Rep. Anna Moeller

Filed: 5/31/2026

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1 AMENDMENT TO SENATE BILL 3365

2 AMENDMENT NO. ______. Amend Senate Bill 3365 by replacing

3 everything after the enacting clause with the following:

4 "ARTICLE 2.

5 Section 2-5. The Illinois Public Aid Code is amended by

6 changing Section 5-5 as follows:

7 (305 ILCS 5/5-5)

8 Sec. 5-5. Medical services. The Illinois Department, by

9 rule, shall determine the quantity and quality of and the rate

10 of reimbursement for the medical assistance for which payment

11 will be authorized, and the medical services to be provided,

12 which may include all or part of the following: (1) inpatient

13 hospital services; (2) outpatient hospital services; (3) other

14 laboratory and X-ray services; (4) skilled nursing home

15 services; (5) physicians' services whether furnished in the

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1 office, the patient's home, a hospital, a skilled nursing

2 home, or elsewhere; (6) medical care, or any other type of

3 remedial care furnished by licensed practitioners; (7) home

4 health care services; (8) private duty nursing service; (9)

5 clinic services; (10) dental services, including prevention

6 and treatment of periodontal disease and dental caries disease

7 for pregnant individuals, provided by an individual licensed

8 to practice dentistry or dental surgery; for purposes of this

9 item (10), "dental services" means diagnostic, preventive, or

10 corrective procedures provided by or under the supervision of

11 a dentist in the practice of his or her profession; (11)

12 physical therapy and related services; (12) prescribed drugs,

13 dentures, and prosthetic devices; and eyeglasses prescribed by

14 a physician skilled in the diseases of the eye, or by an

15 optometrist, whichever the person may select; (13) other

16 diagnostic, screening, preventive, and rehabilitative

17 services, including to ensure that the individual's need for

18 intervention or treatment of mental disorders or substance use

19 disorders or co-occurring mental health and substance use

20 disorders is determined using a uniform screening, assessment,

21 and evaluation process inclusive of criteria, for children and

22 adults; for purposes of this item (13), a uniform screening,

23 assessment, and evaluation process refers to a process that

24 includes an appropriate evaluation and, as warranted, a

25 referral; "uniform" does not mean the use of a singular

26 instrument, tool, or process that all must utilize; (14)

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1 transportation and such other expenses as may be necessary;

2 (15) medical treatment of sexual assault survivors, as defined

3 in Section 1a of the Sexual Assault Survivors Emergency

4 Treatment Act, for injuries sustained as a result of the

5 sexual assault, including examinations and laboratory tests to

6 discover evidence which may be used in criminal proceedings

7 arising from the sexual assault; (16) the diagnosis and

8 treatment of sickle cell disease ~~anemia~~; (16.5) services

9 performed by a chiropractic physician licensed under the

10 Medical Practice Act of 1987 and acting within the scope of his

11 or her license, including, but not limited to, chiropractic

12 manipulative treatment; and (17) any other medical care, and

13 any other type of remedial care recognized under the laws of

14 this State. The term "any other type of remedial care" shall

15 include nursing care and nursing home service for persons who

16 rely on treatment by spiritual means alone through prayer for

17 healing.

18 Notwithstanding any other provision of this Section, a

19 comprehensive tobacco use cessation program that includes

20 purchasing prescription drugs or prescription medical devices

21 approved by the Food and Drug Administration shall be covered

22 under the medical assistance program under this Article for

23 persons who are otherwise eligible for assistance under this

24 Article.

25 Notwithstanding any other provision of this Code,

26 reproductive health care that is otherwise legal in Illinois

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1 shall be covered under the medical assistance program for

2 persons who are otherwise eligible for medical assistance

3 under this Article.

4 Notwithstanding any other provision of this Section, all

5 tobacco cessation medications approved by the United States

6 Food and Drug Administration and all individual and group

7 tobacco cessation counseling services and telephone-based

8 counseling services and tobacco cessation medications provided

9 through the Illinois Tobacco Quitline shall be covered under

10 the medical assistance program for persons who are otherwise

11 eligible for assistance under this Article. The Department

12 shall comply with all federal requirements necessary to obtain

13 federal financial participation, as specified in 42 CFR

14 433.15(b)(7), for telephone-based counseling services provided

15 through the Illinois Tobacco Quitline, including, but not

16 limited to: (i) entering into a memorandum of understanding or

17 interagency agreement with the Department of Public Health, as

18 administrator of the Illinois Tobacco Quitline; and (ii)

19 developing a cost allocation plan for Medicaid-allowable

20 Illinois Tobacco Quitline services in accordance with 45 CFR

21 95.507. The Department shall submit the memorandum of

22 understanding or interagency agreement, the cost allocation

23 plan, and all other necessary documentation to the Centers for

24 Medicare and Medicaid Services for review and approval.

25 Coverage under this paragraph shall be contingent upon federal

26 approval.

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1 Notwithstanding any other provision of this Code, the

2 Illinois Department may not require, as a condition of payment

3 for any laboratory test authorized under this Article, that a

4 physician's handwritten signature appear on the laboratory

5 test order form. The Illinois Department may, however, impose

6 other appropriate requirements regarding laboratory test order

7 documentation.

8 Upon receipt of federal approval of an amendment to the

9 Illinois Title XIX State Plan for this purpose, the Department

10 shall authorize the Chicago Public Schools (CPS) to procure a

11 vendor or vendors to manufacture eyeglasses for individuals

12 enrolled in a school within the CPS system. CPS shall ensure

13 that its vendor or vendors are enrolled as providers in the

14 medical assistance program and in any capitated Medicaid

15 managed care entity (MCE) serving individuals enrolled in a

16 school within the CPS system. Under any contract procured

17 under this provision, the vendor or vendors must serve only

18 individuals enrolled in a school within the CPS system. Claims

19 for services provided by CPS's vendor or vendors to recipients

20 of benefits in the medical assistance program under this Code,

21 the Children's Health Insurance Program, or the Covering ALL

22 KIDS Health Insurance Program shall be submitted to the

23 Department or the MCE in which the individual is enrolled for

24 payment and shall be reimbursed at the Department's or the

25 MCE's established rates or rate methodologies for eyeglasses.

26 On and after July 1, 2012, the Department of Healthcare

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1 and Family Services may provide the following services to

2 persons eligible for assistance under this Article who are

3 participating in education, training or employment programs

4 operated by the Department of Human Services as successor to

5 the Department of Public Aid:

6 (1) dental services provided by or under the

7 supervision of a dentist; and

8 (2) eyeglasses prescribed by a physician skilled in

9 the diseases of the eye, or by an optometrist, whichever

10 the person may select.

11 On and after July 1, 2018, the Department of Healthcare

12 and Family Services shall provide dental services to any adult

13 who is otherwise eligible for assistance under the medical

14 assistance program. As used in this paragraph, "dental

15 services" means diagnostic, preventative, restorative, or

16 corrective procedures, including procedures and services for

17 the prevention and treatment of periodontal disease and dental

18 caries disease, provided by an individual who is licensed to

19 practice dentistry or dental surgery or who is under the

20 supervision of a dentist in the practice of his or her

21 profession.

22 On and after July 1, 2018, targeted dental services, as

23 set forth in Exhibit D of the Consent Decree entered by the

24 United States District Court for the Northern District of

25 Illinois, Eastern Division, in the matter of Memisovski v.

26 Maram, Case No. 92 C 1982, that are provided to adults under

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1 the medical assistance program shall be established at no less

2 than the rates set forth in the "New Rate" column in Exhibit D

3 of the Consent Decree for targeted dental services that are

4 provided to persons under the age of 18 under the medical

5 assistance program.

6 Subject to federal approval, on and after January 1, 2025,

7 the rates paid for sedation evaluation and the provision of

8 deep sedation and intravenous sedation for the purpose of

9 dental services shall be increased by 33% above the rates in

10 effect on December 31, 2024. The rates paid for nitrous oxide

11 sedation shall not be impacted by this paragraph and shall

12 remain the same as the rates in effect on December 31, 2024.

13 Notwithstanding any other provision of this Code and

14 subject to federal approval, the Department may adopt rules to

15 allow a dentist who is volunteering his or her service at no

16 cost to render dental services through an enrolled

17 not-for-profit health clinic without the dentist personally

18 enrolling as a participating provider in the medical

19 assistance program. A not-for-profit health clinic shall

20 include a public health clinic or Federally Qualified Health

21 Center or other enrolled provider, as determined by the

22 Department, through which dental services covered under this

23 Section are performed. The Department shall establish a

24 process for payment of claims for reimbursement for covered

25 dental services rendered under this provision.

26 Subject to appropriation and to federal approval, the

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1 Department shall file administrative rules updating the

2 Handicapping Labio-Lingual Deviation orthodontic scoring tool

3 by January 1, 2025, or as soon as practicable.

4 On and after January 1, 2022, the Department of Healthcare

5 and Family Services shall administer and regulate a

6 school-based dental program that allows for the out-of-office

7 delivery of preventative dental services in a school setting

8 to children under 19 years of age. The Department shall

9 establish, by rule, guidelines for participation by providers

10 and set requirements for follow-up referral care based on the

11 requirements established in the Dental Office Reference Manual

12 published by the Department that establishes the requirements

13 for dentists participating in the All Kids Dental School

14 Program. Every effort shall be made by the Department when

15 developing the program requirements to consider the different

16 geographic differences of both urban and rural areas of the

17 State for initial treatment and necessary follow-up care. No

18 provider shall be charged a fee by any unit of local government

19 to participate in the school-based dental program administered

20 by the Department. Nothing in this paragraph shall be

21 construed to limit or preempt a home rule unit's or school

22 district's authority to establish, change, or administer a

23 school-based dental program in addition to, or independent of,

24 the school-based dental program administered by the

25 Department.

26 The Illinois Department, by rule, may distinguish and

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1 classify the medical services to be provided only in

2 accordance with the classes of persons designated in Section

3 5-2.

4 The Department of Healthcare and Family Services must

5 provide coverage and reimbursement for amino acid-based

6 elemental formulas, regardless of delivery method, for the

7 diagnosis and treatment of (i) eosinophilic disorders and (ii)

8 short bowel syndrome when the prescribing physician has issued

9 a written order stating that the amino acid-based elemental

10 formula is medically necessary.

11 The Illinois Department shall authorize the provision of,

12 and shall authorize payment for, screening by low-dose

13 mammography for the presence of occult breast cancer for

14 individuals 35 years of age or older who are eligible for

15 medical assistance under this Article, as follows:

16 (A) A baseline mammogram for individuals 35 to 39

17 years of age.

18 (B) An annual mammogram for individuals 40 years of

19 age or older.

20 (C) A mammogram at the age and intervals considered

21 medically necessary by the individual's health care

22 provider for individuals under 40 years of age and having

23 a family history of breast cancer, prior personal history

24 of breast cancer, positive genetic testing, or other risk

25 factors.

26 (D) A comprehensive ultrasound screening and MRI of an

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1 entire breast or breasts if a mammogram demonstrates

2 heterogeneous or dense breast tissue or when medically

3 necessary as determined by a physician licensed to

4 practice medicine in all of its branches.

5 (E) A screening MRI when medically necessary, as

6 determined by a physician licensed to practice medicine in

7 all of its branches.

8 (F) A diagnostic mammogram when medically necessary,

9 as determined by a physician licensed to practice medicine

10 in all its branches, advanced practice registered nurse,

11 or physician assistant.

12 (G) Molecular breast imaging (MBI) and MRI of an

13 entire breast or breasts if a mammogram demonstrates

14 heterogeneous or dense breast tissue or when medically

15 necessary as determined by a physician licensed to

16 practice medicine in all of its branches, advanced

17 practice registered nurse, or physician assistant.

18 The Department shall not impose a deductible, coinsurance,

19 copayment, or any other cost-sharing requirement on the

20 coverage provided under this paragraph; except that this

21 sentence does not apply to coverage of diagnostic mammograms

22 to the extent such coverage would disqualify a high-deductible

23 health plan from eligibility for a health savings account

24 pursuant to Section 223 of the Internal Revenue Code (26

25 U.S.C. 223).

26 All screenings shall include a physical breast exam,

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1 instruction on self-examination and information regarding the

2 frequency of self-examination and its value as a preventative

3 tool.

4 For purposes of this Section:

5 "Diagnostic mammogram" means a mammogram obtained using

6 diagnostic mammography.

7 "Diagnostic mammography" means a method of screening that

8 is designed to evaluate an abnormality in a breast, including

9 an abnormality seen or suspected on a screening mammogram or a

10 subjective or objective abnormality otherwise detected in the

11 breast.

12 "Low-dose mammography" means the x-ray examination of the

13 breast using equipment dedicated specifically for mammography,

14 including the x-ray tube, filter, compression device, and

15 image receptor, with an average radiation exposure delivery of

16 less than one rad per breast for 2 views of an average size

17 breast. The term also includes digital mammography and

18 includes breast tomosynthesis.

19 "Breast tomosynthesis" means a radiologic procedure that

20 involves the acquisition of projection images over the

21 stationary breast to produce cross-sectional digital

22 three-dimensional images of the breast.

23 If, at any time, the Secretary of the United States

24 Department of Health and Human Services, or its successor

25 agency, promulgates rules or regulations to be published in

26 the Federal Register or publishes a comment in the Federal

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1 Register or issues an opinion, guidance, or other action that

2 would require the State, pursuant to any provision of the

3 Patient Protection and Affordable Care Act (Public Law

4 111-148), including, but not limited to, 42 U.S.C.

5 18031(d)(3)(B) or any successor provision, to defray the cost

6 of any coverage for breast tomosynthesis outlined in this

7 paragraph, then the requirement that an insurer cover breast

8 tomosynthesis is inoperative other than any such coverage

9 authorized under Section 1902 of the Social Security Act, 42

10 U.S.C. 1396a, and the State shall not assume any obligation

11 for the cost of coverage for breast tomosynthesis set forth in

12 this paragraph.

13 On and after January 1, 2016, the Department shall ensure

14 that all networks of care for adult clients of the Department

15 include access to at least one breast imaging Center of

16 Imaging Excellence as certified by the American College of

17 Radiology.

18 On and after January 1, 2012, providers participating in a

19 quality improvement program approved by the Department shall

20 be reimbursed for screening and diagnostic mammography at the

21 same rate as the Medicare program's rates, including the

22 increased reimbursement for digital mammography and, after

23 January 1, 2023 (the effective date of Public Act 102-1018),

24 breast tomosynthesis.

25 The Department shall convene an expert panel including

26 representatives of hospitals, free-standing mammography

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1 facilities, and doctors, including radiologists, to establish

2 quality standards for mammography.

3 On and after January 1, 2017, providers participating in a

4 breast cancer treatment quality improvement program approved

5 by the Department shall be reimbursed for breast cancer

6 treatment at a rate that is no lower than 95% of the Medicare

7 program's rates for the data elements included in the breast

8 cancer treatment quality program.

9 The Department shall convene an expert panel, including

10 representatives of hospitals, free-standing breast cancer

11 treatment centers, breast cancer quality organizations, and

12 doctors, including radiologists that are trained in all forms

13 of FDA-approved breast imaging technologies, breast surgeons,

14 reconstructive breast surgeons, oncologists, and primary care

15 providers to establish quality standards for breast cancer

16 treatment.

17 Subject to federal approval, the Department shall

18 establish a rate methodology for mammography at federally

19 qualified health centers and other encounter-rate clinics.

20 These clinics or centers may also collaborate with other

21 hospital-based mammography facilities. By January 1, 2016, the

22 Department shall report to the General Assembly on the status

23 of the provision set forth in this paragraph.

24 The Department shall establish a methodology to remind

25 individuals who are age-appropriate for screening mammography,

26 but who have not received a mammogram within the previous 18

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1 months, of the importance and benefit of screening

2 mammography. The Department shall work with experts in breast

3 cancer outreach and patient navigation to optimize these

4 reminders and shall establish a methodology for evaluating

5 their effectiveness and modifying the methodology based on the

6 evaluation.

7 The Department shall establish a performance goal for

8 primary care providers with respect to their female patients

9 over age 40 receiving an annual mammogram. This performance

10 goal shall be used to provide additional reimbursement in the

11 form of a quality performance bonus to primary care providers

12 who meet that goal.

13 The Department shall devise a means of case-managing or

14 patient navigation for beneficiaries diagnosed with breast

15 cancer. This program shall initially operate as a pilot

16 program in areas of the State with the highest incidence of

17 mortality related to breast cancer. At least one pilot program

18 site shall be in the metropolitan Chicago area and at least one

19 site shall be outside the metropolitan Chicago area. On or

20 after July 1, 2016, the pilot program shall be expanded to

21 include one site in western Illinois, one site in southern

22 Illinois, one site in central Illinois, and 4 sites within

23 metropolitan Chicago. An evaluation of the pilot program shall

24 be carried out measuring health outcomes and cost of care for

25 those served by the pilot program compared to similarly

26 situated patients who are not served by the pilot program.

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1 The Department shall require all networks of care to

2 develop a means either internally or by contract with experts

3 in navigation and community outreach to navigate cancer

4 patients to comprehensive care in a timely fashion. The

5 Department shall require all networks of care to include

6 access for patients diagnosed with cancer to at least one

7 academic commission on cancer-accredited cancer program as an

8 in-network covered benefit.

9 The Department shall provide coverage and reimbursement

10 for a human papillomavirus (HPV) vaccine that is approved for

11 marketing by the federal Food and Drug Administration for all

12 persons between the ages of 9 and 45. Subject to federal

13 approval, the Department shall provide coverage and

14 reimbursement for a human papillomavirus (HPV) vaccine for

15 persons of the age of 46 and above who have been diagnosed with

16 cervical dysplasia with a high risk of recurrence or

17 progression. The Department shall disallow any

18 preauthorization requirements for the administration of the

19 human papillomavirus (HPV) vaccine.

20 On or after July 1, 2022, individuals who are otherwise

21 eligible for medical assistance under this Article shall

22 receive coverage for perinatal depression screenings for the

23 12-month period beginning on the last day of their pregnancy.

24 Medical assistance coverage under this paragraph shall be

25 conditioned on the use of a screening instrument approved by

26 the Department.

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1 Any medical or health care provider shall immediately

2 recommend, to any pregnant individual who is being provided

3 prenatal services and is suspected of having a substance use

4 disorder as defined in the Substance Use Disorder Act,

5 referral to a local substance use disorder treatment program

6 licensed by the Department of Human Services or to a licensed

7 hospital which provides substance abuse treatment services.

8 The Department of Healthcare and Family Services shall assure

9 coverage for the cost of treatment of the drug abuse or

10 addiction for pregnant recipients in accordance with the

11 Illinois Medicaid Program in conjunction with the Department

12 of Human Services.

13 All medical providers providing medical assistance to

14 pregnant individuals under this Code shall receive information

15 from the Department on the availability of services under any

16 program providing case management services for addicted

17 individuals, including information on appropriate referrals

18 for other social services that may be needed by addicted

19 individuals in addition to treatment for addiction.

20 The Illinois Department, in cooperation with the

21 Departments of Human Services (as successor to the Department

22 of Alcoholism and Substance Abuse) and Public Health, through

23 a public awareness campaign, may provide information

24 concerning treatment for alcoholism and drug abuse and

25 addiction, prenatal health care, and other pertinent programs

26 directed at reducing the number of drug-affected infants born

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1 to recipients of medical assistance.

2 Neither the Department of Healthcare and Family Services

3 nor the Department of Human Services shall sanction the

4 recipient solely on the basis of the recipient's substance

5 abuse.

6 The Illinois Department shall establish such regulations

7 governing the dispensing of health services under this Article

8 as it shall deem appropriate. The Department should seek the

9 advice of formal professional advisory committees appointed by

10 the Director of the Illinois Department for the purpose of

11 providing regular advice on policy and administrative matters,

12 information dissemination and educational activities for

13 medical and health care providers, and consistency in

14 procedures to the Illinois Department.

15 The Illinois Department may develop and contract with

16 Partnerships of medical providers to arrange medical services

17 for persons eligible under Section 5-2 of this Code.

18 Implementation of this Section may be by demonstration

19 projects in certain geographic areas. The Partnership shall be

20 represented by a sponsor organization. The Department, by

21 rule, shall develop qualifications for sponsors of

22 Partnerships. Nothing in this Section shall be construed to

23 require that the sponsor organization be a medical

24 organization.

25 The sponsor must negotiate formal written contracts with

26 medical providers for physician services, inpatient and

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1 outpatient hospital care, home health services, treatment for

2 alcoholism and substance abuse, and other services determined

3 necessary by the Illinois Department by rule for delivery by

4 Partnerships. Physician services must include prenatal and

5 obstetrical care. The Illinois Department shall reimburse

6 medical services delivered by Partnership providers to clients

7 in target areas according to provisions of this Article and

8 the Illinois Health Finance Reform Act, except that:

9 (1) Physicians participating in a Partnership and

10 providing certain services, which shall be determined by

11 the Illinois Department, to persons in areas covered by

12 the Partnership may receive an additional surcharge for

13 such services.

14 (2) The Department may elect to consider and negotiate

15 financial incentives to encourage the development of

16 Partnerships and the efficient delivery of medical care.

17 (3) Persons receiving medical services through

18 Partnerships may receive medical and case management

19 services above the level usually offered through the

20 medical assistance program.

21 Medical providers shall be required to meet certain

22 qualifications to participate in Partnerships to ensure the

23 delivery of high quality medical services. These

24 qualifications shall be determined by rule of the Illinois

25 Department and may be higher than qualifications for

26 participation in the medical assistance program. Partnership

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1 sponsors may prescribe reasonable additional qualifications

2 for participation by medical providers, only with the prior

3 written approval of the Illinois Department.

4 Nothing in this Section shall limit the free choice of

5 practitioners, hospitals, and other providers of medical

6 services by clients. In order to ensure patient freedom of

7 choice, the Illinois Department shall immediately promulgate

8 all rules and take all other necessary actions so that

9 provided services may be accessed from therapeutically

10 certified optometrists to the full extent of the Illinois

11 Optometric Practice Act of 1987 without discriminating between

12 service providers.

13 The Department shall apply for a waiver from the United

14 States Health Care Financing Administration to allow for the

15 implementation of Partnerships under this Section.

16 The Illinois Department shall require health care

17 providers to maintain records that document the medical care

18 and services provided to recipients of Medical Assistance

19 under this Article. Such records must be retained for a period

20 of not less than 6 years from the date of service or as

21 provided by applicable State law, whichever period is longer,

22 except that if an audit is initiated within the required

23 retention period then the records must be retained until the

24 audit is completed and every exception is resolved. The

25 Illinois Department shall require health care providers to

26 make available, when authorized by the patient, in writing,

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1 the medical records in a timely fashion to other health care

2 providers who are treating or serving persons eligible for

3 Medical Assistance under this Article. All dispensers of

4 medical services shall be required to maintain and retain

5 business and professional records sufficient to fully and

6 accurately document the nature, scope, details and receipt of

7 the health care provided to persons eligible for medical

8 assistance under this Code, in accordance with regulations

9 promulgated by the Illinois Department. The rules and

10 regulations shall require that proof of the receipt of

11 prescription drugs, dentures, prosthetic devices and

12 eyeglasses by eligible persons under this Section accompany

13 each claim for reimbursement submitted by the dispenser of

14 such medical services. No such claims for reimbursement shall

15 be approved for payment by the Illinois Department without

16 such proof of receipt, unless the Illinois Department shall

17 have put into effect and shall be operating a system of

18 post-payment audit and review which shall, on a sampling

19 basis, be deemed adequate by the Illinois Department to assure

20 that such drugs, dentures, prosthetic devices and eyeglasses

21 for which payment is being made are actually being received by

22 eligible recipients. Within 90 days after September 16, 1984

23 (the effective date of Public Act 83-1439), the Illinois

24 Department shall establish a current list of acquisition costs

25 for all prosthetic devices and any other items recognized as

26 medical equipment and supplies reimbursable under this Article

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1 and shall update such list on a quarterly basis, except that

2 the acquisition costs of all prescription drugs shall be

3 updated no less frequently than every 30 days as required by

4 Section 5-5.12.

5 Notwithstanding any other law to the contrary, the

6 Illinois Department shall, within 365 days after July 22, 2013

7 (the effective date of Public Act 98-104), establish

8 procedures to permit skilled care facilities licensed under

9 the Nursing Home Care Act to submit monthly billing claims for

10 reimbursement purposes. Following development of these

11 procedures, the Department shall, by July 1, 2016, test the

12 viability of the new system and implement any necessary

13 operational or structural changes to its information

14 technology platforms in order to allow for the direct

15 acceptance and payment of nursing home claims.

16 Notwithstanding any other law to the contrary, the

17 Illinois Department shall, within 365 days after August 15,

18 2014 (the effective date of Public Act 98-963), establish

19 procedures to permit ID/DD facilities licensed under the ID/DD

20 Community Care Act and MC/DD facilities licensed under the

21 MC/DD Act to submit monthly billing claims for reimbursement

22 purposes. Following development of these procedures, the

23 Department shall have an additional 365 days to test the

24 viability of the new system and to ensure that any necessary

25 operational or structural changes to its information

26 technology platforms are implemented.

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1 The Illinois Department shall require all dispensers of

2 medical services, other than an individual practitioner or

3 group of practitioners, desiring to participate in the Medical

4 Assistance program established under this Article to disclose

5 all financial, beneficial, ownership, equity, surety or other

6 interests in any and all firms, corporations, partnerships,

7 associations, business enterprises, joint ventures, agencies,

8 institutions or other legal entities providing any form of

9 health care services in this State under this Article.

10 The Illinois Department may require that all dispensers of

11 medical services desiring to participate in the medical

12 assistance program established under this Article disclose,

13 under such terms and conditions as the Illinois Department may

14 by rule establish, all inquiries from clients and attorneys

15 regarding medical bills paid by the Illinois Department, which

16 inquiries could indicate potential existence of claims or

17 liens for the Illinois Department.

18 Enrollment of a vendor shall be subject to a provisional

19 period and shall be conditional for one year. During the

20 period of conditional enrollment, the Department may terminate

21 the vendor's eligibility to participate in, or may disenroll

22 the vendor from, the medical assistance program without cause.

23 Unless otherwise specified, such termination of eligibility or

24 disenrollment is not subject to the Department's hearing

25 process. However, a disenrolled vendor may reapply without

26 penalty.

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1 The Department has the discretion to limit the conditional

2 enrollment period for vendors based upon the category of risk

3 of the vendor.

4 Prior to enrollment and during the conditional enrollment

5 period in the medical assistance program, all vendors shall be

6 subject to enhanced oversight, screening, and review based on

7 the risk of fraud, waste, and abuse that is posed by the

8 category of risk of the vendor. The Illinois Department shall

9 establish the procedures for oversight, screening, and review,

10 which may include, but need not be limited to: criminal and

11 financial background checks; fingerprinting; license,

12 certification, and authorization verifications; unscheduled or

13 unannounced site visits; database checks; prepayment audit

14 reviews; audits; payment caps; payment suspensions; and other

15 screening as required by federal or State law.

16 The Department shall define or specify the following: (i)

17 by provider notice, the "category of risk of the vendor" for

18 each type of vendor, which shall take into account the level of

19 screening applicable to a particular category of vendor under

20 federal law and regulations; (ii) by rule or provider notice,

21 the maximum length of the conditional enrollment period for

22 each category of risk of the vendor; and (iii) by rule, the

23 hearing rights, if any, afforded to a vendor in each category

24 of risk of the vendor that is terminated or disenrolled during

25 the conditional enrollment period.

