ending on December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2011 or October 1, 2012 shall be a Safety-Net Hospital.
(c-5) Beginning July 1, 2020 and ending on December 31, 2026, a hospital that would have qualified for the rate year beginning October 1, 2020 and was designated a federal rural referral center under 42 CFR 412.96 as of October 1, 2020 shall be a Safety-Net Hospital.
(d) No later than August 15 preceding the rate year, each hospital shall submit the OBRA form to the Department. Prior to October 1, the Department shall notify each hospital whether it has qualified as a Safety-Net Hospital.
(e) The Department may promulgate rules in order to implement this Section.
(f)         Nothing in this Section shall be construed as limiting the ability of the Department to include the Safety-Net Hospitals in the hospital rate reform mandated by Section 14-11 of this Code and implemented under Section 14-12 of this Code and by administrative rulemaking.
(Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21; 102-886, eff. 5-17-22.)
(305 ILCS 5/5-5e.2)
Sec. 5-5e.2. Academic medical centers and major teaching hospital status.
(a) Hospitals dedicated to medical research and medical education shall be classified each State fiscal year in 3 tiers based on specific criteria:
(1) Tier I. A private academic medical center must:
(A) be a hospital located in Illinois which is         either:
(i) under common ownership with the college             of medicine of a non-public college or university;
(ii) a freestanding hospital in which the             majority of the clinical chiefs of service or clinical department chairs are department chairmen in an affiliated non-public Illinois medical school; or
(iii) a children's hospital which is             separately incorporated and non-integrated into the academic medical center hospital but which is the pediatric partner for an academic medical center hospital and which serves as the primary teaching hospital for pediatrics for its affiliated Illinois medical school.  A hospital identified herein is deemed to meet the additional Tier I criteria if its partner academic medical center hospital meets the Tier I criteria;
(B) serve as the training site for at least 30         graduate medical education programs accredited by Accreditation Council for Graduate Medical Education;
(C) facilitate the training on its campus or on         affiliated off-campus sites no less than 500 medical students, interns, residents, and fellows during the calendar year preceding the beginning of the State fiscal year;
(D) perform, either itself or through its         affiliated university, at least $12,000,000 in medical research funded through grants or contracts from the National Institutes of Health either directly or, with respect to hospitals described in item (ii) of subparagraph (A) of this paragraph, have as its affiliated non-public Illinois medical school a medical school that performs either itself or through its affiliated University medical research funded using at least $12,000,000 in grants or contracts from the National Institutes of Health; and
(E) expend directly or indirectly through an         affiliated non-public medical school or as part of a hospital system as defined in paragraph (4) of subsection (h) of Section 3-8 of the Service Use Tax Act no less than $5,000,000 toward medical research and education during the calendar year preceding the beginning of the State fiscal year.
(2) Tier II. A public academic medical center must:
(A) be a hospital located in Illinois which is a         primary teaching hospital affiliated with;
(i) University of Illinois School of Medicine             at Chicago; or
(ii) University of Illinois School of             Medicine at Peoria; or
(iii) University of Illinois School of             Medicine at Rockford; or
(iv) University of Illinois School of             Medicine at Urbana; or
(v) Southern Illinois University School of             Medicine in Springfield; and
(B) contribute no less than $2,500,000 toward         medical research and education during the calendar year preceding the beginning of the State fiscal year.
(3) Tier III. A major teaching hospital must:
(A) be an Illinois hospital with 100 or more         interns and residents or with a ratio of interns and residents to beds greater than or equal to 0.25; and
(B) support at least one graduate medical         education program accredited by Accreditation Council for Graduate Medical Education.
(b) All hospitals seeking to qualify for Tier I, Tier II, or Tier III recognition must annually submit a report to the Department with supporting documentation and attesting to meeting the requirements in this Section. Such reporting must also describe each hospital's education and research activities for the preceding year.
(Source: P.A. 98-104, eff. 7-22-13.)
(305 ILCS 5/5-5f)
Sec. 5-5f. Elimination and limitations of medical assistance services. Notwithstanding any other provision of this Code to the contrary, on and after July 1, 2012:
(a) The following service shall no longer be a     covered service available under this Code: group psychotherapy for residents of any facility licensed under the Nursing Home Care Act or the Specialized Mental Health Rehabilitation Act of 2013.
(b) The Department shall place the following     limitations on services: (i) the Department shall limit adult eyeglasses to one pair every 2 years; however, the limitation does not apply to an individual who needs different eyeglasses following a surgical procedure such as cataract surgery; (ii) the Department shall set an annual limit of a maximum of 20 visits for each of the following services: adult speech, hearing, and language therapy services, adult occupational therapy services, and physical therapy services; on or after October 1, 2014, the annual maximum limit of 20 visits shall expire but the Department may require prior approval for all individuals for speech, hearing, and language therapy services, occupational therapy services, and physical therapy services; (iii) the Department shall limit adult podiatry services to individuals with diabetes;  on or after October 1, 2014, podiatry services shall not be limited to individuals with diabetes; (iv) the Department shall pay for caesarean sections at the normal vaginal delivery rate unless a caesarean section was medically necessary; (v) the Department shall limit adult dental services to emergencies; beginning July 1, 2013, the Department shall ensure that the following conditions are recognized as emergencies: (A) dental services necessary for an individual in order for the individual to be cleared for a medical procedure, such as a transplant; (B) extractions and dentures necessary for a diabetic to receive proper nutrition; (C) extractions and dentures necessary as a result of cancer treatment; and (D) dental services necessary for the health of a pregnant woman prior to delivery of her baby; on or after July 1, 2014, adult dental services shall no longer be limited to emergencies, and dental services necessary for the health of a pregnant woman prior to delivery of her baby shall continue to be covered; and (vi) effective July 1, 2012 through June 30, 2021, the Department shall place limitations and require concurrent review on every inpatient detoxification stay to prevent repeat admissions to any hospital for detoxification within 60 days of a previous inpatient detoxification stay. The Department shall convene a workgroup of hospitals, substance abuse providers, care coordination entities, managed care plans, and other stakeholders to develop recommendations for quality standards, diversion to other settings, and admission criteria for patients who need inpatient detoxification, which shall be published on the Department's website no later than September 1, 2013.
(c) The Department shall require prior approval of     the following services: wheelchair repairs costing more than $750, coronary artery bypass graft, and bariatric surgery consistent with Medicare standards concerning patient responsibility. Wheelchair repair prior approval requests shall be adjudicated within one business day of receipt of complete supporting documentation. Providers may not break wheelchair repairs into separate claims for purposes of staying under the $750 threshold for requiring prior approval. The wholesale price of manual and power wheelchairs, durable medical equipment and supplies, and complex rehabilitation technology products and services shall be defined as actual acquisition cost including all discounts.
(d) The Department shall establish benchmarks for     hospitals to measure and align payments to reduce potentially preventable hospital readmissions, inpatient complications, and unnecessary emergency room visits. In doing so, the Department shall consider items, including, but not limited to, historic and current acuity of care and historic and current trends in readmission. The Department shall publish provider-specific historical readmission data and anticipated potentially preventable targets 60 days prior to the start of the program. In the instance of readmissions, the Department shall adopt policies and rates of reimbursement for services and other payments provided under this Code to ensure that, by June 30, 2013, expenditures to hospitals are reduced by, at a minimum, $40,000,000.
(e) The Department shall establish utilization     controls for the hospice program such that it shall not pay for other care services when an individual is in hospice.
(f) For home health services, the Department shall     require Medicare certification of providers participating in the program and implement the Medicare face-to-face encounter rule. The Department shall require providers to implement auditable electronic service verification based on global positioning systems or other cost-effective technology.
(g) For the Home Services Program operated by the     Department of Human Services and the Community Care Program operated by  the Department on Aging, the Department of Human Services, in cooperation with the Department on Aging, shall implement an electronic service verification based on global positioning systems or other cost-effective technology.
(h) Effective with inpatient hospital admissions on     or after July 1, 2012, the Department shall reduce the payment for a claim that indicates the occurrence of a provider-preventable condition during the admission as specified by the Department in rules. The Department shall not pay for services related to an other provider-preventable condition.
As used in this subsection (h):
"Provider-preventable condition" means a health care     acquired condition as defined under the federal Medicaid regulation found at 42 CFR 447.26 or an other provider-preventable condition.
"Other provider-preventable condition" means a wrong     surgical or other invasive procedure performed on a patient, a surgical or other invasive procedure performed on the wrong body part, or a surgical procedure or other invasive procedure performed on the wrong patient.
(i) The Department shall implement cost savings     initiatives for advanced imaging services, cardiac imaging services, pain management services, and back surgery. Such initiatives shall be designed to achieve annual costs savings.
(j) The Department shall ensure that beneficiaries     with a diagnosis of epilepsy or seizure disorder in Department records will not require prior approval for anticonvulsants. (Source: P.A. 101-209, eff. 8-5-19; 102-43, Article 5, Section 5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-5g)
Sec. 5-5g. Long-term care patient; resident status. Long-term care providers shall submit all changes in resident status, including, but not limited to, death, discharge, changes in patient credit, third party liability, and Medicare coverage, to the Department through the Medical Electronic Data Interchange System, the Recipient Eligibility Verification System, or  the Electronic Data Interchange System established under 89 Ill. Adm. Code  140.55(b) in compliance with the schedule below:
(1) 15 calendar days after a resident's death;
(2) 15 calendar days after a resident's discharge;
(3) 45 calendar days after being informed of a change     in the resident's income;
(4) 45 calendar days after being informed of a change     in a resident's third party liability;
(5) 45 calendar days after a resident's move to     exceptional care services; and
(6) 45 calendar days after a resident's need for     services requiring reimbursement under the ventilator or traumatic brain injury enhanced rate.
(Source: P.A. 100-665, eff. 8-2-18.)
(305 ILCS 5/5-5h)
Sec. 5-5h. Long-term acute care hospital base rates.
(a) The base per diem rate paid to long-term acute care hospitals for Medicaid services on and after January 1, 2020 must be $60 more than the base rate in effect on June 30, 2019.
(b) Nothing in this Section shall change the rates authorized under Section 5A-12.6 or the Long-Term Acute Care Hospital Quality Improvement Transfer Program Act.
(Source: P.A. 101-10, eff. 6-5-19.)
(305 ILCS 5/5-5i)
Sec. 5-5i. Rate increase for speech, physical, and occupational therapy services. Subject to federal approval, beginning January 1, 2024, the Department shall increase reimbursement rates for speech therapy services, physical therapy services, and occupational therapy services provided by licensed speech-language pathologists and speech-language pathology assistants, physical therapists and physical therapy assistants, and occupational therapists and certified occupational therapy assistants, including those in their clinical fellowship, by 14.2%.
(Source: P.A. 103-102, eff. 1-1-24.)
(305 ILCS 5/5-6) (from Ch. 23, par. 5-6)
Sec. 5-6. Obligations incurred prior to death of a recipient. Obligations incurred but not paid for at the time of a recipient's death
for services authorized under Section 5-5, including medical and other
care in facilities as defined in the Nursing Home Care
Act, the Specialized Mental Health Rehabilitation Act of 2013, the ID/DD Community Care Act, or the MC/DD Act, or in like facilities
not required to be licensed under that Act, may be paid, subject to the
rules and regulations of the Illinois Department, after the death of the recipient.
(Source: P.A. 98-104, eff. 7-22-13; 99-180, eff. 7-29-15.)
(305 ILCS 5/5-7) (from Ch. 23, par. 5-7)
Sec. 5-7. 
		(Repealed).
(Source: P.A. 81-487.  Repealed by P.A. 93-20, eff. 6-20-03.)
(305 ILCS 5/5-8) (from Ch. 23, par. 5-8)
Sec. 5-8. Practitioners.  In supplying medical assistance, the Illinois
Department may provide for the legally authorized services of (i) persons
licensed under the Medical Practice Act of 1987, as amended, except as
hereafter in this Section stated, whether under a
general or limited license, (ii) persons licensed under the Nurse Practice Act as advanced practice registered nurses, regardless of whether or not the persons have written collaborative agreements, (iii) persons licensed or registered
under
other laws of this State to provide dental, medical, pharmaceutical,
optometric, podiatric, or nursing services, or other remedial care
recognized under State law, (iv) persons licensed under other laws of
this State as a clinical social worker, and (v) persons licensed under other laws of this State as  physician assistants. The Department shall adopt rules, no later than 90 days after January 1, 2017 (the effective date of Public Act 99-621), for the legally authorized services of persons licensed under other laws of this State as a clinical social worker.
The Department shall provide for the legally authorized services of persons licensed under the Professional Counselor and Clinical Professional Counselor Licensing and Practice Act as clinical professional counselors and for the legally
authorized services of persons licensed under the Marriage and
Family Therapy Licensing Act as marriage and family
therapists. The
utilization of the services of persons engaged in the treatment or care of
the sick, which persons are not required to be licensed or registered under
the laws of this State, is not prohibited by this Section.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-9) (from Ch. 23, par. 5-9)
Sec. 5-9. Choice of medical dispensers. Applicants and recipients shall
be entitled to free choice of those qualified practitioners, hospitals,
nursing homes, and other dispensers of medical services meeting the
requirements and complying with the rules and regulations of the Illinois
Department. However, the Director of Healthcare and Family Services may, after providing
reasonable notice and opportunity for hearing, deny, suspend or terminate
any otherwise qualified person, firm, corporation, association, agency,
institution, or other legal entity, from participation as a vendor of goods
or services under the medical assistance program authorized by this Article
if the Director finds such vendor of medical services in violation of this
Act or the policy or rules and regulations issued pursuant to this Act.
(Source: P.A. 100-538, eff. 1-1-18.)
(305 ILCS 5/5-10) (from Ch. 23, par. 5-10)
Sec. 5-10. 
		Entitlement to Social Services. 
		Persons receiving medical
assistance shall be entitled to receive, under Article IX and the Illinois
Act on the Aging, such
rehabilitative, training or other social services as are appropriate to their
condition.
(Source: P.A. 92-651, eff. 7-11-02.)
(305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
Sec. 5-11. Co-operative arrangements; contracts with other State
agencies, health care and rehabilitation organizations, and fiscal
intermediaries.
(a) The Illinois Department may enter into co-operative arrangements
with
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services to
the end that there may be maximum utilization of such services in the
provision of medical assistance.
The Illinois Department shall, not later than June 30, 1993, enter into
one or more co-operative arrangements with the Department of Mental Health
and Developmental Disabilities providing that the Department of Mental
Health and Developmental Disabilities will be responsible for administering
or supervising all programs for services to persons in community care
facilities for persons with developmental disabilities, including but not
limited to intermediate care facilities, that are supported by State funds or
by funding under Title XIX of the federal Social Security Act.  The
responsibilities of the Department of Mental Health and Developmental
Disabilities under these agreements are transferred to the Department of
Human Services as provided in the Department of Human Services Act.
The Department may also contract with such State health and
rehabilitation agencies and other public or private health care and
rehabilitation organizations to act for it in supplying designated medical
services to persons eligible therefor under this Article. Any contracts
with health services or health maintenance organizations shall be
restricted to organizations which have been certified as being in
compliance with standards promulgated pursuant to the laws of this State
governing the establishment and operation of health services or health
maintenance organizations. The Department shall renegotiate the contracts with health maintenance organizations and managed care community
networks that took effect August 1, 2003, so as to produce $70,000,000 savings to the Department net of resulting increases to the fee-for-service program for State fiscal year 2006. The Department may also contract with insurance
companies or other corporate entities serving as fiscal intermediaries in
this State for the Federal Government in respect to Medicare payments under
Title XVIII of the Federal Social Security Act to act for the Department in
paying medical care suppliers.  The provisions of Section 9 of "An Act in
relation to State finance", approved June 10, 1919, as amended,
notwithstanding, such contracts with State agencies, other health care and
rehabilitation organizations, or fiscal intermediaries may provide for
advance payments.
(b) For purposes of this subsection (b), "managed care community
network" means an entity, other than a health maintenance organization, that
is owned, operated, or governed by providers of health care services within
this State and that provides or arranges primary, secondary, and tertiary
managed health care services under contract with the Illinois Department
exclusively to persons participating in programs administered by the Illinois
Department.
The Illinois Department may certify managed care community
networks, including managed care community networks owned, operated, managed,
or
governed by State-funded medical schools, as risk-bearing entities eligible to
contract with the Illinois Department as Medicaid managed care
organizations.  The Illinois Department may contract with those managed
care community networks to furnish health care services to or arrange those
services for individuals participating in programs administered by the Illinois
Department.  The rates for those provider-sponsored organizations may be
determined on a prepaid, capitated basis.   A managed care community
network may choose to contract with the Illinois Department to provide only
pediatric
health care services.
The
Illinois Department shall by rule adopt the criteria, standards, and procedures
by
which a managed care community network may be permitted to contract with
the Illinois Department and shall consult with the Department of Insurance in
adopting these rules.
A county provider as defined in Section 15-1 of this Code may
contract with the Illinois Department to provide primary, secondary, or
tertiary managed health care services as a managed care
community network without the need to establish a separate entity and shall
be deemed a managed care community network for purposes of this Code
only to the extent it provides services to participating individuals.  A county
provider is entitled to contract with the Illinois Department with respect to
any contracting region located in whole or in part within the county.  A
county provider is not required to accept enrollees who do not reside within
the county.
In order
to (i) accelerate and facilitate the development of integrated health care in
contracting areas outside counties with populations in excess of 3,000,000 and
counties adjacent to those counties and (ii) maintain and sustain the high
quality of education and residency programs coordinated and associated with
local area hospitals, the Illinois Department may develop and implement a
demonstration program from managed care community networks owned, operated,
managed, or
governed by State-funded medical schools.  The Illinois Department shall
prescribe by rule the criteria, standards, and procedures for effecting this
demonstration program.
A managed care community network that
contracts with the Illinois Department to furnish health care services to or
arrange those services for enrollees participating in programs administered by
the Illinois Department shall do all of the following:
(1) Provide that any provider affiliated with the     managed care community network may also provide services on a fee-for-service basis to Illinois Department clients not enrolled in such managed care entities.
(2) Provide client education services as determined     and approved by the Illinois Department, including but not limited to (i) education regarding appropriate utilization of health care services in a managed care system, (ii) written disclosure of treatment policies and restrictions or limitations on health services, including, but not limited to, physical services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, and radiological examinations, and (iii) written notice that the enrollee may receive from another provider those covered services that are not provided by the managed care community network.
(3) Provide that enrollees within the system may     choose the site for provision of services and the panel of health care providers.
(4) Not discriminate in enrollment or disenrollment     practices among recipients of medical services or enrollees based on health status.
(5) Provide a quality assurance and utilization     review program that meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.
(6) Issue a managed care community network     identification card to each enrollee upon enrollment.  The card must contain all of the following:
(A) The enrollee's health plan.
(B) The name and telephone number of the         enrollee's primary care physician or the site for receiving primary care services.
(C) A telephone number to be used to confirm         eligibility for benefits and authorization for services that is available 24 hours per day, 7 days per week.
(7) Ensure that every primary care physician and     pharmacy in the managed care community network meets the standards established by the Illinois Department for accessibility and quality of care. The Illinois Department shall arrange for and oversee an evaluation of the standards established under this paragraph (7) and may recommend any necessary changes to these standards.
(8) Provide a procedure for handling complaints that     meets the requirements established by the Illinois Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.
(9) Maintain, retain, and make available to the     Illinois Department records, data, and information, in a uniform manner determined by the Illinois Department, sufficient for the Illinois Department to monitor utilization, accessibility, and quality of care.
(10) (Blank).
The Illinois Department shall contract with an entity or entities to provide
external peer-based quality assurance review for the managed health care
programs administered by the Illinois Department.  The entity shall meet all federal requirements for an external quality review organization.
Each managed care community network must demonstrate its ability to
bear the financial risk of serving individuals under this program.
The Illinois Department shall by rule adopt standards for assessing the
solvency and financial soundness of each managed care community network.
Any solvency and financial standards adopted for managed care community
networks
shall be no more restrictive than the solvency and financial standards adopted
under
Section 1856(a) of the Social Security Act for provider-sponsored
organizations under Part C of Title XVIII of the Social Security Act.
The Illinois
Department may implement the amendatory changes to this
Code made by this amendatory Act of 1998 through the use of emergency
rules in accordance with Section 5-45 of the Illinois Administrative Procedure
Act.  For purposes of that Act, the adoption of rules to implement these
changes is deemed an emergency and necessary for the public interest,
safety, and welfare.