26 To be eligible for payment consideration, a vendor's

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1 payment claim or bill, either as an initial claim or as a

2 resubmitted claim following prior rejection, must be received

3 by the Illinois Department, or its fiscal intermediary, no

4 later than 180 days after the latest date on the claim on which

5 medical goods or services were provided, with the following

6 exceptions:

7 (1) In the case of a provider whose enrollment is in

8 process by the Illinois Department, the 180-day period

9 shall not begin until the date on the written notice from

10 the Illinois Department that the provider enrollment is

11 complete.

12 (2) In the case of errors attributable to the Illinois

13 Department or any of its claims processing intermediaries

14 which result in an inability to receive, process, or

15 adjudicate a claim, the 180-day period shall not begin

16 until the provider has been notified of the error.

17 (3) In the case of a provider for whom the Illinois

18 Department initiates the monthly billing process.

19 (4) In the case of a provider operated by a unit of

20 local government with a population exceeding 3,000,000

21 when local government funds finance federal participation

22 for claims payments.

23 For claims for services rendered during a period for which

24 a recipient received retroactive eligibility, claims must be

25 filed within 180 days after the Department determines the

26 applicant is eligible. For claims for which the Illinois

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1 Department is not the primary payer, claims must be submitted

2 to the Illinois Department within 180 days after the final

3 adjudication by the primary payer.

4 In the case of long term care facilities, within 120

5 calendar days of receipt by the facility of required

6 prescreening information, new admissions with associated

7 admission documents shall be submitted through the Medical

8 Electronic Data Interchange (MEDI) or the Recipient

9 Eligibility Verification (REV) System or shall be submitted

10 directly to the Department of Human Services using required

11 admission forms. Effective September 1, 2014, admission

12 documents, including all prescreening information, must be

13 submitted through MEDI or REV. Confirmation numbers assigned

14 to an accepted transaction shall be retained by a facility to

15 verify timely submittal. Once an admission transaction has

16 been completed, all resubmitted claims following prior

17 rejection are subject to receipt no later than 180 days after

18 the admission transaction has been completed.

19 Claims that are not submitted and received in compliance

20 with the foregoing requirements shall not be eligible for

21 payment under the medical assistance program, and the State

22 shall have no liability for payment of those claims.

23 To the extent consistent with applicable information and

24 privacy, security, and disclosure laws, State and federal

25 agencies and departments shall provide the Illinois Department

26 access to confidential and other information and data

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1 necessary to perform eligibility and payment verifications and

2 other Illinois Department functions. This includes, but is not

3 limited to: information pertaining to licensure;

4 certification; earnings; immigration status; citizenship; wage

5 reporting; unearned and earned income; pension income;

6 employment; supplemental security income; social security

7 numbers; National Provider Identifier (NPI) numbers; the

8 National Practitioner Data Bank (NPDB); program and agency

9 exclusions; taxpayer identification numbers; tax delinquency;

10 corporate information; and death records.

11 The Illinois Department shall enter into agreements with

12 State agencies and departments, and is authorized to enter

13 into agreements with federal agencies and departments, under

14 which such agencies and departments shall share data necessary

15 for medical assistance program integrity functions and

16 oversight. The Illinois Department shall develop, in

17 cooperation with other State departments and agencies, and in

18 compliance with applicable federal laws and regulations,

19 appropriate and effective methods to share such data. At a

20 minimum, and to the extent necessary to provide data sharing,

21 the Illinois Department shall enter into agreements with State

22 agencies and departments, and is authorized to enter into

23 agreements with federal agencies and departments, including,

24 but not limited to: the Secretary of State; the Department of

25 Revenue; the Department of Public Health; the Department of

26 Human Services; and the Department of Financial and

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1 Professional Regulation.

2 Beginning in fiscal year 2013, the Illinois Department

3 shall set forth a request for information to identify the

4 benefits of a pre-payment, post-adjudication, and post-edit

5 claims system with the goals of streamlining claims processing

6 and provider reimbursement, reducing the number of pending or

7 rejected claims, and helping to ensure a more transparent

8 adjudication process through the utilization of: (i) provider

9 data verification and provider screening technology; and (ii)

10 clinical code editing; and (iii) pre-pay, pre-adjudicated, or

11 post-adjudicated predictive modeling with an integrated case

12 management system with link analysis. Such a request for

13 information shall not be considered as a request for proposal

14 or as an obligation on the part of the Illinois Department to

15 take any action or acquire any products or services.

16 The Illinois Department shall establish policies,

17 procedures, standards and criteria by rule for the

18 acquisition, repair and replacement of orthotic and prosthetic

19 devices and durable medical equipment. Such rules shall

20 provide, but not be limited to, the following services: (1)

21 immediate repair or replacement of such devices by recipients;

22 and (2) rental, lease, purchase or lease-purchase of durable

23 medical equipment in a cost-effective manner, taking into

24 consideration the recipient's medical prognosis, the extent of

25 the recipient's needs, and the requirements and costs for

26 maintaining such equipment. Subject to prior approval, such

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1 rules shall enable a recipient to temporarily acquire and use

2 alternative or substitute devices or equipment pending repairs

3 or replacements of any device or equipment previously

4 authorized for such recipient by the Department.

5 Notwithstanding any provision of Section 5-5f to the contrary,

6 the Department may, by rule, exempt certain replacement

7 wheelchair parts from prior approval and, for wheelchairs,

8 wheelchair parts, wheelchair accessories, and related seating

9 and positioning items, determine the wholesale price by

10 methods other than actual acquisition costs.

11 The Department shall require, by rule, all providers of

12 durable medical equipment to be accredited by an accreditation

13 organization approved by the federal Centers for Medicare and

14 Medicaid Services and recognized by the Department in order to

15 bill the Department for providing durable medical equipment to

16 recipients. No later than 15 months after the effective date

17 of the rule adopted pursuant to this paragraph, all providers

18 must meet the accreditation requirement.

19 In order to promote environmental responsibility, meet the

20 needs of recipients and enrollees, and achieve significant

21 cost savings, the Department, or a managed care organization

22 under contract with the Department, may provide recipients or

23 managed care enrollees who have a prescription or Certificate

24 of Medical Necessity access to refurbished durable medical

25 equipment under this Section (excluding prosthetic and

26 orthotic devices as defined in the Orthotics, Prosthetics, and

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1 Pedorthics Practice Act and complex rehabilitation technology

2 products and associated services) through the State's

3 assistive technology program's reutilization program, using

4 staff with the Assistive Technology Professional (ATP)

5 Certification if the refurbished durable medical equipment:

6 (i) is available; (ii) is less expensive, including shipping

7 costs, than new durable medical equipment of the same type;

8 (iii) is able to withstand at least 3 years of use; (iv) is

9 cleaned, disinfected, sterilized, and safe in accordance with

10 federal Food and Drug Administration regulations and guidance

11 governing the reprocessing of medical devices in health care

12 settings; and (v) equally meets the needs of the recipient or

13 enrollee. The reutilization program shall confirm that the

14 recipient or enrollee is not already in receipt of the same or

15 similar equipment from another service provider, and that the

16 refurbished durable medical equipment equally meets the needs

17 of the recipient or enrollee. Nothing in this paragraph shall

18 be construed to limit recipient or enrollee choice to obtain

19 new durable medical equipment or place any additional prior

20 authorization conditions on enrollees of managed care

21 organizations.

22 The Department shall execute, relative to the nursing home

23 prescreening project, written inter-agency agreements with the

24 Department of Human Services and the Department on Aging, to

25 effect the following: (i) intake procedures and common

26 eligibility criteria for those persons who are receiving

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1 non-institutional services; and (ii) the establishment and

2 development of non-institutional services in areas of the

3 State where they are not currently available or are

4 undeveloped; and (iii) notwithstanding any other provision of

5 law, subject to federal approval, on and after July 1, 2012, an

6 increase in the determination of need (DON) scores from 29 to

7 37 for applicants for institutional and home and

8 community-based long term care; if and only if federal

9 approval is not granted, the Department may, in conjunction

10 with other affected agencies, implement utilization controls

11 or changes in benefit packages to effectuate a similar savings

12 amount for this population; and (iv) no later than July 1,

13 2013, minimum level of care eligibility criteria for

14 institutional and home and community-based long term care; and

15 (v) no later than October 1, 2013, establish procedures to

16 permit long term care providers access to eligibility scores

17 for individuals with an admission date who are seeking or

18 receiving services from the long term care provider. In order

19 to select the minimum level of care eligibility criteria, the

20 Governor shall establish a workgroup that includes affected

21 agency representatives and stakeholders representing the

22 institutional and home and community-based long term care

23 interests. This Section shall not restrict the Department from

24 implementing lower level of care eligibility criteria for

25 community-based services in circumstances where federal

26 approval has been granted.

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1 The Illinois Department shall develop and operate, in

2 cooperation with other State Departments and agencies and in

3 compliance with applicable federal laws and regulations,

4 appropriate and effective systems of health care evaluation

5 and programs for monitoring of utilization of health care

6 services and facilities, as it affects persons eligible for

7 medical assistance under this Code.

8 The Illinois Department shall report annually to the

9 General Assembly, no later than the second Friday in April of

10 1979 and each year thereafter, in regard to:

11 (a) actual statistics and trends in utilization of

12 medical services by public aid recipients;

13 (b) actual statistics and trends in the provision of

14 the various medical services by medical vendors;

15 (c) current rate structures and proposed changes in

16 those rate structures for the various medical vendors; and

17 (d) efforts at utilization review and control by the

18 Illinois Department.

19 The period covered by each report shall be the 3 years

20 ending on the June 30 prior to the report. The report shall

21 include suggested legislation for consideration by the General

22 Assembly. The requirement for reporting to the General

23 Assembly shall be satisfied by filing copies of the report as

24 required by Section 3.1 of the General Assembly Organization

25 Act, and filing such additional copies with the State

26 Government Report Distribution Center for the General Assembly

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1 as is required under paragraph (t) of Section 7 of the State

2 Library Act.

3 Rulemaking authority to implement Public Act 95-1045, if

4 any, is conditioned on the rules being adopted in accordance

5 with all provisions of the Illinois Administrative Procedure

6 Act and all rules and procedures of the Joint Committee on

7 Administrative Rules; any purported rule not so adopted, for

8 whatever reason, is unauthorized.

9 On and after July 1, 2012, the Department shall reduce any

10 rate of reimbursement for services or other payments or alter

11 any methodologies authorized by this Code to reduce any rate

12 of reimbursement for services or other payments in accordance

13 with Section 5-5e.

14 Because kidney transplantation can be an appropriate,

15 cost-effective alternative to renal dialysis when medically

16 necessary and notwithstanding the provisions of Section 1-11

17 of this Code, beginning October 1, 2014, the Department shall

18 cover kidney transplantation for noncitizens with end-stage

19 renal disease who are not eligible for comprehensive medical

20 benefits, who meet the residency requirements of Section 5-3

21 of this Code, and who would otherwise meet the financial

22 requirements of the appropriate class of eligible persons

23 under Section 5-2 of this Code. To qualify for coverage of

24 kidney transplantation, such person must be receiving

25 emergency renal dialysis services covered by the Department.

26 Providers under this Section shall be prior approved and

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1 certified by the Department to perform kidney transplantation

2 and the services under this Section shall be limited to

3 services associated with kidney transplantation.

4 Notwithstanding any other provision of this Code to the

5 contrary, on or after July 1, 2015, all FDA-approved forms of

6 medication assisted treatment prescribed for the treatment of

7 alcohol dependence or treatment of opioid dependence shall be

8 covered under both fee-for-service and managed care medical

9 assistance programs for persons who are otherwise eligible for

10 medical assistance under this Article and shall not be subject

11 to any (1) utilization control, other than those established

12 under the American Society of Addiction Medicine patient

13 placement criteria, (2) prior authorization mandate, (3)

14 lifetime restriction limit mandate, or (4) limitations on

15 dosage.

16 On or after July 1, 2015, opioid antagonists prescribed

17 for the treatment of an opioid overdose, including the

18 medication product, administration devices, and any pharmacy

19 fees or hospital fees related to the dispensing, distribution,

20 and administration of the opioid antagonist, shall be covered

21 under the medical assistance program for persons who are

22 otherwise eligible for medical assistance under this Article.

23 As used in this Section, "opioid antagonist" means a drug that

24 binds to opioid receptors and blocks or inhibits the effect of

25 opioids acting on those receptors, including, but not limited

26 to, naloxone hydrochloride or any other similarly acting drug

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1 approved by the U.S. Food and Drug Administration. The

2 Department shall not impose a copayment on the coverage

3 provided for naloxone hydrochloride under the medical

4 assistance program.

5 Upon federal approval, the Department shall provide

6 coverage and reimbursement for all drugs that are approved for

7 marketing by the federal Food and Drug Administration and that

8 are recommended by the federal Public Health Service or the

9 United States Centers for Disease Control and Prevention for

10 pre-exposure prophylaxis and related pre-exposure prophylaxis

11 services, including, but not limited to, HIV and sexually

12 transmitted infection screening, treatment for sexually

13 transmitted infections, medical monitoring, assorted labs, and

14 counseling to reduce the likelihood of HIV infection among

15 individuals who are not infected with HIV but who are at high

16 risk of HIV infection.

17 A federally qualified health center, as defined in Section

18 1905(l)(2)(B) of the federal Social Security Act, shall be

19 reimbursed by the Department in accordance with the federally

20 qualified health center's encounter rate for services provided

21 to medical assistance recipients that are performed by a

22 dental hygienist, as defined under the Illinois Dental

23 Practice Act, working under the general supervision of a

24 dentist and employed by a federally qualified health center.

25 Within 90 days after October 8, 2021 (the effective date

26 of Public Act 102-665), the Department shall seek federal

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1 approval of a State Plan amendment to expand coverage for

2 family planning services that includes presumptive eligibility

3 to individuals whose income is at or below 208% of the federal

4 poverty level. Coverage under this Section shall be effective

5 beginning no later than December 1, 2022.

6 Subject to approval by the federal Centers for Medicare

7 and Medicaid Services of a Title XIX State Plan amendment

8 electing the Program of All-Inclusive Care for the Elderly

9 (PACE) as a State Medicaid option, as provided for by Subtitle

10 I (commencing with Section 4801) of Title IV of the Balanced

11 Budget Act of 1997 (Public Law 105-33) and Part 460

12 (commencing with Section 460.2) of Subchapter E of Title 42 of

13 the Code of Federal Regulations, PACE program services shall

14 become a covered benefit of the medical assistance program,

15 subject to criteria established in accordance with all

16 applicable laws.

17 Notwithstanding any other provision of this Code,

18 community-based pediatric palliative care from a trained

19 interdisciplinary team shall be covered under the medical

20 assistance program as provided in Section 15 of the Pediatric

21 Palliative Care Act.

22 Notwithstanding any other provision of this Code, within

23 12 months after June 2, 2022 (the effective date of Public Act

24 102-1037) and subject to federal approval, acupuncture

25 services performed by an acupuncturist licensed under the

26 Acupuncture Practice Act who is acting within the scope of his

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1 or her license shall be covered under the medical assistance

2 program. The Department shall apply for any federal waiver or

3 State Plan amendment, if required, to implement this

4 paragraph. The Department may adopt any rules, including

5 standards and criteria, necessary to implement this paragraph.

6 Notwithstanding any other provision of this Code, the

7 medical assistance program shall, subject to federal approval,

8 reimburse hospitals for costs associated with a newborn

9 screening test for the presence of metachromatic

10 leukodystrophy, as required under the Newborn Metabolic

11 Screening Act, at a rate not less than the fee charged by the

12 Department of Public Health. Notwithstanding any other

13 provision of this Code, the medical assistance program shall,

14 subject to appropriation and federal approval, also reimburse

15 hospitals for costs associated with all newborn screening

16 tests added on and after August 9, 2024 (the effective date of

17 Public Act 103-909) to the Newborn Metabolic Screening Act and

18 required to be performed under that Act at a rate not less than

19 the fee charged by the Department of Public Health. The

20 Department shall seek federal approval before the

21 implementation of the newborn screening test fees by the

22 Department of Public Health.

23 Notwithstanding any other provision of this Code,

24 beginning on January 1, 2024, subject to federal approval,

25 cognitive assessment and care planning services provided to a

26 person who experiences signs or symptoms of cognitive

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1 impairment, as defined by the Diagnostic and Statistical

2 Manual of Mental Disorders, Fifth Edition, shall be covered

3 under the medical assistance program for persons who are

4 otherwise eligible for medical assistance under this Article.

5 Notwithstanding any other provision of this Code,

6 medically necessary reconstructive services that are intended

7 to restore physical appearance shall be covered under the

8 medical assistance program for persons who are otherwise

9 eligible for medical assistance under this Article. As used in

10 this paragraph, "reconstructive services" means treatments

11 performed on structures of the body damaged by trauma to

12 restore physical appearance.

13 Subject to federal approval, for dates of services on and

14 after January 1, 2026, over-the-counter choline dietary

15 supplements for pregnant persons shall be covered under the

16 medical assistance program.

17 (Source: P.A. 103-102, Article 15, Section 15-5, eff. 1-1-24;

18 103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff.

19 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-593,

20 Article 5, Section 5-5, eff. 6-7-24; 103-593, Article 90,

21 Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-808, eff.

22 1-1-26; 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; 104-9,

23 eff. 6-16-25; 104-417, eff. 8-15-25.)

24 ARTICLE 6.

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1 Section 6-5. The Illinois Public Aid Code is amended by

2 adding Article V-J as follows:

3 (305 ILCS 5/Art. V-J heading new)

4 ARTICLE V-J. DISTRESSED HOSPITAL LOAN PROGRAM

5 (305 ILCS 5/5J-1 new)

6 Sec. 5J-1. References to Article. This Article may be

7 referred to as the Distressed Hospital Loan Program Law.

8 (305 ILCS 5/5J-5 new)

9 Sec. 5J-5. Distressed Hospital Loan Program. The

10 Distressed Hospital Loan Program is created. The purpose of

11 the Program is to provide, subject to appropriation and the

12 availability of funds, interest-free cash flow loans to

13 public, not-for-profit, and for-profit hospitals in

14 significant financial distress to prevent the closure of or to

15 facilitate the reopening of those hospitals.

16 (305 ILCS 5/5J-10 new)

17 Sec. 5J-10. Definitions. As used in this Article:

18 "Closed hospital" means a hospital that closed after

19 January 1, 2019.

20 "Department" means the Department of Healthcare and Family

21 Services.

22 "Program" means the Distressed Hospital Loan Program.

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1 "Public hospital" means a hospital that is licensed by the

2 Hospital Licensing Act and is either owned or operated by a

3 governmental body in Illinois, excluding a State agency, a

4 State university, or a county with a population of 3,000,000

5 or more.

6 (305 ILCS 5/5J-15 new)

7 Sec. 5J-15. Administration. The Department shall

8 administer the Distressed Hospital Loan Program in

9 coordination with the Department of Public Health and the

10 Governor's Office of Management and Budget. The Department

11 shall adopt rules to implement this Program.

12 (305 ILCS 5/5J-18 new)

13 Sec. 5J-18. Application requirements. A hospital applying

14 for aid under this Program shall provide the Department with

15 financial information, in a format determined by the

16 Department, demonstrating the hospital's need for bridge

17 financing due to financial hardship.

18 (1) Before receiving bridge financing under this

19 Program, an eligible hospital shall submit a plan to the

20 Department, with projections detailing the uses of the

21 proposed loan and a structured plan proposed by the

22 hospital's governing body to regain financial viability

23 and continue operations.

24 (2) Before issuing a loan under this Program, the

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1 Department shall review the plan submitted by an eligible

2 hospital and make a determination both that the plan is

3 viable and that there is a reasonable likelihood that the

4 hospital will be able to regain financial viability,

5 continue to operate as a hospital, and be able to repay the

6 loan. The Department shall not issue a loan award if the

7 Department is unable to make these determinations.

8 (3) All funds loaned in accordance with this Article

9 shall be used as described in the application approved by

10 the Department, which shall be incorporated into any

11 resulting loan agreement. Any misused funds shall be

12 recouped by the Department subject to the recoupment

13 methods under Section 5J-25. In addition to any other

14 remedies provided for by law and without sending a notice

15 of liability, the Department may withhold, as payment of

16 any amounts due and owing as repayment of loans issued in

17 accordance with this Article, reimbursements or other

18 amounts otherwise payable by the Department to the loan

19 recipient, including, but not limited to, amounts

20 otherwise payable from a managed care organization

21 performing duties under contract with the Department.

22 (305 ILCS 5/5J-20 new)

23 Sec. 5J-20. Application evaluation.

24 (a) In collaboration with the Governor's Office of

25 Management and Budget and the Department of Public Health, the

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1 Department shall develop a methodology to evaluate a

2 hospital's application for a loan through the Program.

3 (b) The methodology shall consider factors including, but

4 not limited to, whether the hospital is in financial distress

5 as solely determined by the State; whether the hospital is

6 small, rural, a safety-net hospital, a critical access

7 hospital, a trauma center, an urban hospital providing access

8 for an underserved area, a hospital that serves a

9 disproportionate share of Medicaid patients, or serving a

10 rural catchment area; and whether closure of the hospital or

11 service line reduction as a result of the financial distress

12 would significantly impact access to services in the

13 hospital's health service area.

14 (c) The methodology for determining financial distress may

15 consider such factors as the hospital's prior and projected

16 performance on financial metrics, including the amount of cash

17 on hand, and whether the hospital has experienced, or is

18 projected to experience, negative operating margins.

19 (d) Subject to appropriation and the availability of

20 funds, any loan to a hospital with an approved loan

21 application shall be issued as soon as reasonably practicable

22 following approval of an application. Approved applications

23 shall receive funding on a first-come, first-served basis

24 until funding appropriated by the General Assembly for this

25 purpose has been expended. The Department maintains discretion

26 to determine the amount of a loan approved for a hospital and

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1 may approve less than the amount requested by a hospital. The

2 Department may consider the amount of appropriations available

3 to this Program in the exercise of its discretion.

4 (e) Hospitals ineligible for State assistance under the

5 Program include:

6 (1) Hospitals that belong to integrated health care

7 systems with more than 3 separately licensed hospital

8 facilities.

9 (2) A hospital that maintains unpaid hospital

10 assessment liability owed to the State and either does not

11 have a negotiated tax repayment agreement with the State

12 or is delinquent under an existing negotiated assessment

13 repayment agreement.

14 (3) A hospital that is not current on a repayment

15 schedule for a prior advance issued in accordance with 89

16 Ill. Adm. Code 140.71.

17 (4) A hospital that has not provided required

18 reporting on its finances as mandated by State law or

19 administrative rule.

20 (5) A hospital that is subject to a stop payment

21 order, as defined by the Grant Accountability and

22 Transparency Act, with the State for any reason.

23 (6) A hospital that has been under investigation or

24 been issued an immediate jeopardy by the Centers for

25 Medicare and Medicaid Services in the prior 12 months from

26 the time of loan application.

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1 (f) The Department shall give preference to not-for-profit

2 and public hospitals. Hospitals owned and operated by a

3 for-profit entity shall be subject to a maximum funding limit,

4 expedited repayment time frames, and additional financial and

5 operational transparency requirements as defined in rule.

6 (g) The Department shall determine the application

7 process, underwriting review, and methodology for approval and

8 distribution of the loans under the Program.

9 (h) The Department shall have the authority to determine

10 service provision requirements in approving, and for the

11 duration of, loans to eligible hospitals. In making its

12 determination, the Department shall consider the impact of any

13 changes to the hospital's service delivery or access to

14 necessary medical care, particularly for beneficiaries of the

15 State's medical assistance Program.

16 (i) The application process shall allow for at least 30

17 days for the Department to issue an initial response to any

18 loan application.

19 (305 ILCS 5/5J-25 new)

20 Sec. 5J-25. Repayment agreement.

21 (a) A hospital shall be required to enter into a repayment

22 agreement with the Department to execute the approved loan.

23 Terms must include, but are not limited to, monthly repayments

24 of the loan beginning no later than 18 months after receipt of

25 the loan and discharge of the loan within 36 months of the date

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1 of the loan.

2 (b) Notwithstanding any other law and to the extent

3 permissible under federal rules, security for the cash flow

4 loans in this Article shall, at a minimum, include

5 reimbursements due to the hospital from the Department,

6 including, but not limited to, any reimbursements under this

7 Code. The repayment agreement may provide for additional

8 security for any cash flow loans under this Article.

9 (c) If the hospital provider fails to comply with the

10 repayment terms of the agreement, the remaining balance of the

11 loan shall be immediately recouped from reimbursements or

12 other amounts otherwise payable by the Department to the loan

13 recipient, including, but not limited to, amounts otherwise

14 payable from a managed care organization performing duties

15 under contract with the Department. The Department may also

16 recoup amounts otherwise payable by any State agency to the

17 provider, including, but not limited to, State grants and

18 grant appropriations, and apply such amounts as repayment of

19 the unpaid advance. If such reimbursements or other amounts

20 otherwise payable to the loan recipient are insufficient for

21 complete recovery, the remaining balance shall become

22 immediately due and payable by check to the Department of

23 Healthcare and Family Services. Failure by the provider to

24 remit such check shall result in the Department pursuing other

25 collection methods.

26 (d) Any unpaid loan under this Article shall become a lien

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1 upon the assets of the hospital that received the loan. If any

2 hospital provider, outside the usual course of its business,

3 sells or transfers the major part of any one or more of (A) the

4 real property and improvements, (B) the machinery and

5 equipment, or (C) the furniture or fixtures, of any hospital

6 that is subject to the provisions of this Article, the seller

7 or transferor shall pay the Department the amount of any loan,

8 penalty, and interest (if any) due from it under this Article

9 up to the date of the sale or transfer. The Department may, in

10 its discretion, foreclose on such a lien, but shall do so in a

11 manner that is consistent with Section 5e of the Retailers'

12 Occupation Tax Act. If the seller or transferor fails to pay

13 any loan, penalty, and interest (if any) due, the purchaser or

14 transferee of such asset shall be liable for the amount of the

15 loan, penalties, and interest (if any) up to the amount of the

16 reasonable value of the property acquired by the purchaser or

17 transferee. The purchaser or transferee shall continue to be

18 liable until the purchaser or transferee pays the full amount

19 of the loan, penalties, and interest (if any) up to the amount

20 of the reasonable value of the property acquired by the

21 purchaser or transferee or until the purchaser or transferee

22 receives from the Department a certificate showing that such

23 loan, penalty, and interest have been paid or a certificate

24 from the Department showing that no loan, penalty, or interest

25 is due from the seller or transferor under this Article.

26 (e) If a hospital provider fails to pay any monthly

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LRB104 18483 KTG 38682 a

1 installment repayments, there shall, unless waived by the

2 Department for reasonable cause, be added to the loan

3 repayment obligation a penalty equal to the lesser of (i) 5% of

4 the amount of the installment not paid on or before the due

5 date plus 5% of the portion thereof remaining unpaid on the

6 last day of each 30-day period thereafter or (ii) 100% of the

7 installment amount not paid on or before the due date.

8 (305 ILCS 5/5J-30 new)

9 Sec. 5J-30. Distressed Hospital Loan Program Fund.

10 (a) The Distressed Hospital Loan Program Fund is created

11 as a special fund in the State treasury.