(c) Not later than June 30, 1996, the Illinois Department shall
enter into one or more cooperative arrangements with the Department of Public
Health for the purpose of developing a single survey for
nursing facilities, including but not limited to facilities funded under Title
XVIII or Title XIX of the federal Social Security Act or both, which shall be
administered and conducted solely by the Department of Public Health.
The Departments shall test the single survey process on a pilot basis, with
both the Departments of Public Aid and Public Health represented on the
consolidated survey team.  The pilot will sunset June 30, 1997.  After June 30,
1997, unless otherwise determined by the Governor, a single survey shall be
implemented by the Department of Public Health which would not preclude staff
from the Department of Healthcare and Family Services (formerly Department of Public Aid) from going on-site to nursing facilities to
perform necessary audits and reviews which shall not replicate the single State
agency survey required by this Act.  This Section shall not apply to community
or intermediate care facilities for persons with developmental disabilities.
(d) Nothing in this Code in any way limits or otherwise impairs the
authority or power of the Illinois Department to enter into a negotiated
contract pursuant to this Section with a managed care community network or
a health maintenance organization, as defined in the Health Maintenance
Organization Act, that provides for
termination or nonrenewal of the contract without cause, upon notice as
provided in the contract, and without a hearing.
(Source: P.A. 95-331, eff. 8-21-07; 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-11.1)
Sec. 5-11.1. Cooperative arrangements; contracts. The Illinois Department
may enter into cooperative
arrangements with
State agencies responsible for administering or supervising the
administration of health services and vocational rehabilitation services to
maximize utilization of these services in the provision of medical assistance.
The Illinois Department shall, not later than June 30, 1994, enter into
one or more cooperative arrangements with the Department of Mental Health
and Developmental Disabilities providing that the Department of Mental
Health and Developmental Disabilities will be responsible for administering
or supervising all programs for services to persons in community care
facilities for persons with mental illness, including but not limited to
intermediate care facilities, that are supported by State funds or by funding
under Title XIX of the federal Social Security Act.
The responsibilities of the Department of Mental Health and Developmental
Disabilities under these agreements are transferred to the Department of
Human Services as provided in the Department of Human Services Act.
The Department may also contract with State health and rehabilitation
agencies and other public or private health care and rehabilitation
organizations to act for it in supplying designated medical services to persons
eligible under this Section.  Any contracts with health services or health
maintenance organizations shall be restricted to organizations which have been
certified as being in compliance with standards promulgated under the laws of
this State governing the establishment and operation of health services or
health maintenance organizations. The Department may also contract with
insurance companies or other corporate entities serving as fiscal
intermediaries in this State for the federal government in respect to Medicare
payments under Title XVIII of the federal Social Security Act to act for the
Department in paying medical care suppliers.  Nothing in this Section shall be
construed to abrogate any existing doctor/patient relationships with 
Department of Healthcare and Family Services recipients or the free choice of clients or their
guardians to select a physician to provide medical care.  The provisions of
Section 9 of the State Finance Act notwithstanding, such contracts with State
agencies, other health care and rehabilitation organizations, or fiscal
intermediaries may provide for advance payments.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-11a)
Sec. 5-11a. Health Benefit Information Systems.
(a) It is the intent of the General Assembly to support unified electronic systems initiatives that will improve management of information related to medical assistance programs.  This will include improved management capabilities and new systems for Eligibility, Verification, and Enrollment (EVE) that will simplify and increase efficiencies in and access to the medical assistance programs and ensure program integrity. The Department of Healthcare and Family Services, in coordination with the Department of Human Services and other appropriate state agencies, shall develop a plan by July 1, 2011, that will:
(1) Subject to federal and State privacy and     confidentiality laws and regulations, meet standards for timely eligibility verification and enrollment, and annual redetermination of eligibility, of applicants for and recipients of means-tested health benefits sponsored by the State, including medical assistance under this Code.
(2) Receive and update data electronically from the     Social Security Administration, the U.S. Postal Service, the Illinois Secretary of State, the Department of Revenue, the Department of Employment Security, and other governmental entities, as appropriate and to the extent allowed by law, for verification of any factor of eligibility for medical assistance and for updating addresses of applicants and recipients of medical assistance and other health benefit programs administered by the Department. Data relevant to eligibility shall be provided for no other purpose than to verify the eligibility of new applicants or current recipients of health benefits provided by the State. Data shall be requested or provided for any individual only insofar as that new applicant or current recipient's circumstances are relevant to that individual's or another individual's eligibility for State-sponsored health benefits.
(3) Meet federal requirements for timely installation     by January 1, 2014 to provide integration with a Health Benefits Exchange pursuant to the requirements of the federal Affordable Care Act and the Reconciliation Act and any subsequent amendments thereto and to ensure capture of the maximum available federal financial  participation  (FFP).
(4) Meet federal requirements for compliance with     architectural standards, including, but not limited to, (i) the use of a module development as outlined by the Medicaid Information Technology Architecture standards, (ii) the use of federally approved open-interfaces where they exist, (iii) the use or the creation of open-interfaces where necessary, and (iv) the use of rules technology that can dynamically accept and modify rules in standard formats.
(5) Include plans to ensure coordination with the     State of Illinois Framework Project that will (i) expedite and simplify access to services provided by Illinois human services programs; (ii) streamline administration and data sharing; (iii) enhance planning capacity, program evaluation, and fraud detection or prevention with access to cross-agency data; and (iv) simplify service reporting for contracted providers.
(b) The Department of Healthcare and Family Services shall continue to plan for and implement a new Medicaid Management Information System (MMIS) and upgrade the capabilities of the MMIS data warehouse.  Upgrades shall include, among other things, enhanced capabilities in data analysis including the ability to identify risk factors that could impact the treatment and resulting quality of care, and tools that perform predictive analytics on data applying to newborns, women with high risk pregnancies, and other populations served by the Department.
(c) The Department of Healthcare and Family Services shall report in its annual Medical Assistance program report each April through April, 2015 on the progress and implementation of this plan.
(Source: P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-12) (from Ch. 23, par. 5-12)
Sec. 5-12. 
		Funeral and burial. 
		Upon the death of a recipient who
qualified under class 2, 3 or 4 of Section 5-2, if his estate is
insufficient to pay his funeral and burial expenses and if no other
resources, including assistance from legally responsible relatives, are
available for such purposes, there shall be paid, in accordance with the
standards, rules and regulations of the Illinois Department of Human
Services, such reasonable amounts as may be necessary to meet the costs of
the funeral, burial space, and cemetery charges, or to reimburse any person not
financially responsible for the deceased who has voluntarily made
expenditures for such costs.
(Source: P.A. 92-651, eff. 7-11-02.)
(305 ILCS 5/5-13) (from Ch. 23, par. 5-13)
Sec. 5-13. Claim against estate of recipients. To the extent permitted under
the federal Social Security Act, the amount expended under this Article (1) for
a person of any age who is an inpatient in a nursing facility, an intermediate
care facility for persons with intellectual disabilities, or other medical institution, or (2)
for a person aged 55 or more, shall be a claim against the person's
estate or a claim against the estate of the person's spouse,
regardless of the order of death, but no recovery may
be had thereon until after the death of the surviving spouse, if any, and then
only at such time when there is no surviving child who is under age 21, or
blind, or is a child with a permanent total disability. This Section, however, shall not
bar recovery at the death of the person of amounts of medical assistance paid
to or in his behalf to which he was not entitled; provided that such
recovery shall not be enforced against any real estate while it is occupied
as a homestead by the surviving spouse or other dependent, if no claims by
other creditors have been filed against the estate, or if such claims have
been filed, they remain dormant for failure of prosecution or failure of
the claimant to compel administration of the estate for the purpose of
payment.  The term "estate", as used in this Section, with respect to a
deceased person, means all real and personal property and other assets included
within the person's estate, as that term is used in the Probate Act of 1975;
however, in the case of a deceased person who has received (or is entitled to
receive) benefits under a long-term care insurance policy in connection with
which assets or resources are disregarded to the extent that payments are made
or because the deceased person received (or was entitled to receive) benefits
under a long-term care insurance policy, "estate" also includes any
other real and personal property and other assets in which the deceased person
had any legal title or interest at the time of his or her death (to the extent
of that interest), including assets conveyed to a survivor, heir, or assignee
of the deceased person through joint tenancy, tenancy in common, survivorship,
life estate, living trust, or other arrangement. The term "homestead", as used
in this Section, means the dwelling house and contiguous real estate occupied
by a surviving spouse or relative, as defined by the rules and regulations of
the Illinois Department, regardless of the value of the property.
A claim arising under this Section against assets conveyed to a survivor,
heir, or assignee of the deceased person through joint tenancy, tenancy in
common, survivorship, life estate, living trust, or other arrangement is not
effective until the claim is recorded or filed in the manner provided for a
notice of lien in Section 3-10.2.  The claim is subject to the same
requirements and conditions to which liens on real property interests are
subject under Sections 3-10.1 through 3-10.10.  A claim arising under this
Section attaches to interests owned or subsequently acquired by the estate of a
recipient or the estate of a recipient's surviving spouse.
The transfer or conveyance of any real or personal property of the estate
as
defined in this Section shall be subject to the fraudulent transfer conditions
that apply to real property in Section 3-11 of this Code.
The provisions of this Section shall not affect the validity of claims
against estates for medical assistance provided prior to January 1, 1966 to
aged or blind persons or persons with disabilities receiving aid under Articles V, VII and
VII-A of the 1949 Code.
(Source: P.A. 99-143, eff. 7-27-15.)
(305 ILCS 5/5-13.1)
Sec. 5-13.1. Cost-effectiveness waiver, hardship waivers, and making information about waivers more accessible.
(a) It is the intent of the General Assembly to ease the burden of liens and estate recovery for correctly paid benefits for participants, applicants, and their families and heirs, and to make information about waivers more widely available.
(b) The Department shall waive estate recovery under Sections 3-9 and 5-13 where recovery would not be cost-effective, would work an undue hardship, or for any other just reason, and shall make information about waivers and estate recovery easily accessible.
(1) Cost-effectiveness waiver. Subject to federal     approval, the Department shall waive any claim against the first $25,000 of any estate to prevent substantial and unreasonable hardship. The Department shall consider the gross assets in the estate, including, but not limited to, the net value of real estate less mortgages or liens with priority over the Department's claims. The Department may increase the cost-effectiveness threshold in the future.
(2) Undue hardship waiver. The Department may develop     additional hardship waiver standards in addition to those already employed, including, but not limited to, waivers aimed at preserving  income-producing real property or a modest home as defined by rule.
(3) Accessible information. The Department shall make     information about estate recovery and hardship waivers easily accessible. The Department shall maintain information about how to request a hardship waiver on its website in English, Spanish, and the next 4 most commonly used languages, including a short guide and simple form to facilitate requesting hardship exemptions in each language. On an annual basis, the Department shall publicly report on the number of estate recovery cases that are pursued and the number of undue hardship exemptions granted, including demographic data of the deceased beneficiaries where available.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-13.2)
Sec. 5-13.2. 
		Notice of claim for payment or against estate. 
		If the Illinois Department determines, more than 120 days after a person
becomes an institutionalized person, that (i) the institutionalized person, the
institutionalized person's spouse, or any other person is required under this
Code to reimburse the Illinois Department for any part of the amount of medical
assistance provided under this Article to or on behalf of the institutionalized
person or (ii) the institutionalized person's estate is liable for any amount
of medical assistance provided to or on behalf of the institutionalized person,
the Illinois Department shall not make any claim for payment of that amount on
demand, but rather shall establish, in cooperation with the institutionalized
person (and that person's spouse or primary caretaker, if applicable), a
schedule for payment of the amount owed to the Illinois Department.
(Source: P.A. 88-162; 88-670, eff. 12-2-94.)
(305 ILCS 5/5-13.5)
Sec. 5-13.5. (Repealed).
(Source: P.A. 88-670, eff. 12-2-94. Repealed by P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-14) (from Ch. 23, par. 5-14)
Sec. 5-14. 
		Exemption for Townships. 
		Nothing in this Article shall be
construed as requiring townships to provide, in whole or in part, medical
assistance to persons who are not residents of the State of Illinois.
In all instances under this Article where medical aid or assistance to
a person who is not a resident of this State would otherwise be in whole
or in part, the responsibility of a township, the Illinois Department shall
be responsible for such aid or assistance.
The Illinois Department shall, by rule or regulation, insure that provision
of such aid or assistance to a non-resident is identical to the uniform
standard of eligibility established by the Illinois Department.
(Source: P.A. 81-519.)
(305 ILCS 5/5-15) (from Ch. 23, par. 5-15)
Sec. 5-15. (a) The Illinois Department is authorized to contract
with community based organizations serving low income communities for a
three year period to demonstrate how and the extent to which preventive
health programs can decrease utilization of medical care services and/or
improve health status.
(b) As used in this Section (1) a community based organization is an
organization established as a not-for-profit corporation under laws of the
State of Illinois which serves a defined geographic community and is
governed by members of that community; and (2) a preventive health program
is any program, service or intervention the purpose of which is to
identify, resolve, or ameliorate problems which contribute to the
utilization of medical services.
(c) The Illinois Department is authorized, for evaluation purposes, to
release names of recipients and other pertinent identification and medical
utilization information to the community organizations under contract.
(d) Contractors shall maintain strict confidentiality of information
released by the Illinois Department by following guidelines established by
the Illinois Department, which shall require that recipients sign a release
for any further use or disclosure of such information.
(Source: P.A. 93-632, eff. 2-1-04.)
(305 ILCS 5/5-15.5)
Sec. 5-15.5. 
		Preventive physical examinations; demonstration program.
(a) The Illinois Department may establish and implement a demonstration
program of preventive physical examinations over a 3-year period commencing on
January 1, 1994, for persons receiving assistance under Article IV of this
Code and persons eligible for assistance under this Article who are otherwise
eligible for assistance under Article IV but who fail to qualify for cash
assistance under Article IV on the basis of need.  Notwithstanding any other
provision of this Section, however, persons who are pregnant or who are less
than 21 years of age shall not be eligible to participate in the demonstration
program.  The demonstration program may be implemented for recipients in at
least 2 counties, one with a population of not more than 650,000 as determined
by the 1990 federal census, and one with a population of not more than 100,000
as determined by the 1990 federal census.  The Illinois Department may
establish by rule the nature and scope of the preventive physical examinations
required under this Section, except that the services may include, as
appropriate, blood pressure reading, complete blood test appropriate to the
population and risk factors, family planning, nutrition counselling, smoking
evaluation, temperature, urinalysis, chest x-ray, tuberculosis screening, and
appropriate referrals.
(b) Participation in the demonstration program shall be voluntary, and
eligible recipients shall not be subject to sanctions for refusing or failing
to submit to a preventive physical examination or any portion of such an
examination.  The Illinois Department may by rule limit each eligible recipient
to one examination during the demonstration period.
(c) For the purpose of carrying out its responsibilities under this Section,
the Illinois Department is authorized to enter into cooperative arrangements
with for-profit and non-profit medical clinics and hospitals, local health
departments, and other providers of medical services. The Illinois Department
of Public Health shall cooperate in the development and establishment of this
demonstration program. During the period of the demonstration program, the
Illinois Department of Public Aid shall study the cost benefit of providing
preventive physical examinations to the targeted group of recipients of public
aid.
(d) Implementation of the demonstration program shall be contingent on the
receipt of all necessary federal waivers.
(Source: P.A. 88-396.)
(305 ILCS 5/5-16) (from Ch. 23, par. 5-16)
Sec. 5-16. 
		Managed Care. 
		The Illinois Department may develop and implement
a Primary Care Sponsor System consistent with the provisions of this Section.
The purpose of this managed care delivery system shall be to contain the costs
of providing medical care to Medicaid recipients by having one provider
responsible for managing all aspects of a recipient's medical care.  This
managed care system shall have the following characteristics:
(a) The Department, by rule, shall establish criteria     to determine which clients must participate in this program;
(b) Providers participating in the program may be     paid an amount per patient per month, to be set by the Illinois Department, for managing each recipient's medical care;
(c) Providers eligible to participate in the program     shall be physicians licensed to practice medicine in all its branches, and the Illinois Department may terminate a provider's participation if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department;
(d) Each recipient required to participate in the     program must select from a panel of primary care providers or networks established by the Department in their communities;
(e) A recipient may change his designated primary     care provider:
(1) when the designated source becomes         unavailable, as the Illinois Department shall determine by rule; or
(2) when the designated primary care provider         notifies the Illinois Department that it wishes to withdraw from any obligation as primary care provider; or
(3) in other situations, as the Illinois         Department shall provide by rule;
(f) The Illinois Department shall, by rule, establish     procedures for providing medical services when the designated source becomes unavailable or wishes to withdraw from any obligation as primary care provider taking into consideration the need for emergency or temporary medical assistance and ensuring that the recipient has continuous and unrestricted access to medical care from the date on which such unavailability or withdrawal becomes effective until such time as the recipient designates a primary care source;
(g) Only medical care services authorized by a     recipient's designated provider, except for emergency services, services performed by a provider that is owned or operated by a county and that provides non-emergency services without regard to ability to pay and such other services as provided by the Illinois Department, shall be subject to payment by the Illinois Department.  The Illinois Department shall enter into an intergovernmental agreement with each county that owns or operates such a provider to develop and implement policies to minimize the provision of medical care services provided by county owned or operated providers pursuant to the foregoing exception.
The Illinois Department shall seek and obtain necessary authorization
provided under federal law to implement such a program including the waiver of
any federal regulations.
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.
The Illinois Department may establish a managed care system demonstration
program, on a limited basis, as described in this Section.  The demonstration
program shall terminate on June 30, 1997.  Within 30 days after the end of each
year of the demonstration program's operation, the Illinois Department shall
report to the Governor and the General Assembly concerning the operation of the
demonstration program.
(Source: P.A. 87-14; 88-490.)
(305 ILCS 5/5-16.1) (from Ch. 23, par. 5-16.1)
Sec. 5-16.1. Case Management Services. The Illinois Department may
develop, implement and evaluate a Case Management Services Program which
provides services consistent with the provisions of this Section, and the
Inter-Agency Agreement between the Department of Healthcare and Family Services (formerly Department of Public Aid) and the
Department of Public Health, for a targeted population on a less than
Statewide basis in the State of Illinois.  The purpose of this Case
Management Services Program shall be to assist eligible participants in
gaining access to needed medical, social, educational and other services
thereby reducing the likelihood of long-term welfare dependency.  The Case
Management Services Program shall have the following characteristics:
(a) It shall be conducted for a period of no less     than 5 consecutive fiscal years in one urban area containing a high proportion, as determined by Department of Healthcare and Family Services and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment and in one rural area containing a high proportion, as determined by Department of Healthcare and Family Services and Department of Public Health records, of Medicaid eligible pregnant or parenting girls under 17 years of age at the time of the initial assessment.
(b) Providers participating in the program shall be     paid an amount per patient per month, to be set by the Illinois Department, for the case management services provided.
(c) Providers eligible to participate in the program     shall be nurses or social workers, licensed to practice in Illinois, who comply with the rules and regulations established by the Illinois Department and the Inter-Agency Agreement between the Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Public Health.  The Illinois Department may terminate a provider's participation in the program if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department.
(d) Each eligible participant in an area where the     Case Management Services Program is being conducted may voluntarily designate a case manager, of her own choosing to assume responsibility for her care.
(e) A participant may change her designated case     manager provided that she informs the Illinois Department by the 20th day of the month in order for the change to be effective in the following month.
(f) The Illinois Department shall, by rule, establish     procedures for providing case management services when the designated source becomes unavailable or wishes to withdraw from any obligation as case management services provider.
(g) In accordance with rules adopted by the Illinois     Department, a participant may discontinue participation in the program upon timely notice to the Illinois Department, in which case the participant shall remain eligible for assistance under all applicable provisions of Article V of this Code.
The Illinois Department shall take any necessary steps to obtain
authorization or waiver under federal law to implement a Case Management
Services Program.  Participation shall be voluntary for the provider and
the recipient.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-16.2)
Sec. 5-16.2. 
		Long range plan for case management. 