12 (b) Subject to appropriation, the Department may make

13 secured and unsecured loans from amounts in the Distressed

14 Hospital Loan Program Fund to a hospital, or a governmental

15 entity representing a closed hospital, for purposes of

16 preventing the hospital's closure in accordance with the

17 provisions of this Article.

18 (c) On January 1, 2027, or as soon thereafter as

19 practical, the State Comptroller shall direct and the State

20 Treasurer shall transfer, at the direction of the Director of

21 the Department, an amount not to exceed $85,000,000 from the

22 Healthcare Provider Relief Fund to the Distressed Hospital

23 Loan Program Fund.

24 (d) All moneys accruing to the Department under this

25 Article from any source, including, but not limited to, all

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LRB104 18483 KTG 38682 a

1 amounts repaid under the terms of any loan agreements, shall

2 be deposited into the Fund.

3 (e) On June 30, 2033, or as soon thereafter as practical,

4 the State Comptroller shall direct and the State Treasurer

5 shall transfer the remaining balance in the Distressed

6 Hospital Loan Program Fund to the Healthcare Provider Relief

7 Fund. Upon completion of the transfers, the Distressed

8 Hospital Loan Program Fund is dissolved and any outstanding

9 obligations or liabilities of the Fund pass to the Healthcare

10 Provider Relief Fund. The Department shall deposit all

11 subsequent loan repayments or medical assistance program or

12 other reimbursements withheld for due cause in accordance with

13 this Article into the Healthcare Provider Relief Fund.

14 (f) The Department may require any hospital receiving a

15 loan under this Article to provide the Department with an

16 independent financial audit of the hospital's operations for

17 any fiscal year in which a loan is outstanding.

18 (305 ILCS 5/5J-35 new)

19 Sec. 5J-35. Implementation. The Program described in this

20 Article shall be operative on and after January 1, 2027 and

21 shall be implemented upon administrative rules being in

22 effect.

23 (305 ILCS 5/5J-40 new)

24 Sec. 5J-40. Repealer. This Article is repealed on June 30,

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LRB104 18483 KTG 38682 a

1 2033.

2 Section 6-70. The State Finance Act is amended by adding

3 Section 5.1038 as follows:

4 (30 ILCS 105/5.1038 new)

5 Sec. 5.1038. The Distressed Hospital Loan Program Fund.

6 This Section is repealed June 30, 2033.

7 Section 6-72. The Illinois Administrative Procedure Act is

8 amended by adding Section 5-45.71 as follows:

9 (5 ILCS 100/5-45.71 new)

10 Sec. 5-45.71. Emergency rulemaking; Health Facilities and

11 Services Review Board. To provide for the expeditious and

12 timely implementation of the changes made by this amendatory

13 Act of the 104th General Assembly to Section 13 of the Illinois

14 Health Facilities Planning Act, emergency rules may be adopted

15 in accordance with Section 5-45 by the Health Facilities and

16 Services Review Board. The adoption of emergency rules

17 authorized by Section 5-45 and this Section is deemed to be

18 necessary for the public interest, safety, and welfare.

19 This Section is repealed one year after the effective date

20 of this amendatory Act of the 104th General Assembly.

21 Section 6-73. The Freedom of Information Act is amended by

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LRB104 18483 KTG 38682 a

1 changing Section 7.5 as follows:

2 (5 ILCS 140/7.5)

3 (Text of Section before amendment by P.A. 104-441 and

4 104-457)

5 Sec. 7.5. Statutory exemptions. To the extent provided for

6 by the statutes referenced below, the following shall be

7 exempt from inspection and copying:

8 (a) All information determined to be confidential

9 under Section 4002 of the Technology Advancement and

10 Development Act.

11 (b) Library circulation and order records identifying

12 library users with specific materials under the Library

13 Records Confidentiality Act.

14 (c) Applications, related documents, and medical

15 records received by the Experimental Organ Transplantation

16 Procedures Board and any and all documents or other

17 records prepared by the Experimental Organ Transplantation

18 Procedures Board or its staff relating to applications it

19 has received.

20 (d) Information and records held by the Department of

21 Public Health and its authorized representatives relating

22 to known or suspected cases of sexually transmitted

23 infection or any information the disclosure of which is

24 restricted under the Illinois Sexually Transmitted

25 Infection Control Act.

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LRB104 18483 KTG 38682 a

1 (e) Information the disclosure of which is exempted

2 under Section 30 of the Radon Industry Licensing Act.

3 (f) Firm performance evaluations under Section 55 of

4 the Architectural, Engineering, and Land Surveying

5 Qualifications Based Selection Act.

6 (g) Information the disclosure of which is restricted

7 and exempted under Section 50 of the Illinois Prepaid

8 Tuition Act.

9 (h) Information the disclosure of which is exempted

10 under the State Officials and Employees Ethics Act, and

11 records of any lawfully created State or local inspector

12 general's office that would be exempt if created or

13 obtained by an Executive Inspector General's office under

14 that Act.

15 (i) Information contained in a local emergency energy

16 plan submitted to a municipality in accordance with a

17 local emergency energy plan ordinance that is adopted

18 under Section 11-21.5-5 of the Illinois Municipal Code.

19 (j) Information and data concerning the distribution

20 of surcharge moneys collected and remitted by carriers

21 under the Emergency Telephone System Act.

22 (k) Law enforcement officer identification information

23 or driver identification information compiled by a law

24 enforcement agency or the Department of Transportation

25 under Section 11-212 of the Illinois Vehicle Code.

26 (l) Records and information provided to a residential

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LRB104 18483 KTG 38682 a

1 health care facility resident sexual assault and death

2 review team or the Executive Council under the Abuse

3 Prevention Review Team Act.

4 (m) Information provided to the predatory lending

5 database created pursuant to Article 3 of the Residential

6 Real Property Disclosure Act, except to the extent

7 authorized under that Article.

8 (n) Defense budgets and petitions for certification of

9 compensation and expenses for court appointed trial

10 counsel as provided under Sections 10 and 15 of the

11 Capital Crimes Litigation Act (repealed). This subsection

12 (n) shall apply until the conclusion of the trial of the

13 case, even if the prosecution chooses not to pursue the

14 death penalty prior to trial or sentencing.

15 (o) Information that is prohibited from being

16 disclosed under Section 4 of the Illinois Health and

17 Hazardous Substances Registry Act.

18 (p) Security portions of system safety program plans,

19 investigation reports, surveys, schedules, lists, data, or

20 information compiled, collected, or prepared by or for the

21 Department of Transportation under Sections 2705-300 and

22 2705-616 of the Department of Transportation Law of the

23 Civil Administrative Code of Illinois, the Regional

24 Transportation Authority under Section 2.11 of the

25 Regional Transportation Authority Act, or the St. Clair

26 County Transit District under the Bi-State Transit Safety

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LRB104 18483 KTG 38682 a

1 Act (repealed).

2 (q) Information prohibited from being disclosed by the

3 Personnel Record Review Act.

4 (r) Information prohibited from being disclosed by the

5 Illinois School Student Records Act.

6 (s) Information the disclosure of which is restricted

7 under Section 5-108 of the Public Utilities Act.

8 (t) (Blank).

9 (u) Records and information provided to an independent

10 team of experts under the Developmental Disability and

11 Mental Health Safety Act (also known as Brian's Law).

12 (v) Names and information of people who have applied

13 for or received Firearm Owner's Identification Cards under

14 the Firearm Owners Identification Card Act or applied for

15 or received a concealed carry license under the Firearm

16 Concealed Carry Act, unless otherwise authorized by the

17 Firearm Concealed Carry Act; and databases under the

18 Firearm Concealed Carry Act, records of the Concealed

19 Carry Licensing Review Board under the Firearm Concealed

20 Carry Act, and law enforcement agency objections under the

21 Firearm Concealed Carry Act.

22 (v-5) Records of the Firearm Owner's Identification

23 Card Review Board that are exempted from disclosure under

24 Section 10 of the Firearm Owners Identification Card Act.

25 (w) Personally identifiable information which is

26 exempted from disclosure under subsection (g) of Section

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LRB104 18483 KTG 38682 a

1 19.1 of the Toll Highway Act.

2 (x) Information which is exempted from disclosure

3 under Section 5-1014.3 of the Counties Code or Section

4 8-11-21 of the Illinois Municipal Code.

5 (y) Confidential information under the Adult

6 Protective Services Act and its predecessor enabling

7 statute, the Elder Abuse and Neglect Act, including

8 information about the identity and administrative finding

9 against any caregiver of a verified and substantiated

10 decision of abuse, neglect, or financial exploitation of

11 an eligible adult maintained in the Registry established

12 under Section 7.5 of the Adult Protective Services Act.

13 (z) Records and information provided to a fatality

14 review team or the Illinois Fatality Review Team Advisory

15 Council under Section 15 of the Adult Protective Services

16 Act.

17 (aa) Information which is exempted from disclosure

18 under Section 2.37 of the Wildlife Code.

19 (bb) Information which is or was prohibited from

20 disclosure by the Juvenile Court Act of 1987.

21 (cc) Recordings made under the Law Enforcement

22 Officer-Worn Body Camera Act, except to the extent

23 authorized under that Act.

24 (dd) Information that is prohibited from being

25 disclosed under Section 45 of the Condominium and Common

26 Interest Community Ombudsperson Act.

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LRB104 18483 KTG 38682 a

1 (ee) Information that is exempted from disclosure

2 under Section 30.1 of the Pharmacy Practice Act.

3 (ff) Information that is exempted from disclosure

4 under the Revised Uniform Unclaimed Property Act.

5 (gg) Information that is prohibited from being

6 disclosed under Section 7-603.5 of the Illinois Vehicle

7 Code.

8 (hh) Records that are exempt from disclosure under

9 Section 1A-16.7 of the Election Code.

10 (ii) Information which is exempted from disclosure

11 under Section 2505-800 of the Department of Revenue Law of

12 the Civil Administrative Code of Illinois.

13 (jj) Information and reports that are required to be

14 submitted to the Department of Labor by registering day

15 and temporary labor service agencies but are exempt from

16 disclosure under subsection (a-1) of Section 45 of the Day

17 and Temporary Labor Services Act.

18 (kk) Information prohibited from disclosure under the

19 Seizure and Forfeiture Reporting Act.

20 (ll) Information the disclosure of which is restricted

21 and exempted under Section 5-30.8 of the Illinois Public

22 Aid Code.

23 (mm) Records that are exempt from disclosure under

24 Section 4.2 of the Crime Victims Compensation Act.

25 (nn) Information that is exempt from disclosure under

26 Section 70 of the Higher Education Student Assistance Act.

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LRB104 18483 KTG 38682 a

1 (oo) Communications, notes, records, and reports

2 arising out of a peer support counseling session

3 prohibited from disclosure under the First Responders

4 Suicide Prevention Act.

5 (pp) Names and all identifying information relating to

6 an employee of an emergency services provider or law

7 enforcement agency under the First Responders Suicide

8 Prevention Act.

9 (qq) Information and records held by the Department of

10 Public Health and its authorized representatives collected

11 under the Reproductive Health Act.

12 (rr) Information that is exempt from disclosure under

13 the Cannabis Regulation and Tax Act.

14 (ss) Data reported by an employer to the Department of

15 Human Rights pursuant to Section 2-108 of the Illinois

16 Human Rights Act.

17 (tt) Recordings made under the Children's Advocacy

18 Center Act, except to the extent authorized under that

19 Act.

20 (uu) Information that is exempt from disclosure under

21 Section 50 of the Sexual Assault Evidence Submission Act.

22 (vv) Information that is exempt from disclosure under

23 subsections (f) and (j) of Section 5-36 of the Illinois

24 Public Aid Code.

25 (ww) Information that is exempt from disclosure under

26 Section 16.8 of the State Treasurer Act.

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LRB104 18483 KTG 38682 a

1 (xx) Information that is exempt from disclosure or

2 information that shall not be made public under the

3 Illinois Insurance Code.

4 (yy) Information prohibited from being disclosed under

5 the Illinois Educational Labor Relations Act.

6 (zz) Information prohibited from being disclosed under

7 the Illinois Public Labor Relations Act.

8 (aaa) Information prohibited from being disclosed

9 under Section 1-167 of the Illinois Pension Code.

10 (bbb) Information that is prohibited from disclosure

11 by the Illinois Police Training Act and the Illinois State

12 Police Act.

13 (ccc) Records exempt from disclosure under Section

14 2605-304 of the Illinois State Police Law of the Civil

15 Administrative Code of Illinois.

16 (ddd) Information prohibited from being disclosed

17 under Section 35 of the Address Confidentiality for

18 Victims of Domestic Violence, Sexual Assault, Human

19 Trafficking, or Stalking Act.

20 (eee) Information prohibited from being disclosed

21 under subsection (b) of Section 75 of the Domestic

22 Violence Fatality Review Act.

23 (fff) Images from cameras under the Expressway Camera

24 Act and all automated license plate reader (ALPR)

25 information used and collected by the Illinois State

26 Police. "ALPR information" means information gathered by

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LRB104 18483 KTG 38682 a

1 an ALPR or created from the analysis of data generated by

2 an ALPR. This subsection (fff) is inoperative on and after

3 July 1, 2028.

4 (ggg) Information prohibited from disclosure under

5 paragraph (3) of subsection (a) of Section 14 of the Nurse

6 Agency Licensing Act.

7 (hhh) Information submitted to the Illinois State

8 Police in an affidavit or application for an assault

9 weapon endorsement, assault weapon attachment endorsement,

10 .50 caliber rifle endorsement, or .50 caliber cartridge

11 endorsement under the Firearm Owners Identification Card

12 Act.

13 (iii) Data exempt from disclosure under Section 50 of

14 the School Safety Drill Act.

15 (jjj) Information exempt from disclosure under Section

16 30 of the Insurance Data Security Law.

17 (kkk) Confidential business information prohibited

18 from disclosure under Section 45 of the Paint Stewardship

19 Act.

20 (lll) Data exempt from disclosure under Section

21 2-3.196 of the School Code.

22 (mmm) Information prohibited from being disclosed

23 under subsection (e) of Section 1-129 of the Illinois

24 Power Agency Act.

25 (nnn) Materials received by the Department of Commerce

26 and Economic Opportunity that are confidential under the

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LRB104 18483 KTG 38682 a

1 Music and Musicians Tax Credit and Jobs Act.

2 (ooo) Data or information provided pursuant to Section

3 20 of the Statewide Recycling Needs and Assessment Act.

4 (ppp) Information that is exempt from disclosure under

5 Section 28-11 of the Lawful Health Care Activity Act.

6 (qqq) Information that is exempt from disclosure under

7 Section 7-101 of the Illinois Human Rights Act.

8 (rrr) Information prohibited from being disclosed

9 under Section 4-2 of the Uniform Money Transmission

10 Modernization Act.

11 (sss) Information exempt from disclosure under Section

12 40 of the Student-Athlete Endorsement Rights Act.

13 (ttt) Audio recordings made under Section 30 of the

14 Illinois State Police Act, except to the extent authorized

15 under that Section.

16 (uuu) Information prohibited from being disclosed

17 under Section 30-5 of the Digital Assets Regulation Act.

18 (Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;

19 103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.

20 8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,

21 eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;

22 103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.

23 8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,

24 eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;

25 104-417, eff. 8-15-25; 104-428, eff. 8-18-25; revised

26 9-10-25.)

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LRB104 18483 KTG 38682 a

1 (Text of Section after amendment by P.A. 104-457 but

2 before 104-441)

3 Sec. 7.5. Statutory exemptions. To the extent provided for

4 by the statutes referenced below, the following shall be

5 exempt from inspection and copying:

6 (a) All information determined to be confidential

7 under Section 4002 of the Technology Advancement and

8 Development Act.

9 (b) Library circulation and order records identifying

10 library users with specific materials under the Library

11 Records Confidentiality Act.

12 (c) Applications, related documents, and medical

13 records received by the Experimental Organ Transplantation

14 Procedures Board and any and all documents or other

15 records prepared by the Experimental Organ Transplantation

16 Procedures Board or its staff relating to applications it

17 has received.

18 (d) Information and records held by the Department of

19 Public Health and its authorized representatives relating

20 to known or suspected cases of sexually transmitted

21 infection or any information the disclosure of which is

22 restricted under the Illinois Sexually Transmitted

23 Infection Control Act.

24 (e) Information the disclosure of which is exempted

25 under Section 30 of the Radon Industry Licensing Act.

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LRB104 18483 KTG 38682 a

1 (f) Firm performance evaluations under Section 55 of

2 the Architectural, Engineering, and Land Surveying

3 Qualifications Based Selection Act.

4 (g) Information the disclosure of which is restricted

5 and exempted under Section 50 of the Illinois Prepaid

6 Tuition Act.

7 (h) Information the disclosure of which is exempted

8 under the State Officials and Employees Ethics Act, and

9 records of any lawfully created State or local inspector

10 general's office that would be exempt if created or

11 obtained by an Executive Inspector General's office under

12 that Act.

13 (i) Information contained in a local emergency energy

14 plan submitted to a municipality in accordance with a

15 local emergency energy plan ordinance that is adopted

16 under Section 11-21.5-5 of the Illinois Municipal Code.

17 (j) Information and data concerning the distribution

18 of surcharge moneys collected and remitted by carriers

19 under the Emergency Telephone System Act.

20 (k) Law enforcement officer identification information

21 or driver identification information compiled by a law

22 enforcement agency or the Department of Transportation

23 under Section 11-212 of the Illinois Vehicle Code.

24 (l) Records and information provided to a residential

25 health care facility resident sexual assault and death

26 review team or the Executive Council under the Abuse

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LRB104 18483 KTG 38682 a

1 Prevention Review Team Act.

2 (m) Information provided to the predatory lending

3 database created pursuant to Article 3 of the Residential

4 Real Property Disclosure Act, except to the extent

5 authorized under that Article.

6 (n) Defense budgets and petitions for certification of

7 compensation and expenses for court appointed trial

8 counsel as provided under Sections 10 and 15 of the

9 Capital Crimes Litigation Act (repealed). This subsection

10 (n) shall apply until the conclusion of the trial of the

11 case, even if the prosecution chooses not to pursue the

12 death penalty prior to trial or sentencing.

13 (o) Information that is prohibited from being

14 disclosed under Section 4 of the Illinois Health and

15 Hazardous Substances Registry Act.

16 (p) Security portions of system safety program plans,

17 investigation reports, surveys, schedules, lists, data, or

18 information compiled, collected, or prepared by or for the

19 Department of Transportation under Sections 2705-300 and

20 2705-616 of the Department of Transportation Law of the

21 Civil Administrative Code of Illinois, the Northern

22 Illinois Transit Authority under Section 2.11 of the

23 Northern Illinois Transit Authority Act, or the St. Clair

24 County Transit District under the Bi-State Transit Safety

25 Act (repealed).

26 (q) Information prohibited from being disclosed by the

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LRB104 18483 KTG 38682 a

1 Personnel Record Review Act.

2 (r) Information prohibited from being disclosed by the

3 Illinois School Student Records Act.

4 (s) Information the disclosure of which is restricted

5 under Section 5-108 of the Public Utilities Act.

6 (t) (Blank).

7 (u) Records and information provided to an independent

8 team of experts under the Developmental Disability and

9 Mental Health Safety Act (also known as Brian's Law).

10 (v) Names and information of people who have applied

11 for or received Firearm Owner's Identification Cards under

12 the Firearm Owners Identification Card Act or applied for

13 or received a concealed carry license under the Firearm

14 Concealed Carry Act, unless otherwise authorized by the

15 Firearm Concealed Carry Act; and databases under the

16 Firearm Concealed Carry Act, records of the Concealed

17 Carry Licensing Review Board under the Firearm Concealed

18 Carry Act, and law enforcement agency objections under the

19 Firearm Concealed Carry Act.

20 (v-5) Records of the Firearm Owner's Identification

21 Card Review Board that are exempted from disclosure under

22 Section 10 of the Firearm Owners Identification Card Act.

23 (w) Personally identifiable information which is

24 exempted from disclosure under subsection (g) of Section

25 19.1 of the Toll Highway Act.

26 (x) Information which is exempted from disclosure

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LRB104 18483 KTG 38682 a

1 under Section 5-1014.3 of the Counties Code or Section

2 8-11-21 of the Illinois Municipal Code.

3 (y) Confidential information under the Adult

4 Protective Services Act and its predecessor enabling

5 statute, the Elder Abuse and Neglect Act, including

6 information about the identity and administrative finding

7 against any caregiver of a verified and substantiated

8 decision of abuse, neglect, or financial exploitation of

9 an eligible adult maintained in the Registry established

10 under Section 7.5 of the Adult Protective Services Act.

11 (z) Records and information provided to a fatality

12 review team or the Illinois Fatality Review Team Advisory

13 Council under Section 15 of the Adult Protective Services

14 Act.

15 (aa) Information which is exempted from disclosure

16 under Section 2.37 of the Wildlife Code.

17 (bb) Information which is or was prohibited from

18 disclosure by the Juvenile Court Act of 1987.

19 (cc) Recordings made under the Law Enforcement

20 Officer-Worn Body Camera Act, except to the extent

21 authorized under that Act.

22 (dd) Information that is prohibited from being

23 disclosed under Section 45 of the Condominium and Common

24 Interest Community Ombudsperson Act.

25 (ee) Information that is exempted from disclosure

26 under Section 30.1 of the Pharmacy Practice Act.

10400SB3365ham001

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LRB104 18483 KTG 38682 a

1 (ff) Information that is exempted from disclosure

2 under the Revised Uniform Unclaimed Property Act.

3 (gg) Information that is prohibited from being

4 disclosed under Section 7-603.5 of the Illinois Vehicle

5 Code.

6 (hh) Records that are exempt from disclosure under

7 Section 1A-16.7 of the Election Code.

8 (ii) Information which is exempted from disclosure

9 under Section 2505-800 of the Department of Revenue Law of

10 the Civil Administrative Code of Illinois.

11 (jj) Information and reports that are required to be

12 submitted to the Department of Labor by registering day

13 and temporary labor service agencies but are exempt from

14 disclosure under subsection (a-1) of Section 45 of the Day

15 and Temporary Labor Services Act.

16 (kk) Information prohibited from disclosure under the

17 Seizure and Forfeiture Reporting Act.

18 (ll) Information the disclosure of which is restricted

19 and exempted under Section 5-30.8 of the Illinois Public

20 Aid Code.

21 (mm) Records that are exempt from disclosure under

22 Section 4.2 of the Crime Victims Compensation Act.

23 (nn) Information that is exempt from disclosure under

24 Section 70 of the Higher Education Student Assistance Act.

25 (oo) Communications, notes, records, and reports

26 arising out of a peer support counseling session

10400SB3365ham001

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LRB104 18483 KTG 38682 a

1 prohibited from disclosure under the First Responders

2 Suicide Prevention Act.

3 (pp) Names and all identifying information relating to

4 an employee of an emergency services provider or law

5 enforcement agency under the First Responders Suicide

6 Prevention Act.

7 (qq) Information and records held by the Department of

8 Public Health and its authorized representatives collected

9 under the Reproductive Health Act.

10 (rr) Information that is exempt from disclosure under

11 the Cannabis Regulation and Tax Act.

12 (ss) Data reported by an employer to the Department of

13 Human Rights pursuant to Section 2-108 of the Illinois

14 Human Rights Act.

15 (tt) Recordings made under the Children's Advocacy

16 Center Act, except to the extent authorized under that

17 Act.

18 (uu) Information that is exempt from disclosure under

19 Section 50 of the Sexual Assault Evidence Submission Act.

20 (vv) Information that is exempt from disclosure under

21 subsections (f) and (j) of Section 5-36 of the Illinois

22 Public Aid Code.

23 (ww) Information that is exempt from disclosure under

24 Section 16.8 of the State Treasurer Act.

25 (xx) Information that is exempt from disclosure or

26 information that shall not be made public under the

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LRB104 18483 KTG 38682 a

1 Illinois Insurance Code.

2 (yy) Information prohibited from being disclosed under

3 the Illinois Educational Labor Relations Act.

4 (zz) Information prohibited from being disclosed under

5 the Illinois Public Labor Relations Act.

6 (aaa) Information prohibited from being disclosed

7 under Section 1-167 of the Illinois Pension Code.

8 (bbb) Information that is prohibited from disclosure

9 by the Illinois Police Training Act and the Illinois State

10 Police Act.

11 (ccc) Records exempt from disclosure under Section

12 2605-304 of the Illinois State Police Law of the Civil

13 Administrative Code of Illinois.

14 (ddd) Information prohibited from being disclosed

15 under Section 35 of the Address Confidentiality for

16 Victims of Domestic Violence, Sexual Assault, Human

17 Trafficking, or Stalking Act.

18 (eee) Information prohibited from being disclosed

19 under subsection (b) of Section 75 of the Domestic

20 Violence Fatality Review Act.

21 (fff) Images from cameras under the Expressway Camera

22 Act and all automated license plate reader (ALPR)

23 information used and collected by the Illinois State

24 Police. "ALPR information" means information gathered by

25 an ALPR or created from the analysis of data generated by

26 an ALPR. This subsection (fff) is inoperative on and after

10400SB3365ham001

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LRB104 18483 KTG 38682 a

1 July 1, 2028.

2 (ggg) Information prohibited from disclosure under

3 paragraph (3) of subsection (a) of Section 14 of the Nurse

4 Agency Licensing Act.

5 (hhh) Information submitted to the Illinois State

6 Police in an affidavit or application for an assault

7 weapon endorsement, assault weapon attachment endorsement,

8 .50 caliber rifle endorsement, or .50 caliber cartridge

9 endorsement under the Firearm Owners Identification Card

10 Act.

11 (iii) Data exempt from disclosure under Section 50 of

12 the School Safety Drill Act.

13 (jjj) Information exempt from disclosure under Section

14 30 of the Insurance Data Security Law.

15 (kkk) Confidential business information prohibited

16 from disclosure under Section 45 of the Paint Stewardship

17 Act.

18 (lll) Data exempt from disclosure under Section

19 2-3.196 of the School Code.

20 (mmm) Information prohibited from being disclosed

21 under subsection (e) of Section 1-129 of the Illinois

22 Power Agency Act.

23 (nnn) Materials received by the Department of Commerce

24 and Economic Opportunity that are confidential under the

25 Music and Musicians Tax Credit and Jobs Act.

26 (ooo) Data or information provided pursuant to Section

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LRB104 18483 KTG 38682 a

1 20 of the Statewide Recycling Needs and Assessment Act.

2 (ppp) Information that is exempt from disclosure under

3 Section 28-11 of the Lawful Health Care Activity Act.

4 (qqq) Information that is exempt from disclosure under

5 Section 7-101 of the Illinois Human Rights Act.

6 (rrr) Information prohibited from being disclosed

7 under Section 4-2 of the Uniform Money Transmission

8 Modernization Act.

9 (sss) Information exempt from disclosure under Section

10 40 of the Student-Athlete Endorsement Rights Act.

11 (ttt) Audio recordings made under Section 30 of the

12 Illinois State Police Act, except to the extent authorized

13 under that Section.

14 (uuu) Information prohibited from being disclosed

15 under Section 30-5 of the Digital Assets Regulation Act.

16 (www) Annual summary financial and utilization data

17 reports submitted to the Health Facilities and Services

18 Review Board under Section 13 of the Illinois Health

19 Facilities Planning Act.

20 (Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;

21 103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.

22 8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,

23 eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;

24 103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.

25 8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,

26 eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;

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1 104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-457, eff.

2 6-1-26; revised 1-7-26.)