		The Illinois Department
shall develop a long range plan for the implementation of case management
services, as defined in Section 5-16.1 of this Act, throughout Illinois.  The
long range plan shall include:  (i) a geographic overview of the State and the
proportion, as determined by the Department of Public Aid and the Department of
Public Health records, of Medicaid eligible pregnant or parenting girls under
17 years of age at the time of the initial assessment;  (ii) identification of
high proportion areas; (iii) goals for reducing the likelihood of long-term
welfare dependency; (iv) the time frames for accomplishing the identified
goals; and (v) specific recommendations for administrative or legislative
policies and programs necessary to complete the identified goals.  The long
range plan shall take into consideration other resources currently serving the
identified population.  The long range plan shall be completed no later than
July 1, 1994, and provided to the Governor and the General Assembly in the form
of a written report.
(Source: P.A. 88-70.)
(305 ILCS 5/5-16.3)
Sec. 5-16.3. 
		(Repealed).
(Source: P.A. 90-742, eff. 8-13-98. Repealed by P.A. 92-370, eff. 8-15-01.)
(305 ILCS 5/5-16.4)
Sec. 5-16.4. (Repealed).
(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 99-933, eff. 1-27-17.)
(305 ILCS 5/5-16.5)
Sec. 5-16.5. 
		Expedited payments.
(a) (Blank).
(b) In a county with a population of 3,000,000 or more, a managed care
community network shall receive expedited payment of its capitated
reimbursement for each of its managed care enrollees if both of the following
criteria are met:
(1) At least 75% of its membership is composed of     hospitals that are qualified on or after July 1, 1994 as disproportionate share hospitals.
(2) At least 75% of its managed care enrollees     receive services at the disproportionate share hospitals or those hospitals' affiliated sites.
(c) For counties whose population is less than 3,000,000, the Illinois
Department shall establish by rule the terms and conditions under which a
managed care community network shall receive expedited payment, including a
determination of the qualifying percentage criteria for
disproportionate share hospitals and managed care enrollees
within a network receiving services at disproportionate share hospitals or
their affiliated sites.
(Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95.)
(305 ILCS 5/5-16.6)
Sec. 5-16.6. 
		Provider compliance with certain requirements. 
		The Illinois
Department shall inquire of appropriate State agencies concerning the status of
all providers' compliance with State income tax requirements, child support
payments in accordance with Article X of this Code, and educational loans
guaranteed by the Illinois State Scholarship Commission.  The Illinois
Department may suspend from participation in the medical assistance program,
after reasonable notice and opportunity for a hearing in accordance with
Section
12-4.25 of this Code, those providers not in compliance with
these
requirements, unless payment arrangements acceptable to the appropriate State
agency are made.
(Source: P.A. 90-655, eff. 7-30-98.)
(305 ILCS 5/5-16.7)
Sec. 5-16.7. Post-parturition care. The medical assistance program shall
provide the post-parturition care benefits required to be covered by a policy
of accident and health insurance under Section 356s of the
Illinois Insurance Code.
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.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-16.7a)
Sec. 5-16.7a. Reimbursement for epidural anesthesia services.
In addition to other procedures authorized by the
Department under this Code, the
Department shall provide reimbursement to medical providers for epidural
anesthesia services when ordered by the attending practitioner at the time of
delivery.
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.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-16.8)
(Text of Section from P.A. 102-1117)
Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, and 356z.60 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.
The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.
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.
To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.
(Source: P.A. 101-81, eff. 7-12-19; 101-218, eff. 1-1-20; 101-281, eff. 1-1-20; 101-371, eff. 1-1-20; 101-574, eff. 1-1-20; 101-649, eff. 7-7-20; 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23.)
(Text of Section from P.A. 103-84, 103-91, and 103-420)
Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, and 356z.61 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.
The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.
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.
To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.
(Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24.)
(305 ILCS 5/5-16.9)
Sec. 5-16.9. Woman's health care provider. The medical assistance
program is subject to the provisions of Section 356r of the Illinois
Insurance Code.  The Illinois Department shall adopt rules to implement the
requirements of Section 356r of the Illinois Insurance Code in the medical
assistance program including managed care components.
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.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-16.10)
Sec. 5-16.10. 
		Managed care entities; marketing. 
		
A managed health care entity
providing services under this Article V
may not engage in door-to-door
marketing activities or marketing activities at an office of the Illinois
Department or a county department in order to enroll
recipients
in the entity's health
care
delivery system.  The Department shall adopt rules defining "marketing
activities" prohibited by this Section.
Before a managed health care entity
providing services under this Article V
may market its health care delivery
system
to recipients,
the Illinois Department must approve a marketing plan submitted
by the entity to the Illinois Department. The Illinois Department shall adopt
guidelines for approving marketing plans submitted by managed health care
entities under this Section. Besides prohibiting door-to-door marketing
activities and marketing activities at public aid offices, the guidelines shall
include at least the following:
(1) A managed health care entity may not offer or     provide any gift, favor, or other inducement in marketing its health care delivery system to integrated health care program enrollees. A managed health care entity may provide health care related items that are of nominal value and pre-approved by the Department to prospective enrollees. A managed health care entity may also provide to enrollees health care related items that have been pre-approved by the Department as an incentive to manage their health care appropriately.
(2) All persons employed or otherwise engaged by a     managed health care entity to market the entity's health care delivery system to recipients or to supervise  that marketing shall register with the Illinois Department.
The Inspector General appointed under Section 12-13.1 may conduct
investigations to determine whether the marketing practices of managed health
care entities
providing services under this Article V
comply with
the guidelines.
(Source: P.A. 90-538, eff. 12-1-97.)
(305 ILCS 5/5-16.11)
Sec. 5-16.11. 
		Uniform standards applied to managed care entities. 
		Any
managed care entity providing services under this Code shall use a pharmacy
formulary that is no more restrictive than the Illinois Department's
pharmaceutical program.
(Source: P.A. 92-370, eff. 8-15-01.)
(305 ILCS 5/5-16.12)
Sec. 5-16.12. 
		Managed Care Reform and Patient Rights Act. 
		The medical
assistance
program and other programs administered by the Department are subject to the
provisions of the Managed Care Reform and Patient Rights Act.
The
Department may adopt rules
to
implement those provisions.  These rules shall require compliance with
that Act in
the medical assistance managed care programs and other programs administered by
the Department.  The medical assistance
fee-for-service program is not subject to the provisions of the Managed Care
Reform and Patient Rights Act.
Nothing in the Managed Care Reform and Patient Rights Act shall be
construed to mean that the Department is a health care plan as defined in that
Act simply because the Department enters into contractual relationships with
health care plans.
(Source: P.A. 91-617, eff. 1-1-00.)
(305 ILCS 5/5-16.13)
Sec. 5-16.13. (Repealed).
(Source: P.A. 93-674, eff. 6-10-04. Repealed internally, eff. 12-31-04.)
(305 ILCS 5/5-17) (from Ch. 23, par. 5-17)
Sec. 5-17. Programs to improve access to hospital care.
(a) (1) The General Assembly finds:
(A) That while hospitals have traditionally         provided charitable care to indigent patients, this burden is not equally borne by all hospitals operating in this State.  Some hospitals continue to provide significant amounts of care to low-income persons while others provide very little such care; and
(B) That access to hospital care in this State by         the indigent citizens of Illinois would be seriously impaired by the closing of hospitals that provide significant amounts of care to low-income persons.
(2) To help expand the availability of hospital care     for all citizens of this State, it is the policy of the State to implement programs that more equitably distribute the burden of providing hospital care to Illinois' low-income population and that improve access to health care in Illinois.
(3) The Illinois Department may develop and implement     a program that lessens the burden of providing hospital care to Illinois' low-income population, taking into account the costs that must be incurred by hospitals providing significant amounts of care to low-income persons, and may develop adjustments to increase rates to improve access to health care in Illinois. The Illinois Department shall prescribe by rule the criteria, standards and procedures for effecting such adjustments in the rates of hospital payments for services provided to eligible low-income persons (under Articles V, VI and VII of this Code) under this Article.
(b) The Illinois Department shall require hospitals certified to
participate in the federal Medicaid program to:
(1) provide equal access to available services to     low-income persons who are eligible for assistance under Articles V, VI and VII of this Code;
(2) provide data and reports on the provision of     uncompensated care.
(c) From the effective date of this amendatory Act of 1992 until July
1, 1992, nothing in this Section 5-17 shall be construed as creating a
private right of action on behalf of any individual.
(d) 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.
(Source: P.A. 97-689, eff. 6-14-12.)
(305 ILCS 5/5-18) (from Ch. 23, par. 5-18)
Sec. 5-18. 
		(Repealed).
(Source: P.A. 87-895. Repealed by P.A. 92-275, eff. 8-7-01.)
(305 ILCS 5/5-18.5)
Sec. 5-18.5. Perinatal doula and evidence-based home visiting services.
(a) As used in this Section:
"Home visiting" means a voluntary, evidence-based strategy used to support pregnant people, infants, and young children and their caregivers to promote infant, child, and maternal health, to foster educational development and school readiness, and to help prevent child abuse and neglect. Home visitors are trained professionals whose visits and activities focus on promoting strong parent-child attachment to foster healthy child development.
"Perinatal doula" means a trained provider who provides regular, voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period.
"Perinatal doula training" means any doula training that focuses on providing support throughout the prenatal, labor and delivery, or postpartum period, and reflects the type of doula care that the doula seeks to provide.
(b) Notwithstanding any other provision of this Article, perinatal doula services and evidence-based home visiting services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article.  Perinatal doula services include regular visits beginning in the prenatal period and continuing into the postnatal period, inclusive of continuous support during labor and delivery, that support healthy pregnancies and positive birth outcomes. Perinatal doula services may be embedded in an existing program, such as evidence-based home visiting. Perinatal doula services provided during the prenatal period may be provided weekly, services provided during the labor and delivery period may be provided for the entire duration of labor and the time immediately following birth, and services provided during the postpartum period may be provided up to 12 months postpartum.
(b-5) Notwithstanding any other provision of this Article, beginning January 1, 2023, licensed certified professional midwife services shall be covered under the medical assistance program, subject to appropriation, for persons who are otherwise eligible for medical assistance under this Article. The Department shall consult with midwives on reimbursement rates for midwifery services.
(c) The Department of Healthcare and Family Services shall adopt rules to administer this Section. In this rulemaking, the Department shall consider the expertise of and consult with doula program experts, doula training providers, practicing doulas, and home visiting experts, along with State agencies implementing perinatal doula services and relevant bodies under the Illinois Early Learning Council. This body of experts shall inform the Department on the credentials necessary for perinatal doula and home visiting services to be eligible for Medicaid reimbursement and the rate of reimbursement for home visiting and perinatal doula services in the prenatal, labor and delivery, and postpartum periods. Every 2 years, the Department shall assess the rates of reimbursement for perinatal doula and home visiting services and adjust rates accordingly.
(d) The Department shall seek such State plan amendments or waivers as may be necessary to implement this Section and shall secure federal financial participation for expenditures made by the Department in accordance with this Section.
(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-18.10)
Sec. 5-18.10. Reimbursement for postpartum visits.
(a) In this Section:
"Certified lactation counselor" means a health care professional in lactation counseling who has demonstrated the necessary skills, knowledge, and attitudes to provide clinical breastfeeding counseling and management support to families who are thinking about breastfeeding or who have questions or problems during the course of breastfeeding.
"Certified nurse midwife" means a person who exceeds the competencies for a midwife contained in the Essential Competencies for Midwifery Practice, published by the International Confederation of Midwives, and who qualifies as an advanced practice registered nurse.
"Community health worker" means a frontline public health worker who is a trusted member or has an unusually close understanding of the community served. This trusting relationship enables the community health worker to serve as a liaison, link, and intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
"International board-certified lactation consultant" means a health care professional who is certified by the International Board of Lactation Consultant Examiners and specializes in the clinical management of breastfeeding.
"Medical caseworker" means a health care professional who assists in the planning, coordination, monitoring, and evaluation of medical services for a patient with emphasis on quality of care, continuity of services, and affordability.
"Perinatal doula" means a trained provider of regular and voluntary physical, emotional, and educational support, but not medical or midwife care, to pregnant and birthing persons before, during, and after childbirth, otherwise known as the perinatal period.
"Public health nurse" means a registered nurse who promotes and protects the health of populations using knowledge from nursing, social, and public health sciences.
(b) The Illinois Department shall establish a medical assistance program to cover a universal postpartum visit within the first 3 weeks after childbirth and a comprehensive visit within 4 to 12 weeks postpartum for persons who are otherwise eligible for medical assistance under this Article. In addition, postpartum care services rendered by perinatal doulas, certified lactation counselors, international board-certified lactation consultants, public health nurses, certified nurse midwives, community health workers, and medical caseworkers shall be covered under the medical assistance program.
(Source: P.A. 102-665, eff. 10-8-21.)
(305 ILCS 5/5-19) (from Ch. 23, par. 5-19)
Sec. 5-19. Healthy Kids Program.
(a) Any child under the age of 21 eligible to receive Medical Assistance
from the Illinois Department under Article V of this Code shall be eligible
for Early and Periodic Screening, Diagnosis and Treatment services provided
by the Healthy Kids Program of the Illinois Department under the Social
Security Act, 42 U.S.C. 1396d(r).
(b) Enrollment of Children in Medicaid.  The Illinois Department shall
provide for receipt and initial processing of applications for Medical
Assistance for all pregnant women and children under the age of 21 at
locations in addition to those used for processing applications for cash
assistance, including disproportionate share hospitals, federally qualified
health centers and other sites as selected by the Illinois Department.
(c) Healthy Kids Examinations.  The Illinois Department shall consider
any examination of a child eligible for the Healthy Kids services provided
by a medical provider meeting the requirements and complying with the rules
and regulations of the Illinois Department to be reimbursed as a Healthy
Kids examination.
(d) Medical Screening Examinations.
(1) The Illinois Department shall insure Medicaid     coverage for periodic health, vision, hearing, and dental screenings for children eligible for Healthy Kids services scheduled from a child's birth up until the child turns 21 years. The Illinois Department shall pay for vision, hearing, dental and health screening examinations for any child eligible for Healthy Kids services by qualified providers at intervals established by Department rules.
(2) The Illinois Department shall pay for an     interperiodic health, vision, hearing, or dental screening examination for any child eligible for Healthy Kids services whenever an examination is:
(A) requested by a child's parent, guardian, or         custodian, or is determined to be necessary or appropriate by social services, developmental, health, or educational personnel; or
(B) necessary for enrollment in school; or
(C) necessary for enrollment in a licensed day         care program, including Head Start; or
(D) necessary for placement in a licensed child         welfare facility, including a foster home, group home or child care institution; or
(E) necessary for attendance at a camping         program; or
(F) necessary for participation in an organized         athletic program; or
(G) necessary for enrollment in an early         childhood education program recognized by the Illinois State Board of Education; or
(H) necessary for participation in a Women,         Infant, and Children (WIC) program; or
(I) deemed appropriate by the Illinois Department.
(e) Minimum Screening Protocols For Periodic Health Screening
Examinations.  Health Screening Examinations must include the following
services:
(1) Comprehensive Health and Development Assessment     including:
(A) Development/Mental Health/Psychosocial         Assessment; and
(B) Assessment of nutritional status including         tests for iron deficiency and anemia for children at the following ages: 9 months, 2 years, 8 years, and 18 years;
(2) Comprehensive unclothed physical exam;
(3) Appropriate immunizations at a minimum, as     required by the Secretary of the U.S. Department of Health and Human Services under 42 U.S.C. 1396d(r).
(4) Appropriate laboratory tests including blood lead     levels appropriate for age and risk factors.
(A) Anemia test.
(B) Sickle cell test.
(C) Tuberculin test at 12 months of age and every         1-2 years thereafter unless the treating health care professional determines that testing is medically contraindicated.
(D) Other -- The Illinois Department shall insure         that testing for HIV, drug exposure, and sexually transmitted diseases is provided for as clinically indicated.
(5) Health Education.  The Illinois Department shall     require providers to provide anticipatory guidance as recommended by the American Academy of Pediatrics.
(6) Vision Screening.  The Illinois Department shall     require providers to provide vision screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
(7) Hearing Screening.  The Illinois Department shall     require providers to provide hearing screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
(8) Dental Screening.  The Illinois Department shall     require providers to provide dental screenings consistent with those set forth in the Department of Public Health's Administrative Rules.
(f) Covered Medical Services.  The Illinois Department shall provide
coverage for all necessary health care, diagnostic services, treatment and
other measures to correct or ameliorate defects, physical and mental
illnesses, and conditions whether discovered by the screening services or
not for all children eligible for Medical Assistance under Article V of
this Code.
(g) Notice of Healthy Kids Services.
(1) The Illinois Department shall inform any child     eligible for Healthy Kids services and the child's family about the benefits provided under the Healthy Kids Program, including, but not limited to, the following:  what services are available under Healthy Kids, including discussion of the periodicity schedules and immunization schedules, that services are provided at no cost to eligible children, the benefits of preventive health care, where the services are available, how to obtain them, and that necessary transportation and scheduling assistance is available.
(2) The Illinois Department shall widely disseminate     information regarding the availability of the Healthy Kids Program throughout the State by outreach activities which shall include, but not be limited to, (i) the development of cooperation agreements with local school districts, public health agencies, clinics, hospitals and other health care providers, including developmental disability and mental health providers, and with charities, to notify the constituents of each of the Program and assist individuals, as feasible, with applying for the Program, (ii) using the media for public service announcements and advertisements of the Program, and (iii) developing posters advertising the Program for display in hospital and clinic waiting rooms.
(3) The Illinois Department shall utilize accepted     methods for informing persons who are illiterate, blind, deaf, or cannot understand the English language, including but not limited to public services announcements and advertisements in the foreign language media of radio, television and newspapers.
(4) The Illinois Department shall provide notice of     the Healthy Kids Program to every child eligible for Healthy Kids services and his or her family at the following times:
(A) orally by the intake worker and in writing at         the time of application for Medical Assistance;
(B) at the time the applicant is informed that he         or she is eligible for Medical Assistance benefits; and
(C) at least 20 days before the date of any         periodic health, vision, hearing, and dental examination for any child eligible for Healthy Kids services. Notice given under this subparagraph (C) must state that a screening examination is due under the periodicity schedules and must advise the eligible child and his or her family that the Illinois Department will provide assistance in scheduling an appointment and arranging medical transportation.
(h) Data Collection.  The Illinois Department shall collect data in a
usable form to track utilization of Healthy Kids screening examinations by
children eligible for Healthy Kids services, including but not limited to
data showing screening examinations and immunizations received, a summary
of follow-up treatment received by children eligible for Healthy Kids
services and the number of children receiving dental, hearing and vision
services.
(i) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
(j) To ensure full access to the benefits set forth in this
Section, on and after January 1, 2022, the Illinois Department
shall ensure that provider and hospital reimbursements for
immunization as required under this Section are no lower than
70% of the median regional maximum administration fee for the State of Illinois as established
by the U.S. Department of Health and Human Services' Centers
for Medicare and Medicaid Services.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-20)
Sec. 5-20. Electronic health care card. By December 31, 1994, the
Illinois Department may develop and implement by rule an electronic health
information system to process claims electronically and to electronically store
Medicare and Medicaid patient records, medical histories, and billing
information.  The Illinois Department may issue each Medicare and Medicaid
recipient a health card containing electronically coded information that will
access the system, verify their Medicare or Medicaid status, and display how
much the patient must pay in deductibles or copayments for a medical procedure.
 The Illinois Department may also develop safeguards to protect recipients'
health information from misuse or unauthorized disclosure.
On or before July 1, 2011, the Department shall cease issuing monthly MediPlan cards and shall instead issue permanent or semi-permanent member  cards to individuals enrolled for medical assistance.  Furthermore, the Department may employ any reasonable means by which providers may verify an individual's eligibility for medical assistance in place of MediPlan cards.
(Source: P.A. 96-940, eff. 1-1-11.)
(305 ILCS 5/5-21)
Sec. 5-21. Immunization. By July 1, 1994, the Illinois Department shall,
in cooperation with the Department of Public Health, establish and implement a
pilot program that will provide immunization services for children on a walk-in
basis at local public aid offices.  The Director shall determine the number and
location of the local public aid offices that will participate in the pilot
program.  The Illinois Department shall submit a report on the effectiveness
of the program to the General Assembly on or before December 31, 1995.
The Department of Healthcare and Family Services (formerly Department of Public Aid) and the Department of Human Services, in
cooperation with the Department of Public Health, shall continue to implement
the pilot program after the effective date of this amendatory Act of 1996.
(Source: P.A. 95-331, eff. 8-21-07.)
(305 ILCS 5/5-22)
Sec. 5-22. (Repealed).
(Source: P.A. 90-655, eff. 7-30-98. Repealed by P.A. 96-1123, eff. 1-1-11.)
(305 ILCS 5/5-23)
Sec. 5-23. 
		(Repealed).
(Source: P.A. 92-581, eff. 6-26-02. Repealed internally, eff. 7-1-03.)
(305 ILCS 5/5-24)
Sec. 5-24. (Repealed).
(Source: P.A. 97-689, eff. 6-14-12. Repealed internally, eff. 1-1-14.)
(305 ILCS 5/5-25)
Sec. 5-25. Pediatric asthma initiative.
(a) During fiscal year 2006, the Department of Public Aid shall evaluate current standards of treatment of asthma for its beneficiaries. The review may include state-of-the-art programs in asthma disease management as well as evidence-based best practices for the early diagnosis, treatment, and control of asthma, particularly in children. The Department's review may include asthma disease management as one component of a comprehensive disease management model. The Department shall consult with the Department of Public Health and other State agencies, advocates, and providers in conducting this review. The Department's review shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The review shall also assess the available methods of implementing and funding asthma disease management and treatment within the Medicaid program.
(b) After completing the review under subsection (a), the Department of Public Aid shall develop a pilot asthma disease management program. The pilot program shall be targeted to an area or areas with the highest prevalence of asthma.

The Department shall consult with the Department of Public Health and other State agencies, federal health agencies, experts in asthma and immunology, providers, and consumers in developing the pilot program. The pilot program shall also seek to maximize collaborations between existing asthma programs in the State of Illinois. The pilot   program shall be subject to specific appropriations or budget savings derived from the program due to reduced asthma-related hospitalizations or emergency room visits.
(Source: P.A. 94-328, eff. 7-26-05.)
(305 ILCS 5/5-26)
Sec. 5-26. Federal Family Opportunity Act.
(a) As used in this Section, "the federal Act" means the federal Family Opportunity Act, enacted as part of the Deficit Reduction Act of 2005.
(b) Subject to appropriations for program administration and services, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall implement the Medical Assistance provisions of the federal Act as soon as possible after the effective date of this amendatory Act of the 95th General Assembly.
(c) As soon as possible after the effective date of this amendatory Act of the 95th General Assembly, the Department of Human Services, in conjunction with the Department of Healthcare and Family Services, shall take all necessary and appropriate steps to try to secure (i) any available federal funds for a demonstration project regarding home and community-based alternatives to psychiatric residential treatment facilities for children, as authorized by the federal Act, and (ii) the location in Illinois of a family-to-family health information center, as authorized by the federal Act.
(Source: P.A. 97-48, eff. 6-28-11.)
(305 ILCS 5/5-27)
Sec. 5-27. (Repealed).
(Source: P.A. 96-1372, eff. 7-29-10. Repealed internally, eff. 1-1-11.)
(305 ILCS 5/5-28)
Sec. 5-28. Community transition resources.  The Department of Healthcare and Family Services, in collaboration with all relevant agencies,  shall develop a Community Transition Plan to allow nursing facility residents who are determined to be appropriate for transition to the community to access or acquire resources to support the transition.  These strategies may include, but need not be limited to, enhancement of the Community Home Maintenance Allowance, retention of income from work, and incorporation of community transition services into existing home and community-based waiver programs.
(Source: P.A. 96-1372, eff. 7-29-10.)
(305 ILCS 5/5-29)
Sec. 5-29. Income Limits and Parental Responsibility. In light of the unprecedented fiscal crisis confronting the State, it is the intent of the General Assembly to explore whether the income limits and income counting methods established for children under  the  Covering  ALL KIDS  Health  Insurance  Act,  pursuant to this amendatory Act of the 96th General Assembly, should apply to medical assistance programs available to children made eligible under the Illinois Public Aid Code, including through home and community based services waiver programs authorized under Section 1915(c) of the Social Security Act, where parental income is currently not considered in determining a child's eligibility for medical assistance.  The Department of Healthcare and Family Services is hereby directed, with the participation of the Department of Human Services and stakeholders, to conduct an analysis of these programs to determine parental cost sharing opportunities, how these opportunities may impact the children currently in the programs, waivers and on the waiting list, and any other factors which may increase efficiencies and decrease State costs.  The Department is further directed to review how services under these programs and waivers may be provided by the use of a combination of skilled, unskilled, and uncompensated care and to advise as to what revisions to the Nurse Practice Act, and Acts regulating other relevant professions, are necessary to accomplish this combination of care.  The Department shall submit a written analysis on the children's programs and waivers as part of the Department's annual Medicaid reports due to the General Assembly in 2011 and 2012.
(Source: P.A. 96-1501, eff. 1-25-11.)
(305 ILCS 5/5-30)
Sec. 5-30. Care coordination.
(a) At least 50% of recipients eligible for comprehensive medical benefits in all medical assistance programs or other health benefit programs administered by the Department, including the Children's Health Insurance Program Act and the Covering ALL KIDS Health Insurance Act, shall be enrolled in a care coordination program by no later than  January  1,  2015.  For  purposes  of  this  Section,  "coordinated care" or "care coordination" means delivery  systems where recipients will receive their care from providers who participate under contract in integrated delivery systems that are responsible for providing or arranging the majority of care, including primary care physician services, referrals from primary care physicians, diagnostic and treatment services, behavioral health services, in-patient and outpatient hospital services, dental services, and rehabilitation and long-term care services. The Department shall designate or contract for such integrated delivery systems (i) to ensure enrollees have a choice of systems and of primary care providers within such systems; (ii) to ensure that enrollees receive quality care in a culturally and linguistically appropriate manner; and (iii) to ensure that coordinated care programs meet the diverse needs of enrollees with developmental, mental health, physical, and age-related disabilities.
(b) Payment for such coordinated care shall be based on arrangements where the State pays for performance related to health care outcomes, the use of evidence-based practices, the use of primary care delivered through comprehensive medical homes, the use of electronic medical records, and the appropriate exchange of health information electronically made either on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements.
(c) To qualify for compliance with this Section, the 50% goal shall be achieved by enrolling medical assistance enrollees from each medical assistance enrollment category, including parents, children, seniors, and people with disabilities to the extent that current State Medicaid payment laws would not limit federal matching funds for recipients in care coordination programs. In addition, services must be more comprehensively defined and more risk shall be assumed than in the Department's primary care case management program as of January 25, 2011 (the effective date of Public Act 96-1501).
(d) The  Department  shall  report to the General Assembly  in  a  separate  part  of  its  annual medical assistance program report, beginning April, 2012  until  April,  2016,  on  the  progress  and  implementation  of  the  care coordination  program  initiatives  established by the  provisions  of Public Act 96-1501. The Department shall include in its April 2011 report a full analysis of federal laws or regulations regarding upper payment limitations to providers and the necessary revisions or adjustments in rate methodologies and payments to providers under this Code that would be necessary to implement coordinated care with full financial risk by a party other than the Department.
(e) Integrated Care Program for individuals with chronic mental health conditions.
(1) The Integrated Care Program shall encompass     services administered to recipients of medical assistance under this Article to prevent exacerbations and complications using cost-effective, evidence-based practice guidelines and mental health management strategies.
(2) The Department may utilize and expand upon     existing contractual arrangements with integrated care plans under the Integrated Care Program for providing the coordinated care provisions of this Section.
(3) Payment for such coordinated care shall be based     on arrangements where the State pays for performance related to mental health outcomes on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements such as provider-based care coordination.
(4) The Department shall examine whether chronic     mental health management programs and services for recipients with specific chronic mental health conditions do any or all of the following:
(A) Improve the patient's overall mental health         in a more expeditious and cost-effective manner.
(B) Lower costs in other aspects of the medical         assistance program, such as hospital admissions, emergency room visits, or more frequent and inappropriate psychotropic drug use.
(5) The Department shall work with the facilities and     any integrated care plan participating in the program to identify and correct barriers to the successful implementation of this subsection (e) prior to and during the implementation to best facilitate the goals and objectives of this subsection (e).
(f) A hospital that is located in a county of the State in which the Department mandates some or all of the beneficiaries of the Medical Assistance Program residing in the county to enroll in a Care Coordination Program, as set forth in Section 5-30 of this Code, shall not be eligible for any non-claims based payments not mandated by Article V-A of this Code for which it would otherwise be qualified to receive, unless the hospital is a Coordinated Care Participating Hospital no later than 60 days after June 14, 2012 (the effective date of Public Act 97-689) or 60 days after the first mandatory enrollment of a beneficiary in a Coordinated Care program. For purposes of this subsection, "Coordinated Care Participating Hospital" means a hospital that meets one of the following criteria:
(1) The hospital has entered  into a contract to     provide hospital services with one or more MCOs to enrollees of the care coordination program.
(2) The hospital has not been offered a contract by a     care coordination plan that the Department has determined to be a good faith offer and that pays at least as much as the Department would pay, on a fee-for-service basis, not including disproportionate share hospital adjustment payments or any other supplemental adjustment or add-on payment to the base fee-for-service rate, except to the extent such adjustments or add-on payments are incorporated into the development of the applicable MCO capitated rates.
As used in this subsection (f), "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis.
(g) No later than August 1, 2013, the Department shall issue a purchase of care solicitation for Accountable Care Entities (ACE) to serve any children and parents or caretaker relatives of children eligible for medical assistance under this Article.  An ACE may be a single corporate structure or a network of providers organized through contractual relationships with a single corporate entity. The solicitation shall require that:
(1) An ACE operating in Cook County be capable of     serving at least 40,000 eligible individuals in that county; an ACE operating in Lake, Kane, DuPage, or Will Counties be capable of serving at least 20,000 eligible individuals in those counties and an ACE operating in other regions of the State be capable of serving at least 10,000 eligible individuals in the region in which it operates. During initial periods of mandatory enrollment, the Department shall  require its enrollment services contractor to use a default assignment algorithm that ensures if possible an ACE reaches the minimum enrollment levels set forth in this paragraph.
(2) An ACE must include at a minimum the following     types of providers: primary care, specialty care, hospitals, and behavioral healthcare.
(3) An ACE shall have a governance structure that     includes the major components of the health care delivery system, including one representative from each of the groups listed in paragraph (2).
(4) An ACE must be an integrated delivery system,     including  a network able to provide the full range of services needed by Medicaid beneficiaries and system capacity to securely pass clinical information across participating entities and to aggregate and analyze that data in order to coordinate care.
(5) An ACE must be capable of providing both care     coordination and complex case management, as necessary, to beneficiaries.  To be responsive to the solicitation, a potential ACE must outline its care coordination and complex case management model and plan to reduce the cost of care.
(6) In the first 18 months  of operation, unless the     ACE selects a shorter period, an ACE shall be paid care coordination fees on a per member per month basis that are projected to be cost neutral to the State during the term of their payment and, subject to federal approval, be eligible to share in additional savings generated by their care coordination.
(7) In months 19 through 36 of operation, unless the     ACE selects a shorter period, an ACE shall be paid on a pre-paid capitation basis for all medical assistance covered services, under contract terms similar to Managed Care Organizations (MCO), with the Department sharing the risk through either stop-loss insurance for extremely high cost individuals or corridors of shared risk based on the overall cost of the total enrollment in the ACE. The ACE shall be responsible for claims processing, encounter data submission, utilization control, and quality assurance.
(8) In the fourth and subsequent years of operation,     an ACE shall convert to a Managed Care Community Network (MCCN), as defined in this Article, or Health Maintenance Organization pursuant to the Illinois Insurance Code, accepting full-risk capitation payments.
The Department shall allow potential ACE entities 5  months from the date of the posting of the solicitation to submit proposals.  After the solicitation is released, in addition to the MCO rate development data available on the Department's website, subject to federal and State confidentiality and privacy laws and regulations, the Department shall provide 2 years of de-identified summary service data on the targeted population, split between children and adults, showing the historical type and volume of services received and the cost of those services to those potential bidders that sign a data use agreement.  The Department may add up to 2 non-state government employees with expertise in creating integrated delivery systems to its review team for the purchase of care solicitation described in this subsection.  Any such individuals must sign a no-conflict disclosure and confidentiality agreement and agree to act in accordance with all applicable State laws.
During the first 2 years of an ACE's operation, the Department  shall provide claims data to the ACE on its enrollees on a periodic basis no less frequently than monthly.
Nothing in this subsection shall be construed to limit the Department's mandate to enroll 50% of its beneficiaries into care coordination systems by January 1, 2015, using all available care coordination delivery systems, including Care Coordination Entities (CCE), MCCNs, or MCOs,  nor be construed to affect the current CCEs, MCCNs, and MCOs selected to serve seniors and persons with disabilities prior to that date.
Nothing in this subsection precludes the Department from considering future proposals for new ACEs or expansion of existing ACEs at the discretion of the Department.
(h) Department  contracts with MCOs and other entities reimbursed by risk based capitation shall have a minimum medical loss ratio of 85%, shall require the entity to establish an appeals and grievances process for consumers and providers, and shall require the entity to provide a quality assurance and utilization review program. Entities contracted with the Department to coordinate healthcare regardless of risk shall be measured utilizing the same quality metrics. The quality metrics may be population specific. Any contracted entity serving at least 5,000 seniors or people with disabilities or 15,000 individuals in other populations covered by the Medical Assistance Program that has been receiving full-risk capitation for a year shall be accredited by a national accreditation organization authorized by the Department within 2 years after the date it is eligible to become accredited.  The requirements of this subsection shall apply to contracts with MCOs entered into or renewed or extended after June 1, 2013.
(h-5)   The Department shall monitor and enforce compliance by MCOs with agreements they have entered into with providers on issues that include, but are not limited to, timeliness of  payment, payment rates, and processes for obtaining prior approval.  The Department may impose sanctions on MCOs for violating provisions of those agreements that include, but are not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. As used in this subsection (h-5), "MCO" has the meaning ascribed to that term  in Section 5-30.1 of this Code.
(i) Unless otherwise required by federal law, Medicaid Managed Care Entities and their respective business associates shall not disclose, directly or indirectly, including by sending a bill or explanation of benefits, information concerning the sensitive health services received by enrollees of the Medicaid Managed Care Entity to any person other than covered entities and business associates, which may receive, use, and further disclose such information solely for the purposes permitted under applicable federal and State laws and regulations if such use and further disclosure satisfies all applicable requirements of such laws and regulations. The Medicaid Managed Care Entity or its respective business associates may disclose information concerning the sensitive health services if the enrollee who received the sensitive health services requests the information from the Medicaid Managed Care Entity or its respective business associates and authorized the sending of a bill or explanation of benefits. Communications including, but not limited to, statements of care received or appointment reminders either directly or indirectly to the enrollee from the health care provider, health care professional, and care coordinators, remain permissible. Medicaid Managed Care Entities or their respective business associates may communicate directly with their enrollees regarding care coordination activities for those enrollees.
For the purposes of this subsection, the term "Medicaid Managed Care Entity" includes Care Coordination Entities, Accountable Care Entities, Managed Care Organizations, and Managed Care Community Networks.
For purposes of this subsection, the term "sensitive health services" means mental health services, substance abuse treatment services, reproductive health services, family planning services, services for sexually transmitted infections and sexually transmitted diseases, and services for sexual assault or domestic abuse.   Services include prevention, screening, consultation, examination, treatment, or follow-up.
For purposes of this subsection, "business associate", "covered entity", "disclosure", and "use" have the meanings ascribed to those terms in 45 CFR 160.103.
Nothing in this subsection shall be construed to relieve a Medicaid Managed Care Entity or the Department of any duty to report incidents of sexually transmitted infections to the Department of Public Health or to the local board of health in accordance with regulations adopted under a statute or ordinance or to report incidents of sexually transmitted infections as necessary to comply with the requirements under Section 5 of the Abused and Neglected Child Reporting Act or as otherwise required by State or federal law.
The Department shall create policy in order to implement the requirements in this subsection.
(j) Managed Care Entities (MCEs), including MCOs and all other care coordination organizations, shall develop and maintain a written language access policy that sets forth the standards, guidelines, and operational plan to ensure language appropriate services and that is consistent with the standard of meaningful access for populations with limited English proficiency. The language access policy shall describe how the MCEs will provide all of the following required services:
(1) Translation (the written replacement of text from     one language into another) of all vital documents and forms as identified by the Department.
(2) Qualified interpreter services (the oral     communication of a message from one language into another by a qualified interpreter).
(3) Staff training on the language access policy,     including how to identify language needs, access and provide language assistance services, work with interpreters, request translations, and track the use of language assistance services.
(4) Data tracking that identifies the language need.
(5) Notification to participants on the availability     of language access services and on how to access such services.
(k) The Department shall actively monitor the contractual relationship between Managed Care Organizations (MCOs) and any dental administrator contracted by an MCO to provide dental services.  The Department shall adopt appropriate dental Healthcare Effectiveness Data and Information Set (HEDIS) measures and shall include the Annual Dental Visit (ADV) HEDIS measure in its Health Plan Comparison Tool and Illinois Medicaid Plan Report Card that is available on the Department's website for enrolled individuals.
The Department shall collect from each MCO specific information about the types of contracted, broad-based care coordination occurring between the MCO and any dental administrator, including, but not limited to, pregnant women and diabetic patients in need of oral care.
(Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff. 6-4-18.)
(305 ILCS 5/5-30.1)
Sec. 5-30.1. Managed care protections.
(a) As used in this Section:
"Managed care organization" or "MCO" means any entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis.
"Emergency services" include:
(1) emergency services, as defined by Section 10 of     the Managed Care Reform and Patient Rights Act;
(2) emergency medical screening examinations, as     defined by Section 10 of the Managed Care Reform and Patient Rights Act;
(3) post-stabilization medical services, as defined     by Section 10 of the Managed Care Reform and Patient Rights Act; and
(4) emergency medical conditions, as defined by     Section 10 of the Managed Care Reform and Patient Rights Act.
(b) As provided by Section 5-16.12, managed care organizations are subject to the provisions of the Managed Care Reform and Patient Rights Act.
(c) An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO.  The default rate of reimbursement shall be the rate paid under Illinois Medicaid fee-for-service program methodology, including all policy adjusters, including but not limited to Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates.
(d) An MCO shall pay for all post-stabilization services as a covered service in any of the following situations:
(1) the MCO authorized such services;
(2) such services were administered to maintain the     enrollee's stabilized condition within one hour after a request to the MCO for authorization of further post-stabilization services;
(3) the MCO did not respond to a request to authorize     such services within one hour;
(4) the MCO could not be contacted; or
(5) the MCO and the treating provider, if the     treating provider is a non-affiliated provider, could not reach an agreement concerning the enrollee's care and an affiliated provider was unavailable for a consultation, in which case the MCO must pay for such services rendered by the treating non-affiliated provider until an affiliated provider was reached and either concurred with the treating non-affiliated provider's plan of care or assumed responsibility for the enrollee's care.  Such payment shall be made at the default rate of reimbursement paid under Illinois Medicaid fee-for-service program methodology, including all policy adjusters, including but not limited to Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments and all outlier add-on adjustments to the extent that such adjustments are incorporated in the development of the applicable MCO capitated rates.
(e) The following requirements apply to MCOs in determining payment for all emergency services:
(1) MCOs shall not impose any requirements for prior     approval of emergency services.
(2) The MCO shall cover emergency services provided     to enrollees who are temporarily away from their residence and outside the contracting area to the extent that the enrollees would be entitled to the emergency services if they still were within the contracting area.
(3) The MCO shall have no obligation to cover medical     services provided on an emergency basis that are not covered services under the contract.
(4) The MCO shall not condition coverage for     emergency services on the treating provider notifying the MCO of the enrollee's screening and treatment within 10 days after presentation for emergency services.
(5) The determination of the attending emergency     physician, or the provider actually treating the enrollee, of whether an enrollee is sufficiently stabilized for discharge or transfer to another facility, shall be binding on the MCO. The MCO shall cover emergency services for all enrollees whether the emergency services are provided by an affiliated or non-affiliated provider.
(6) The MCO's financial responsibility for     post-stabilization care services it has not pre-approved ends when:
(A) a plan physician with privileges at the         treating hospital assumes responsibility for the enrollee's care;
(B) a plan physician assumes responsibility for         the enrollee's care through transfer;
(C) a contracting entity representative and the         treating physician reach an agreement concerning the enrollee's care; or
(D) the enrollee is discharged.
(f) Network adequacy and transparency.