3 (Text of Section after amendment by P.A. 104-441)

4 Sec. 7.5. Statutory exemptions. To the extent provided for

5 by the statutes referenced below, the following shall be

6 exempt from inspection and copying:

7 (a) All information determined to be confidential

8 under Section 4002 of the Technology Advancement and

9 Development Act.

10 (b) Library circulation and order records identifying

11 library users with specific materials under the Library

12 Records Confidentiality Act.

13 (c) Applications, related documents, and medical

14 records received by the Experimental Organ Transplantation

15 Procedures Board and any and all documents or other

16 records prepared by the Experimental Organ Transplantation

17 Procedures Board or its staff relating to applications it

18 has received.

19 (d) Information and records held by the Department of

20 Public Health and its authorized representatives relating

21 to known or suspected cases of sexually transmitted

22 infection or any information the disclosure of which is

23 restricted under the Illinois Sexually Transmitted

24 Infection Control Act.

25 (e) Information the disclosure of which is exempted

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1 under Section 30 of the Radon Industry Licensing Act.

2 (f) Firm performance evaluations under Section 55 of

3 the Architectural, Engineering, and Land Surveying

4 Qualifications Based Selection Act.

5 (g) Information the disclosure of which is restricted

6 and exempted under Section 50 of the Illinois Prepaid

7 Tuition Act.

8 (h) Information the disclosure of which is exempted

9 under the State Officials and Employees Ethics Act, and

10 records of any lawfully created State or local inspector

11 general's office that would be exempt if created or

12 obtained by an Executive Inspector General's office under

13 that Act.

14 (i) Information contained in a local emergency energy

15 plan submitted to a municipality in accordance with a

16 local emergency energy plan ordinance that is adopted

17 under Section 11-21.5-5 of the Illinois Municipal Code.

18 (j) Information and data concerning the distribution

19 of surcharge moneys collected and remitted by carriers

20 under the Emergency Telephone System Act.

21 (k) Law enforcement officer identification information

22 or driver identification information compiled by a law

23 enforcement agency or the Department of Transportation

24 under Section 11-212 of the Illinois Vehicle Code.

25 (l) Records and information provided to a residential

26 health care facility resident sexual assault and death

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1 review team or the Executive Council under the Abuse

2 Prevention Review Team Act.

3 (m) Information provided to the predatory lending

4 database created pursuant to Article 3 of the Residential

5 Real Property Disclosure Act, except to the extent

6 authorized under that Article.

7 (n) Defense budgets and petitions for certification of

8 compensation and expenses for court appointed trial

9 counsel as provided under Sections 10 and 15 of the

10 Capital Crimes Litigation Act (repealed). This subsection

11 (n) shall apply until the conclusion of the trial of the

12 case, even if the prosecution chooses not to pursue the

13 death penalty prior to trial or sentencing.

14 (o) Information that is prohibited from being

15 disclosed under Section 4 of the Illinois Health and

16 Hazardous Substances Registry Act.

17 (p) Security portions of system safety program plans,

18 investigation reports, surveys, schedules, lists, data, or

19 information compiled, collected, or prepared by or for the

20 Department of Transportation under Sections 2705-300 and

21 2705-616 of the Department of Transportation Law of the

22 Civil Administrative Code of Illinois, the Northern

23 Illinois Transit Authority under Section 2.11 of the

24 Northern Illinois Transit Authority Act, or the St. Clair

25 County Transit District under the Bi-State Transit Safety

26 Act (repealed).

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1 (q) Information prohibited from being disclosed by the

2 Personnel Record Review Act.

3 (r) Information prohibited from being disclosed by the

4 Illinois School Student Records Act.

5 (s) Information the disclosure of which is restricted

6 under Section 5-108 of the Public Utilities Act.

7 (t) (Blank).

8 (u) Records and information provided to an independent

9 team of experts under the Developmental Disability and

10 Mental Health Safety Act (also known as Brian's Law).

11 (v) Names and information of people who have applied

12 for or received Firearm Owner's Identification Cards under

13 the Firearm Owners Identification Card Act or applied for

14 or received a concealed carry license under the Firearm

15 Concealed Carry Act, unless otherwise authorized by the

16 Firearm Concealed Carry Act; and databases under the

17 Firearm Concealed Carry Act, records of the Concealed

18 Carry Licensing Review Board under the Firearm Concealed

19 Carry Act, and law enforcement agency objections under the

20 Firearm Concealed Carry Act.

21 (v-5) Records of the Firearm Owner's Identification

22 Card Review Board that are exempted from disclosure under

23 Section 10 of the Firearm Owners Identification Card Act.

24 (w) Personally identifiable information which is

25 exempted from disclosure under subsection (g) of Section

26 19.1 of the Toll Highway Act.

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1 (x) Information which is exempted from disclosure

2 under Section 5-1014.3 of the Counties Code or Section

3 8-11-21 of the Illinois Municipal Code.

4 (y) Confidential information under the Adult

5 Protective Services Act and its predecessor enabling

6 statute, the Elder Abuse and Neglect Act, including

7 information about the identity and administrative finding

8 against any caregiver of a verified and substantiated

9 decision of abuse, neglect, or financial exploitation of

10 an eligible adult maintained in the Registry established

11 under Section 7.5 of the Adult Protective Services Act.

12 (z) Records and information provided to a fatality

13 review team or the Illinois Fatality Review Team Advisory

14 Council under Section 15 of the Adult Protective Services

15 Act.

16 (aa) Information which is exempted from disclosure

17 under Section 2.37 of the Wildlife Code.

18 (bb) Information which is or was prohibited from

19 disclosure by the Juvenile Court Act of 1987.

20 (cc) Recordings made under the Law Enforcement

21 Officer-Worn Body Camera Act, except to the extent

22 authorized under that Act.

23 (dd) Information that is prohibited from being

24 disclosed under Section 45 of the Condominium and Common

25 Interest Community Ombudsperson Act.

26 (ee) Information that is exempted from disclosure

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1 under Section 30.1 of the Pharmacy Practice Act.

2 (ff) Information that is exempted from disclosure

3 under the Revised Uniform Unclaimed Property Act.

4 (gg) Information that is prohibited from being

5 disclosed under Section 7-603.5 of the Illinois Vehicle

6 Code.

7 (hh) Records that are exempt from disclosure under

8 Section 1A-16.7 of the Election Code.

9 (ii) Information which is exempted from disclosure

10 under Section 2505-800 of the Department of Revenue Law of

11 the Civil Administrative Code of Illinois.

12 (jj) Information and reports that are required to be

13 submitted to the Department of Labor by registering day

14 and temporary labor service agencies but are exempt from

15 disclosure under subsection (a-1) of Section 45 of the Day

16 and Temporary Labor Services Act.

17 (kk) Information prohibited from disclosure under the

18 Seizure and Forfeiture Reporting Act.

19 (ll) Information the disclosure of which is restricted

20 and exempted under Section 5-30.8 of the Illinois Public

21 Aid Code.

22 (mm) Records that are exempt from disclosure under

23 Section 4.2 of the Crime Victims Compensation Act.

24 (nn) Information that is exempt from disclosure under

25 Section 70 of the Higher Education Student Assistance Act.

26 (oo) Communications, notes, records, and reports

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1 arising out of a peer support counseling session

2 prohibited from disclosure under the First Responders

3 Suicide Prevention Act.

4 (pp) Names and all identifying information relating to

5 an employee of an emergency services provider or law

6 enforcement agency under the First Responders Suicide

7 Prevention Act.

8 (qq) Information and records held by the Department of

9 Public Health and its authorized representatives collected

10 under the Reproductive Health Act.

11 (rr) Information that is exempt from disclosure under

12 the Cannabis Regulation and Tax Act.

13 (ss) Data reported by an employer to the Department of

14 Human Rights pursuant to Section 2-108 of the Illinois

15 Human Rights Act.

16 (tt) Recordings made under the Children's Advocacy

17 Center Act, except to the extent authorized under that

18 Act.

19 (uu) Information that is exempt from disclosure under

20 Section 50 of the Sexual Assault Evidence Submission Act.

21 (vv) Information that is exempt from disclosure under

22 subsections (f) and (j) of Section 5-36 of the Illinois

23 Public Aid Code.

24 (ww) Information that is exempt from disclosure under

25 Section 16.8 of the State Treasurer Act.

26 (xx) Information that is exempt from disclosure or

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1 information that shall not be made public under the

2 Illinois Insurance Code.

3 (yy) Information prohibited from being disclosed under

4 the Illinois Educational Labor Relations Act.

5 (zz) Information prohibited from being disclosed under

6 the Illinois Public Labor Relations Act.

7 (aaa) Information prohibited from being disclosed

8 under Section 1-167 of the Illinois Pension Code.

9 (bbb) Information that is prohibited from disclosure

10 by the Illinois Police Training Act and the Illinois State

11 Police Act.

12 (ccc) Records exempt from disclosure under Section

13 2605-304 of the Illinois State Police Law of the Civil

14 Administrative Code of Illinois.

15 (ddd) Information prohibited from being disclosed

16 under Section 35 of the Address Confidentiality for

17 Victims of Domestic Violence, Sexual Assault, Human

18 Trafficking, or Stalking Act.

19 (eee) Information prohibited from being disclosed

20 under subsection (b) of Section 75 of the Domestic

21 Violence Fatality Review Act.

22 (fff) Images from cameras under the Expressway Camera

23 Act and all automated license plate reader (ALPR)

24 information used and collected by the Illinois State

25 Police. "ALPR information" means information gathered by

26 an ALPR or created from the analysis of data generated by

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1 an ALPR. This subsection (fff) is inoperative on and after

2 July 1, 2028.

3 (ggg) Information prohibited from disclosure under

4 paragraph (3) of subsection (a) of Section 14 of the Nurse

5 Agency Licensing Act.

6 (hhh) Information submitted to the Illinois State

7 Police in an affidavit or application for an assault

8 weapon endorsement, assault weapon attachment endorsement,

9 .50 caliber rifle endorsement, or .50 caliber cartridge

10 endorsement under the Firearm Owners Identification Card

11 Act.

12 (iii) Data exempt from disclosure under Section 50 of

13 the School Safety Drill Act.

14 (jjj) Information exempt from disclosure under Section

15 30 of the Insurance Data Security Law.

16 (kkk) Confidential business information prohibited

17 from disclosure under Section 45 of the Paint Stewardship

18 Act.

19 (lll) Data exempt from disclosure under Section

20 2-3.196 of the School Code.

21 (mmm) Information prohibited from being disclosed

22 under subsection (e) of Section 1-129 of the Illinois

23 Power Agency Act.

24 (nnn) Materials received by the Department of Commerce

25 and Economic Opportunity that are confidential under the

26 Music and Musicians Tax Credit and Jobs Act.

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1 (ooo) Data or information provided pursuant to Section

2 20 of the Statewide Recycling Needs and Assessment Act.

3 (ppp) Information that is exempt from disclosure under

4 Section 28-11 of the Lawful Health Care Activity Act.

5 (qqq) Information that is exempt from disclosure under

6 Section 7-101 of the Illinois Human Rights Act.

7 (rrr) Information prohibited from being disclosed

8 under Section 4-2 of the Uniform Money Transmission

9 Modernization Act.

10 (sss) Information exempt from disclosure under Section

11 40 of the Student-Athlete Endorsement Rights Act.

12 (ttt) Audio recordings made under Section 30 of the

13 Illinois State Police Act, except to the extent authorized

14 under that Section.

15 (uuu) Information prohibited from being disclosed

16 under Section 30-5 of the Digital Assets Regulation Act.

17 (vvv) ~~(uuu)~~ Information exempt from disclosure under

18 Section 70 of the End-of-Life Options for Terminally Ill

19 Patients Act.

20 (www) Annual summary financial and utilization data

21 reports submitted to the Health Facilities and Services

22 Review Board under Section 13 of the Illinois Health

23 Facilities Planning Act.

24 (Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;

25 103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.

26 8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,

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1 eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;

2 103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.

3 8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,

4 eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;

5 104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-441, eff.

6 9-12-26; 104-457, eff. 6-1-26; revised 1-7-26.)

7 Section 6-75. The Illinois Health Facilities Planning Act

8 is amended by changing Sections 2 and 13 as follows:

9 (20 ILCS 3960/2) (from Ch. 111 1/2, par. 1152)

10 (Section scheduled to be repealed on December 31, 2029)

11 Sec. 2. Purpose of the Act. This Act shall establish a

12 procedure (1) which requires a person establishing,

13 constructing or modifying a health care facility, as herein

14 defined, to have the qualifications, background, character and

15 financial resources to adequately provide a proper service for

16 the community; (2) that promotes the orderly and economic

17 development of health care facilities in the State of Illinois

18 that avoids unnecessary duplication of such facilities; and

19 (3) that promotes planning for and development of health care

20 facilities needed for comprehensive health care especially in

21 areas where the health planning process has identified unmet

22 needs.

23 The changes made to this Act by this amendatory Act of the

24 96th General Assembly are intended to accomplish the following

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1 objectives: to improve the financial ability of the public to

2 obtain necessary health services; to establish an orderly and

3 comprehensive health care delivery system that will guarantee

4 the availability of quality health care to the general public;

5 to maintain and improve the provision of essential health care

6 services and increase the accessibility of those services to

7 the medically underserved and indigent; to assure that the

8 reduction and closure of health care services or facilities is

9 performed in an orderly and timely manner, and that these

10 actions are deemed to be in the best interests of the public;

11 and to assess the financial burden to patients caused by

12 unnecessary health care construction and modification.

13 Evidence-based assessments, projections and decisions will be

14 applied regarding capacity, quality, value and equity in the

15 delivery of health care services in Illinois. The integrity of

16 the Certificate of Need process is ensured through revised

17 ethics and communications procedures. Cost containment and

18 support for safety net services must continue to be central

19 tenets of the Certificate of Need process.

20 The changes made to this Act by this amendatory Act of the

21 104th General Assembly are intended to allow the State to

22 collect additional information regarding the financial ability

23 for health care facilities to deliver services in Illinois.

24 (Source: P.A. 99-527, eff. 1-1-17.)

25 (20 ILCS 3960/13) (from Ch. 111 1/2, par. 1163)

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1 (Section scheduled to be repealed on December 31, 2029)

2 Sec. 13. Investigation of applications for permits.

3 (a) Investigations. The State Board shall make or cause to

4 be made such investigations as it deems necessary in

5 connection with an application for a permit, or in connection

6 with a determination of whether or not construction or

7 modification that has been commenced is in accord with the

8 permit issued by the State Board, or whether construction or

9 modification has been commenced without a permit having been

10 obtained. The State Board may issue subpoenas duces tecum

11 requiring the production of records and may administer oaths

12 to such witnesses.

13 Any circuit court of this State, upon the application of

14 the State Board or upon the application of any party to such

15 proceedings, may, in its discretion, compel the attendance of

16 witnesses, the production of books, papers, records, or

17 memoranda and the giving of testimony before the State Board,

18 by a proceeding as for contempt, or otherwise, in the same

19 manner as production of evidence may be compelled before the

20 court.

21 (b) Reports from health facilities. The State Board shall

22 require all health facilities operating in this State to

23 provide such reasonable reports at such times and containing

24 such information as is needed by it to carry out the purposes

25 and provisions of this Act. Prior to collecting information

26 from health facilities, the State Board shall make reasonable

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1 efforts through a public process to consult with health

2 facilities and associations that represent them to determine

3 whether data and information requests will result in useful

4 information for health planning, whether sufficient

5 information is available from other sources, and whether data

6 requested is routinely collected by health facilities and is

7 available without retrospective record review. Data and

8 information requests shall not impose undue paperwork burdens

9 on health care facilities and personnel. Health facilities not

10 complying with this requirement shall be reported to

11 licensing, accrediting, certifying, or payment agencies as

12 being in violation of State law. Health care facilities and

13 other parties at interest shall have reasonable access, under

14 rules established by the State Board, to all planning

15 information submitted in accord with this Act pertaining to

16 their area.

17 (1) Questionnaires. Among the reports to be required

18 by the State Board are facility questionnaires for health

19 care facilities licensed under the Ambulatory Surgical

20 Treatment Center Act, the Hospital Licensing Act, the

21 Nursing Home Care Act, the ID/DD Community Care Act, the

22 MC/DD Act, or the Specialized Mental Health Rehabilitation

23 Act of 2013 and health care facilities that are required

24 to meet the requirements of 42 CFR 494 in order to be

25 certified for participation in Medicare and Medicaid under

26 Titles XVIII and XIX of the federal Social Security Act.

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1 These questionnaires shall be conducted on an annual basis

2 and compiled by the State Board. For health care

3 facilities licensed under the Nursing Home Care Act or the

4 Specialized Mental Health Rehabilitation Act of 2013,

5 these reports shall include, but not be limited to, the

6 identification of specialty services provided by the

7 facility to patients, residents, and the community at

8 large. Annual reports for facilities licensed under the

9 ID/DD Community Care Act and facilities licensed under the

10 MC/DD Act shall be different from the annual reports

11 required of other health care facilities and shall be

12 specific to those facilities licensed under the ID/DD

13 Community Care Act or the MC/DD Act. The Health Facilities

14 and Services Review Board shall consult with associations

15 representing facilities licensed under the ID/DD Community

16 Care Act and associations representing facilities licensed

17 under the MC/DD Act when developing the information

18 requested in these annual reports. For health care

19 facilities that contain long term care beds, the reports

20 shall also include the number of staffed long term care

21 beds, physical capacity for long term care beds at the

22 facility, and long term care beds available for immediate

23 occupancy. For purposes of this paragraph, "long term care

24 beds" means beds (i) licensed under the Nursing Home Care

25 Act, (ii) licensed under the ID/DD Community Care Act,

26 (iii) licensed under the MC/DD Act, (iv) licensed under

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1 the Hospital Licensing Act, or (v) licensed under the

2 Specialized Mental Health Rehabilitation Act of 2013 and

3 certified as skilled nursing or nursing facility beds

4 under Medicaid or Medicare.

5 For health care facilities licensed under the Hospital

6 Licensing Act, the health care facilities operating in

7 this State shall report the following financial and

8 utilization data annually: (i) the most recent audited

9 financial statements; (ii) the most recent month-end

10 balance sheet detailing the assets, liabilities, and net

11 worth at the end of the month immediately preceding the

12 annual reporting cycle; (iii) the most recent income

13 statement for the month immediately preceding the annual

14 reporting cycle summarizing the revenues, expenses, and

15 net income; (iv) the total number of inpatient days,

16 outpatient visits, and discharges by payer, including, but

17 not limited to, Medicare, Medicaid fee-for-service,

18 Medicaid managed care, commercial coverage, and other

19 payers; (v) the total inpatient gross revenues by payer,

20 including, but not limited to, Medicare, Medicaid

21 fee-for-service, Medicaid managed care, commercial

22 coverage, and other payers; and (vi) the total outpatient

23 gross revenues by payer, including, but not limited to,

24 Medicare, Medicaid fee-for-service, Medicaid managed care,

25 commercial coverage, and other payers. The transmission of

26 the financial and utilization data shall be due to the

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1 State Board within 90 days after the effective date of

2 this amendatory Act of the 104th General Assembly, and

3 thereafter, the data shall be due annually on the regular

4 schedule set by the State Board for questionnaires. The

5 State Board, in coordination with the Department of

6 Healthcare and Family Services and the Department of

7 Public Health, shall administer the collection of the

8 financial and utilization data submitted under this

9 Section. The State Board may adopt any administrative

10 rules, including emergency rules, necessary to implement

11 this Section, including requesting additional information

12 or removing information from the reporting requirements.

13 If a health care facility has not filed the required

14 financial and utilization data within 90 days after the

15 close of the annual reporting period, the State Board

16 shall impose fines of not more than $5,000 per week for

17 failure to comply with the provisions of this Section.

18 (2) Confidentiality.

19 (A) The State Board shall keep confidential the

20 annual summary financial and utilization data report

21 submitted under this Section and all information in

22 the report as required by this Section. The financial

23 and utilization data shall remain confidential, is not

24 subject to subpoena, is not subject to discovery or

25 admissible as evidence in private civil litigation, is

26 not subject to disclosure under the Freedom of

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1 Information Act, and must not be made public at any

2 time or used by the State Board or any other person,

3 except as provided in subparagraphs (B), (D), and (E)

4 of this paragraph (2).

5 (B) Notwithstanding subparagraph (A), the State

6 Board may:

7 (i) share the financial and utilization data

8 submitted under this Section with other State

9 agencies;

10 (ii) share the financial and utilization data

11 submitted under this Section with third-party

12 vendors or contractors of a State agency, federal

13 regulatory agencies, or law enforcement

14 authorities, if the recipient agrees to and

15 verifies in writing its legal authority to

16 maintain the confidentiality and privileged status

17 of the financial and utilization data;

18 (iii) enter into agreements governing the

19 sharing and use of information consistent with

20 this Section.

21 (C) Disclosure of the financial and utilization

22 data to the State Board and by the State Board under

23 this Section does not waive any applicable privilege

24 or claim of confidentiality in the report or

25 information.

26 (D) Notwithstanding the confidentiality

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1 requirements of this Section or otherwise imposed by

2 State law, relevant State agencies may make public

3 financial and utilization data submitted under this

4 Section in an aggregated format that does not disclose

5 information or data attributed to any specific

6 facility.

7 (E) Notwithstanding the confidentiality

8 requirements of this Section, a State agency may

9 disclose the financial and utilization data submitted

10 under this Section with the written consent of the

11 hospital that submitted the report.

12 (Source: P.A. 100-681, eff. 8-3-18; 100-957, eff. 8-19-18;

13 101-81, eff. 7-12-19.)

14 Section 6-80. The Hospital Licensing Act is amended by

15 adding Section 4.8 as follows:

16 (210 ILCS 85/4.8 new)

17 Sec. 4.8. Additional licensing requirements.

18 (a) Hospital emergency and financial contingency plan. Any

19 hospital licensed under this Act that has outstanding debts to

20 the State in the form of tax arrears or that maintains debt

21 through the Distressed Hospital Loan Program or other Medicaid

22 advance payments shall submit to the Department a hospital

23 emergency and financial contingency plan for the rapid and

24 orderly resolution of finances and operations in the event of

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1 material financial distress. The plan shall be submitted on an

2 annual basis until any outstanding assessment or advance

3 balances have been fully paid. The plan shall include, but not

4 be limited to, procedures for the safe and orderly transfer

5 and continuity of care for patients if closure of at least one

6 category of service, or a temporary suspension of such service

7 for any reason, were to occur. Potential events precipitating

8 closure or suspended services that shall be addressed in the

9 plan, include, but are not limited to: financial distress,

10 regulatory and compliance issues, operational or workforce

11 challenges, infrastructure and facility issues, emergency or

12 disaster related causes, and strategic organizational

13 decisions. The plan shall contemplate (i) the identification

14 of potential service area gaps created due to emergency

15 closure and suspension of services and (ii) the orderly

16 preservation and transfer of medical records in accordance

17 with the Medical Patient Rights Act, the Health Insurance

18 Portability and Accountability Act of 1996, and other

19 applicable medical privacy laws.

20 (b) Hospital emergency and financial contingency plans for

21 hospitals with multiple locations operating under a single

22 license. Any hospital licensed by the Department under Section

23 4.5 of this Act and required to submit a hospital emergency and

24 financial contingency plan shall submit a hospital emergency

25 and financial contingency plan as outlined in subsection (a)

26 considering each location, campus, or facility administered

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1 under the license that could reasonably be affected.

2 (c) Annual filing. Hospital emergency and financial

3 contingency plans shall be filed with the Department no later

4 than 3 months after the effective date of this amendatory Act

5 of the 104th General Assembly. Hospital emergency and

6 financial contingency plans, or annual affirmations of

7 previously filed hospital emergency and financial contingency

8 plans, as outlined in this Section shall be submitted on an

9 annual basis as determined by the Department through

10 administrative rule.

11 (d) Penalties for noncompliance. The Department may impose

12 fines of not more than $500 per week for failure to comply with

13 the provisions of this Section.

14 (e) This Section is operative on and after January 1,

15 2027.

16 ARTICLE 10.

17 Section 10-5. The Rebuild Illinois Mental Health Workforce

18 Act is amended by changing Section 20-10 as follows:

19 (305 ILCS 66/20-10)

20 Sec. 20-10. Medicaid funding for community mental health

21 services. Medicaid funding for the specific community mental

22 health services listed in this Act shall be adjusted and paid

23 as set forth in this Act. Such payments shall be paid in

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1 addition to the base Medicaid reimbursement rate and add-on

2 payment rates per service unit.

3 (a) The following payment adjustments shall begin on July

4 1, 2022 for State Fiscal Year 2023 and shall continue for every

5 State fiscal year thereafter.

6 (1) Individual Therapy Medicaid Payment rate for

7 services provided under the H0004 Code:

8 (A) The Medicaid total payment rate for individual

9 therapy provided by a qualified mental health

10 professional shall be increased by no less than $9 per

11 service unit.

12 (B) The Medicaid total payment rate for individual

13 therapy provided by a mental health professional shall

14 be increased by no less than $9 per service unit.

15 (2) Community Support - Individual Medicaid Payment

16 rate for services provided under the H2015 Code: All

17 community support - individual services shall be increased

18 by no less than $15 per service unit.

19 (3) Case Management Medicaid Add-on Payment for

20 services provided under the T1016 code: All case

21 management services rates shall be increased by no less

22 than $15 per service unit.

23 (4) Assertive Community Treatment Medicaid Add-on

24 Payment for services provided under the H0039 code: The

25 Medicaid total payment rate for assertive community

26 treatment services shall increase by no less than $8 per

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1 service unit.

2 (b) ~~(5)~~ Medicaid user-based directed payments. The

3 following directed payments shall be paid to qualifying

4 providers for State Fiscal Year 2023 through State Fiscal Year

5 2026. This subsection does not prevent the Department from

6 making payments in future State fiscal years to correct errors

7 or omissions made in State Fiscal Year 2023 through State

8 Fiscal Year 2026 payments.

9 (1) ~~(A)~~ For each State fiscal year, a monthly directed

10 payment shall be paid to a community mental health

11 provider of community support team services based on the

12 number of Medicaid users of community support team

13 services documented by Medicaid fee-for-service and

14 managed care encounter claims delivered by that provider

15 in the base year. The Department of Healthcare and Family

16 Services shall make the monthly directed payment to each

17 provider entitled to directed payments under this Act by

18 no later than the last day of each month throughout each

19 State fiscal year.

20 (A) ~~(i)~~ The monthly directed payment for a

21 community support team provider shall be calculated as

22 follows: The sum total number of individual Medicaid

23 users of community support team services delivered by

24 that provider throughout the base year, multiplied by

25 $4,200 per Medicaid user, divided into 12 equal

26 monthly payments for the State fiscal year.

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1 (B) ~~(ii)~~ As used in this subparagraph, "user"

2 means an individual who received at least 200 units of

3 community support team services (H2016) during the

4 base year.

5 (2) ~~(B)~~ For each State fiscal year, a monthly directed

6 payment shall be paid to each community mental health

7 provider of assertive community treatment services based

8 on the number of Medicaid users of assertive community

9 treatment services documented by Medicaid fee-for-service

10 and managed care encounter claims delivered by the

11 provider in the base year.

12 (A) ~~(i)~~ The monthly direct payment for an

13 assertive community treatment provider shall be

14 calculated as follows: The sum total number of

15 Medicaid users of assertive community treatment

16 services provided by that provider throughout the base

17 year, multiplied by $6,000 per Medicaid user, divided

18 into 12 equal monthly payments for that State fiscal

19 year.

20 (B) ~~(ii)~~ As used in this subparagraph, "user"

21 means an individual that received at least 300 units

22 of assertive community treatment services during the

23 base year.

24 (3) ~~(C)~~ The base year for directed payments under this

25 Section shall be calendar year 2019 for State Fiscal Year

26 2023 and State Fiscal Year 2024. For the State fiscal year

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1 beginning on July 1, 2024, and for every State fiscal year

2 thereafter, the base year shall be the calendar year that

3 ended 18 months prior to the start of the State fiscal year

4 in which payments are made.

5 (b-5) ~~(b)~~ Subject to federal approval, a one-time directed

6 payment must be made in calendar year 2023 for community

7 mental health services provided by community mental health

8 providers. The one-time directed payment shall be for an

9 amount appropriated for these purposes. The one-time directed

10 payment shall be for services for Integrated Assessment and

11 Treatment Planning and other intensive services, including,

12 but not limited to, services for Mobile Crisis Response,

13 crisis intervention, and medication monitoring. The amounts

14 and services used for designing and distributing these

15 one-time directed payments shall not be construed to require

16 any future rate or funding increases for the same or other

17 mental health services.

18 (b-6) Subject to federal approval, for dates of service on

19 and after July 1, 2026, the Medicaid reimbursement rates for

20 Assertive Community Treatment and Community Support Team

21 services shall be increased by an amount no less than the

22 following targeted pools. The Department must use service

23 units delivered under the fee-for-service and managed care

24 programs by community mental health centers during State

25 Fiscal Year 2024 for distributing the targeted pools and

26 setting rates.

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1 (1) Assertive Community Treatment, $10,600,000; and

2 (2) Community Support Team services, $17,500,000.

3 (c) The following payment adjustments shall be made:

4 (1) Subject to federal approval, beginning on January

5 1, 2024, the Department shall introduce rate increases to

6 behavioral health services no less than by the following

7 targeted pool for the specified services provided by

8 community mental health centers:

9 (A) Mobile Crisis Response, $6,800,000;

10 (B) Crisis Intervention, $4,000,000;

11 (C) Integrative Assessment and Treatment Planning

12 services, $10,500,000;

13 (D) Group Therapy, $1,200,000;

14 (E) Family Therapy, $500,000;

15 (F) Community Support Group, $4,000,000; and

16 (G) Medication Monitoring, $3,000,000.

17 (2) Rate increases shall be determined with

18 significant input from Illinois behavioral health trade

19 associations and advocates. The Department must use

20 service units delivered under the fee-for-service and

21 managed care programs by community mental health centers

22 during State Fiscal Year 2022. These services are used for

23 distributing the targeted pools and setting rates but do

24 not prohibit the Department from paying providers not

25 enrolled as community mental health centers the same rate

26 if providing the same services.

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1 (d) Rate simplification for team-based services.

2 (1) The Department shall work with stakeholders to

3 redesign reimbursement rates for behavioral health

4 team-based services established under the Rehabilitation

5 Option of the Illinois Medicaid State Plan supporting

6 individuals with chronic or complex behavioral health

7 conditions and crisis services. Subject to federal

8 approval, the redesigned rates shall seek to introduce

9 bundled payment systems that minimize provider claiming

10 activities while transitioning the focus of treatment

11 towards metrics and outcomes. Federally approved rate

12 models shall seek to ensure reimbursement levels are no

13 less than the State's total reimbursement for similar

14 services in calendar year 2023, including all service

15 level payments, add-ons, and all other payments specified

16 in this Section.

17 (2) In State Fiscal Year 2024, the Department shall

18 identify an existing, or establish a new, Behavioral

19 Health Outcomes Stakeholder Workgroup to help inform the

20 identification of metrics and outcomes for team-based

21 services.

22 (3) In State Fiscal Year 2025, subject to federal

23 approval, the Department shall introduce a

24 pay-for-performance model for team-based services to be

25 informed by the Behavioral Health Outcomes Stakeholder

26 Workgroup.

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1 (Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23;

2 103-102, eff. 7-1-23; 103-154, eff. 6-30-23.)

3 ARTICLE 15.

4 Section 15-5. The State Finance Act is amended by changing

5 Section 5.945 as follows:

6 (30 ILCS 105/5.945)

7 Sec. 5.945. The Medicaid Technical Assistance Center Fund.

8 Notwithstanding any other provision of law, in addition to any

9 other transfers that may be provided by law, on July 1, 2026,

10 or as soon thereafter as practical, the State Comptroller

11 shall direct and the State Treasurer shall transfer the

12 remaining balance from the Medicaid Technical Assistance

13 Center Fund into the Healthcare Provider Relief Fund. Upon

14 completion of the transfers, the Medicaid Technical Assistance

15 Center Fund is dissolved, and any future deposits due to that

16 Fund and any outstanding obligations or liabilities of that

17 Fund pass to the Healthcare Provider Relief Fund.

18 (Source: P.A. 102-4, Article 185, Section 185-90, eff.

19 4-27-21; 102-813, eff. 5-13-22.)

20 Section 15-10. The Medicaid Technical Assistance Act is

21 amended by changing Sections 185-5 and 185-15 as follows:

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1 (305 ILCS 75/185-5)

2 Sec. 185-5. Definitions. As used in this Act:

3 "Behavioral health providers" includes providers of mental

4 health, substance use disorder, developmental disabilities,

5 and autism services for purposes of this Act, but does not

6 change any other legal, programmatic, diagnostic, or clinical

7 provisions defining or relating to coverage of such services.

8 ~~means mental health and substance use disorder providers.~~

9 "Department" means the Department of Healthcare and Family

10 Services.

11 "Health care providers" means individuals and

12 organizations that ~~who~~ provide physical, mental, or substance

13 use disorder services, or services supporting social

14 determinants ~~determinant~~ of health ~~services~~.

15 "Health equity" means providing care that does not vary in

16 quality because of personal characteristics such as gender,

17 ethnicity, geographic location, and socioeconomic status.

18 ~~"Network adequacy" means a Medicaid beneficiaries' ability~~

19 ~~to access all necessary provider types within time and~~

20 ~~distance standards as defined in the Managed Care Organization~~

21 ~~model contract.~~

22 "Service deserts" means geographic areas of the State with

23 no or limited Medicaid providers that accept Medicaid.

24 "Social determinants of health" means any conditions that

25 impact an individual's health, including, but not limited to,

26 access to healthy food, safety, education, and housing

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1 stability.

2 "Stakeholders" means, but are not limited to, health care

3 providers, advocacy organizations, managed care organizations,

4 Medicaid beneficiaries, and State and city partners.

5 (Source: P.A. 102-4, eff. 4-27-21.)

6 (305 ILCS 75/185-15)

7 Sec. 185-15. Collaboration. The Medicaid Technical

8 Assistance Center shall collaborate with public and private

9 partners throughout the State to identify, establish, and

10 maintain best practices necessary for health providers to

11 ensure their capacity to participate in the Illinois Medical

12 Assistance Program. The Medicaid Technical Assistance Center

13 shall promote equitable delivery systems, remaining committed

14 to the principle that all Medicaid recipients have accessible

15 and equitable physical and mental health care services

16 ~~HealthChoice Illinois or YouthCare~~. The Medicaid Technical

17 Assistance Center shall administer the following:

18 (1) Outreach and engagement: The Medicaid Technical

19 Assistance Center shall undertake efforts to identify and

20 engage community-based providers offering services to

21 customers funded by the Department, including, but not

22 limited to, behavioral health services and ~~or~~ services

23 addressing the social determinants of health, especially

24 those predominantly serving communities of color or those

25 operating within or near service deserts, for the purpose

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1 of offering training and technical assistance to them

2 through the Medicaid Technical Assistance Center. Outreach

3 and engagement services may be subcontracted.

4 (2) Trainings: The Medicaid Technical Assistance

5 Center shall create and administer ongoing trainings for

6 health care providers. Trainings may be subcontracted. The

7 Medicaid Technical Assistance Center shall provide

8 in-person and web-based trainings. In-person training

9 shall be conducted throughout the State. All trainings

10 must be free of charge. The Medicaid Technical Assistance

11 Center shall administer post-training surveys and

12 incorporate feedback. Training content and delivery must

13 be reflective of Illinois providers' varying levels of

14 readiness, resources, and client populations.

15 (3) Web-based resources: The Medicaid Technical

16 Assistance Center shall maintain an independent, easy to

17 navigate, and up-to-date website that includes, but is not

18 limited to: recorded training archives, a training

19 calendar, provider resources and tools, up-to-date

20 explanations of Department and managed care organization

21 guidance, a running database of frequently asked questions

22 and contact information for key staff members of the

23 Department, managed care organizations, and the Medicaid

24 Technical Assistance Center.

25 (4) Learning collaboratives: The Medicaid Technical

26 Assistance Center shall host regional learning

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1 collaboratives that will supplement the Medicaid Technical

2 Assistance Center training curriculum to bring together

3 groups of stakeholders to share issues and best practices,

4 and to escalate issues. Leadership of the Department and

5 managed care organizations shall attend learning

6 collaboratives on a quarterly basis.

7 (5) Network recruitment plan: Using reports and data

8 provided by the Department's External Quality Review

9 Organization on ~~adequacy reports: The Medicaid Technical~~

10 ~~Assistance Center shall publicly release a report on~~

11 ~~Medicaid provider~~ network adequacy, ~~within the first 3~~

12 ~~years of implementation and annually thereafter. The~~

13 ~~reports shall identify~~ provider service deserts, and

14 health care disparities by race and ethnicity, the

15 Medicaid Technical Assistance Center shall propose for

16 Department review and approval an annual plan for

17 recruiting providers to participate in the Illinois

18 Medical Assistance Program and report on outcomes of its

19 recruitment efforts to the Department for continuous

20 improvement. Recruitment plans shall prioritize efforts to

21 bolster access in provider service deserts and in

22 communities experiencing health care disparities by race

23 and ethnicity, with a special focus on behavioral health

24 services and services that address social determinants of

25 health.

26 (6) Equitable delivery system: The Medicaid Technical

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1 Assistance Center is committed to the principle that all

2 Medicaid recipients have accessible and equitable physical

3 and mental health care services. All providers served

4 through the Medicaid Technical Assistance Center shall

5 deliver services notwithstanding the patient's race,

6 color, gender, gender identity, age, ancestry, marital

7 status, military status, religion, national origin,

8 disability status, sexual orientation, order of protection

9 status, as defined under Section 1-103 of the Illinois

10 Human Rights Act, or immigration status.

11 (Source: P.A. 102-4, eff. 4-27-21.)

12 (305 ILCS 75/185-20 rep.)

13 (305 ILCS 75/185-25 rep.)

14 Section 15-15. The Medicaid Technical Assistance Act is

15 amended by repealing Sections 185-20 and 185-25.

16 ARTICLE 20.

17 Section 20-5. The Illinois Public Aid Code is amended by

18 changing Section 5-5f as follows:

19 (305 ILCS 5/5-5f)

20 Sec. 5-5f. Elimination and limitations of medical

21 assistance services. Notwithstanding any other provision of

22 this Code to the contrary, on and after July 1, 2012:

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1 (a) The following service shall no longer be a covered

2 service available under this Code: group psychotherapy for

3 residents of any facility licensed under the Nursing Home

4 Care Act or the Specialized Mental Health Rehabilitation

5 Act of 2013.

6 (b) The Department shall place the following

7 limitations on services: (i) the Department shall limit

8 adult eyeglasses to one pair every 2 years; however, the

9 limitation does not apply to an individual who needs

10 different eyeglasses following a surgical procedure such

11 as cataract surgery; (ii) the Department shall set an

12 annual limit of a maximum of 20 visits for each of the

13 following services: adult speech, hearing, and language

14 therapy services, adult occupational therapy services, and

15 physical therapy services; on or after October 1, 2014,

16 the annual maximum limit of 20 visits shall expire but the

17 Department may require prior approval for all individuals

18 for speech, hearing, and language therapy services,

19 occupational therapy services, and physical therapy

20 services; (iii) the Department shall limit adult podiatry

21 services to individuals with diabetes; on or after October

22 1, 2014, podiatry services shall not be limited to

23 individuals with diabetes; (iv) the Department shall pay

24 for caesarean sections at the normal vaginal delivery rate

25 unless a caesarean section was medically necessary; (v)

26 the Department shall limit adult dental services to

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1 emergencies; beginning July 1, 2013, the Department shall

2 ensure that the following conditions are recognized as

3 emergencies: (A) dental services necessary for an

4 individual in order for the individual to be cleared for a

5 medical procedure, such as a transplant; (B) extractions

6 and dentures necessary for a diabetic to receive proper

7 nutrition; (C) extractions and dentures necessary as a

8 result of cancer treatment; and (D) dental services

9 necessary for the health of a pregnant woman prior to

10 delivery of her baby; on or after July 1, 2014, adult

11 dental services shall no longer be limited to emergencies,

12 and dental services necessary for the health of a pregnant

13 woman prior to delivery of her baby shall continue to be

14 covered; and (vi) effective July 1, 2012 through June 30,

15 2021, the Department shall place limitations and require

16 concurrent review on every inpatient detoxification stay

17 to prevent repeat admissions to any hospital for

18 detoxification within 60 days of a previous inpatient

19 detoxification stay. The Department shall convene a

20 workgroup of hospitals, substance abuse providers, care

21 coordination entities, managed care plans, and other

22 stakeholders to develop recommendations for quality

23 standards, diversion to other settings, and admission

24 criteria for patients who need inpatient detoxification,

25 which shall be published on the Department's website no

26 later than September 1, 2013.

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1 (c) The Department shall require prior approval of the

2 following services: wheelchair repairs costing more than

3 $750, coronary artery bypass graft, and bariatric surgery

4 consistent with Medicare standards concerning patient

5 responsibility. Wheelchair repair prior approval requests

6 shall be adjudicated within one business day of receipt of

7 complete supporting documentation. Providers may not break

8 wheelchair repairs into separate claims for purposes of

9 staying under the $750 threshold for requiring prior

10 approval. The wholesale price of manual and power

11 wheelchairs, durable medical equipment and supplies, and

12 complex rehabilitation technology products and services

13 shall be defined as actual acquisition cost including all

14 discounts.

15 (d) (Blank). ~~The Department shall establish benchmarks~~

16 ~~for hospitals to measure and align payments to reduce~~

17 ~~potentially preventable hospital readmissions, inpatient~~

18 ~~complications, and unnecessary emergency room visits. In~~

19 ~~doing so, the Department shall consider items, including,~~

20 ~~but not limited to, historic and current acuity of care~~

21 ~~and historic and current trends in readmission. The~~

22 ~~Department shall publish provider-specific historical~~

23 ~~readmission data and anticipated potentially preventable~~

24 ~~targets 60 days prior to the start of the program. In the~~

25 ~~instance of readmissions, the Department shall adopt~~

26 ~~policies and rates of reimbursement for services and other~~

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1 ~~payments provided under this Code to ensure that, by June~~

2 ~~30, 2013, expenditures to hospitals are reduced by, at a~~

3 ~~minimum, $40,000,000.~~

4 (e) The Department shall establish utilization

5 controls for the hospice program such that it shall not

6 pay for other care services when an individual is in

7 hospice.

8 (f) For home health services, the Department shall

9 require Medicare certification of providers participating

10 in the program and implement the Medicare face-to-face

11 encounter rule. The Department shall require providers to

12 implement auditable electronic service verification based

13 on global positioning systems or other cost-effective

14 technology.

15 (g) For the Home Services Program operated by the

16 Department of Human Services and the Community Care

17 Program operated by the Department on Aging, the

18 Department of Human Services, in cooperation with the

19 Department on Aging, shall implement an electronic service

20 verification based on global positioning systems or other

21 cost-effective technology.

22 (h) Effective with inpatient hospital admissions on or

23 after July 1, 2012, the Department shall reduce the

24 payment for a claim that indicates the occurrence of a

25 provider-preventable condition during the admission as

26 specified by the Department in rules. The Department shall

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1 not pay for services related to an other

2 provider-preventable condition.

3 As used in this subsection (h):

4 "Provider-preventable condition" means a health care

5 acquired condition as defined under the federal Medicaid

6 regulation found at 42 CFR 447.26 or an other

7 provider-preventable condition.

8 "Other provider-preventable condition" means a wrong

9 surgical or other invasive procedure performed on a

10 patient, a surgical or other invasive procedure performed

11 on the wrong body part, or a surgical procedure or other

12 invasive procedure performed on the wrong patient.

13 (i) The Department shall implement cost savings

14 initiatives for advanced imaging services, cardiac imaging

15 services, pain management services, and back surgery. Such

16 initiatives shall be designed to achieve annual costs

17 savings.

18 (j) The Department shall ensure that beneficiaries

19 with a diagnosis of epilepsy or seizure disorder in

20 Department records will not require prior approval for

21 anticonvulsants.

22 (Source: P.A. 101-209, eff. 8-5-19; 102-43, Article 5, Section

23 5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff.

24 7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21;

25 102-813, eff. 5-13-22.)

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1 ARTICLE 25.

2 Section 25-5. The Illinois Public Aid Code is amended by

3 changing Section 14-12 as follows:

4 (305 ILCS 5/14-12)

5 Sec. 14-12. Hospital rate reform payment system. The

6 hospital payment system pursuant to Section 14-11 of this

7 Article shall be as follows:

8 (a) Inpatient hospital services. Effective on and after

9 the effective date of this amendatory Act of the 104th General

10 Assembly, reimbursement for inpatient general acute care

11 services shall utilize the All Patient Refined Diagnosis

12 Related Grouping (APR-DRG) software distributed by Solventum^TM

13 previously known as 3M^TM Health Information System. Solventum^TM

14 shall be the exclusive provider of this software unless the

15 Department determines that Solventum^TM is unable to meet the

16 required operational or contractual terms. Only under these

17 circumstances may an alternative authorized provider of the

18 software be considered.

19 (1) The Department shall establish Medicaid weighting

20 factors to be used in the reimbursement system established

21 under this subsection. Initial weighting factors shall be

22 the weighting factors as published by the authorized

23 provider of this software adjusted for the Illinois

24 experience.

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1 (2) The Department shall establish a

2 statewide-standardized amount to be used in the inpatient

3 reimbursement system. The Department shall publish these

4 amounts on its website no later than 10 calendar days

5 prior to their effective date.

6 (3) In addition to the statewide-standardized amount,

7 the Department shall develop adjusters to adjust the rate

8 of reimbursement for critical Medicaid providers or

9 services for trauma, transplantation services, perinatal

10 care, and Graduate Medical Education (GME).

11 (4) The Department shall develop add-on payments to

12 account for exceptionally costly inpatient stays,

13 consistent with Medicare outlier principles. Outlier fixed

14 loss thresholds may be updated to control for excessive

15 growth in outlier payments no more frequently than on an

16 annual basis, but at least once every 4 years. Upon

17 updating the fixed loss thresholds, the Department shall

18 be required to update base rates within 12 months.

19 (5) The Department shall define those hospitals or

20 distinct parts of hospitals that shall be exempt from the

21 APR-DRG reimbursement system established under this

22 Section. The Department shall publish these hospitals'

23 inpatient rates on its website no later than 10 calendar

24 days prior to their effective date.

25 (6) Beginning July 1, 2014 and ending on December 31,

26 2023, in addition to the statewide-standardized amount,

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1 the Department shall develop an adjustor to adjust the

2 rate of reimbursement for safety-net hospitals defined in

3 Section 5-5e.1 of this Code excluding pediatric hospitals.

4 (7) Beginning July 1, 2014, in addition to the

5 statewide-standardized amount, the Department shall

6 develop an adjustor to adjust the rate of reimbursement

7 for Illinois freestanding inpatient psychiatric hospitals

8 that are not designated as children's hospitals by the

9 Department but are primarily treating patients under the

10 age of 21.

11 (7.5) (Blank).

12 (8) Beginning July 1, 2018, in addition to the

13 statewide-standardized amount, the Department shall adjust

14 the rate of reimbursement for hospitals designated by the

15 Department of Public Health as a Perinatal Level II or II+

16 center by applying the same adjustor that is applied to

17 Perinatal and Obstetrical care cases for Perinatal Level

18 III centers, as of December 31, 2017.

19 (9) Beginning July 1, 2018, in addition to the

20 statewide-standardized amount, the Department shall apply

21 the same adjustor that is applied to trauma cases as of

22 December 31, 2017 to inpatient claims to treat patients

23 with burns, including, but not limited to, APR-DRGs 841,

24 842, 843, and 844.

25 (10) Beginning July 1, 2018, the

26 statewide-standardized amount for inpatient general acute

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1 care services shall be uniformly increased so that base

2 claims projected reimbursement is increased by an amount

3 equal to the funds allocated in paragraph (1) of

4 subsection (b) of Section 5A-12.6, less the amount

5 allocated under paragraphs (8) and (9) of this subsection

6 and paragraphs (3) and (4) of subsection (b) multiplied by

7 40%.

8 (11) Beginning July 1, 2018, the reimbursement for

9 inpatient rehabilitation services shall be increased by

10 the addition of a $96 per day add-on.

11 (b) Outpatient hospital services. Effective on and after

12 the effective date of this amendatory Act of the 104th General

13 Assembly, reimbursement for outpatient services shall utilize

14 the Enhanced Ambulatory Procedure Grouping (EAPG) software

15 distributed by Solventum^TM previously known as 3M^TM Health

16 Information System. Solventum^TM shall be the exclusive

17 provider of this software unless the Agency determines that

18 Solventum^TM is unable to meet the required operational or

19 contractual terms. Only under these circumstances may an

20 alternative authorized provider of the software be considered.

21 (1) The Department shall establish Medicaid weighting

22 factors to be used in the reimbursement system established

23 under this subsection. The initial weighting factors shall

24 be the weighting factors as published by the authorized

25 provider.

26 (2) The Department shall establish service specific

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1 statewide-standardized amounts to be used in the

2 reimbursement system.

3 (A) The initial statewide standardized amounts,

4 with the labor portion adjusted by the Calendar Year

5 2013 Medicare Outpatient Prospective Payment System

6 wage index with reclassifications, shall be published

7 by the Department on its website no later than 10

8 calendar days prior to their effective date.

9 (B) The Department shall establish adjustments to

10 the statewide-standardized amounts for each Critical

11 Access Hospital, as designated by the Department of

12 Public Health in accordance with 42 CFR 485, Subpart

13 F. For outpatient services provided on or before June

14 30, 2018, the EAPG standardized amounts are determined

15 separately for each critical access hospital such that

16 simulated EAPG payments using outpatient base period

17 paid claim data plus payments under Section 5A-12.4 of

18 this Code net of the associated tax costs are equal to

19 the estimated costs of outpatient base period claims

20 data with a rate year cost inflation factor applied.

21 (3) In addition to the statewide-standardized amounts,

22 the Department shall develop adjusters to adjust the rate

23 of reimbursement for critical Medicaid hospital outpatient

24 providers or services, including outpatient high volume or

25 safety-net hospitals. Beginning July 1, 2018, the

26 outpatient high volume adjustor shall be increased to

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1 increase annual expenditures associated with this adjustor

2 by $79,200,000, based on the State Fiscal Year 2015 base

3 year data and this adjustor shall apply to public

4 hospitals, except for large public hospitals, as defined

5 under 89 Ill. Adm. Code 148.25(a).

6 (4) Beginning July 1, 2018, in addition to the

7 statewide standardized amounts, the Department shall make

8 an add-on payment for outpatient expensive devices and

9 drugs. This add-on payment shall at least apply to claim

10 lines that: (i) are assigned with one of the following

11 EAPGs: 490, 1001 to 1020, and coded with one of the

12 following revenue codes: 0274 to 0276, 0278; or (ii) are

13 assigned with one of the following EAPGs: 430 to 441, 443,

14 444, 460 to 465, 495, 496, 1090. The add-on payment shall

15 be calculated as follows: the claim line's covered charges

16 multiplied by the hospital's total acute cost to charge

17 ratio, less the claim line's EAPG payment plus $1,000,

18 multiplied by 0.8.

19 (5) Beginning July 1, 2018, the statewide-standardized

20 amounts for outpatient services shall be increased by a

21 uniform percentage so that base claims projected

22 reimbursement is increased by an amount equal to no less

23 than the funds allocated in paragraph (1) of subsection

24 (b) of Section 5A-12.6, less the amount allocated under

25 paragraphs (8) and (9) of subsection (a) and paragraphs

26 (3) and (4) of this subsection multiplied by 46%.

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1 (6) Effective for dates of service on or after July 1,

2 2018, the Department shall establish adjustments to the

3 statewide-standardized amounts for each Critical Access

4 Hospital, as designated by the Department of Public Health

5 in accordance with 42 CFR 485, Subpart F, such that each

6 Critical Access Hospital's standardized amount for

7 outpatient services shall be increased by the applicable

8 uniform percentage determined pursuant to paragraph (5) of

9 this subsection. It is the intent of the General Assembly

10 that the adjustments required under this paragraph (6) by

11 Public Act 100-1181 shall be applied retroactively to

12 claims for dates of service provided on or after July 1,

13 2018.

14 (7) Effective for dates of service on or after March

15 8, 2019 (the effective date of Public Act 100-1181), the

16 Department shall recalculate and implement an updated

17 statewide-standardized amount for outpatient services

18 provided by hospitals that are not Critical Access

19 Hospitals to reflect the applicable uniform percentage

20 determined pursuant to paragraph (5).

21 (1) Any recalculation to the

22 statewide-standardized amounts for outpatient services

23 provided by hospitals that are not Critical Access

24 Hospitals shall be the amount necessary to achieve the

25 increase in the statewide-standardized amounts for

26 outpatient services increased by a uniform percentage,

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1 so that base claims projected reimbursement is

2 increased by an amount equal to no less than the funds

3 allocated in paragraph (1) of subsection (b) of

4 Section 5A-12.6, less the amount allocated under

5 paragraphs (8) and (9) of subsection (a) and

6 paragraphs (3) and (4) of this subsection, for all

7 hospitals that are not Critical Access Hospitals,

8 multiplied by 46%.

9 (2) It is the intent of the General Assembly that

10 the recalculations required under this paragraph (7)

11 by Public Act 100-1181 shall be applied prospectively

12 to claims for dates of service provided on or after

13 March 8, 2019 (the effective date of Public Act

14 100-1181) and that no recoupment or repayment by the

15 Department or an MCO of payments attributable to

16 recalculation under this paragraph (7), issued to the

17 hospital for dates of service on or after July 1, 2018

18 and before March 8, 2019 (the effective date of Public

19 Act 100-1181), shall be permitted.

20 (8) The Department shall ensure that all necessary

21 adjustments to the managed care organization capitation

22 base rates necessitated by the adjustments under

23 subparagraph (6) or (7) of this subsection are completed

24 and applied retroactively in accordance with Section

25 5-30.8 of this Code within 90 days of March 8, 2019 (the

26 effective date of Public Act 100-1181).

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1 (9) Within 60 days after federal approval of the

2 change made to the assessment in Section 5A-2 by Public

3 Act 101-650, the Department shall incorporate into the

4 EAPG system for outpatient services those services

5 performed by hospitals currently billed through the

6 Non-Institutional Provider billing system.

7 (b-5) Notwithstanding any other provision of this Section,

8 beginning with dates of service on and after January 1, 2023,

9 any general acute care hospital with more than 500 outpatient

10 psychiatric Medicaid services to persons under 19 years of age

11 in any calendar year shall be paid the outpatient add-on

12 payment of no less than $113.