(1) The Department shall:
(A) ensure that an adequate  provider network is         in place, taking into consideration health professional shortage areas and medically underserved areas;
(B) publicly release an explanation of its         process for analyzing network adequacy;
(C) periodically ensure that an MCO continues to         have an adequate network in place;
(D) require MCOs, including Medicaid Managed Care         Entities as defined in Section 5-30.2,  to meet provider directory requirements under Section 5-30.3;
(E) require MCOs to ensure that any         Medicaid-certified provider under contract with an MCO and previously submitted on a roster on the date of service is paid for any medically necessary, Medicaid-covered, and authorized  service rendered to any of the MCO's enrollees, regardless of inclusion on the MCO's published and publicly available directory of available providers; and
(F)    require MCOs, including Medicaid Managed         Care Entities as defined in Section 5-30.2, to meet each of the requirements under subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act; with necessary exceptions to the MCO's network to ensure that admission and treatment with a provider or at a treatment facility in accordance with the network adequacy standards in paragraph (3) of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act is limited to providers or facilities that are Medicaid certified.
(2) Each MCO shall confirm its receipt of information     submitted specific to physician or dentist additions or physician or dentist deletions from the MCO's provider network within 3 days after receiving all required information from contracted physicians or dentists, and electronic physician and dental directories must be updated consistent with current rules as published by the Centers for Medicare and Medicaid Services or its successor agency.
(g) Timely payment of claims.
(1) The MCO shall pay a claim within 30 days of     receiving a claim that contains all the essential information needed to adjudicate the claim.
(2) The MCO shall notify the billing party of its     inability to adjudicate a claim within 30 days of receiving that claim.
(3) The MCO shall pay a penalty that is at least     equal to the timely payment interest penalty imposed under Section 368a of the Illinois Insurance Code for any claims not timely paid.
(A) When an MCO is required to pay a timely         payment interest penalty to a provider, the MCO must calculate and pay the timely payment interest penalty that is due to the provider within 30 days after the payment of the claim. In no event shall a provider be required to request or apply for payment of any owed timely payment interest penalties.
(B) Such payments shall be reported separately         from the claim payment for services rendered to the MCO's enrollee and clearly identified as interest payments.
(4)(A) The Department shall require MCOs to expedite     payments to providers identified on the Department's expedited provider list, determined in accordance with 89 Ill. Adm. Code 140.71(b), on a schedule  at least as frequently as the providers are paid under  the Department's fee-for-service expedited provider  schedule.
(B) Compliance with the expedited provider     requirement may be satisfied by an MCO through the use of a Periodic Interim Payment (PIP) program that has been mutually agreed to and documented between the MCO and the provider, if the PIP program ensures that any expedited provider receives regular and periodic payments based on prior period payment experience from that MCO. Total payments under the PIP program may be reconciled against future PIP payments on a schedule mutually agreed to between the MCO and the provider.
(C) The Department shall share at least monthly its     expedited provider list and the frequency with which it pays providers on the expedited list.
(g-5) Recognizing that the rapid transformation of the Illinois Medicaid program may have unintended operational challenges for both payers and providers:
(1) in no instance shall a medically necessary     covered service rendered in good faith, based upon eligibility information documented by the provider, be denied coverage or diminished in payment amount if the eligibility or coverage information available at the time the service was rendered is later found to be inaccurate in the assignment of coverage responsibility  between MCOs or the fee-for-service system, except for instances when an individual is deemed to have not been eligible for coverage under the Illinois Medicaid program; and
(2) the Department shall, by December 31, 2016, adopt     rules establishing policies that shall be included in the Medicaid managed care policy and procedures manual addressing payment resolutions in situations in which a provider renders services based upon information obtained after verifying a patient's eligibility and coverage plan through either the Department's current enrollment system or a system operated by the coverage plan identified by the patient presenting for services:
(A) such medically necessary covered services         shall be considered rendered in good faith;
(B) such policies and procedures shall be         developed in consultation with industry representatives of the Medicaid managed care health plans and representatives of provider associations representing the majority of providers within the identified provider industry; and
(C) such rules shall be published for a review         and comment period of no less than 30 days on the Department's website with final rules remaining available on the Department's website.
The rules on payment resolutions shall include, but     not be limited to:
(A) the extension of the timely filing period;
(B) retroactive prior authorizations; and
(C) guaranteed minimum payment rate of no less         than the current, as of the date of service, fee-for-service rate, plus all applicable add-ons, when the resulting service relationship is out of network.
The rules shall be applicable for both MCO coverage     and fee-for-service coverage.
If the fee-for-service system is ultimately determined to have been responsible for coverage on the date of service, the Department shall provide for an extended period for claims submission outside the standard timely filing requirements.
(g-6)  MCO Performance Metrics Report.
(1) The Department shall publish, on at least a     quarterly basis, each MCO's operational performance, including, but not limited to, the following categories of metrics:
(A) claims payment, including timeliness and         accuracy;
(B) prior authorizations;
(C) grievance and appeals;
(D) utilization statistics;
(E) provider disputes;
(F) provider credentialing; and
(G) member and provider customer service.
(2)  The Department shall ensure that the metrics     report is accessible to providers online by January 1, 2017.
(3) The metrics shall be developed in consultation     with industry representatives of the Medicaid managed care health plans and representatives of associations representing the majority of providers within the identified industry.
(4) Metrics shall be defined and incorporated into     the applicable Managed Care Policy Manual issued by the Department.
(g-7)  MCO claims processing and performance analysis. In order to monitor MCO payments to hospital providers, pursuant to Public Act 100-580, the Department shall post  an analysis of MCO claims processing and payment performance on its website every 6 months.  Such analysis shall include a review and evaluation of a representative sample of hospital claims that are rejected and denied for clean and unclean claims and the top 5 reasons for such actions and timeliness of claims adjudication, which identifies the percentage of claims adjudicated within 30, 60, 90, and over 90 days, and the dollar amounts associated with those claims.
(g-8)  Dispute resolution process. The Department shall maintain a provider complaint portal through which a provider can submit to the Department unresolved disputes with an MCO.  An unresolved dispute means an MCO's decision that denies in whole or in part a claim for reimbursement to a provider for health care services rendered by the provider to an enrollee of the MCO with which the provider disagrees.  Disputes shall not be submitted to the portal until the provider has availed itself of the MCO's internal dispute resolution process.  Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the Department of Healthcare and Family Services' complaint portal no sooner than 30 days after submitting to the MCO's internal process and not later than 30 days after the unsatisfactory resolution of the internal MCO process or 60 days after submitting the dispute to the MCO internal process. Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy.  Within 10 business days of receipt of a complaint, the Department shall present such disputes to the appropriate MCO, which shall then have 30 days to issue its written proposal to resolve the dispute.  The Department may grant one 30-day extension of this time frame to one of the parties to resolve the dispute. If the dispute remains unresolved at the end of this time frame or the provider is not satisfied with the MCO's written proposal to resolve the dispute, the provider may, within 30 days, request the Department to review the dispute and make a final determination.  Within 30 days of the request for Department review of the dispute, both the provider and the MCO shall present all relevant information to the Department for resolution and make individuals with knowledge of the issues available to the Department for further inquiry if needed.  Within 30 days of receiving the relevant information on the dispute, or the lapse of the period for submitting such information, the Department shall issue a written decision on the dispute based on contractual terms between the provider and the MCO, contractual terms between the MCO and the Department of Healthcare and Family Services and applicable Medicaid policy.  The decision of the Department shall be final. By January 1, 2020, the Department shall establish by rule further details of this dispute resolution process.  Disputes between MCOs and providers presented to the Department for resolution are not contested cases, as defined in Section 1-30 of the Illinois Administrative Procedure Act, conferring any right to an administrative hearing.
(g-9)(1) The Department shall publish annually on its website a report on the calculation of each managed care organization's medical loss ratio showing the following:
(A) Premium revenue, with appropriate adjustments.
(B) Benefit expense, setting forth the aggregate     amount spent for the following:
(i) Direct paid claims.
(ii) Subcapitation payments.
(iii)
Other claim payments.
(iv)
Direct reserves.
(v)
Gross recoveries.
(vi) Expenses for activities that improve health         care quality as allowed by the Department.
(2) The medical loss ratio shall be calculated consistent with federal law and regulation following a claims runout period determined by the Department.
(g-10)(1) "Liability effective date" means the date on which an MCO becomes responsible for payment for medically necessary and covered services rendered by a provider to one of its enrollees in accordance with the contract terms between the MCO and the provider. The liability effective date shall be the later of:
(A)  The execution date of a network participation     contract agreement.
(B) The date the provider or its representative     submits to the MCO the complete and accurate standardized roster form for the provider in the format approved by the Department.
(C) The provider effective date contained within the     Department's provider enrollment subsystem within the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) System.
(2) The standardized roster form may be submitted to the MCO at the same time that the provider submits an enrollment application to the Department through IMPACT.
(3)  By October 1, 2019, the Department shall require all MCOs to update their provider directory with information for new practitioners of existing contracted providers within 30 days of receipt of a complete and accurate standardized roster template in the format approved by the Department provided that the provider is effective in the Department's provider enrollment subsystem within the IMPACT system. Such provider directory shall be readily accessible for purposes of selecting an approved health care provider and comply with all other federal and State requirements.
(g-11) The Department shall work with relevant stakeholders on the development of operational guidelines to enhance and improve operational performance of Illinois' Medicaid managed care program, including, but not limited to, improving provider billing practices, reducing claim rejections and inappropriate payment denials, and standardizing processes, procedures, definitions, and response timelines, with the goal of reducing provider and MCO administrative burdens and conflict.  The Department shall include a report on the progress of these program improvements and other topics in its Fiscal Year 2020 annual report to the General Assembly.
(g-12) Notwithstanding any other provision of law, if the
Department or an MCO requires submission of a claim for payment
in a non-electronic format, a provider shall always be afforded
a period of no less than 90 business days, as a correction
period, following any notification of rejection by either the
Department or the MCO to correct errors or omissions in the
original submission.
Under no circumstances, either by an MCO or under the
State's fee-for-service system, shall a provider be denied
payment for failure to comply with any timely  submission
requirements under this Code or under any existing contract,
unless the non-electronic format claim submission occurs after
the initial 180 days following the latest date of service on
the claim, or after the 90 business days correction period
following notification to the provider of rejection or denial
of payment.
(h) The Department shall not expand mandatory MCO enrollment into new counties beyond those counties already designated by the Department as of June 1, 2014 for the individuals whose eligibility for medical assistance is not the seniors or people with disabilities population until the Department provides an opportunity for accountable care entities and MCOs to participate in such newly designated counties.
(h-5) Leading indicator data sharing. By January 1, 2024, the Department shall obtain input from the Department of Human Services, the Department of Juvenile Justice, the Department of Children and Family Services, the State Board of Education, managed care organizations, providers, and clinical experts to identify and analyze key indicators from assessments and data sets available to the Department that can be shared with managed care organizations and similar care coordination entities contracted with the Department as leading indicators for elevated behavioral health crisis risk for children. To the extent permitted by State and federal law, the identified leading indicators shall be shared with managed care organizations and similar care coordination entities contracted with the Department within 6 months of identification for the purpose of improving care coordination with the early detection of elevated risk. Leading indicators shall be reassessed annually with stakeholder input.
(i) The requirements of this Section apply to contracts with accountable care entities and MCOs entered into, amended, or renewed after June 16, 2014 (the effective date of Public Act 98-651).
(j) Health care information released to managed care organizations. A health care provider shall release to a Medicaid managed care organization, upon request, and subject to the Health Insurance Portability and Accountability Act of 1996 and  any other law applicable to the release of health information, the health care information of the MCO's enrollee, if the enrollee has completed and signed a general release form that grants to the health care provider permission to release the recipient's health care information to the recipient's insurance carrier.
(k) The Department of Healthcare and Family Services, managed care organizations, a statewide organization representing hospitals, and a statewide organization representing safety-net hospitals shall explore ways to support billing departments in safety-net hospitals.
(l) The requirements of this Section added by Public Act 102-4 shall apply to
services provided on or after the first day of the month that
begins 60 days after April 27, 2021 (the effective date of Public Act 102-4).
(Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff. 5-13-22; 103-546, eff. 8-11-23.)
(305 ILCS 5/5-30.2)
Sec. 5-30.2. Monthly reports; managed care enrollment.
(a) As used in this Section, "Medicaid Managed Care Entity" means a Managed Care Organization (MCO), a Managed Care Community Network (MCCN), an Accountable Care Entity (ACE), or a  Care Coordination Entity (CCE) contracted by the Department.
(b) As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of persons in the State's medical assistance program. In addition,  as soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website on the enrollment of recipients of medical assistance into a Medicaid Managed Care Entity contracted by the Department.  As soon as practical if the data is reasonably available, but no later than January 1, 2017, the monthly reports shall include all of the following information for the medical assistance program generally and, separately, for each Medicaid Managed Care Entity contracted by the Department:
(1) Total enrollment.
(2) The number of persons enrolled in the medical     assistance program under items 18 and 19 of Section 5-2.
(3) The number of children enrolled.
(4) The number of parents and caretakers of minor     children enrolled.
(5) The number of women enrolled on the basis of     pregnancy.
(6) The number of seniors enrolled.
(7) The number of persons enrolled on the basis of     disability.
(c)  As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall publish monthly reports on its website detailing the percentage of persons enrolled in each Medicaid Managed Care Entity that was assigned using an auto-assignment algorithm. This percentage should also report the type of enrollee who was assigned using an auto-assignment algorithm, including, but not limited to, persons enrolled in the medical assistance program in each of the groups listed in subsection (b) of this Section.
(d)  As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include data on the 2 most recently available months and data comparing the most recently available month to that month in the prior year.
(e)  As soon as practical if the data is reasonably available, but no later than January 1, 2017, monthly enrollment reports for each Medicaid Managed Care Entity shall include a breakdown of language preference for enrollees by English, Spanish, and the next 4 most commonly used languages.
(f) The Department must annually publish on its website each Medicaid Managed Care Entity's quality metrics outcomes and must make public an independent annual quality review report on the State's Medicaid managed care delivery system.
(Source: P.A. 99-86, eff. 7-21-15.)
(305 ILCS 5/5-30.3)
Sec. 5-30.3. Empowering meaningful patient choice in Medicaid Managed Care.
(a) Definitions. As used in this Section:
"Client enrollment services broker" means a vendor the Department contracts with to carry out activities related to Medicaid recipients' enrollment, disenrollment, and renewal with Medicaid Managed Care Entities.
"Composite domains" means the synthesized categories reflecting the standardized quality performance measures included in the consumer quality comparison tool. At a minimum, these composite domains shall display Medicaid Managed Care Entities' individual Plan performance on standardized quality, timeliness, and access measures.
"Consumer quality comparison tool" means an online and paper tool developed by the Department with input from interested stakeholders reflecting the performance of Medicaid Managed Care Entity Plans on standardized quality performance measures. This tool shall be designed in a consumer-friendly and easily understandable format.
"Covered services" means those health care services to which a covered person is entitled to under the terms of the Medicaid Managed Care Entity Plan.
"Facilities" includes, but is not limited to, federally qualified health centers, skilled nursing facilities, and rehabilitation centers.
"Hospitals" includes, but is not limited to, acute care, rehabilitation, children's, and cancer hospitals.
"Integrated provider directory" means a searchable database bringing together network data from multiple Medicaid Managed Care Entities that is available through client enrollment services.
"Medicaid eligibility redetermination" means the process by which the eligibility of a Medicaid recipient is reviewed by the Department to determine if the recipient's medical benefits will continue, be modified, or terminated.
"Medicaid Managed Care Entity" has the same meaning as defined in Section 5-30.2 of this Code.
(b) Provider directory transparency.
(1) Each Medicaid Managed Care Entity shall:
(A) Make available on the entity's website a         provider directory in a machine readable file and format.
(B) Make provider directories publicly accessible         without the necessity of providing a password, a username, or personally identifiable information.
(C) Comply with all federal and State statutes         and regulations, including 42 CFR 438.10, pertaining to provider directories within Medicaid Managed Care.
(D) Request, at least annually,  provider office         hours for each of the following provider types:
(i) Health care professionals, including             dental and vision providers.
(ii) Hospitals.
(iii) Facilities, other than hospitals.
(iv) Pharmacies, other than hospitals.
(v) Durable medical equipment suppliers,             other than hospitals.
Medicaid Managed Care Entities shall publish the         provider office hours in the provider directory upon receipt.
(E) Confirm with the Medicaid Managed Care         Entity's contracted providers who have not submitted claims within the past 6 months that the contracted providers intend to remain in the network and correct any incorrect provider directory information as necessary.
(F) Ensure that in situations in which a Medicaid         Managed Care Entity Plan enrollee receives covered services from a non-participating provider due to a material misrepresentation in a Medicaid Managed Care Entity's online electronic provider directory, the Medicaid Managed Care Entity Plan enrollee shall not be held responsible for any costs resulting from that material misrepresentation.
(G) Conspicuously display an e-mail address and a         toll-free telephone number to which any individual may report any inaccuracy in the provider directory. If the Medicaid Managed Care Entity receives a report from any person who specifically identifies provider directory information as inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic directory.
(2) The Department shall:
(A) Regularly monitor Medicaid Managed Care         Entities to ensure that they are compliant with the requirements under paragraph (1) of subsection (b).
(B) Require that the client enrollment services         broker use the Medicaid provider number for all providers with a Medicaid Provider number to populate the provider information in the integrated provider directory.
(C) Ensure that each Medicaid Managed Care Entity         shall, at minimum, make the information in subparagraph (D) of paragraph (1) of subsection (b) available to the client enrollment services broker.
(D) Ensure that the client enrollment services         broker shall, at minimum, have the information in subparagraph (D) of paragraph (1) of subsection (b) available and searchable through the integrated provider directory on its website as soon as possible but no later than January 1, 2017.
(E) Require the client enrollment services broker         to conspicuously display near the integrated provider directory an email address and a toll-free telephone number provided by the Department to which any individual may report inaccuracies in the integrated provider directory. If the Department receives a report that identifies an inaccuracy in the integrated provider directory, the Department shall provide the information about the reported inaccuracy to the appropriate Medicaid Managed Care Entity within 3 business days after the reported inaccuracy is received.
(c) Formulary transparency.
(1) Medicaid Managed Care Entities shall publish on     their respective websites a formulary for each Medicaid Managed Care Entity Plan offered and make the formularies easily understandable and publicly accessible without the necessity of providing a password, a username, or personally identifiable information.
(2) Medicaid Managed Care Entities shall provide     printed formularies upon request.
(3) Electronic and print formularies shall display:
(A) the medications covered (both generic and         name brand);
(B) if the medication is preferred or not         preferred, and what each term means;
(C) what tier each medication is in and the         meaning of each tier;
(D) any utilization controls including, but not         limited to, step therapy, prior approval, dosage limits, gender or age restrictions, quantity limits, or other policies that affect access to medications;
(E) any required cost-sharing;
(F) a glossary of key terms and explanation of         utilization controls and cost-sharing requirements;
(G) a key or legend for all utilization controls         visible on every page in which specific medication coverage information is displayed; and
(H) directions explaining the process or         processes a consumer may follow to obtain more information if a medication the consumer requires  is not covered or listed in the formulary.
(4) Each Medicaid Managed Care Entity shall display     conspicuously with each electronic and printed medication formulary an e-mail address and a toll-free telephone number to which any individual may report any inaccuracy in the formulary.  If the Medicaid Managed Care Entity receives a report that the formulary information is inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic formulary.
(5) Each Medicaid Managed Care Entity shall include a     disclosure in the electronic and requested print formularies that provides the date of publication, a statement that the formulary is up to date as of publication, and contact information for questions and requests to receive updated information.
(6) The client enrollment services broker's website     shall display prominently a website URL link to each Medicaid Managed Care Entity's Plan formulary. If a Medicaid enrollee calls the client enrollment services broker with questions regarding formularies, the client enrollment services broker shall offer a brief description of what a formulary is and shall refer the Medicaid enrollee to the appropriate Medicaid Managed Care Entity regarding his or her questions about a specific entity's formulary.
(d) Grievances and appeals.  The Department shall display prominently on its website consumer-oriented information describing how a Medicaid enrollee can file a complaint or grievance, request a fair hearing for any adverse action taken by the Department or a Medicaid Managed Care Entity, and access free legal assistance or other assistance made available by the State for Medicaid enrollees to pursue an action.
(e) Medicaid redetermination information.
The Department shall require the client enrollment services broker to display prominently on the client enrollment services broker's website a description of where a Medicaid enrollee can access information regarding the Medicaid redetermination process.