13 (c) In consultation with the hospital community, the

14 Department is authorized to replace 89 Ill. Adm. Code 152.150

15 as published in 38 Ill. Reg. 4980 through 4986 within 12 months

16 of June 16, 2014 (the effective date of Public Act 98-651). If

17 the Department does not replace these rules within 12 months

18 of June 16, 2014 (the effective date of Public Act 98-651), the

19 rules in effect for 152.150 as published in 38 Ill. Reg. 4980

20 through 4986 shall remain in effect until modified by rule by

21 the Department. Nothing in this subsection shall be construed

22 to mandate that the Department file a replacement rule.

23 (d) Transition period. There shall be a transition period

24 to the reimbursement systems authorized under this Section

25 that shall begin on the effective date of these systems and

26 continue until June 30, 2018, unless extended by rule by the

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1 Department. To help provide an orderly and predictable

2 transition to the new reimbursement systems and to preserve

3 and enhance access to the hospital services during this

4 transition, the Department shall allocate a transitional

5 hospital access pool of at least $290,000,000 annually so that

6 transitional hospital access payments are made to hospitals.

7 (1) After the transition period, the Department may

8 begin incorporating the transitional hospital access pool

9 into the base rate structure; however, the transitional

10 hospital access payments in effect on June 30, 2018 shall

11 continue to be paid, if continued under Section 5A-16.

12 (2) After the transition period, if the Department

13 reduces payments from the transitional hospital access

14 pool, it shall increase base rates, develop new adjustors,

15 adjust current adjustors, develop new hospital access

16 payments based on updated information, or any combination

17 thereof by an amount equal to the decreases proposed in

18 the transitional hospital access pool payments, ensuring

19 that the entire transitional hospital access pool amount

20 shall continue to be used for hospital payments.

21 (d-5) Hospital and health care transformation program. The

22 Department shall develop a hospital and health care

23 transformation program to provide financial assistance to

24 hospitals in transforming their services and care models to

25 better align with the needs of the communities they serve. The

26 payments authorized in this Section shall be subject to

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1 approval by the federal government.

2 (1) Phase 1. In State fiscal years 2019 through 2020,

3 the Department shall allocate funds from the transitional

4 access hospital pool to create a hospital transformation

5 pool of at least $262,906,870 annually and make hospital

6 transformation payments to hospitals. Subject to Section

7 5A-16, in State fiscal years 2019 and 2020, an Illinois

8 hospital that received either a transitional hospital

9 access payment under subsection (d) or a supplemental

10 payment under subsection (f) of this Section in State

11 fiscal year 2018, shall receive a hospital transformation

12 payment as follows:

13 (A) If the hospital's Rate Year 2017 Medicaid

14 inpatient utilization rate is equal to or greater than

15 45%, the hospital transformation payment shall be

16 equal to 100% of the sum of its transitional hospital

17 access payment authorized under subsection (d) and any

18 supplemental payment authorized under subsection (f).

19 (B) If the hospital's Rate Year 2017 Medicaid

20 inpatient utilization rate is equal to or greater than

21 25% but less than 45%, the hospital transformation

22 payment shall be equal to 75% of the sum of its

23 transitional hospital access payment authorized under

24 subsection (d) and any supplemental payment authorized

25 under subsection (f).

26 (C) If the hospital's Rate Year 2017 Medicaid

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1 inpatient utilization rate is less than 25%, the

2 hospital transformation payment shall be equal to 50%

3 of the sum of its transitional hospital access payment

4 authorized under subsection (d) and any supplemental

5 payment authorized under subsection (f).

6 (2) Phase 2.

7 (A) The funding amount from phase one shall be

8 incorporated into directed payment and pass-through

9 payment methodologies described in Section 5A-12.7.

10 (B) Because there are communities in Illinois that

11 experience significant health care disparities due to

12 systemic racism, as recently emphasized by the

13 COVID-19 pandemic, aggravated by social determinants

14 of health and a lack of sufficiently allocated health

15 care resources, particularly community-based services,

16 preventive care, obstetric care, chronic disease

17 management, and specialty care, the Department shall

18 establish a health care transformation program that

19 shall be supported by the transformation funding pool.

20 It is the intention of the General Assembly that

21 innovative partnerships funded by the pool must be

22 designed to establish or improve integrated health

23 care delivery systems that will provide significant

24 access to the Medicaid and uninsured populations in

25 their communities, as well as improve health care

26 equity. It is also the intention of the General

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1 Assembly that partnerships recognize and address the

2 disparities revealed by the COVID-19 pandemic, as well

3 as the need for post-COVID care. During State fiscal

4 years 2021 through 2027, the hospital and health care

5 transformation program shall be supported by an annual

6 transformation funding pool of up to $150,000,000,

7 pending federal matching funds, to be allocated during

8 the specified fiscal years for the purpose of

9 facilitating hospital and health care transformation.

10 Funds that had been budgeted but unexpended in State

11 fiscal years 2021 through 2027 may be allocated in

12 State fiscal year 2028 in an amount not to exceed

13 $150,000,000. No disbursement of moneys for

14 transformation projects from the transformation

15 funding pool described under this Section shall be

16 considered an award, a grant, or an expenditure of

17 grant funds. Funding agreements made in accordance

18 with the transformation program shall be considered

19 purchases of care under the Illinois Procurement Code,

20 and funds shall be expended by the Department in a

21 manner that maximizes federal funding to expend the

22 entire allocated amount.

23 The Department shall convene, within 30 days after

24 March 12, 2021 (the effective date of Public Act

25 101-655), a workgroup that includes subject matter

26 experts on health care disparities and stakeholders

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1 from distressed communities, which could be a

2 subcommittee of the Medicaid Advisory Committee, to

3 review and provide recommendations on how Department

4 policy, including health care transformation, can

5 improve health disparities and the impact on

6 communities disproportionately affected by COVID-19.

7 The workgroup shall consider and make recommendations

8 on the following issues: a community safety-net

9 designation of certain hospitals, racial equity, and a

10 regional partnership to bring additional specialty

11 services to communities.

12 (C) As provided in paragraph (9) of Section 3 of

13 the Illinois Health Facilities Planning Act, any

14 hospital participating in the transformation program

15 may be excluded from the requirements of the Illinois

16 Health Facilities Planning Act for those projects

17 related to the hospital's transformation. To be

18 eligible, the hospital must submit to the Health

19 Facilities and Services Review Board approval from the

20 Department that the project is a part of the

21 hospital's transformation.

22 (D) As provided in subsection (a-20) of Section

23 32.5 of the Emergency Medical Services (EMS) Systems

24 Act, a hospital that received hospital transformation

25 payments under this Section may convert to a

26 freestanding emergency center. To be eligible for such

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1 a conversion, the hospital must submit to the

2 Department of Public Health approval from the

3 Department that the project is a part of the

4 hospital's transformation.

5 (E) Criteria for proposals. To be eligible for

6 funding under this Section, a transformation proposal

7 shall meet all of the following criteria:

8 (i) the proposal shall be designed based on

9 community needs assessment completed by either a

10 University partner or other qualified entity with

11 significant community input;

12 (ii) the proposal shall be a collaboration

13 among providers across the care and community

14 spectrum, including preventative care, primary

15 care, specialty care, hospital services, mental

16 health and substance abuse services, as well as

17 community-based entities that address the social

18 determinants of health;

19 (iii) the proposal shall be specifically

20 designed to improve health care outcomes and

21 reduce health care disparities, and improve the

22 coordination, effectiveness, and efficiency of

23 care delivery;

24 (iv) the proposal shall have specific

25 measurable metrics related to disparities that

26 will be tracked by the Department and made public

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1 by the Department;

2 (v) the proposal shall include a commitment to

3 include Business Enterprise Program certified

4 vendors or other entities controlled and managed

5 by minorities or women; and

6 (vi) the proposal shall specifically increase

7 access to primary, preventive, or specialty care.

8 (F) Entities eligible to be funded.

9 (i) Proposals for funding should come from

10 collaborations operating in one of the most

11 distressed communities in Illinois as determined

12 by the U.S. Centers for Disease Control and

13 Prevention's Social Vulnerability Index for

14 Illinois and areas disproportionately impacted by

15 COVID-19 or from rural areas of Illinois.

16 (ii) The Department shall prioritize

17 partnerships from distressed communities, which

18 include Business Enterprise Program certified

19 vendors or other entities controlled and managed

20 by minorities or women and also include one or

21 more of the following: safety-net hospitals,

22 critical access hospitals, the campuses of

23 hospitals that have closed since January 1, 2018,

24 or other health care providers designed to address

25 specific health care disparities, including the

26 impact of COVID-19 on individuals and the

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1 community and the need for post-COVID care. All

2 funded proposals must include specific measurable

3 goals and metrics related to improved outcomes and

4 reduced disparities which shall be tracked by the

5 Department.

6 (iii) The Department should target the funding

7 in the following ways: $30,000,000 of

8 transformation funds to projects that are a

9 collaboration between a safety-net hospital,

10 particularly community safety-net hospitals, and

11 other providers and designed to address specific

12 health care disparities, $20,000,000 of

13 transformation funds to collaborations between

14 safety-net hospitals and a larger hospital partner

15 that increases specialty care in distressed

16 communities, $30,000,000 of transformation funds

17 to projects that are a collaboration between

18 hospitals and other providers in distressed areas

19 of the State designed to address specific health

20 care disparities, $15,000,000 to collaborations

21 between critical access hospitals and other

22 providers designed to address specific health care

23 disparities, and $15,000,000 to cross-provider

24 collaborations designed to address specific health

25 care disparities, and $5,000,000 to collaborations

26 that focus on workforce development.

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1 (iv) The Department may allocate up to

2 $5,000,000 for planning, racial equity analysis,

3 or consulting resources for the Department or

4 entities without the resources to develop a plan

5 to meet the criteria of this Section. Any contract

6 for consulting services issued by the Department

7 under this subparagraph shall comply with the

8 provisions of Section 5-45 of the State Officials

9 and Employees Ethics Act. Based on availability of

10 federal funding, the Department may directly

11 procure consulting services or provide funding to

12 the collaboration. The provision of resources

13 under this subparagraph is not a guarantee that a

14 project will be approved.

15 (v) The Department shall take steps to ensure

16 that safety-net hospitals operating in

17 under-resourced communities receive priority

18 access to hospital and health care transformation

19 funds, including consulting funds, as provided

20 under this Section.

21 (G) Process for submitting and approving projects

22 for distressed communities. The Department shall issue

23 a template for application. The Department shall post

24 any proposal received on the Department's website for

25 at least 2 weeks for public comment, and any such

26 public comment shall also be considered in the review

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1 process. Applicants may request that proprietary

2 financial information be redacted from publicly posted

3 proposals and the Department in its discretion may

4 agree. Proposals for each distressed community must

5 include all of the following:

6 (i) A detailed description of how the project

7 intends to affect the goals outlined in this

8 subsection, describing new interventions, new

9 technology, new structures, and other changes to

10 the health care delivery system planned.

11 (ii) A detailed description of the racial and

12 ethnic makeup of the entities' board and

13 leadership positions and the salaries of the

14 executive staff of entities in the partnership

15 that is seeking to obtain funding under this

16 Section.

17 (iii) A complete budget, including an overall

18 timeline and a detailed pathway to sustainability

19 within a 5-year period, specifying other sources

20 of funding, such as in-kind, cost-sharing, or

21 private donations, particularly for capital needs.

22 There is an expectation that parties to the

23 transformation project dedicate resources to the

24 extent they are able and that these expectations

25 are delineated separately for each entity in the

26 proposal.

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1 (iv) A description of any new entities formed

2 or other legal relationships between collaborating

3 entities and how funds will be allocated among

4 participants.

5 (v) A timeline showing the evolution of sites

6 and specific services of the project over a 5-year

7 period, including services available to the

8 community by site.

9 (vi) Clear milestones indicating progress

10 toward the proposed goals of the proposal as

11 checkpoints along the way to continue receiving

12 funding. The Department is authorized to refine

13 these milestones in agreements, and is authorized

14 to impose reasonable penalties, including

15 repayment of funds, for substantial lack of

16 progress.

17 (vii) A clear statement of the level of

18 commitment the project will include for minorities

19 and women in contracting opportunities, including

20 as equity partners where applicable, or as

21 subcontractors and suppliers in all phases of the

22 project.

23 (viii) If the community study utilized is not

24 the study commissioned and published by the

25 Department, the applicant must define the

26 methodology used, including documentation of clear

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1 community participation.

2 (ix) A description of the process used in

3 collaborating with all levels of government in the

4 community served in the development of the

5 project, including, but not limited to,

6 legislators and officials of other units of local

7 government.

8 (x) Documentation of a community input process

9 in the community served, including links to

10 proposal materials on public websites.

11 (xi) Verifiable project milestones and quality

12 metrics that will be impacted by transformation.

13 These project milestones and quality metrics must

14 be identified with improvement targets that must

15 be met.

16 (xii) Data on the number of existing employees

17 by various job categories and wage levels by the

18 zip code of the employees' residence and

19 benchmarks for the continued maintenance and

20 improvement of these levels. The proposal must

21 also describe any retraining or other workforce

22 development planned for the new project.

23 (xiii) If a new entity is created by the

24 project, a description of how the board will be

25 reflective of the community served by the

26 proposal.

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1 (xiv) An explanation of how the proposal will

2 address the existing disparities that exacerbated

3 the impact of COVID-19 and the need for post-COVID

4 care in the community, if applicable.

5 (xv) An explanation of how the proposal is

6 designed to increase access to care, including

7 specialty care based upon the community's needs.

8 (H) The Department shall evaluate proposals for

9 compliance with the criteria listed under subparagraph

10 (G). Proposals meeting all of the criteria may be

11 eligible for funding with the areas of focus

12 prioritized as described in item (ii) of subparagraph

13 (F). Based on the funds available, the Department may

14 negotiate funding agreements with approved applicants

15 to maximize federal funding. Nothing in this

16 subsection requires that an approved project be funded

17 to the level requested. Agreements shall specify the

18 amount of funding anticipated annually, the

19 methodology of payments, the limit on the number of

20 years such funding may be provided, and the milestones

21 and quality metrics that must be met by the projects in

22 order to continue to receive funding during each year

23 of the program. Agreements shall specify the terms and

24 conditions under which a health care facility that

25 receives funds under a purchase of care agreement and

26 closes in violation of the terms of the agreement must

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1 pay an early closure fee no greater than 50% of the

2 funds it received under the agreement, prior to the

3 Health Facilities and Services Review Board

4 considering an application for closure of the

5 facility. Any project that is funded shall be required

6 to provide quarterly written progress reports, in a

7 form prescribed by the Department, and at a minimum

8 shall include the progress made in achieving any

9 milestones or metrics or Business Enterprise Program

10 commitments in its plan. The Department may reduce or

11 end payments, as set forth in transformation plans, if

12 milestones or metrics or Business Enterprise Program

13 commitments are not achieved. The Department shall

14 seek to make payments from the transformation fund in

15 a manner that is eligible for federal matching funds.

16 In reviewing the proposals, the Department shall

17 take into account the needs of the community, data

18 from the study commissioned by the Department from the

19 University of Illinois-Chicago if applicable, feedback

20 from public comment on the Department's website, as

21 well as how the proposal meets the criteria listed

22 under subparagraph (G). Alignment with the

23 Department's overall strategic initiatives shall be an

24 important factor. To the extent that fiscal year

25 funding is not adequate to fund all eligible projects

26 that apply, the Department shall prioritize

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1 applications that most comprehensively and effectively

2 address the criteria listed under subparagraph (G).

3 (3) (Blank).

4 (4) Hospital Transformation Review Committee. There is

5 created the Hospital Transformation Review Committee. The

6 Committee shall consist of 14 members. No later than 30

7 days after March 12, 2018 (the effective date of Public

8 Act 100-581), the 4 legislative leaders shall each appoint

9 3 members; the Governor shall appoint the Director of

10 Healthcare and Family Services, or his or her designee, as

11 a member; and the Director of Healthcare and Family

12 Services shall appoint one member. Any vacancy shall be

13 filled by the applicable appointing authority within 15

14 calendar days. The members of the Committee shall select a

15 Chair and a Vice-Chair from among its members, provided

16 that the Chair and Vice-Chair cannot be appointed by the

17 same appointing authority and must be from different

18 political parties. The Chair shall have the authority to

19 establish a meeting schedule and convene meetings of the

20 Committee, and the Vice-Chair shall have the authority to

21 convene meetings in the absence of the Chair. The

22 Committee may establish its own rules with respect to

23 meeting schedule, notice of meetings, and the disclosure

24 of documents; however, the Committee shall not have the

25 power to subpoena individuals or documents and any rules

26 must be approved by 9 of the 14 members. The Committee

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1 shall perform the functions described in this Section and

2 advise and consult with the Director in the administration

3 of this Section. In addition to reviewing and approving

4 the policies, procedures, and rules for the hospital and

5 health care transformation program, the Committee shall

6 consider and make recommendations related to qualifying

7 criteria and payment methodologies related to safety-net

8 hospitals and children's hospitals. Members of the

9 Committee appointed by the legislative leaders shall be

10 subject to the jurisdiction of the Legislative Ethics

11 Commission, not the Executive Ethics Commission, and all

12 requests under the Freedom of Information Act shall be

13 directed to the applicable Freedom of Information officer

14 for the General Assembly. The Department shall provide

15 operational support to the Committee as necessary. The

16 Committee is dissolved on April 1, 2019.

17 (e) Beginning 36 months after initial implementation, the

18 Department shall update the reimbursement components in

19 subsections (a) and (b), including standardized amounts and

20 weighting factors, and at least once every 4 years and no more

21 frequently than annually thereafter. The Department shall

22 publish these updates on its website no later than 30 calendar

23 days prior to their effective date.

24 (f) Continuation of supplemental payments. Any

25 supplemental payments authorized under 89 Illinois

26 Administrative Code 148 effective January 1, 2014 and that

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1 continue during the period of July 1, 2014 through December

2 31, 2014 shall remain in effect as long as the assessment

3 imposed by Section 5A-2 that is in effect on December 31, 2017

4 remains in effect.

5 (g) Notwithstanding subsections (a) through (f) of this

6 Section and notwithstanding the changes authorized under

7 Section 5-5b.1, any updates to the system shall not result in

8 any diminishment of the overall effective rates of

9 reimbursement as of the implementation date of the new system

10 (July 1, 2014). These updates shall not preclude variations in

11 any individual component of the system or hospital rate

12 variations. Nothing in this Section shall prohibit the

13 Department from increasing the rates of reimbursement or

14 developing payments to ensure access to hospital services.

15 Nothing in this Section shall be construed to guarantee a

16 minimum amount of spending in the aggregate or per hospital as

17 spending may be impacted by factors, including, but not

18 limited to, the number of individuals in the medical

19 assistance program and the severity of illness of the

20 individuals.

21 (h) The Department shall have the authority to modify by

22 rulemaking any changes to the rates or methodologies in this

23 Section as required by the federal government to obtain

24 federal financial participation for expenditures made under

25 this Section.

26 (i) Except for subsections (g) and (h) of this Section,

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1 the Department shall, pursuant to subsection (c) of Section

2 5-40 of the Illinois Administrative Procedure Act, provide for

3 presentation at the June 2014 hearing of the Joint Committee

4 on Administrative Rules (JCAR) additional written notice to

5 JCAR of the following rules in order to commence the second

6 notice period for the following rules: rules published in the

7 Illinois Register, rule dated February 21, 2014 at 38 Ill.

8 Reg. 4559 (Medical Payment), 4628 (Specialized Health Care

9 Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic

10 Related Grouping (DRG) Prospective Payment System (PPS)), and

11 4977 (Hospital Reimbursement Changes), and published in the

12 Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499

13 (Specialized Health Care Delivery Systems) and 6505 (Hospital

14 Services).

15 (j) Out-of-state hospitals. Beginning July 1, 2018, for

16 purposes of determining for State fiscal years 2019 and 2020

17 and subsequent fiscal years the hospitals eligible for the

18 payments authorized under subsections (a) and (b) of this

19 Section, the Department shall include out-of-state hospitals

20 that are designated a Level I pediatric trauma center or a

21 Level I trauma center by the Department of Public Health as of

22 December 1, 2017.

23 (k) The Department shall notify each hospital and managed

24 care organization, in writing, of the impact of the updates

25 under this Section at least 30 calendar days prior to their

26 effective date.

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1 (k-5) The Department shall adopt amended rules, in advance

2 of the development of annual Calendar Year 2027 hospital

3 rates, to address the standardized process and time frame for

4 updates to the reimbursement components described in

5 subsections (a) and (b), including, but not limited to, the

6 definition of "excessive growth" in paragraph (4) of

7 subsection (a), in consultation with a statewide association

8 representing a majority of hospitals, to be undertaken prior

9 to initiating rulemaking in accordance with the Illinois

10 Administrative Procedure Act.

11 (l) This Section is subject to Section 14-12.5.

12 (Source: P.A. 103-102, eff. 6-16-23; 103-154, eff. 6-30-23;

13 104-9, eff. 6-16-25; 104-417, eff. 8-15-25.)

14 ARTICLE 30.

15 Section 30-5. The Illinois Public Aid Code is amended by

16 changing Section 12-9 as follows:

17 (305 ILCS 5/12-9) (from Ch. 23, par. 12-9)

18 Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The

19 Public Aid Recoveries Trust Fund shall consist of (1)

20 recoveries by the Department of Healthcare and Family Services

21 (formerly Illinois Department of Public Aid) authorized by

22 this Code in respect to applicants or recipients under

23 Articles III, IV, V, and VI, including recoveries made by the

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1 Department of Healthcare and Family Services (formerly

2 Illinois Department of Public Aid) from the estates of

3 deceased recipients, (2) recoveries made by the Department of

4 Healthcare and Family Services (formerly Illinois Department

5 of Public Aid) in respect to applicants and recipients under

6 the Children's Health Insurance Program Act, and the Covering

7 ALL KIDS Health Insurance Act, (2.5) recoveries made by the

8 Department of Healthcare and Family Services in connection

9 with the imposition of an administrative penalty as provided

10 under Section 12-4.45, (3) federal funds received on behalf of

11 and earned by State universities, other State agencies or

12 departments, and local governmental entities for services

13 provided to applicants or recipients covered under this Code,

14 the Children's Health Insurance Program Act, and the Covering

15 ALL KIDS Health Insurance Act, (3.5) federal financial

16 participation revenue related to eligible disbursements made

17 by the Department of Healthcare and Family Services from

18 appropriations required by this Section, and (4) all other

19 moneys received to the Fund, including interest thereon. The

20 Fund shall be held as a special fund in the State Treasury.

21 Disbursements from this Fund shall be only (1) for the

22 reimbursement of claims collected by the Department of

23 Healthcare and Family Services (formerly Illinois Department

24 of Public Aid) through error or mistake, (2) for payment to

25 persons or agencies designated as payees or co-payees on any

26 instrument, whether or not negotiable, delivered to the

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1 Department of Healthcare and Family Services (formerly

2 Illinois Department of Public Aid) as a recovery under this

3 Section, such payment to be in proportion to the respective

4 interests of the payees in the amount so collected, (3) for

5 payments to the Department of Human Services for collections

6 made by the Department of Healthcare and Family Services

7 (formerly Illinois Department of Public Aid) on behalf of the

8 Department of Human Services under this Code, the Children's

9 Health Insurance Program Act, and the Covering ALL KIDS Health

10 Insurance Act, (4) for payment of administrative expenses

11 incurred in performing the activities authorized under this

12 Code, the Children's Health Insurance Program Act, and the

13 Covering ALL KIDS Health Insurance Act, (5) for payment of

14 fees to persons or agencies in the performance of activities

15 pursuant to the collection of monies owed the State that are

16 collected under this Code, the Children's Health Insurance

17 Program Act, and the Covering ALL KIDS Health Insurance Act,

18 (6) separate from those disbursements allowed under items (4)

19 and (5), for payment of contingency fees to third-party

20 entities that the Office of Inspector General authorizes to

21 conduct audits under Sections 12-4.25 and 12-4.40, or any

22 similar audits required by State or federal law, (7) for

23 payments of any amounts which are reimbursable to the federal

24 government which are required to be paid by State warrant by

25 either the State or federal government, and (8) ~~(7)~~ for

26 payments to State universities, other State agencies or

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1 departments, and local governmental entities of federal funds

2 for services provided to applicants or recipients covered

3 under this Code, the Children's Health Insurance Program Act,

4 and the Covering ALL KIDS Health Insurance Act. Disbursements

5 from this Fund for purposes of items (4) and (5) of this

6 paragraph shall be subject to appropriations from the Fund to

7 the Department of Healthcare and Family Services (formerly

8 Illinois Department of Public Aid).

9 The balance in this Fund after payment therefrom of any

10 amounts reimbursable to the federal government, and minus the

11 amount anticipated to be needed to make the disbursements

12 authorized by this Section, shall be certified by the Director

13 of Healthcare and Family Services and transferred by the State

14 Comptroller to the Drug Rebate Fund or the Healthcare Provider

15 Relief Fund in the State Treasury, as appropriate, on at least

16 an annual basis by June 30th of each fiscal year. The Director

17 of Healthcare and Family Services may certify and the State

18 Comptroller shall transfer to the Drug Rebate Fund or the

19 Healthcare Provider Relief Fund amounts on a more frequent

20 basis.

21 (Source: P.A. 103-593, eff. 6-7-24.)

22 ARTICLE 35.

23 Section 35-5. The Illinois Public Aid Code is amended by

24 changing Section 5-5.4 as follows:

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1 (305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)

2 Sec. 5-5.4. Standards of payment; Department of Healthcare

3 and Family Services. The Department of Healthcare and Family

4 Services shall develop standards of payment of nursing

5 facility and ICF/DD services in facilities providing such

6 services under this Article which:

7 (1) Provide for the determination of a facility's payment

8 for nursing facility or ICF/DD services on a prospective

9 basis. The amount of the payment rate for all nursing

10 facilities certified by the Department of Public Health under

11 the ID/DD Community Care Act or the Nursing Home Care Act as

12 Intermediate Care for the Developmentally Disabled facilities,

13 Long Term Care for Under Age 22 facilities, Skilled Nursing

14 facilities, or Intermediate Care facilities under the medical

15 assistance program shall be prospectively established annually

16 on the basis of historical, financial, and statistical data

17 reflecting actual costs from prior years, which shall be

18 applied to the current rate year and updated for inflation,

19 except that the capital cost element for newly constructed

20 facilities shall be based upon projected budgets. The annually

21 established payment rate shall take effect on July 1 in 1984

22 and subsequent years. No rate increase and no update for

23 inflation shall be provided on or after July 1, 1994, unless

24 specifically provided for in this Section. The changes made by

25 Public Act 93-841 extending the duration of the prohibition

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1 against a rate increase or update for inflation are effective

2 retroactive to July 1, 2004.