(f) Medicaid care coordination information. The client enrollment services broker shall display prominently on its website, in an easily understandable format, consumer-oriented information regarding the role of care coordination services within Medicaid Managed Care.  Such information shall include, but shall not be limited to:
(1) a basic description of  the role of care     coordination services and examples of specific care coordination activities; and
(2) how a Medicaid enrollee may request care     coordination services from a Medicaid Managed Care Entity.
(g) Consumer quality comparison tool.
(1) The Department shall create a consumer quality     comparison tool to assist Medicaid enrollees with Medicaid Managed Care Entity Plan selection.  This tool shall provide Medicaid Managed Care Entities' individual Plan performance on a set of standardized quality performance measures.  The Department shall ensure that this tool shall be accessible in both a print and online format, with the online format allowing for individuals to access additional detailed Plan performance information.
(2) At a minimum, a printed version of the consumer     quality comparison tool shall be provided by the Department on an annual basis to Medicaid enrollees who are required by the Department to enroll in a Medicaid Managed Care Entity Plan during an enrollee's open enrollment period.  The consumer quality comparison tool shall also meet all of the following criteria:
(A) Display Medicaid Managed Care Entities'         individual Plan  performance on at least 4 composite domains that reflect Plan quality, timeliness, and access. The composite domains shall draw from the most current available performance data sets including, but not limited to:
(i) Healthcare Effectiveness Data and             Information Set (HEDIS) measures.
(ii) Core Set of Children's Health Care             Quality measures as required under the Children's Health Insurance Program Reauthorization Act (CHIPRA).
(iii) Adult Core Set measures.
(iv) Consumer Assessment of Healthcare             Providers and Systems (CAHPS) survey results.
(v) Additional performance measures the             Department deems appropriate to populate the composite domains.
(B) Use a quality rating system developed by the         Department to reflect Medicaid Managed Care Entities' individual Plan performance.  The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan  performance and, when possible, plan performance relative to national Medicaid percentiles.
(C) Be customized to reflect the specific         Medicaid Managed Care Entities' Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
(D) Include contact information for the client         enrollment services broker and contact information for Medicaid Managed Care Entities available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
(E) Include guiding questions designed to assist         individuals selecting a Medicaid Managed Care Entity Plan.
(3) At a minimum, the online version of the consumer     quality comparison tool shall meet all of the following criteria:
(A) Display Medicaid Managed Care Entities'         individual Plan performance for the same composite domains selected by the Department in the printed version of the consumer quality comparison tool.  The Department may display additional composite domains in the online version of the consumer quality comparison tool as appropriate.
(B) Display Medicaid Managed Care Entities'         individual Plan performance on each of the standardized performance measures that contribute to each composite domain displayed on the online version of the consumer quality comparison tool.
(C) Use a quality rating system developed by the         Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.
(D)  Include the specific Medicaid Managed Care         Entity Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
(E) Include a sort function to view Medicaid         Managed Care Entities' individual Plan performance by quality rating and by standardized quality performance measures.
(F) Include contact information for the client         enrollment services broker and for each Medicaid Managed Care Entity.
(G) Include guiding questions designed to assist         individuals in selecting a Medicaid Managed Care Entity Plan.
(H) Prominently display current notice of quality         performance sanctions against Medicaid Managed Care Entities.  Notice of the sanctions shall remain present on the online version of the consumer quality comparison tool until the sanctions are lifted.
(4) The online version of the consumer quality     comparison tool shall be displayed prominently on the client enrollment services broker's website.
(5) In the development of the consumer quality     comparison tool, the Department shall establish and publicize a formal process to collect and consider written and oral feedback from consumers, advocates, and stakeholders on aspects of the consumer quality comparison tool, including, but not limited to, the following:
(A) The standardized data sets and surveys,         specific performance measures, and composite domains represented in the consumer quality comparison tool.
(B) The format and presentation of the consumer         quality comparison tool.
(C) The methods undertaken by the Department to         notify Medicaid enrollees of the availability of the consumer quality comparison tool.
(6) The Department shall review and update as     appropriate the composite domains and performance measures represented in the print and online versions of the consumer quality comparison tool at least once every 3 years. During the Department's review process, the Department shall solicit engagement in the public feedback process described in paragraph (5).
(7) The Department shall ensure that the consumer     quality comparison tool is available for consumer use as soon as possible but no later than January 1, 2018.
(h)

The Department may adopt rules and take any other appropriate action necessary to implement its responsibilities under this Section.
(Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.4)
Sec. 5-30.4. Provider inquiry portal. The Department shall establish, no later than January 1, 2018, a web-based portal to accept inquiries and requests for assistance from managed care organizations under contract with the State and providers under contract with managed care organizations to provide direct care.
(Source: P.A. 99-719, eff. 1-1-17; 100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.5)
Sec. 5-30.5. Managed care; automatic assignment. The
Department shall, within a reasonable period of time after
relevant data from managed care entities has been collected and
analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and
implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes
into account quality scores and other operational proficiency
criteria developed, defined, and adopted by the Department, to
automatically assign Medicaid enrollees served under the
Family Health Plan and the Integrated Care Program and those
Medicaid enrollees eligible for medical assistance pursuant to
the Patient Protection and Affordable Care Act (Public Law  111-148) into managed care entities, including Accountable
Care Entities, Managed Care Community Networks, and Managed
Care Organizations. The quality metrics used shall be
measurable for all entities. The algorithm shall not use the
quality and proficiency metrics to reassign enrollees out of
any plan in which they are enrolled at the time and shall only
be used if the client has not voluntarily selected a primary
care physician and a managed care entity or care coordination
entity. Clients shall have one opportunity within 90 calendar
days after auto-assignment by algorithm to select a different
managed care entity. The algorithm developed and implemented
shall favor assignment into managed care entities with the
highest quality scores and levels of compliance with the
operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists.
(Source: P.A. 99-898, eff. 1-1-17; 100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.6)
Sec. 5-30.6. Managed care organization contracts procurement requirement. Beginning on March 12, 2018 (the effective date of Public Act 100-580), any new contract between the Department and a managed care organization as defined in Section 5-30.1 shall be procured in accordance with the Illinois Procurement Code.
(a) Application.
(1) This Section does not apply to the State of     Illinois Medicaid Managed Care Organization Request for Proposals (2018-24-001) or any agreement, regardless of what it may be called, related to or arising from this procurement, including, but not limited to, contracts, renewals, renegotiated contracts, amendments, and change orders.
(2) This Section does not apply to Medicare-Medicaid     Alignment Initiative contracts executed under Article V-F of this  Code.
(b) In the event any provision of this Section or of the Illinois Procurement Code is inconsistent with applicable federal law or would have the effect of foreclosing the use, potential use, or receipt of federal financial participation, the applicable federal law or funding condition shall prevail, but only to the extent of such inconsistency.
(Source: P.A. 100-580, eff. 3-12-18; 101-81, eff. 7-12-19.)
(305 ILCS 5/5-30.7)
Sec. 5-30.7. Encounter data guidelines; provider fee schedule.
(a) No later than 60 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall publish on its website comprehensive written guidance on the submission of encounter data by managed care organizations. This information shall be updated and published as needed, but at least quarterly. The Department shall inform providers and managed care organizations of any updates via provider notices.
(b) The Department shall publish on its website provider fee schedules on both a portable document format (PDF) and EXCEL format. The portable document format shall serve as the ultimate source if there is a discrepancy.
(Source: P.A. 100-580, eff. 3-12-18.)
(305 ILCS 5/5-30.8)
Sec. 5-30.8. Managed care organization rate transparency.
(a)     For the establishment of managed care
organization (MCO) capitation base rate payments from the State,
including, but not limited to: (i) hospital fee schedule
reforms and updates, (ii) rates related to a single
State-mandated preferred drug list, (iii) rate updates related
to the State's preferred drug list, (iv) inclusion of coverage
for children with special needs, (v) inclusion of coverage for
children within the child welfare system, (vi) annual MCO
capitation rates, and (vii) any retroactive provider fee
schedule adjustments or other changes required by legislation
or other actions, the Department of Healthcare and Family
Services shall implement a capitation base rate setting process beginning
on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following
elements of transparency:
(1)      The Department shall include participating     MCOs and a statewide trade association representing a majority of participating MCOs in meetings to discuss the impact to base capitation rates as a result  of any new or updated hospital fee schedules or     other provider fee schedules. Additionally, the Department     shall share any data or reports used to develop MCO capitation rates     with participating MCOs. This data shall be comprehensive     enough for MCO actuaries to recreate and verify the     accuracy of the capitation base rate build-up.
(2) The Department shall not limit the number of         experts that each MCO is allowed to bring to the draft capitation base rate     meeting or the final capitation base rate review meeting. Draft and final capitation base rate review meetings shall be held in at least 2 locations.
(3) The Department and its contracted actuary shall         meet with all participating MCOs simultaneously and     together along with consulting actuaries contracted with     statewide trade association representing a majority of Medicaid health plans at the request of the plans.     Participating MCOs shall additionally, at their request,     be granted individual capitation rate development meetings with the     Department.
(4)         (Blank).
(4.5) Effective for calendar year 2024, a quality     withhold program may be established by the Department for the HealthChoice Illinois Managed Care Program or any successor program. If such program withholds a portion of the actuarially certified capitation rates, the program must meet the following criteria: (i) benchmarks must be discussed publicly, based on predetermined quality standards that align with the Department's federally approved quality strategy, and set by publication on the Department's website at least 4 months prior to the start of the calendar year; (ii) incentive measures and benchmarks must be reasonable and attainable within the measurement year; and (iii) no less than 75% of the metrics shall be tied to nationally recognized measures.  Any non-nationally recognized measures shall be in the reporting category for at least 2 years of experience and evaluation for consistency among MCOs prior to setting a performance baseline. The Department shall provide MCOs with biannual industry average data on the quality withhold measures. If all the money withheld is not earned back by individual MCOs, the Department shall reallocate unearned funds among the MCOs in one or both of the following manners: based upon their quality performance or for quality and equity improvement projects. Nothing in this paragraph prohibits the Department and the MCOs from establishing any other quality performance program.
(5)         Upon request, the Department shall     provide written responses to     questions regarding MCO capitation base rates, the capitation base  development     methodology, and MCO capitation rate data, and all other requests regarding     capitation rates from MCOs.  Upon request, the Department shall also provide to the MCOs materials used in incorporating provider fee schedules into base capitation rates.
(b) For the development of capitation base rates for new capitation rate years:
(1) The Department shall take into account emerging         experience in the development of the annual MCO capitation base rates,     including, but not limited to, current-year cost and     utilization trends observed by MCOs in an actuarially sound manner and in accordance with federal law and regulations.
(2) No later than January 1 of each year, the     Department shall release an agreed upon annual calendar that outlines dates for capitation rate setting meetings for that year. The calendar shall include at least the following meetings and deadlines:
(A) An initial meeting  for the Department to         review MCO data and draft rate assumptions to be used in the development of capitation base rates for the following year.
(B) A draft rate meeting after the Department         provides the MCOs with the      draft capitation base     rates     to discuss, review, and seek feedback regarding the draft capitation base     rates.
(3)     Prior to the submission of final capitation     rates to the federal Centers for     Medicare and Medicaid Services, the Department shall     provide the MCOs with a final actuarial report including     the final capitation base rates for the following year and     subsequently conduct a final capitation base  review meeting.     Final capitation rates shall be marked final.
(c) For the development of capitation base rates reflecting policy changes:
(1) Unless contrary to federal law and regulation,       the Department must provide notice to MCOs     of any significant operational policy change no later than 60 days     prior to the effective date of an operational policy change in order to give MCOs time to  prepare for and implement the operational policy change and to ensure that the quality and delivery of enrollee health care is not disrupted. "Operational policy change" means a change to operational requirements such as reporting formats, encounter submission definitional changes, or required provider interfaces  made at the sole discretion of the Department     and not required by legislation with a retroactive effective date. Nothing in this Section shall be construed as a requirement to delay or prohibit implementation of policy changes that impact enrollee benefits as determined in the sole discretion of the Department.
(2)         No later than 60 days after the effective     date of the policy change or     program implementation, the Department shall meet with the     MCOs regarding the initial data collection needed to     establish capitation base rates for the policy change. Additionally,     the Department shall share with the participating MCOs what     other data is needed to estimate the change and the processes for collection of that data that shall be     utilized to develop capitation base rates.
(3) No later than 60 days after the effective date of     the policy change or     program implementation, the Department shall meet with     MCOs to review data and the Department's written draft     assumptions to be used in development of capitation base rates for the policy change, and shall provide opportunities for     questions to be asked and answered.
(4)         No later than 60 days after the effective     date of the policy change or     program implementation, the Department shall provide the     MCOs with draft capitation base rates and shall also conduct     a draft capitation base rate meeting with MCOs to discuss, review, and seek     feedback regarding the draft capitation base rates.
(d) For the development of capitation base rates for retroactive policy or
fee schedule changes:
(1) The Department shall meet with the MCOs regarding         the initial data collection needed to establish capitation base rates for     the policy change. Additionally, the Department shall     share with the participating MCOs what other data is needed to estimate the change and the     processes for collection of the data that shall be utilized to develop capitation base     rates.
(2) The Department shall meet with MCOs to review     data     and the Department's written draft assumptions to be used     in development of capitation base rates for the policy change. The Department shall     provide opportunities for questions to be asked and     answered.
(3) The Department shall provide the MCOs with draft         capitation rates and shall also conduct a draft rate meeting     with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.
(4) The Department shall inform MCOs no less than     quarterly of upcoming benefit and policy changes to the Medicaid program.
(e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.
(Source: P.A. 103-102, eff. 1-1-24.)
(305 ILCS 5/5-30.9)
Sec. 5-30.9. Disenrollment requirements; managed care organization. Disenrollment of a Medicaid enrollee from a managed care organization under contract with the Department shall be in accordance with the requirements of 42 CFR 438.56 whenever a contract is terminated between a Medicaid managed care health plan and a primary care provider that results in a disruption to the Medicaid enrollee's provider-beneficiary relationship.
(Source: P.A. 100-950, eff. 8-19-18; 101-81, eff. 7-12-19.)
(305 ILCS 5/5-30.10)
Sec. 5-30.10. Electronic report submission. To preserve the quality of data and ensure productive oversight of Medicaid managed care organizations, all regular reports required, either by contract or statute, to be collected by the Department from managed care organizations shall be collected through a secure electronic format and medium as designated by the Department. The Department shall consider concerns raised by the contractor about potential burdens associated with producing the report. Ad hoc reports may be collected in alternative manners.
(Source: P.A. 100-1105, eff. 8-27-18; 101-81, eff. 7-12-19.)
(305 ILCS 5/5-30.11)
Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when (1) ordered by a physician licensed to practice medicine in all its branches or a psychologist licensed by the Department of Financial and Professional Regulation and (2) evaluated by  a behavior analyst as recognized by the Department or licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019. Pursuant to the flexibilities allowed by the federal Centers for Medicare and Medicaid Services to Illinois under the Medical Assistance Program, the Department shall enroll and reimburse qualified staff to perform applied behavior analysis services in advance of Illinois licensure activities performed by the Department of Financial and Professional Regulation.  These services shall be covered if they are provided in a home or community setting or in an office-based setting. The Department may conduct annual on-site reviews of the services authorized under this Section. Provider enrollment shall occur no later than September 1, 2023.
(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22; 103-102, eff. 7-1-23.)
(305 ILCS 5/5-30.12)
Sec. 5-30.12. Managed care claim rejection and denial management.
(a) In order to provide greater transparency to managed care organizations (MCOs) and providers, the Department shall explore the availability of and, if reasonably available, procure technology that, for all electronic claims, with the exception of direct data entry claims, meets the following needs:
(1) The technology shall allow the Department to     fully analyze the root cause of claims denials in the Medicaid managed care programs operated by the Department and expedite solutions that reduce the number of denials to the extent possible.
(2) The technology shall create a single electronic     pipeline through which all claims from all providers submitted for adjudication by the Department or a managed care organization under contract with the Department shall be directed by clearing houses and providers or other claims submitting entities not using clearing houses prior to forwarding to the Department or the appropriate managed care organization.
(3) The technology shall cause all HIPAA-compliant     responses to submitted claims, including rejections, denials, and payments, returned to the submitting provider to pass through the established single pipeline.
(4) The technology shall give the Department the     ability to create edits to be placed at the front end of the pipeline that will reject claims back to the submitting provider with an explanation of why the claim cannot be properly adjudicated by the payer.
(5) The technology shall allow the Department to     customize the language used to explain why a claim is being rejected and how the claim can be corrected for adjudication.
(6) The technology shall send copies of all claims     and claim responses that pass through the pipeline, regardless of the payer to whom they are directed, to the Department's Enterprise Data Warehouse.
(b) If the Department chooses to implement front end edits or customized responses to claims submissions, the MCOs and other stakeholders shall be consulted prior to implementation and providers shall be notified of edits at least 30 days prior to their effective date.
(c) Neither the technology nor MCO policy shall require providers to submit claims through a process other than the pipeline.  MCOs may request supplemental information needed for adjudication which cannot be contained in the claim file to be submitted separately to the MCOs.
(d) The technology shall allow the Department to fully analyze and report on MCO claims processing and payment performance by provider type.
(Source: P.A. 101-209, eff. 8-5-19.)
(305 ILCS 5/5-30.13)
Sec. 5-30.13. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information:
(1) The administrative expenses paid to the Medicaid     managed care health plan.
(2) The amount of  money the Medicaid managed care     health plan has spent with Business Enterprise Program certified businesses.
(3) The amount of  money the Medicaid managed care     health plan has spent with minority-owned and women-owned businesses that are certified by other agencies or private organizations.
(4) The amount of  money the Medicaid managed care     health plan has spent with not-for-profit community-based organizations serving predominantly minority communities, as defined by the Department.
(5) The proportion of minorities, people with     disabilities, and women that make up the staff of the Medicaid managed care health plan.
(6) Recommendations for increasing expenditures with     minority-owned and women-owned businesses.
(7) A list of the types of services to which the     Medicaid managed care health plan is contemplating adding new vendors.
(8) The certifications the Medicaid managed care     health plan accepts for minority-owned and women-owned businesses.
(9) The point of contact for potential vendors     seeking to do business with the Medicaid managed care health plan.
The Department shall publish the reports on its website and shall maintain each report on its website for 5 years. In May of 2020 and every May thereafter, the Department shall hold 2 annual public workshops, one in Chicago and one in Springfield. The workshops shall include each Medicaid managed care health plan and shall be open to vendor communities to discuss the submitted plans and to seek to connect vendors with the Medicaid managed care health plans.
(Source: P.A. 101-209, eff. 8-5-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5-30.14)
Sec. 5-30.14. Medicaid managed care organizations; preferred drug lists.
(a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy,  and community-based organizations, providers, and entities with expertise in drug formulary development.
(b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website.  Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls.
(c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall:
(A) convene and meet no less than once per calendar     quarter;
(B) provide regular opportunities for public comment;     and
(C) comply with the provisions of the Open Meetings     Act.
All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act.
(2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation:
(A) one pharmacist licensed to practice pharmacy in     Illinois who is recommended by a statewide organization representing pharmacists;
(B) 4 physicians, recommended by a statewide     organization representing physicians, who are licensed to practice medicine in all its branches in Illinois, have knowledge of and adhere to best practice standards, and have experience treating Illinois Medicaid beneficiaries;
(C) at least one clinician who specializes in the     prevention and treatment of HIV, recommended by an HIV healthcare advocacy organization;
(D) at least one clinician recommended by a     healthcare advocacy organization that serves individuals who are affected by chronic diseases that require significant pharmaceutical treatments;
(E) one clinician representing  the Illinois     Department; and
(F) one licensed psychiatrist, recommended by a     statewide organization representing psychiatrists, who has experience treating Illinois Medicaid beneficiaries.
One non-voting clinician recommended by an association of Medicaid managed care health plans shall serve a term of 3 years on the Board without compensation.
Organizations interested in nominating non-voting clinicians to advise the Board may submit requests to participate to the Illinois Department.
A licensed physician recommended by the Rare Disease Commission who is a rare disease specialist and possesses scientific knowledge and medical training with respect to rare diseases and is familiar with drug and biological products and treatment  shall  be notified in advance to attend an Illinois Drug and Therapeutics Advisory Board meeting when a drug or biological product is scheduled to be reviewed in order to advise and make recommendations on drugs or biological products.
(d) The Illinois Department shall adopt rules, to be in place no later than January 1, 2020, for the purpose of establishing and maintaining the Board.
(Source: P.A. 101-62, eff. 7-12-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5-30.16)
Sec. 5-30.16. Medicaid Business Opportunity Commission.
(a) The Medicaid Business Opportunity Commission is
created within the Department of Healthcare and Family Services
to develop a program to support and grow minority, women, and persons with disability owned businesses.
(b) The Commission shall consist of the following members:
(1) Two members appointed by the Illinois Legislative     Black Caucus.
(2) Two members appointed by the Illinois Legislative     Latino Caucus.
(3) Two members appointed by the Conference of Women       Legislators of the Illinois General Assembly.
(4) Two members representing a statewide Medicaid     health plan association, appointed by the Governor.
(5)  One  member  representing  the  Department  of     Healthcare and Family Services, appointed by the Governor.
(6) Three members representing businesses currently     registered with the Business Enterprise Program, appointed by the Governor.
(7)  One member representing the disability     community, appointed by the Governor.
(8)  One member representing the Business Enterprise     Council, appointed by the Governor.
(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's   executive   administrators   in   providing administrative  support,  research  support,  and   other administrative tasks requested by the Commission's co-chairs.  Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d) The members of the Commission shall receive no compensation for their services as members of the Commission.
(e)  The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission.
(f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(g)  The Commission shall:
(1) Develop a recommendation on a Medicaid Business     Opportunity Program for Minority, Women, and Persons with Disability Owned business contracting requirements to be included in the contracts between the Department of Healthcare and Family Services and the Managed Care entities for the provision of Medicaid Services.
(2) Make recommendations on the process by which     vendors or providers would be certified as eligible to be included in the program and appropriate eligibility standards relative to the healthcare industry.
(3) Make a recommendation on whether to include not     for profit organizations, diversity councils, or diversity chambers as eligible for certification.
(4) Make a recommendation on whether diverse staff     shall be considered within the goals set for managed care entities.
(5) Make a recommendation on whether a new platform     for certification is necessary to administer this program or if the existing platform for the Business Enterprise Program is capable of including recommended changes coming from this Commission.
(6) Make a recommendation on the ongoing activity of     the Commission including structure, frequency of meetings, and agendas to ensure ongoing oversight of the program by the Commission.
(h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program.
(i)  Beginning  January  1,  2022,  and  for  each  year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
(305 ILCS 5/5-30.17)
Sec. 5-30.17. Medicaid Managed Care Oversight Commission.
(a)   The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program.
(b)   The Commission shall consist of the following members:
(1)   One member of the Senate, appointed by the     Senate President, who shall serve as co-chair.
(2)   One member of the House of Representatives,     appointed by the Speaker of the House of Representatives, who shall serve as co-chair.
(3)   One member of the House of Representatives,     appointed by the Minority Leader of the House of Representatives.
(4)   One member of the Senate, appointed by the     Senate Minority Leader.
(5)    One member representing the Department of     Healthcare and Family Services, appointed by the Governor.
(6)   One member representing the Department of     Public Health, appointed by the Governor.
(7)   One member representing the Department of Human     Services, appointed by the Governor.
(8)   One member representing the Department of     Children and Family Services, appointed by the Governor.
(9)   One member of a statewide association     representing Medicaid managed care plans, appointed by the Governor.
(10)   One member of a statewide association     representing a majority of hospitals, appointed by the Governor.
(11)   Two academic experts on Medicaid managed care     programs, appointed by the Governor.
(12)   One member of a statewide association     representing primary care providers, appointed by the Governor.
(13)   One member of a statewide association     representing behavioral health providers, appointed by the Governor.
(14) Members representing Federally Qualified Health     Centers, a long-term care association, a dental association, pharmacies, pharmacists, a developmental disability association, a Medicaid consumer advocate, a Medicaid consumer, an association representing physicians, a behavioral health association, and an association representing pediatricians, appointed by the Governor.
(15) A member of a statewide association representing     only safety-net hospitals, appointed by the Governor.
(c)   The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d)   The members of the Commission shall receive no compensation for their services as members of the Commission.
(e)   The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(f)   The Commission shall:
(1)   review data on health outcomes of Medicaid     managed care members;
(2)   review current care coordination and case     management efforts and make recommendations on expanding care coordination to additional populations with a focus on the social determinants of health;
(3)   review and assess the appropriateness of     metrics used in the Pay-for-Performance programs;
(4)   review the Department's prior authorization and     utilization management requirements and recommend adaptations for the Medicaid population;
(5)   review managed care performance in meeting     diversity contracting goals and the use of funds dedicated to meeting such goals, including, but not limited to, contracting requirements set forth in the Business Enterprise for Minorities, Women, and Persons with Disabilities Act; recommend strategies to increase compliance with diversity contracting goals in collaboration with the Chief Procurement Officer for General Services and the Business Enterprise Council for Minorities, Women, and Persons with Disabilities; and recoup any misappropriated funds for diversity contracting;
(6)     review data on the effectiveness of      processing to medical providers;
(7)   review member access to health care services in     the Medicaid Program, including specialty care services;
(8)   review value-based and other alternative     payment methodologies to make recommendations to enhance program efficiency and improve health outcomes;
(9)   review the compliance of all managed care     entities in State contracts and recommend reasonable financial penalties for any noncompliance;
(10)   produce an annual report detailing the     Commission's findings based upon its review of research conducted under this Section, including specific recommendations, if any, and any other information the Commission may deem proper in furtherance of its duties under this Section;
(11) review provider availability and make     recommendations to increase providers where needed, including reviewing the regulatory environment and making recommendations for reforms;
(12) review capacity for culturally competent     services, including translation services among providers; and
(13) review and recommend changes to the safety-net     hospital definition to create different classifications of safety-net hospitals.
(f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding  processing.
(g)     Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
(305 ILCS 5/5-30a)
Sec. 5-30a. Exemptions from managed care enrollment; children. Notwithstanding any other provision of law, the Department shall not require any of the following children to enroll in or transition to the State's managed care medical assistance program:
(1) Children who are authorized by the Department to     receive in-home shift nursing services as required by the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions under 42 CFR 441.50 et seq.
(2) Children made eligible for medical assistance     through any home and community-based services waiver program for medically fragile and technology dependent children authorized under Section 1915(c) of the Social Security Act.
Any children who meet the criteria under paragraph (1) or (2) and who are enrolled in the State's managed care medical assistance program on or before the effective date of this amendatory Act of the 100th General Assembly shall be given the option to disenroll from the State's managed care medical assistance program and receive medical assistance coverage under the State's traditional fee-for-service program.
(Source: P.A. 100-990, eff. 1-1-19.)
(305 ILCS 5/5-30b)
Sec. 5-30b. Exemptions from managed care; ground ambulance services.  Notwithstanding any other provision of law, beginning on the effective date of this amendatory Act of the 102nd General Assembly, the Department shall exempt ground ambulance services as described in subsections (c-1) and (c-2) of Section 5-4.2. These services shall continue to be paid under the State's traditional fee-for-service program.
(Source: P.A. 102-661, eff. 1-1-22.)
(305 ILCS 5/5-30d)
Sec. 5-30d. Increased funding for transportation services. Beginning no later than January 1, 2023 and subject to federal approval, the amount allocated to fund rates for medi-car, service car, and attendant services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $24,000,000.
(Source: P.A. 102-1037, eff. 6-2-22.)
(305 ILCS 5/5-31)
Sec. 5-31. Medicaid Research and Education Support Fund.
(a) There is created in the State treasury the Medicaid Research and Education Support Fund. Interest earned by the Fund shall be credited to the Fund. The Fund shall not be used to replace any moneys appropriated to the Medicaid program by the General Assembly.
(b) The Fund is created for the purpose of receiving moneys, donations, and grants from private and public colleges and universities and disbursing moneys only for the following purposes, notwithstanding any other provision of law, for making payments to hospitals as required under Section 5-32  of this Code and any amounts which are reimbursable to the federal government for payments from this Fund which are required to be paid by State warrant.
Disbursements from the Fund shall be by warrants drawn by the State Comptroller upon receipt of vouchers duly executed and certified by the Illinois Department.
(c) The Fund shall consist of the following:
(1) All moneys collected or received by the Illinois      Department from donations and grants from private and public colleges and universities.
(2) All federal matching funds received by the     Illinois Department as a result of expenditures made by the Illinois Department that are attributable to moneys deposited in the Fund.
(3) Any interest or penalty levied in conjunction     with the administration of this Section.
(4) Moneys transferred from another fund in the State     treasury.
(5) All other moneys received for the Fund from any     other source, including interest earned thereon.
(d) Interfund transfers from the Medicaid Research and Education Support Fund are prohibited.
(Source: P.A. 98-104, eff. 7-22-13.)
(305 ILCS 5/5-32)
Sec. 5-32. Medicaid research and education enhancement payments.
(a) The Department shall make Medicaid enhancement payments to Tier I and Tier II academic medical centers as defined in Section 5-5e.2 of this Code identified as primary affiliates by any university or college that makes a donation to the Medicaid Research and Education Support Fund.
(b) By April 30 of each year, a university or college that intends to make a donation to the Medicaid Research and Education Support Fund for the upcoming State fiscal year must notify the Department of this intent and identify a primary Tier I or Tier II academic medical center as defined in Section 5-5e.2 of this Code.
(c) Only Tier I and Tier II academic medical centers as defined in Section 5-5e.2 of this Code identified by a university or college as required under subsection (b) of this Section are eligible to receive payments under this Section.
(d) Reimbursement methodology. The Department shall develop a reimbursement methodology consistent with this Section for distribution of moneys from the funds in a manner that would allow distributions from these funds to be matchable under Title XIX of the Social Security Act. The Department may enhance payment rates to any combination of Medicaid inpatient or outpatient Medicaid services. The Department may enhance Medicaid physician services for physicians employed by Tier I or Tier II academic medical centers as defined in Section 5-5e.2 of this Code qualified to receive payment under this Section if the Department and the Tier I or Tier II academic medical centers as defined in Section 5-5e.2 of this Code agree prior to the start of the State fiscal year for which payments are made. The Department shall promulgate rules necessary to make these distributions matchable.
(e) The Department of Healthcare and Family Services must submit a State Medicaid Plan Amendment to the Centers for Medicare and Medicaid Services to implement the payments under this Section within 60 days of the effective date of this amendatory Act of the 98th General Assembly.
(f) Reimbursements or payments by the State. Nothing in this Section may be used to reduce reimbursements or payments by the State to a hospital under any other Act.
(Source: P.A. 98-104, eff. 7-22-13.)
(305 ILCS 5/5-33)
Sec. 5-33. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)
(305 ILCS 5/5-34)
Sec. 5-34. (Repealed).
(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)
(305 ILCS 5/5-35)
Sec.  5-35. Personal needs allowance.  For a  person who is a resident in a facility licensed under the ID/DD Community Care Act, the Community-Integrated Living Arrangements Licensure  and Certification Act, the Specialized Mental Health Rehabilitation Act of 2013, or the MC/DD Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the State shall pay an amount in addition to the minimum monthly personal needs allowance authorized under Section 1902(q) of Title XIX of the Social Security Act (42 U.S.C. 1396(q)) so that the person's total monthly personal needs allowance from both State and federal sources equals $60.
(Source: P.A. 100-23, eff. 7-6-17.)
(305 ILCS 5/5-35.5)
Sec. 5-35.5. Personal needs allowance; nursing home residents. Subject to federal approval, on and after January 1, 2024, for a person who is a resident in a facility licensed under the Nursing Home Care Act for whom payments are made under this Article throughout a month and who is determined to be eligible for medical assistance under this Article, the monthly personal needs allowance shall be $60.
(Source: P.A. 103-102, eff. 1-1-24.)
(305 ILCS 5/5-36)
Sec. 5-36. Pharmacy benefits.
(a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law.
(2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies:
(A) the Department shall approve any contract between     a third-party administrator and a pharmacy;
(B) the Department's third-party administrator shall     not change the terms of a contract between a third-party administrator and a pharmacy without written approval by the Department; and
(C) the Department's third-party administrator shall     not create, modify, implement, or indirectly establish any fee on a pharmacy, pharmacist, or a recipient of medical assistance without written approval by the Department.
(b) The provisions of this Section shall not apply to outpatient pharmacy services provided by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b or any pharmacy owned by or contracted with the covered entity. A Medicaid managed care organization shall, either directly or through a pharmacy benefit manager, administer and reimburse outpatient pharmacy claims submitted by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b, its owned pharmacies, and contracted pharmacies in accordance with the contractual agreements the Medicaid managed care organization or its pharmacy benefit manager has with such facilities and pharmacies and in accordance with subsection (h-5).
(b-5) Any pharmacy benefit manager that contracts with a Medicaid managed care organization to administer and reimburse pharmacy claims as provided in this Section must be registered with the Director of Insurance in accordance with  Section 513b2 of the Illinois Insurance Code.
(c) On at least an annual basis, the Director of the Department of Healthcare and Family Services shall submit a report beginning no later than one year after January 1, 2020 (the effective date of Public Act 101-452) that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section.
(d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department.
(e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information:
(1) whether the pharmacy benefit manager has a     contract, agreement, or other arrangement with a pharmaceutical manufacturer to exclusively dispense or provide a drug to a managed care organization's enrollees, and the aggregate amounts of consideration of economic benefits collected or received pursuant to that arrangement;
(2) the percentage of claims payments made by the     pharmacy benefit manager to pharmacies owned, managed, or controlled by the pharmacy benefit manager or any of the pharmacy benefit manager's management companies, parent companies, subsidiary companies, or jointly held companies;
(3) the aggregate amount of the fees or assessments     imposed on, or collected from, pharmacy providers; and
(4) the average annualized percentage of revenue     collected by the pharmacy benefit manager as a result of each contract it has executed with a managed care organization contracted by the Department to provide medical assistance benefits which is not paid by the pharmacy benefit manager to pharmacy providers and pharmaceutical manufacturers or labelers or in order to perform administrative functions pursuant to its contracts with managed care organizations.
(f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made

available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value.  The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable.
(g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization  shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification.  As used in this  Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers.  A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies.
(h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider:
(1) a provision prohibiting the provider from     informing a patient of a less costly alternative to a prescribed medication; or
(2) a provision that prohibits the provider from     dispensing a particular amount of a prescribed medication, if the pharmacy benefit manager allows that amount to be dispensed through a pharmacy owned or controlled by the pharmacy benefit manager, unless the prescription drug is subject to restricted distribution by the United States Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.
(h-5) Unless required by law, a Medicaid managed care organization or pharmacy benefit manager administering or managing benefits on behalf of a Medicaid managed care organization shall not refuse to contract with a 340B entity or 340B pharmacy for refusing to accept less favorable payment terms or reimbursement methodologies when compared to similarly situated non-340B entities and shall not include in a contract with a 340B  entity or 340B pharmacy a provision that:
(1) imposes any fee, chargeback, or rate adjustment     that is not similarly imposed on similarly situated pharmacies that are not  340B entities or 340B pharmacies;
(2) imposes any fee, chargeback, or rate adjustment     that exceeds the fee, chargeback, or rate adjustment that is not similarly imposed on similarly situated pharmacies that are not  340B entities or 340B pharmacies;
(3) prevents or interferes with an individual's     choice to receive a prescription drug from a 340B entity or 340B pharmacy through any legally permissible means;
(4) excludes a 340B entity or 340B pharmacy from a     pharmacy network on the basis of whether the 340B entity or 340B pharmacy participates in the 340B drug discount program;
(5) prevents a 340B entity or 340B pharmacy from     using a drug purchased under the 340B drug discount program so long as the drug recipient is a patient of the 340B entity; nothing in this Section exempts a 340B pharmacy from following the Department's preferred drug list or from any prior approval requirements of the Department or the Medicaid managed care organization that are imposed on the drug for all pharmacies; or
(6) any other provision that discriminates against a     340B entity or 340B pharmacy by treating a 340B entity or 340B pharmacy differently than non-340B entities or non-340B pharmacies for any reason relating to the entity's participation in the 340B drug discount program.
A provision that violates this subsection in any contract between a Medicaid managed care organization or its pharmacy benefit manager and a 340B entity entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
In this subsection (h-5):
"340B entity" means a covered entity as defined in 42 U.S.C. 256b(a)(4) authorized to participate in the 340B drug discount program.
"340B pharmacy" means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
(i) Nothing in this Section shall be construed to prohibit a pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy provider as for a pharmacy owned, controlled, or otherwise associated with the pharmacy benefit manager.
(j) A pharmacy benefit manager shall establish and implement a process for the resolution of disputes arising out of this Section, which shall be approved by the Department.
(k) The Department shall adopt rules  establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.
(Source: P.A. 101-452, eff. 1-1-20; 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)
(305 ILCS 5/5-36.1)
Sec. 5-36.1. Earned income for residents of community-integrated living arrangements.
(a) Beginning no later than July 1, 2021, residents of facilities licensed under the Community-Integrated Living Arrangements Licensure and Certification Act who are determined to be eligible for medical assistance under this Code and who are enrolled in the State's home and community-based services waiver program for adults with developmental disabilities shall retain all earned income from employment or community day services activities.
(b)   No portion of earned income shall be applied toward the facilities rate reimbursement methodology. The Department of Human Services shall ensure the rates of payments paid to facilities under the Code are held harmless.
(Source: P.A. 102-343, eff. 8-13-21.)
(305 ILCS 5/5-36.5)
Sec. 5-36.5. Education on mental health and substance use treatment services for children and young adults.  The Department of Healthcare and Family Services shall develop a layman's guide to the mental health and substance use treatment services available in Illinois through the Medical Assistance Program and through the Family Support Program, or other publicly funded programs, similar to what Massachusetts developed, to help families understand what services are available to them when they have a child in need of treatment or support.  The guide shall be in easy-to-understand language, be prominently available on the Department of Healthcare and Family Services' website, and be part of a statewide communications campaign to ensure families are aware of  Family Support Program services.  It shall briefly explain the service and whether it is covered by the Medical Assistance Program, the Family Support Program, or any other public funding source.  Within one year after January 1, 2020 (the effective date of Public Act 101-461), the Department of Healthcare and Family Services shall complete this guide, have it available on its website, and launch the communications campaign.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.)
(305 ILCS 5/5-37)
Sec. 5-37. Billing mechanism for preventive mental health services delivered to children.
(a) The General Assembly finds:
(1) It is common for children to have mental health     needs but to not have a full-blown diagnosis of a mental illness.  Examples include, but are not limited to, children who have mild or emerging symptoms of a mental health condition (such as meeting some but not all the criteria for a diagnosis, including, but not limited to, symptoms of depression, attentional deficits, anxiety or prodromal symptoms of bipolar disorder or schizophrenia); cutting or engaging in other forms of self-harm; or experiencing violence or trauma).
(2) The federal requirement that Medicaid-covered     children have access to Early and Periodic Screening, Diagnostic and Treatment services includes ensuring that Medicaid-covered children who have a mental health need but do not have a mental health diagnosis have access to treatment.
(3) The Department of Healthcare and Family Services'     existing policy acknowledges this federal requirement by allowing for Medicaid billing for mental health services for children who have a need for services but who do not have a mental health diagnosis in Section 207.3.3 of the Community-Based Behavioral Services Provider Handbook.  However, the current policy of the Department of Healthcare and Family Services requires clinicians to specify a diagnosis code and make a notation in the child's medical record that the service is preventive.  This effectively requires the clinician to associate a diagnosis with the child and is a major barrier for services because many clinicians rightly are unwilling to document a mental health diagnosis in the medical record when a diagnosis is not medically appropriate.
(b) Consistent with the existing policy of the Department of Healthcare and Family Services and the federal Early and Periodic Screening, Diagnostic and Treatment requirement, within 3 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services shall convene a working group that includes children's mental health providers to receive input on recommendations to develop a medically appropriate and practical solution that enables mental health providers and professionals to deliver and receive reimbursement for medically necessary mental health services provided to a Medicaid-eligible child under age 21  that has a mental health need but does not have a mental health diagnosis in order to prevent the development of a serious mental health condition. The working group shall ensure that the recommended solution works in practice and does not deter clinicians from delivering prevention and early treatment to children with mental health needs but who do not have a diagnosed mental illness.  The Department of Healthcare and Family Services shall meet with this working group at least 4 times prior to finalizing the solution to enable and allow for mental health services for a child without a mental health diagnosis for purposes of prevention and early treatment when recommended by a licensed practitioner of the healing arts.  If the Department of Healthcare and Family Services determines that an Illinois Title XIX State Plan amendment is necessary to implement this Section, the State Plan amendment shall be filed with the federal Centers for Medicare and Medicaid Services by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly.  If rulemaking is required to implement this Section, the rule shall be filed by the Department of Healthcare and Family Services with the Joint Committee on Administrative Rules by no later than  12 months after the effective date of this amendatory Act of the 101st General Assembly, or if federal approval is required, within 6 months after federal approval. If federal approval is required but not granted, this Section shall become inoperative.