3 For facilities licensed by the Department of Public Health

4 under the Nursing Home Care Act as Intermediate Care for the

5 Developmentally Disabled facilities or Long Term Care for

6 Under Age 22 facilities, the rates taking effect on July 1,

7 1998 shall include an increase of 3%. For facilities licensed

8 by the Department of Public Health under the Nursing Home Care

9 Act as Skilled Nursing facilities or Intermediate Care

10 facilities, the rates taking effect on July 1, 1998 shall

11 include an increase of 3% plus $1.10 per resident-day, as

12 defined by the Department. For facilities licensed by the

13 Department of Public Health under the Nursing Home Care Act as

14 Intermediate Care Facilities for the Developmentally Disabled

15 or Long Term Care for Under Age 22 facilities, the rates taking

16 effect on January 1, 2006 shall include an increase of 3%. For

17 facilities licensed by the Department of Public Health under

18 the Nursing Home Care Act as Intermediate Care Facilities for

19 the Developmentally Disabled or Long Term Care for Under Age

20 22 facilities, the rates taking effect on January 1, 2009

21 shall include an increase sufficient to provide a $0.50 per

22 hour wage increase for non-executive staff. For facilities

23 licensed by the Department of Public Health under the ID/DD

24 Community Care Act as ID/DD Facilities the rates taking effect

25 within 30 days after July 6, 2017 (the effective date of Public

26 Act 100-23) shall include an increase sufficient to provide a

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1 $0.75 per hour wage increase for non-executive staff. The

2 Department shall adopt rules, including emergency rules under

3 subsection (y) of Section 5-45 of the Illinois Administrative

4 Procedure Act, to implement the provisions of this paragraph.

5 For facilities licensed by the Department of Public Health

6 under the ID/DD Community Care Act as ID/DD Facilities and

7 under the MC/DD Act as MC/DD Facilities, the rates taking

8 effect within 30 days after June 5, 2019 (the effective date of

9 Public Act 101-10) shall include an increase sufficient to

10 provide a $0.50 per hour wage increase for non-executive

11 frontline personnel, including, but not limited to, direct

12 support persons, aides, frontline supervisors, qualified

13 intellectual disabilities professionals, nurses, and

14 non-administrative support staff. The Department shall adopt

15 rules, including emergency rules under subsection (bb) of

16 Section 5-45 of the Illinois Administrative Procedure Act, to

17 implement the provisions of this paragraph.

18 For facilities licensed by the Department of Public Health

19 under the Nursing Home Care Act as Intermediate Care for the

20 Developmentally Disabled facilities or Long Term Care for

21 Under Age 22 facilities, the rates taking effect on July 1,

22 1999 shall include an increase of 1.6% plus $3.00 per

23 resident-day, as defined by the Department. For facilities

24 licensed by the Department of Public Health under the Nursing

25 Home Care Act as Skilled Nursing facilities or Intermediate

26 Care facilities, the rates taking effect on July 1, 1999 shall

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1 include an increase of 1.6% and, for services provided on or

2 after October 1, 1999, shall be increased by $4.00 per

3 resident-day, as defined by the Department.

4 For facilities licensed by the Department of Public Health

5 under the Nursing Home Care Act as Intermediate Care for the

6 Developmentally Disabled facilities or Long Term Care for

7 Under Age 22 facilities, the rates taking effect on July 1,

8 2000 shall include an increase of 2.5% per resident-day, as

9 defined by the Department. For facilities licensed by the

10 Department of Public Health under the Nursing Home Care Act as

11 Skilled Nursing facilities or Intermediate Care facilities,

12 the rates taking effect on July 1, 2000 shall include an

13 increase of 2.5% per resident-day, as defined by the

14 Department.

15 For facilities licensed by the Department of Public Health

16 under the Nursing Home Care Act as skilled nursing facilities

17 or intermediate care facilities, a new payment methodology

18 must be implemented for the nursing component of the rate

19 effective July 1, 2003. The Department of Public Aid (now

20 Healthcare and Family Services) shall develop the new payment

21 methodology using the Minimum Data Set (MDS) as the instrument

22 to collect information concerning nursing home resident

23 condition necessary to compute the rate. The Department shall

24 develop the new payment methodology to meet the unique needs

25 of Illinois nursing home residents while remaining subject to

26 the appropriations provided by the General Assembly. A

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1 transition period from the payment methodology in effect on

2 June 30, 2003 to the payment methodology in effect on July 1,

3 2003 shall be provided for a period not exceeding 3 years and

4 184 days after implementation of the new payment methodology

5 as follows:

6 (A) For a facility that would receive a lower nursing

7 component rate per patient day under the new system than

8 the facility received effective on the date immediately

9 preceding the date that the Department implements the new

10 payment methodology, the nursing component rate per

11 patient day for the facility shall be held at the level in

12 effect on the date immediately preceding the date that the

13 Department implements the new payment methodology until a

14 higher nursing component rate of reimbursement is achieved

15 by that facility.

16 (B) For a facility that would receive a higher nursing

17 component rate per patient day under the payment

18 methodology in effect on July 1, 2003 than the facility

19 received effective on the date immediately preceding the

20 date that the Department implements the new payment

21 methodology, the nursing component rate per patient day

22 for the facility shall be adjusted.

23 (C) Notwithstanding paragraphs (A) and (B), the

24 nursing component rate per patient day for the facility

25 shall be adjusted subject to appropriations provided by

26 the General Assembly.

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1 For facilities licensed by the Department of Public Health

2 under the Nursing Home Care Act as Intermediate Care for the

3 Developmentally Disabled facilities or Long Term Care for

4 Under Age 22 facilities, the rates taking effect on March 1,

5 2001 shall include a statewide increase of 7.85%, as defined

6 by the Department.

7 Notwithstanding any other provision of this Section, for

8 facilities licensed by the Department of Public Health under

9 the Nursing Home Care Act as skilled nursing facilities or

10 intermediate care facilities, except facilities participating

11 in the Department's demonstration program pursuant to the

12 provisions of Title 77, Part 300, Subpart T of the Illinois

13 Administrative Code, the numerator of the ratio used by the

14 Department of Healthcare and Family Services to compute the

15 rate payable under this Section using the Minimum Data Set

16 (MDS) methodology shall incorporate the following annual

17 amounts as the additional funds appropriated to the Department

18 specifically to pay for rates based on the MDS nursing

19 component methodology in excess of the funding in effect on

20 December 31, 2006:

21 (i) For rates taking effect January 1, 2007,

22 $60,000,000.

23 (ii) For rates taking effect January 1, 2008,

24 $110,000,000.

25 (iii) For rates taking effect January 1, 2009,

26 $194,000,000.

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1 (iv) For rates taking effect April 1, 2011, or the

2 first day of the month that begins at least 45 days after

3 February 16, 2011 (the effective date of Public Act

4 96-1530), $416,500,000 or an amount as may be necessary to

5 complete the transition to the MDS methodology for the

6 nursing component of the rate. Increased payments under

7 this item (iv) are not due and payable, however, until (i)

8 the methodologies described in this paragraph are approved

9 by the federal government in an appropriate State Plan

10 amendment and (ii) the assessment imposed by Section 5B-2

11 of this Code is determined to be a permissible tax under

12 Title XIX of the Social Security Act.

13 Notwithstanding any other provision of this Section, for

14 facilities licensed by the Department of Public Health under

15 the Nursing Home Care Act as skilled nursing facilities or

16 intermediate care facilities, the support component of the

17 rates taking effect on January 1, 2008 shall be computed using

18 the most recent cost reports on file with the Department of

19 Healthcare and Family Services no later than April 1, 2005,

20 updated for inflation to January 1, 2006.

21 For facilities licensed by the Department of Public Health

22 under the Nursing Home Care Act as Intermediate Care for the

23 Developmentally Disabled facilities or Long Term Care for

24 Under Age 22 facilities, the rates taking effect on April 1,

25 2002 shall include a statewide increase of 2.0%, as defined by

26 the Department. This increase terminates on July 1, 2002;

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1 beginning July 1, 2002 these rates are reduced to the level of

2 the rates in effect on March 31, 2002, as defined by the

3 Department.

4 For facilities licensed by the Department of Public Health

5 under the Nursing Home Care Act as skilled nursing facilities

6 or intermediate care facilities, the rates taking effect on

7 July 1, 2001 shall be computed using the most recent cost

8 reports on file with the Department of Public Aid no later than

9 April 1, 2000, updated for inflation to January 1, 2001. For

10 rates effective July 1, 2001 only, rates shall be the greater

11 of the rate computed for July 1, 2001 or the rate effective on

12 June 30, 2001.

13 Notwithstanding any other provision of this Section, for

14 facilities licensed by the Department of Public Health under

15 the Nursing Home Care Act as skilled nursing facilities or

16 intermediate care facilities, the Illinois Department shall

17 determine by rule the rates taking effect on July 1, 2002,

18 which shall be 5.9% less than the rates in effect on June 30,

19 2002.

20 Notwithstanding any other provision of this Section, for

21 facilities licensed by the Department of Public Health under

22 the Nursing Home Care Act as skilled nursing facilities or

23 intermediate care facilities, if the payment methodologies

24 required under Section 5A-12 and the waiver granted under 42

25 CFR 433.68 are approved by the United States Centers for

26 Medicare and Medicaid Services, the rates taking effect on

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1 July 1, 2004 shall be 3.0% greater than the rates in effect on

2 June 30, 2004. These rates shall take effect only upon

3 approval and implementation of the payment methodologies

4 required under Section 5A-12.

5 Notwithstanding any other provisions of this Section, for

6 facilities licensed by the Department of Public Health under

7 the Nursing Home Care Act as skilled nursing facilities or

8 intermediate care facilities, the rates taking effect on

9 January 1, 2005 shall be 3% more than the rates in effect on

10 December 31, 2004.

11 Notwithstanding any other provision of this Section, for

12 facilities licensed by the Department of Public Health under

13 the Nursing Home Care Act as skilled nursing facilities or

14 intermediate care facilities, effective January 1, 2009, the

15 per diem support component of the rates effective on January

16 1, 2008, computed using the most recent cost reports on file

17 with the Department of Healthcare and Family Services no later

18 than April 1, 2005, updated for inflation to January 1, 2006,

19 shall be increased to the amount that would have been derived

20 using standard Department of Healthcare and Family Services

21 methods, procedures, and inflators.

22 Notwithstanding any other provisions of this Section, for

23 facilities licensed by the Department of Public Health under

24 the Nursing Home Care Act as intermediate care facilities that

25 are federally defined as Institutions for Mental Disease, or

26 facilities licensed by the Department of Public Health under

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1 the Specialized Mental Health Rehabilitation Act of 2013, a

2 socio-development component rate equal to 6.6% of the

3 facility's nursing component rate as of January 1, 2006 shall

4 be established and paid effective July 1, 2006. The

5 socio-development component of the rate shall be increased by

6 a factor of 2.53 on the first day of the month that begins at

7 least 45 days after January 11, 2008 (the effective date of

8 Public Act 95-707). As of August 1, 2008, the

9 socio-development component rate shall be equal to 6.6% of the

10 facility's nursing component rate as of January 1, 2006,

11 multiplied by a factor of 3.53. For services provided on or

12 after April 1, 2011, or the first day of the month that begins

13 at least 45 days after February 16, 2011 (the effective date of

14 Public Act 96-1530), whichever is later, the Illinois

15 Department may by rule adjust these socio-development

16 component rates, and may use different adjustment

17 methodologies for those facilities participating, and those

18 not participating, in the Illinois Department's demonstration

19 program pursuant to the provisions of Title 77, Part 300,

20 Subpart T of the Illinois Administrative Code, but in no case

21 may such rates be diminished below those in effect on August 1,

22 2008.

23 For facilities licensed by the Department of Public Health

24 under the Nursing Home Care Act as Intermediate Care for the

25 Developmentally Disabled facilities or as long-term care

26 facilities for residents under 22 years of age, the rates

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1 taking effect on July 1, 2003 shall include a statewide

2 increase of 4%, as defined by the Department.

3 For facilities licensed by the Department of Public Health

4 under the Nursing Home Care Act as Intermediate Care for the

5 Developmentally Disabled facilities or Long Term Care for

6 Under Age 22 facilities, the rates taking effect on the first

7 day of the month that begins at least 45 days after January 11,

8 2008 (the effective date of Public Act 95-707) shall include a

9 statewide increase of 2.5%, as defined by the Department.

10 Notwithstanding any other provision of this Section, for

11 facilities licensed by the Department of Public Health under

12 the Nursing Home Care Act as skilled nursing facilities or

13 intermediate care facilities, effective January 1, 2005,

14 facility rates shall be increased by the difference between

15 (i) a facility's per diem property, liability, and malpractice

16 insurance costs as reported in the cost report filed with the

17 Department of Public Aid and used to establish rates effective

18 July 1, 2001 and (ii) those same costs as reported in the

19 facility's 2002 cost report. These costs shall be passed

20 through to the facility without caps or limitations, except

21 for adjustments required under normal auditing procedures.

22 Rates established effective each July 1 shall govern

23 payment for services rendered throughout that fiscal year,

24 except that rates established on July 1, 1996 shall be

25 increased by 6.8% for services provided on or after January 1,

26 1997. Such rates will be based upon the rates calculated for

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1 the year beginning July 1, 1990, and for subsequent years

2 thereafter until June 30, 2001 shall be based on the facility

3 cost reports for the facility fiscal year ending at any point

4 in time during the previous calendar year, updated to the

5 midpoint of the rate year. The cost report shall be on file

6 with the Department no later than April 1 of the current rate

7 year. Should the cost report not be on file by April 1, the

8 Department shall base the rate on the latest cost report filed

9 by each skilled care facility and intermediate care facility,

10 updated to the midpoint of the current rate year. In

11 determining rates for services rendered on and after July 1,

12 1985, fixed time shall not be computed at less than zero. The

13 Department shall not make any alterations of regulations which

14 would reduce any component of the Medicaid rate to a level

15 below what that component would have been utilizing in the

16 rate effective on July 1, 1984.

17 (2) Shall take into account the actual costs incurred by

18 facilities in providing services for recipients of skilled

19 nursing and intermediate care services under the medical

20 assistance program.

21 (3) Shall take into account the medical and psycho-social

22 characteristics and needs of the patients.

23 (4) Shall take into account the actual costs incurred by

24 facilities in meeting licensing and certification standards

25 imposed and prescribed by the State of Illinois, any of its

26 political subdivisions or municipalities and by the U.S.

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1 Department of Health and Human Services pursuant to Title XIX

2 of the Social Security Act.

3 The Department of Healthcare and Family Services shall

4 develop precise standards for payments to reimburse nursing

5 facilities for any utilization of appropriate rehabilitative

6 personnel for the provision of rehabilitative services which

7 is authorized by federal regulations, including reimbursement

8 for services provided by qualified therapists or qualified

9 assistants, and which is in accordance with accepted

10 professional practices. Reimbursement also may be made for

11 utilization of other supportive personnel under appropriate

12 supervision.

13 The Department shall develop enhanced payments to offset

14 the additional costs incurred by a facility serving

15 exceptional need residents and shall allocate at least

16 $4,000,000 of the funds collected from the assessment

17 established by Section 5B-2 of this Code for such payments.

18 For the purpose of this Section, "exceptional needs" means,

19 but need not be limited to, ventilator care and traumatic

20 brain injury care. The enhanced payments for exceptional need

21 residents under this paragraph are not due and payable,

22 however, until (i) the methodologies described in this

23 paragraph are approved by the federal government in an

24 appropriate State Plan amendment and (ii) the assessment

25 imposed by Section 5B-2 of this Code is determined to be a

26 permissible tax under Title XIX of the Social Security Act.

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1 Beginning January 1, 2014 the methodologies for

2 reimbursement of nursing facility services as provided under

3 this Section 5-5.4 shall no longer be applicable for services

4 provided on or after January 1, 2014.

5 No payment increase under this Section for the MDS

6 methodology, exceptional care residents, or the

7 socio-development component rate established by Public Act

8 96-1530 of the 96th General Assembly and funded by the

9 assessment imposed under Section 5B-2 of this Code shall be

10 due and payable until after the Department notifies the

11 long-term care providers, in writing, that the payment

12 methodologies to long-term care providers required under this

13 Section have been approved by the Centers for Medicare and

14 Medicaid Services of the U.S. Department of Health and Human

15 Services and the waivers under 42 CFR 433.68 for the

16 assessment imposed by this Section, if necessary, have been

17 granted by the Centers for Medicare and Medicaid Services of

18 the U.S. Department of Health and Human Services. Upon

19 notification to the Department of approval of the payment

20 methodologies required under this Section and the waivers

21 granted under 42 CFR 433.68, all increased payments otherwise

22 due under this Section prior to the date of notification shall

23 be due and payable within 90 days of the date federal approval

24 is received.

25 On and after July 1, 2012, the Department shall reduce any

26 rate of reimbursement for services or other payments or alter

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1 any methodologies authorized by this Code to reduce any rate

2 of reimbursement for services or other payments in accordance

3 with Section 5-5e.

4 For facilities licensed by the Department of Public Health

5 under the ID/DD Community Care Act as ID/DD Facilities and

6 under the MC/DD Act as MC/DD Facilities, subject to federal

7 approval, the rates taking effect for services delivered on or

8 after August 1, 2019 shall be increased by 3.5% over the rates

9 in effect on June 30, 2019. The Department shall adopt rules,

10 including emergency rules under subsection (ii) of Section

11 5-45 of the Illinois Administrative Procedure Act, to

12 implement the provisions of this Section, including wage

13 increases for direct care staff.

14 For facilities licensed by the Department of Public Health

15 under the ID/DD Community Care Act as ID/DD Facilities and

16 under the MC/DD Act as MC/DD Facilities, subject to federal

17 approval, the rates taking effect on the latter of the

18 approval date of the State Plan Amendment for these facilities

19 or the Waiver Amendment for the home and community-based

20 services settings shall include an increase sufficient to

21 provide a $0.26 per hour wage increase to the base wage for

22 non-executive staff. The Department shall adopt rules,

23 including emergency rules as authorized by Section 5-45 of the

24 Illinois Administrative Procedure Act, to implement the

25 provisions of this Section, including wage increases for

26 direct care staff.

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1 For facilities licensed by the Department of Public Health

2 under the ID/DD Community Care Act as ID/DD Facilities and

3 under the MC/DD Act as MC/DD Facilities, subject to federal

4 approval of the State Plan Amendment and the Waiver Amendment

5 for the home and community-based services settings, the rates

6 taking effect for the services delivered on or after July 1,

7 2020 shall include an increase sufficient to provide a $1.00

8 per hour wage increase for non-executive staff. For services

9 delivered on or after January 1, 2021, subject to federal

10 approval of the State Plan Amendment and the Waiver Amendment

11 for the home and community-based services settings, shall

12 include an increase sufficient to provide a $0.50 per hour

13 increase for non-executive staff. The Department shall adopt

14 rules, including emergency rules as authorized by Section 5-45

15 of the Illinois Administrative Procedure Act, to implement the

16 provisions of this Section, including wage increases for

17 direct care staff.

18 For facilities licensed by the Department of Public Health

19 under the ID/DD Community Care Act as ID/DD Facilities and

20 under the MC/DD Act as MC/DD Facilities, subject to federal

21 approval of the State Plan Amendment, the rates taking effect

22 for the residential services delivered on or after July 1,

23 2021, shall include an increase sufficient to provide a $0.50

24 per hour increase for aides in the rate methodology. For

25 facilities licensed by the Department of Public Health under

26 the ID/DD Community Care Act as ID/DD Facilities and under the

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1 MC/DD Act as MC/DD Facilities, subject to federal approval of

2 the State Plan Amendment, the rates taking effect for the

3 residential services delivered on or after January 1, 2022

4 shall include an increase sufficient to provide a $1.00 per

5 hour increase for aides in the rate methodology. In addition,

6 for residential services delivered on or after January 1, 2022

7 such rates shall include an increase sufficient to provide

8 wages for all residential non-executive direct care staff,

9 excluding aides, at the federal Department of Labor, Bureau of

10 Labor Statistics' average wage as defined in rule by the

11 Department. The Department shall adopt rules, including

12 emergency rules as authorized by Section 5-45 of the Illinois

13 Administrative Procedure Act, to implement the provisions of

14 this Section.

15 For facilities licensed by the Department of Public Health

16 under the ID/DD Community Care Act as ID/DD facilities and

17 under the MC/DD Act as MC/DD facilities, subject to federal

18 approval of the State Plan Amendment, the rates taking effect

19 for services delivered on or after January 1, 2023, shall

20 include a $1.00 per hour wage increase for all direct support

21 personnel and all other frontline personnel who are not

22 subject to the Bureau of Labor Statistics' average wage

23 increases, who work in residential and community day services

24 settings, with at least $0.50 of those funds to be provided as

25 a direct increase to all aide base wages, with the remaining

26 $0.50 to be used flexibly for base wage increases to the rate

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1 methodology for aides. In addition, for residential services

2 delivered on or after January 1, 2023 the rates shall include

3 an increase sufficient to provide wages for all residential

4 non-executive direct care staff, excluding aides, at the

5 federal Department of Labor, Bureau of Labor Statistics'

6 average wage as determined by the Department. Also, for

7 services delivered on or after January 1, 2023, the rates will

8 include adjustments to employment-related expenses as defined

9 in rule by the Department. The Department shall adopt rules,

10 including emergency rules as authorized by Section 5-45 of the

11 Illinois Administrative Procedure Act, to implement the

12 provisions of this Section.

13 For facilities licensed by the Department of Public Health

14 under the ID/DD Community Care Act as ID/DD facilities and

15 under the MC/DD Act as MC/DD facilities, subject to federal

16 approval of the State Plan Amendment, the rates taking effect

17 for services delivered on or after January 1, 2024 shall

18 include a $2.50 per hour wage increase for all direct support

19 personnel and all other frontline personnel who are not

20 subject to the Bureau of Labor Statistics' average wage

21 increases and who work in residential and community day

22 services settings. At least $1.25 of the per hour wage

23 increase shall be provided as a direct increase to all aide

24 base wages, and the remaining $1.25 of the per hour wage

25 increase shall be used flexibly for base wage increases to the

26 rate methodology for aides. In addition, for residential

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1 services delivered on or after January 1, 2024, the rates

2 shall include an increase sufficient to provide wages for all

3 residential non-executive direct care staff, excluding aides,

4 at the federal Department of Labor, Bureau of Labor

5 Statistics' average wage as determined by the Department.

6 Also, for services delivered on or after January 1, 2024, the

7 rates will include adjustments to employment-related expenses

8 as defined in rule by the Department. The Department shall

9 adopt rules, including emergency rules as authorized by

10 Section 5-45 of the Illinois Administrative Procedure Act, to

11 implement the provisions of this Section.

12 For facilities licensed by the Department of Public Health

13 under the ID/DD Community Care Act as ID/DD facilities and

14 under the MC/DD Act as MC/DD facilities, subject to federal

15 approval of a State Plan Amendment, the rates taking effect

16 for services delivered on or after January 1, 2025 shall

17 include a $1.00 per hour wage increase for all direct support

18 personnel and all other frontline personnel who are not

19 subject to the Bureau of Labor Statistics' average wage

20 increases and who work in residential and community day

21 services settings, with at least $0.75 of those funds to be

22 provided as a direct increase to all aide base wages and the

23 remaining $0.25 to be used flexibly for base wage increases to

24 the rate methodology for aides. These increases shall not be

25 used by facilities for operational and administrative

26 expenses. In addition, for residential services delivered on

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1 or after January 1, 2025, the rates shall include an increase

2 sufficient to provide wages for all residential non-executive

3 direct care staff, excluding aides, at the federal Department

4 of Labor, Bureau of Labor Statistics' average wage as

5 determined by the Department. Also, for services delivered on

6 or after January 1, 2025, the rates will include adjustments

7 to employment-related expenses as defined in rule by the

8 Department. The Department shall adopt rules, including

9 emergency rules as authorized by Section 5-45 of the Illinois

10 Administrative Procedure Act, to implement the provisions of

11 this Section.

12 For facilities licensed by the Department of Public Health

13 under the ID/DD Community Care Act as ID/DD facilities and

14 under the MC/DD Act as MC/DD facilities, subject to federal

15 approval of a State Plan Amendment, the rates taking effect

16 for services delivered on or after January 1, 2026 shall

17 include a $0.80 per hour wage increase for all direct support

18 personnel and all other frontline personnel who are not

19 subject to the Bureau of Labor Statistics' average wage

20 increases and who work in residential and community day

21 services settings, with at least $0.60 of those funds to be

22 provided as a direct increase to all aide base wages and the

23 remaining $0.20 to be used flexibly for base wage increases to

24 the rate methodology for aides. These increases shall not be

25 used by facilities for operational and administrative

26 expenses. In addition, for residential services delivered on

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1 or after January 1, 2026, the rates shall include an increase

2 sufficient to provide wages for all residential non-executive

3 direct care staff, excluding aides, at the federal Department

4 of Labor, Bureau of Labor Statistics' average wage as

5 determined by the Department. Also, for services delivered on

6 or after January 1, 2026, the rates will include adjustments

7 to employment-related expenses as defined in rule by the

8 Department. The Department shall adopt rules, including

9 emergency rules as authorized by Section 5-45 of the Illinois

10 Administrative Procedure Act, to implement the provisions of

11 this Section.

12 Notwithstanding any other provision of this Section to the

13 contrary, any regional wage adjuster for facilities located

14 outside of the counties of Cook, DuPage, Kane, Lake, McHenry,

15 and Will shall be no lower than 1.00, and any regional wage

16 adjuster for facilities located within the counties of Cook,

17 DuPage, Kane, Lake, McHenry, and Will shall be no lower than

18 1.15.

19 (5) For dates of service starting July 1, 2027,

20 reimbursement calculations and direct payments for services

21 provided by facilities licensed under the ID/DD Community Care

22 Act are the responsibility of the Department of Healthcare and

23 Family Services. Appropriations for facilities licensed under

24 the ID/DD Community Care Act must be shifted from the

25 Department of Human Services to the Department of Healthcare

26 and Family Services. Nothing in this Section shall prohibit

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1 the Department of Healthcare and Family Services from paying

2 more than the rates specified in this Section. Nothing in this

3 Section shall affect the requirements of Section 3-213 of the

4 ID/DD Community Care Act.

5 (Source: P.A. 103-8, eff. 6-7-23; 103-588, eff. 7-1-24; 104-2,

6 eff. 6-16-25.)

7 ARTICLE 40.

8 Section 40-5. The Illinois Public Aid Code is amended by

9 changing Section 5-5e.1 as follows:

10 (305 ILCS 5/5-5e.1)

11 Sec. 5-5e.1. Safety-Net Hospitals.

12 (a) A Safety-Net Hospital is an Illinois hospital that:

13 (1) is licensed by the Department of Public Health as

14 a general acute care or pediatric hospital; and

15 (2) is a disproportionate share hospital, as described

16 in Section 1923 of the federal Social Security Act, as

17 determined by the Department; and

18 (3) meets one of the following:

19 (A) has a MIUR of at least 40% and a charity

20 percent of at least 4%; or

21 (B) has a MIUR of at least 50%.

22 (b) Definitions. As used in this Section:

23 (1) "Charity percent" means the ratio of (i) the

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1 hospital's charity charges for services provided to

2 individuals without health insurance or another source of

3 third party coverage to (ii) the Illinois total hospital

4 charges, each as reported on the hospital's OBRA form.

5 (2) "MIUR" means Medicaid Inpatient Utilization Rate

6 and is defined as a fraction, the numerator of which is the

7 number of a hospital's inpatient days provided in the

8 hospital's fiscal year ending 3 years prior to the rate

9 year, to patients who, for such days, were eligible for

10 Medicaid under Title XIX of the federal Social Security

11 Act, 42 USC 1396a et seq., excluding those persons

12 eligible for medical assistance pursuant to 42 U.S.C.