(Source: P.A. 101-461, eff. 1-1-20.)
(305 ILCS 5/5-38)
Sec. 5-38. Alignment of children's mental health treatment systems.  The Governor's Office shall establish, convene, and lead a working group that includes the Director of Healthcare and Family Services, the Secretary of Human Services, the Director of Public Health, the Director of  Children and Family Services, the Director of Juvenile Justice, the State Superintendent of Education, and the appropriate agency staff who will be responsible for implementation or oversight of reforms to children's behavioral health services. The  working group shall meet at least quarterly to foster interagency collaboration and work toward the goal of aligning services and programs to begin to create a coordinated children's behavioral health system consistent with system of care principles that spans across State agencies, rather than  separate siloed systems with different requirements, rates, and administrative processes and standards.
(Source: P.A. 101-461, eff. 1-1-20.)
(305 ILCS 5/5-39)
Sec. 5-39. Behavioral health services for children; diagnostic assessment system. Beginning on July 1, 2022, if it is necessary to provide a diagnostic code for behavioral health services for children ages 5 and under, providers shall utilize a developmentally appropriate and age-appropriate diagnostic assessment system, such as the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised (DC:0-5), for diagnosis and treatment planning.  If necessary for billing purposes, the provider, managed care organization, or Department shall utilize the existing crosswalk tool to convert the developmentally appropriate and age-appropriate diagnosis code to the relevant code available in the State system.
By no later than January 1, 2022, the Department shall make recommendations to the General Assembly  on the resources needed to integrate developmentally appropriate and age-appropriate diagnostic codes into the State system.
(Source: P.A. 101-654, eff. 3-8-21.)
(305 ILCS 5/5-40)
Sec. 5-40. Human breast milk coverage.
(a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
(1) the milk is obtained from a  human milk bank that     meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
(2) the infant's mother is medically or physically     unable to produce maternal breast milk  or produce maternal breast milk in sufficient quantities to meet the infant's needs or the maternal breast milk is contraindicated;
(3) the milk has been determined to be medically     necessary for the infant; and
(4) one or more of the following applies:
(A) the infant's birth weight is below 1,500         grams;
(B) the infant has a congenital or acquired         condition that places the infant at a high risk for development of necrotizing enterocolitis;
(C) the infant has infant hypoglycemia;
(D) the infant has congenital heart disease;
(E) the infant has had or will have an organ         transplant;
(F) the infant has sepsis; or
(G) the infant has any other  serious congenital         or acquired condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the infant.
(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under a health plan for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met:
(1) the milk is obtained from a  human milk bank that     meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
(2) the child's mother is medically or physically     unable to produce maternal breast milk  or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
(3) the milk has been determined to be medically     necessary for the child; and
(4) one or more of the following applies:
(A) the child has spinal muscular atrophy;
(B) the child's birth weight was below 1,500         grams and he or she has long-term feeding or gastrointestinal complications related to prematurity;
(C) the child has had or will have an organ         transplant; or
(D) the child has a  congenital or acquired         condition for which the use of donated human breast milk is medically necessary and supports the treatment and recovery of the child.
(c) Notwithstanding any other provision of this Act,
pasteurized donated human breast milk, which may include human
milk fortifiers if indicated by a prescribing licensed medical
practitioner, shall be covered under a health plan for persons
who are otherwise eligible for coverage under this Act if the
covered person is a child 12 months of age or older, a licensed
medical practitioner prescribes the milk for the covered
person, and all of the following conditions are met:
(1) the milk is obtained from a  human milk bank that     meets quality guidelines established by the Human Milk Banking Association of North America or is licensed by the Department of Public Health;
(2) the child's mother is medically or physically     unable to produce maternal breast milk  or produce maternal breast milk in sufficient quantities to meet the child's needs or the maternal breast milk is contraindicated;
(3) the milk has been determined to be medically     necessary for the child; and
(4) the child has spinal muscular atrophy.
(Source: P.A. 101-511, eff. 1-1-20.)
(305 ILCS 5/5-41)
Sec. 5-41. Inpatient hospitalization for opioid-related overdose or withdrawal patients. Due to the disproportionately high opioid-related fatality rates among African Americans in under-resourced communities in Illinois, the lack of community resources, the comorbidities experienced by these patients, and the high rate of hospital inpatient recidivism associated with this population when improperly treated, the Department shall ensure that patients, whether enrolled under the Medical Assistance Fee For Service program or enrolled with a Medicaid Managed Care Organization, experiencing opioid-related overdose or withdrawal are admitted on an inpatient status and the provider shall be reimbursed accordingly, when deemed medically necessary, as determined by either the patient's primary care physician, or the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents,  using criteria established by the American Society of Addiction Medicine.  If it is determined by the physician or other practitioner responsible for the patient's care at the hospital to which the patient presents, that a patient does not meet medical necessity criteria for the admission,  then the patient may be treated via observation and the provider shall seek reimbursement accordingly.  Nothing in this Section shall diminish the requirements of a provider to document medical necessity in the patient's record.
(Source: P.A. 102-43, eff. 7-6-21; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-42)
Sec. 5-42. Tobacco cessation coverage; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for all tobacco cessation medications approved by the United States Food and Drug Administration, all individual and group tobacco cessation counseling services, and all telephone-based counseling services and tobacco cessation medications provided through the Illinois Tobacco Quitline. The Department may adopt any rules necessary to implement this Section.
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-43)
Sec. 5-43. Supports Waiver Program for Young Adults with Developmental Disabilities.
(a) The Department of Human Services' Division of Developmental Disabilities, in partnership with the Department of Healthcare and Family Services and stakeholders, shall study the development and implementation of a supports waiver program for young adults with developmental disabilities.  The Division shall explore the following components of a supports waiver program to determine what is most appropriate:
(1) The age of individuals to be provided services in     a waiver program.
(2) The number of individuals to be provided services     in a waiver program.
(3) The services to be provided in a waiver program.
(4) The funding to be provided to individuals within     a waiver program.
(5) The transition process to the Waiver for Adults     with Developmental Disabilities.
(6) The type of home and community-based services     waiver to be utilized.
(b) The Department of Human Services and the Department of Healthcare and Family Services are authorized to adopt and implement any rules necessary to study  the supports waiver program.
(c) Subject to appropriation, no later than January 1, 2024, the Department of Healthcare and Family Services shall apply to the federal Centers for Medicare and Medicaid Services for a supports waiver for young adults with developmental disabilities utilizing the information learned from the study under subsection (a).
(Source: P.A. 102-43, eff. 7-6-21.)
(305 ILCS 5/5-44)
Sec. 5-44. Screening, Brief Intervention, and Referral to Treatment. As used in this Section, "SBIRT" means a comprehensive, integrated, public health approach to the delivery of early intervention and treatment
services for persons who are at risk of developing substance use disorders or have substance use disorders including, but not limited to, an addiction to alcohol, opioids,
tobacco, or cannabis.
SBIRT services include all of the following:
(1) Screening to quickly assess the severity of     substance use and to identify the appropriate level of treatment.
(2) Brief intervention focused on increasing insight     and awareness regarding substance use and motivation toward behavioral change.
(3) Referral to treatment provided to those     identified as needing more extensive treatment with access to specialty care.
SBIRT services may include, but are not limited to, the following settings and programs: primary care centers, hospital emergency rooms, hospital in-patient units,
trauma centers, community behavioral health programs, and other community settings that provide opportunities for early intervention with at-risk substance users before more severe
consequences occur.
The Department of Healthcare and Family Services shall develop and seek federal approval of a SBIRT benefit for which
qualified providers shall be reimbursed under the medical assistance program.
In conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, the Department of Healthcare and
Family Services may develop a methodology and reimbursement rate for SBIRT services provided by qualified providers in approved
settings.
For opioid specific SBIRT services provided in a hospital emergency department, the Department of Healthcare and
Family Services shall develop a bundled reimbursement
methodology and rate for a package of opioid treatment services, which include initiation of medication for the treatment of opioid use disorder in
the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services when necessary. This
package of opioid related services shall be billed on a separate claim and shall be reimbursed outside of the Enhanced Ambulatory Patient
Grouping system.
(Source: P.A. 102-598, eff. 1-1-22; 102-813, eff. 5-13-22.)
(305 ILCS 5/5-45)
Sec. 5-45. Reimbursement rates; substance use disorder
treatment providers and facilities. Beginning on July 1, 2022,
the Department of Human Services' Division of Substance Use
Prevention and Recovery in conjunction with the Department of
Healthcare and Family Services, shall provide for an increase
in reimbursement rates by way of an increase to existing rates of
47% for all community-based substance use disorder treatment
services, including, but not limited to, all of the following:
(1) Admission and Discharge Assessment.
(2) Level 1 (Individual).
(3) Level 1 (Group).
(4) Level 2 (Individual).
(5) Level 2 (Group).
(6) Psychiatric/Diagnostic.
(7) Medication Monitoring (Individual).
(8) Methadone as an Adjunct to Treatment.
No existing or future reimbursement rates or add-ons shall be
reduced or changed to address the rate increase proposed under this Section.
The Department of Healthcare and Family Services shall immediately,
no later than 3 months following April 19, 2022 (the effective date of Public Act 102-699),
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.
Beginning in State fiscal year 2023, and every State fiscal year thereafter,
reimbursement rates for those community-based substance use disorder
treatment services shall be adjusted upward by an amount equal
to the Consumer Price Index-U from the previous year, not to
exceed 2% in any State fiscal year. If there is a decrease in
the Consumer Price Index-U, rates shall remain unchanged for
that State fiscal year. The Department of Human Services shall adopt rules,
including emergency rules under Section 5-45.1 of the Illinois
Administrative Procedure Act, to implement the provisions of
this Section.
As used in this Section, "consumer price index-u"
means the index published by the Bureau of Labor Statistics of
the United States Department of Labor that measures the average
change in prices of goods and services purchased by all urban
consumers, United States city average, all items, 1982-84 =
100.
(Source: P.A. 102-699, eff. 4-19-22; 103-154, eff. 6-30-23.)
(305 ILCS 5/5-46)
Sec. 5-46. General acute care hospitals. A general acute care hospital is authorized to file a notice with the Department of Public Health and the Health Facilities and Services Review Board to establish an acute mental illness category of service in accordance with the Illinois Health Facilities Planning Act and add authorized acute mental illness beds if the following conditions are met:
(1) the general acute care hospital qualifies as a     safety-net hospital, as defined in Section 5-5e.1, as determined by the Department of Healthcare and Family Services at the time of filing the notice or for the year immediately prior to the date of filing the notice;
(2) the notice seeks to establish no more than 24     authorized acute mental illness beds; and
(3) the notice seeks to reduce the number of     authorized beds in another category of service to offset the number of authorized acute mental illness beds.
(Source: P.A. 102-886, eff. 5-17-22; 103-154, eff. 6-30-23.)
(305 ILCS 5/5-47)
(Text of Section from P.A. 103-102)
Sec. 5-47. Medicaid reimbursement rates; substance use disorder treatment providers and facilities.
(a) Beginning on January 1, 2024, subject to federal approval, the Department of Healthcare and Family Services, in conjunction with the Department of Human Services' Division of Substance Use Prevention and Recovery, shall provide a 30% increase in reimbursement rates for all Medicaid-covered ASAM Level 3 residential/inpatient substance use disorder treatment services.
No existing or future reimbursement rates or add-ons shall be reduced or changed to address this proposed rate increase. No later than 3 months after the effective date of this amendatory Act of the 103rd General Assembly, the Department of Healthcare and Family Services shall submit any necessary application to the federal Centers for Medicare and Medicaid Services to implement the requirements of this Section.
(b) Parity in community-based behavioral health rates; implementation plan for cost reporting. For the purpose of understanding behavioral health services cost structures and their impact on the Medical Assistance Program, the Department of Healthcare and Family Services shall engage stakeholders to develop a plan for the regular collection of cost reporting for all entity-based substance use disorder providers. Data shall be used to inform on the effectiveness and efficiency of Illinois Medicaid rates. The Department and stakeholders shall develop a plan by April 1, 2024. The Department shall engage stakeholders on implementation of the plan. The plan, at minimum, shall consider all of the following:
(1) Alignment with certified community behavioral     health clinic requirements, standards, policies, and procedures.
(2) Inclusion of prospective costs to measure what is     needed to increase services and capacity.
(3) Consideration of differences in collection and     policies based on the size of providers.
(4) Consideration of additional administrative time     and costs.
(5) Goals, purposes, and usage of data collected from     cost reports.
(6) Inclusion of qualitative data in addition to     quantitative data.
(7) Technical assistance for providers for completing     cost reports including initial training by the Department for providers.
(8) Implementation of a timeline which allows an     initial grace period for providers to adjust internal procedures and data collection.
Details from collected cost reports shall be made publicly available on the Department's website and costs shall be used to ensure the effectiveness and efficiency of Illinois Medicaid rates.
(c) Reporting; access to substance use disorder treatment services and recovery supports. By no later than April 1, 2024, the Department of Healthcare and Family Services, with input from the Department of Human Services' Division of Substance Use Prevention and Recovery, shall submit a report to the General Assembly regarding access to treatment services and recovery supports for persons diagnosed with a substance use disorder. The report shall include, but is not limited to, the following information:
(1) The number of providers enrolled in the Illinois     Medical Assistance Program certified to provide substance use disorder treatment services, aggregated by ASAM level of care, and recovery supports.
(2) The number of Medicaid customers in Illinois with     a diagnosed substance use disorder receiving substance use disorder treatment, aggregated by provider type and ASAM level of care.
(3) A comparison of Illinois' substance use disorder     licensure and certification requirements with those of comparable state Medicaid programs.
(4) Recommendations for and an analysis of the impact     of aligning reimbursement rates for outpatient substance use disorder treatment services with reimbursement rates for community-based mental health treatment services.
(5) Recommendations for expanding substance use     disorder treatment to other qualified provider entities and licensed professionals of the healing arts. The recommendations shall include an analysis of the opportunities to maximize the flexibilities permitted by the federal Centers for Medicare and Medicaid Services for expanding access to the number and types of qualified substance use disorder providers.(Source: P.A. 103-102, eff. 6-16-23.)
(Text of Section from P.A. 103-243)
Sec. 5-47. Coverage for mental health and substance use disorder telehealth services.
(a) As used in this Section:
"Behavioral health care professional" has the meaning given to "health care professional" in Section 5 of the Telehealth Act, but only with respect to professionals licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services engaged in the delivery of mental health or substance use disorder treatment or services.
"Behavioral health facility" means a community mental health center, a behavioral health clinic, a substance use disorder treatment program, or a facility or provider licensed or certified by the Division of Mental Health or Division of Substance Use Prevention and Recovery of the Department of Human Services.
"Behavioral telehealth services" has the meaning given to the term "telehealth services" in Section 5 of the Telehealth Act, but limited solely to mental health and substance use disorder treatment or services to a patient, regardless of patient location.
"Distant site" has the meaning given to that term in Section 5 of the Telehealth Act.
"Originating site" has the meaning given to that term in Section 5 of the Telehealth Act.
(b) The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered.
(c) To ensure behavioral telehealth services are equitably provided, coverage required under this Section shall comply with all of the following:
(1) The Department and any managed care plans under     contract with the Department for the medical assistance program shall not:
(A) require that in-person contact occur between         a behavioral health care professional and a patient before the provision of a behavioral telehealth service;
(B) require patients, behavioral health care         professionals, or behavioral health facilities to prove or document a hardship or access barrier to an in-person consultation for coverage and reimbursement of behavioral telehealth services;
(C) require the use of behavioral telehealth         services when the behavioral health care professional has determined that it is not appropriate;
(D) require the use of behavioral telehealth         services when a patient chooses an in-person consultation;
(E) require a behavioral health care professional         to be physically present in the same room as the patient at the originating site, unless deemed medically necessary by the behavioral health care professional providing the behavioral telehealth service;
(F) create geographic or facility restrictions or         requirements for behavioral telehealth services;
(G) require behavioral health care professionals         or behavioral health facilities to offer or provide behavioral telehealth services;
(H) require patients to use behavioral telehealth         services or require patients to use a separate panel of behavioral health care professionals or behavioral health facilities to receive behavioral telehealth services; or
(I) impose upon behavioral telehealth services         utilization review requirements that are unnecessary, duplicative, or unwarranted or impose any treatment limitations, prior authorization, documentation, or recordkeeping requirements that are more stringent than the requirements applicable to the same behavioral health care service when rendered in-person, except that procedure code modifiers may be required to document behavioral telehealth.
(2) Any cost sharing applicable to services provided     through behavioral telehealth shall not exceed the cost sharing required by the medical assistance program for the same services provided through in-person consultation.
(3) The Department and any managed care plans under     contract with the Department for the medical assistance program shall notify behavioral health care professionals and behavioral health facilities of any instructions necessary to facilitate billing for behavioral telehealth services.
(d) For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service.
(e) Behavioral health care professionals and behavioral health facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a behavioral telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996, 42 CFR Part 2, and the Mental Health and Developmental Disabilities Confidentiality Act.
(f) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from providing benefits for other telehealth services.
(g) There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate.
(h) Nothing in this Section shall be deemed as precluding the Department and any managed care plans under contract with the Department for the medical assistance program from establishing limits on the use of telehealth for a particular behavioral health service when the limits are consistent with generally accepted standards of mental, emotional, nervous, or substance use disorder or condition care.
(i) The Department may adopt rules to implement the provisions of this Section.
(Source: P.A. 103-243, eff. 1-1-24.)
(Text of Section from P.A. 103-325)
Sec. 5-47. Proton beam therapy; managed care. Notwithstanding any other provision of this Article, a managed care organization under contract with the Department to provide services to recipients of medical assistance shall provide coverage for proton beam therapy. As used in this Section, "proton beam therapy" means a type of radiation therapy treatment that utilizes protons as the radiation delivery method for the treatment of tumors and cancerous cells. "Radiation therapy treatment" means the delivery of biological effective doses with proton therapy, intensity modulated radiation therapy, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.
(Source: P.A. 103-325, eff. 1-1-24.)
(305 ILCS 5/5-48)
Sec. 5-48. Increasing behavioral health service capacity in federally qualified health centers. The Department of Healthcare and Family Services shall develop policies and procedures with the goal of increasing the capacity of behavioral health services provided by federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act. Subject to federal approval, the Department shall develop, no later than January 1, 2024, billing policies that provide reimbursement to federally qualified health centers for services rendered by graduate-level, sub-clinical behavioral health professionals who deliver care under the supervision of a fully licensed behavioral health clinician who is licensed as a clinical social worker, clinical professional counselor, marriage and family therapist, or clinical psychologist.
To be eligible for reimbursement as provided for in this Section, a graduate-level, sub-clinical professional must meet the educational requirements set forth by the Department of Financial and Professional Regulation for licensed clinical social workers, licensed clinical professional counselors, licensed marriage and family therapists, or licensed clinical psychologists. An individual seeking to fulfill post-degree experience requirements in order to qualify for licensing as a clinical social worker, clinical professional counselor, marriage and family therapist, or clinical psychologist shall also be eligible for reimbursement under this Section so long as the individual is in compliance with all applicable laws and regulations regarding supervision, including, but not limited to, the requirement that the supervised experience be under the order, control, and full professional responsibility of the individual's supervisor or that the individual is designated by a title that clearly indicates training status.
The Department shall work with a trade association representing a majority of federally qualified health centers operating in Illinois to develop the policies and procedures required under this Section.
(Source: P.A. 103-102, eff. 1-1-24.)
(305 ILCS 5/5-49)
Sec. 5-49. Long-acting reversible contraception. Subject to federal approval, the Department shall adopt policies and rates for long-acting reversible contraception by January 1, 2024 to ensure that reimbursement is not reduced by 4.4% below list price. The Department shall submit any necessary application to the federal Centers for Medicare and Medicaid Services for the purposes of implementing such policies and rates.
(Source: P.A. 103-102, eff. 7-1-23.)