13 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of

14 Section 5-2 of this Article, and the denominator of which

15 is the total number of the hospital's inpatient days in

16 that same period, excluding those persons eligible for

17 medical assistance pursuant to 42 U.S.C.

18 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of

19 Section 5-2 of this Article.

20 (3) "OBRA form" means form HFS-3834, OBRA '93 data

21 collection form, for the rate year.

22 (4) "Rate year" means the 12-month period beginning on

23 October 1.

24 (c) Beginning July 1, 2012 and ending on December 31, 2028

25 ~~2026~~, a hospital that would have qualified for the rate year

26 beginning October 1, 2011 or October 1, 2012 shall be a

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1 Safety-Net Hospital.

2 (c-5) Beginning July 1, 2020 and ending on December 31,

3 2026, a hospital that would have qualified for the rate year

4 beginning October 1, 2020 and was designated a federal rural

5 referral center under 42 CFR 412.96 as of October 1, 2020 shall

6 be a Safety-Net Hospital.

7 (d) No later than August 15 preceding the rate year, each

8 hospital shall submit the OBRA form to the Department. Prior

9 to October 1, the Department shall notify each hospital

10 whether it has qualified as a Safety-Net Hospital.

11 (e) The Department may promulgate rules in order to

12 implement this Section.

13 (f) Nothing in this Section shall be construed as limiting

14 the ability of the Department to include the Safety-Net

15 Hospitals in the hospital rate reform mandated by Section

16 14-11 of this Code and implemented under Section 14-12 of this

17 Code and by administrative rulemaking.

18 (Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;

19 102-886, eff. 5-17-22.)

20 ARTICLE 45.

21 Section 45-5. The Hospital Licensing Act is amended by

22 changing Section 6.09 as follows:

23 (210 ILCS 85/6.09) (from Ch. 111 1/2, par. 147.09)

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1 Sec. 6.09. (a) In order to facilitate the orderly

2 transition of aged patients and patients with disabilities

3 from hospitals to post-hospital care, whenever a patient who

4 qualifies for the federal Medicare program is hospitalized,

5 the patient shall be notified of discharge at least 24 hours

6 prior to discharge from the hospital. With regard to pending

7 discharges to a skilled nursing facility, the hospital must

8 notify the case coordination unit, as defined in 89 Ill. Adm.

9 Code 240.260, at least 24 hours prior to discharge. When the

10 assessment is completed in the hospital, the case coordination

11 unit shall provide a copy of the required assessment

12 documentation directly to the nursing home to which the

13 patient is being discharged prior to discharge. The Department

14 on Aging shall provide notice of this requirement to case

15 coordination units. When a case coordination unit is unable to

16 complete an assessment in a hospital prior to the discharge of

17 a patient, 60 years of age or older, to a nursing home, the

18 case coordination unit shall notify the Department on Aging

19 which shall notify the Department of Healthcare and Family

20 Services. ~~The Department on Aging shall adopt rules to address~~

21 ~~these instances to ensure that the patient is able to access~~

22 ~~nursing home care, the nursing home is not penalized for~~

23 ~~accepting the admission, and the patient's timely discharge~~

24 ~~from the hospital is not delayed, to the extent permitted~~

25 ~~under federal law or regulation.~~ Nothing in this subsection

26 shall preclude federal requirements for a pre-admission

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1 screening/mental health (PAS/MH) as required under Section

2 2-201.5 of the Nursing Home Care Act or State or federal law or

3 regulation. If home health services are ordered, the hospital

4 must inform its designated case coordination unit, as defined

5 in 89 Ill. Adm. Code 240.260, of the pending discharge and must

6 provide the patient with the case coordination unit's

7 telephone number and other contact information.

8 (b) Every hospital shall develop procedures for a

9 physician with medical staff privileges at the hospital or any

10 appropriate medical staff member to provide the discharge

11 notice prescribed in subsection (a) of this Section. The

12 procedures must include prohibitions against discharging or

13 referring a patient to any of the following if unlicensed,

14 uncertified, or unregistered: (i) a board and care facility,

15 as defined in the Board and Care Home Act; (ii) an assisted

16 living and shared housing establishment, as defined in the

17 Assisted Living and Shared Housing Act; (iii) a facility

18 licensed under the Nursing Home Care Act, the Specialized

19 Mental Health Rehabilitation Act of 2013, the ID/DD Community

20 Care Act, or the MC/DD Act; (iv) a supportive living facility,

21 as defined in Section 5-5.01a of the Illinois Public Aid Code;

22 or (v) a free-standing hospice facility licensed under the

23 Hospice Program Licensing Act if licensure, certification, or

24 registration is required. The Department of Public Health

25 shall annually provide hospitals with a list of licensed,

26 certified, or registered board and care facilities, assisted

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1 living and shared housing establishments, nursing homes,

2 supportive living facilities, facilities licensed under the

3 ID/DD Community Care Act, the MC/DD Act, or the Specialized

4 Mental Health Rehabilitation Act of 2013, and hospice

5 facilities. Reliance upon this list by a hospital shall

6 satisfy compliance with this requirement. The procedure may

7 also include a waiver for any case in which a discharge notice

8 is not feasible due to a short length of stay in the hospital

9 by the patient, or for any case in which the patient

10 voluntarily desires to leave the hospital before the

11 expiration of the 24 hour period.

12 (c) At least 24 hours prior to discharge from the

13 hospital, the patient shall receive written information on the

14 patient's right to appeal the discharge pursuant to the

15 federal Medicare program, including the steps to follow to

16 appeal the discharge and the appropriate telephone number to

17 call in case the patient intends to appeal the discharge.

18 (d) Before transfer of a patient to a long term care

19 facility licensed under the Nursing Home Care Act where

20 elderly persons reside, a hospital shall as soon as

21 practicable initiate a name-based criminal history background

22 check by electronic submission to the Illinois State Police

23 for all persons between the ages of 18 and 70 years; provided,

24 however, that a hospital shall be required to initiate such a

25 background check only with respect to patients who:

26 (1) are transferring to a long term care facility for

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1 the first time;

2 (2) have been in the hospital more than 5 days;

3 (3) are reasonably expected to remain at the long term

4 care facility for more than 30 days;

5 (4) have a known history of serious mental illness or

6 substance abuse; and

7 (5) are independently ambulatory or mobile for more

8 than a temporary period of time.

9 A hospital may also request a criminal history background

10 check for a patient who does not meet any of the criteria set

11 forth in items (1) through (5).

12 A hospital shall notify a long term care facility if the

13 hospital has initiated a criminal history background check on

14 a patient being discharged to that facility. In all

15 circumstances in which the hospital is required by this

16 subsection to initiate the criminal history background check,

17 the transfer to the long term care facility may proceed

18 regardless of the availability of criminal history results.

19 Upon receipt of the results, the hospital shall promptly

20 forward the results to the appropriate long term care

21 facility. If the results of the background check are

22 inconclusive, the hospital shall have no additional duty or

23 obligation to seek additional information from, or about, the

24 patient.

25 (Source: P.A. 102-538, eff. 8-20-21; 103-102, eff. 1-1-24.)

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1 ARTICLE 50.

2 Section 50-5. The Illinois Public Aid Code is amended by

3 changing Section 5-5.24 as follows:

4 (305 ILCS 5/5-5.24)

5 Sec. 5-5.24. Prenatal and perinatal care.

6 (a) The Department of Healthcare and Family Services may

7 provide reimbursement under this Article for all prenatal and

8 perinatal health care services that are provided for the

9 purpose of preventing low-birthweight infants, reducing the

10 need for neonatal intensive care hospital services, and

11 promoting perinatal and maternal health. These services may

12 include comprehensive risk assessments for pregnant

13 individuals, individuals with infants, and infants, lactation

14 counseling, nutrition counseling, childbirth support,

15 psychosocial counseling, treatment and prevention of

16 periodontal disease, language translation, nurse home

17 visitation, and other support services that have been proven

18 to improve birth and maternal health outcomes. The Department

19 shall maximize the use of preventive prenatal and perinatal

20 health care services consistent with federal statutes, rules,

21 and regulations. The Department of Public Aid (now Department

22 of Healthcare and Family Services) shall develop a plan for

23 prenatal and perinatal preventive health care and shall

24 present the plan to the General Assembly by January 1, 2004. On

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1 or before January 1, 2006 and every 2 years thereafter, the

2 Department shall report to the General Assembly concerning the

3 effectiveness of prenatal and perinatal health care services

4 reimbursed under this Section in preventing low-birthweight

5 infants and reducing the need for neonatal intensive care

6 hospital services. Each such report shall include an

7 evaluation of how the ratio of expenditures for treating

8 low-birthweight infants compared with the investment in

9 promoting healthy births and infants in local community areas

10 throughout Illinois relates to healthy infant development in

11 those areas.

12 On and after July 1, 2012, the Department shall reduce any

13 rate of reimbursement for services or other payments or alter

14 any methodologies authorized by this Code to reduce any rate

15 of reimbursement for services or other payments in accordance

16 with Section 5-5e.

17 (b)(1) As used in this subsection:

18 "Affiliated provider" means a provider who is enrolled in

19 the medical assistance program and has an active contract with

20 a managed care organization.

21 "Non-affiliated provider" means a provider who is enrolled

22 in the medical assistance program but does not have a contract

23 with an MCO.

24 "Preventive prenatal and perinatal health care services"

25 means services described in subsection (a) including the

26 following non-emergent diagnostic and ancillary services:

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1 (i) Diagnostic labs and imaging, including level II

2 ultrasounds.

3 (ii) RhoGAM injections.

4 (iii) Injectable 17-alpha-hydroxyprogesterone

5 caproate (commonly called 17P).

6 (iv) Intrapartum (labor and delivery) services.

7 (v) Any other outpatient or inpatient service relating

8 to pregnancy or the 12 months following childbirth or

9 fetal loss.

10 (2) In order to maximize the accessibility of preventive

11 prenatal and perinatal health care services, the Department of

12 Healthcare and Family Services shall amend its managed care

13 contracts such that an MCO must pay for preventive prenatal

14 services, perinatal healthcare services, and postpartum

15 services rendered by a non-affiliated provider, for which the

16 health plan would pay if rendered by an affiliated provider,

17 at the rate paid under the Illinois Medicaid fee-for-service

18 program methodology for such services, including all policy

19 adjusters, including, but not limited to, Medicaid High Volume

20 Adjustments, Medicaid Percentage Adjustments, Outpatient High

21 Volume Adjustments, and all outlier add-on adjustments to the

22 extent such adjustments are incorporated in the development of

23 the applicable MCO capitated rates, unless a different rate

24 was agreed upon by the health plan and the non-affiliated

25 provider.

26 (3) In cases where a managed care organization must pay

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1 for preventive prenatal services, perinatal healthcare

2 services, and postpartum services rendered by a non-affiliated

3 provider, the requirements under paragraph (2) shall not apply

4 if the services were not emergency services, as defined in

5 Section 5-30.1, and:

6 (A) the non-affiliated provider is a perinatal

7 hospital and has, within the 12 months preceding the date

8 of service, rejected a contract that was offered in good

9 faith by the health plan as determined by the Department;

10 or

11 (B) the health plan has terminated a contract with the

12 non-affiliated provider for cause, and the Department has

13 not deemed the termination to have been without merit. The

14 Department may deem that a determination for cause has

15 merit if:

16 (i) an institutional provider has repeatedly

17 failed to conduct discharge planning; or

18 (ii) the provider's conduct adversely and

19 substantially impacts the health of Medicaid patients;

20 or

21 (iii) the provider's conduct constitutes fraud,

22 waste, or abuse; or

23 (iv) the provider's conduct violates the code of

24 ethics governing his or her profession.

25 (4) For dates of service on and after January 1, 2026, the

26 medical assistance program shall provide coverage, without

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1 imposing a deductible, coinsurance, copayment, or any other

2 cost-sharing requirement, for preeclampsia biomarker testing

3 for predictive screening in asymptomatic individuals, or for

4 diagnosis and management when symptoms are present.

5 (Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23.)

6 ARTICLE 55.

7 Section 55-5. The Specialized Mental Health Rehabilitation

8 Act of 2013 is amended by changing Sections 2-101 and 3-104 as

9 follows:

10 (210 ILCS 49/2-101)

11 Sec. 2-101. Standards for facilities.

12 (a) The Department shall, by rule, prescribe minimum

13 standards for each level of care for facilities to be in place

14 during the provisional licensure period and thereafter. These

15 standards shall include, but are not limited to, the

16 following:

17 (1) life safety standards that will ensure the health,

18 safety and welfare of residents and their protection from

19 hazards;

20 (2) number and qualifications of all personnel,

21 including management and clinical personnel, having

22 responsibility for any part of the care given to

23 consumers; specifically, the Department shall establish

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1 staffing ratios for facilities which shall specify the

2 number of staff hours per consumer of care that are needed

3 for each level of care offered within the facility;

4 (3) all sanitary conditions within the facility and

5 its surroundings, including water supply, sewage disposal,

6 food handling, and general hygiene which shall ensure the

7 health and comfort of consumers;

8 (4) a program for adequate maintenance of physical

9 plant and equipment;

10 (5) adequate accommodations, staff, and services for

11 the number and types of services being offered to

12 consumers for whom the facility is licensed to care;

13 (6) development of evacuation and other appropriate

14 safety plans for use during weather, health, fire,

15 physical plant, environmental, and national defense

16 emergencies;

17 (7) maintenance of minimum financial or other

18 resources necessary to meet the standards established

19 under this Section, and to operate and conduct the

20 facility in accordance with this Act;

21 (8) standards for coercive free environment,

22 restraint, and therapeutic separation; and

23 (9) each multiple bedroom shall have at least 55

24 square feet of net floor area per consumer, not including

25 space for closets, bathrooms, and clearly defined entryway

26 areas. A minimum of 3 feet of clearance at the foot and one

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1 side of each bed shall be provided.

2 (b) Any requirement contained in administrative rule

3 concerning a percentage of single occupancy rooms shall be

4 calculated based on the total number of licensed or

5 provisionally licensed beds under this Act on January 1, 2019

6 and shall not be calculated on a per-facility basis.

7 (c) A facility licensed under this Act shall not accept

8 any person experiencing an acute medical condition liable to

9 cause death, severe injury, or serious illness.

10 (Source: P.A. 101-10, eff. 6-5-19; 102-558, eff. 8-20-21.)

11 (210 ILCS 49/3-104)

12 Sec. 3-104. Care, treatment, and records. Facilities shall

13 provide, at a minimum, the following services: physician,

14 nursing, pharmaceutical, rehabilitative, and dietary services.

15 To provide these services, the facility shall adhere to the

16 following:

17 (1) Each consumer shall be encouraged and assisted to

18 achieve and maintain the highest level of self-care and

19 independence. Every effort shall be made to keep consumers

20 active and out of bed for reasonable periods of time,

21 except when contraindicated by physician orders.

22 (2) Every consumer shall be engaged in a

23 person-centered planning process regarding his or her

24 total care and treatment.

25 (3) All medical treatment and procedures shall be

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1 administered as ordered by a physician. All new physician

2 orders shall be reviewed by the facility's director of

3 nursing or charge nurse designee within 24 hours after

4 such orders have been issued to ensure facility compliance

5 with such orders. According to rules adopted by the

6 Department, every woman consumer of child bearing age

7 shall receive routine obstetrical and gynecological

8 evaluations as well as necessary prenatal care.

9 (4) Each consumer shall be provided with good

10 nutrition and with necessary fluids for hydration.

11 (5) Each consumer shall be provided visual privacy

12 during treatment and personal care.

13 (6) Every consumer or consumer's guardian shall be

14 permitted to inspect and copy all his or her clinical and

15 other records concerning his or her care kept by the

16 facility or by his or her physician. The facility may

17 charge a reasonable fee for duplication of a record.

18 (7) Each consumer shall be offered at least 15 hours

19 of treatment programming per week and shall be encouraged

20 to attend the treatment domains that meet the consumer's

21 needs, as reflected in the consumer's treatment plans.

22 Each consumer's program engagement and attendance shall be

23 documented in the consumer's clinical record, and each

24 consumer shall be prompted to attend programming regularly

25 as documented in the consumer's clinical record at least

26 quarterly.

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1 (Source: P.A. 98-104, eff. 7-22-13.)

2 ARTICLE 60.

3 Section 60-5. The Illinois Public Aid Code is amended by

4 adding Section 5-5.25a as follows:

5 (305 ILCS 5/5-5.25a new)

6 Sec. 5-5.25a. Coverage for seizure detection devices.

7 (a) As used in this Section, "seizure detection device"

8 means a monitoring device cleared by the United States Food

9 and Drug Administration, and any related technology,

10 application, service, or subscription supporting the

11 prescribed use of the device, that provides the following:

12 (1) individual monitoring and alert services relating

13 to seizure activity;

14 (2) detection or prediction of seizure activity and

15 transmission of notification of the seizure activity to

16 the individual or a caregiver for appropriate medical

17 response; or

18 (3) collection of data of the seizure activity of the

19 individual that can be used by a health care provider to

20 diagnose or appropriately treat a health care condition

21 that causes the seizure activity.

22 (b) All seizure detection devices covered under this

23 Section shall be approved for use by individuals, provided

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1 that the device has been prescribed and determined to be

2 medically necessary. The choice of device shall be made based

3 upon the individual's circumstances and medical needs in

4 consultation with the individual's medical provider.

5 (c) Any individual who has been prescribed a seizure

6 detection device shall not be required to obtain prior

7 authorization for coverage for a seizure detection device, and

8 coverage shall be continuous once the seizure detection device

9 is prescribed.

10 (d) Notwithstanding any other provision of this Section,

11 commencing July 1, 2027, all seizure detection devices cleared

12 by the United States Food and Drug Administration shall be

13 covered under the medical assistance program for persons who

14 have been prescribed a seizure detection device and who are

15 otherwise eligible for assistance under this Article.

16 (e) The Department shall not adopt rules or classification

17 policies that would limit the ability of individuals covered

18 by this Section to obtain seizure detection devices.

19 ARTICLE 65.

20 Section 65-5. The Community-Integrated Living Arrangements

21 Licensure and Certification Act is amended by changing Section

22 13.3 as follows:

23 (210 ILCS 135/13.3)

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1 Sec. 13.3. Community-integrated living arrangement per

2 diem reimbursement. As used in this Section, "medical absence"

3 means a situation in which a resident is temporarily absent

4 from a community-integrated living arrangement to receive

5 medical treatment or for other reasons that have been

6 recommended by third-party medical personnel, including, but

7 not limited to, hospitalizations, placements in short-term

8 stabilization homes or State-operated facilities, stays in

9 nursing facilities, rehabilitation in long-term care

10 facilities, or other absences for legitimate medical reasons.

11 Beginning January 1, 2025, the Department's Division of

12 Developmental Disabilities shall provide 100% of the per diem

13 reimbursement to a 24-hour community-integrated living

14 arrangement provider for up to 20 days for any resident

15 requiring a medical absence. During the medical absence, the

16 provider shall hold the bed for the resident. After the

17 medical absence, the resident shall return to the

18 community-integrated living arrangement when the resident is

19 medically able to return in order for the provider to receive

20 the full per diem reimbursement for the absent days. However,

21 if it is determined by a treating physician that the resident

22 is unable to return to the community-integrated living

23 arrangement, or if the resident dies during the medical

24 absence, the provider shall receive 100% of the per diem

25 reimbursement for up to 20 medical absence days. The per diem

26 reimbursement shall be in addition to the existing occupancy

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1 factor policy set by the Division of Developmental

2 Disabilities. Any Department policy or rulemaking issued to

3 implement this Section shall provide that for medical absences

4 a resident's termination date is the date the resident either

5 passes away or the date it is determined by a treating

6 physician that the resident is unable to return to the

7 community-integrated living arrangement.

8 (Source: P.A. 103-593, eff. 6-7-24.)

9 ARTICLE 75.

10 Section 75-5. The Illinois Public Aid Code is amended by

11 changing Section 5-5.02 as follows:

12 (305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)

13 Sec. 5-5.02. Hospital reimbursements.

14 (a) Reimbursement to hospitals; July 1, 1992 through

15 September 30, 1992. Notwithstanding any other provisions of

16 this Code or the Illinois Department's Rules promulgated under

17 the Illinois Administrative Procedure Act, reimbursement to

18 hospitals for services provided during the period July 1, 1992

19 through September 30, 1992, shall be as follows:

20 (1) For inpatient hospital services rendered, or if

21 applicable, for inpatient hospital discharges occurring,

22 on or after July 1, 1992 and on or before September 30,

23 1992, the Illinois Department shall reimburse hospitals

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1 for inpatient services under the reimbursement

2 methodologies in effect for each hospital, and at the

3 inpatient payment rate calculated for each hospital, as of

4 June 30, 1992. For purposes of this paragraph,

5 "reimbursement methodologies" means all reimbursement

6 methodologies that pertain to the provision of inpatient

7 hospital services, including, but not limited to, any

8 adjustments for disproportionate share, targeted access,

9 critical care access and uncompensated care, as defined by

10 the Illinois Department on June 30, 1992.

11 (2) For the purpose of calculating the inpatient

12 payment rate for each hospital eligible to receive

13 quarterly adjustment payments for targeted access and

14 critical care, as defined by the Illinois Department on

15 June 30, 1992, the adjustment payment for the period July

16 1, 1992 through September 30, 1992, shall be 25% of the

17 annual adjustment payments calculated for each eligible

18 hospital, as of June 30, 1992. The Illinois Department

19 shall determine by rule the adjustment payments for

20 targeted access and critical care beginning October 1,

21 1992.

22 (3) For the purpose of calculating the inpatient

23 payment rate for each hospital eligible to receive

24 quarterly adjustment payments for uncompensated care, as

25 defined by the Illinois Department on June 30, 1992, the

26 adjustment payment for the period August 1, 1992 through

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1 September 30, 1992, shall be one-sixth of the total

2 uncompensated care adjustment payments calculated for each

3 eligible hospital for the uncompensated care rate year, as

4 defined by the Illinois Department, ending on July 31,

5 1992. The Illinois Department shall determine by rule the

6 adjustment payments for uncompensated care beginning

7 October 1, 1992.

8 (b) Inpatient payments. For inpatient services provided on

9 or after October 1, 1993, in addition to rates paid for

10 hospital inpatient services pursuant to the Illinois Health

11 Finance Reform Act, as now or hereafter amended, or the

12 Illinois Department's prospective reimbursement methodology,

13 or any other methodology used by the Illinois Department for

14 inpatient services, the Illinois Department shall make

15 adjustment payments, in an amount calculated pursuant to the

16 methodology described in paragraph (c) of this Section, to

17 hospitals that the Illinois Department determines satisfy any

18 one of the following requirements:

19 (1) Hospitals that are described in Section 1923 of

20 the federal Social Security Act, as now or hereafter

21 amended, except that for rate year 2015 and after a

22 hospital described in Section 1923(b)(1)(B) of the federal

23 Social Security Act and qualified for the payments

24 described in subsection (c) of this Section for rate year

25 2014 provided the hospital continues to meet the

26 description in Section 1923(b)(1)(B) in the current

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1 determination year; or

2 (2) Illinois hospitals that have a Medicaid inpatient

3 utilization rate which is at least one-half a standard

4 deviation above the mean Medicaid inpatient utilization

5 rate for all hospitals in Illinois receiving Medicaid

6 payments from the Illinois Department; or

7 (3) Illinois hospitals that on July 1, 1991 had a

8 Medicaid inpatient utilization rate, as defined in

9 paragraph (h) of this Section, that was at least the mean

10 Medicaid inpatient utilization rate for all hospitals in

11 Illinois receiving Medicaid payments from the Illinois

12 Department and which were located in a planning area with

13 one-third or fewer excess beds as determined by the Health

14 Facilities and Services Review Board, and that, as of June

15 30, 1992, were located in a federally designated Health

16 Manpower Shortage Area; or

17 (4) Illinois hospitals that:

18 (A) have a Medicaid inpatient utilization rate

19 that is at least equal to the mean Medicaid inpatient

20 utilization rate for all hospitals in Illinois

21 receiving Medicaid payments from the Department; and

22 (B) also have a Medicaid obstetrical inpatient

23 utilization rate that is at least one standard

24 deviation above the mean Medicaid obstetrical

25 inpatient utilization rate for all hospitals in

26 Illinois receiving Medicaid payments from the

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1 Department for obstetrical services; or

2 (5) Any children's hospital, which means a hospital

3 devoted exclusively to caring for children. A hospital

4 which includes a facility devoted exclusively to caring

5 for children shall be considered a children's hospital to

6 the degree that the hospital's Medicaid care is provided

7 to children if either (i) the facility devoted exclusively

8 to caring for children is separately licensed as a

9 hospital by a municipality prior to February 28, 2013;

10 (ii) the hospital has been designated by the State as a

11 Level III perinatal care facility, has a Medicaid

12 Inpatient Utilization rate greater than 55% for the rate

13 year 2003 disproportionate share determination, and has

14 more than 10,000 qualified children days as defined by the

15 Department in rulemaking; (iii) the hospital has been

16 designated as a Perinatal Level III center by the State as

17 of December 1, 2017, is a Pediatric Critical Care Center

18 designated by the State as of December 1, 2017 and has a

19 2017 Medicaid inpatient utilization rate equal to or

20 greater than 45%; or (iv) the hospital has been designated

21 as a Perinatal Level II center by the State as of December

22 1, 2017, has a 2017 Medicaid Inpatient Utilization Rate

23 greater than 70%, and has at least 10 pediatric beds as

24 listed on the IDPH 2015 calendar year hospital profile; or

25 (6) A hospital that reopens a previously closed

26 hospital facility within 4 calendar years of the hospital

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1 facility's closure, if the previously closed hospital

2 facility qualified for payments under paragraph (c) at the

3 time of closure, until utilization data for the new

4 facility is available for the Medicaid inpatient

5 utilization rate calculation. For purposes of this clause,

6 a "closed hospital facility" shall include hospitals that

7 have been terminated from participation in the medical

8 assistance program in accordance with Section 12-4.25 of

9 this Code.

10 (c) Inpatient adjustment payments. The adjustment payments

11 required by paragraph (b) shall be calculated based upon the

12 hospital's Medicaid inpatient utilization rate as follows:

13 (1) hospitals with a Medicaid inpatient utilization

14 rate below the mean shall receive a per day adjustment

15 payment equal to $25;

16 (2) hospitals with a Medicaid inpatient utilization

17 rate that is equal to or greater than the mean Medicaid

18 inpatient utilization rate but less than one standard

19 deviation above the mean Medicaid inpatient utilization

20 rate shall receive a per day adjustment payment equal to

21 the sum of $25 plus $1 for each one percent that the

22 hospital's Medicaid inpatient utilization rate exceeds the

23 mean Medicaid inpatient utilization rate;

24 (3) hospitals with a Medicaid inpatient utilization

25 rate that is equal to or greater than one standard

26 deviation above the mean Medicaid inpatient utilization

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1 rate but less than 1.5 standard deviations above the mean

2 Medicaid inpatient utilization rate shall receive a per

3 day adjustment payment equal to the sum of $40 plus $7 for

4 each one percent that the hospital's Medicaid inpatient

5 utilization rate exceeds one standard deviation above the

6 mean Medicaid inpatient utilization rate;

7 (4) hospitals with a Medicaid inpatient utilization

8 rate that is equal to or greater than 1.5 standard

9 deviations above the mean Medicaid inpatient utilization

10 rate shall receive a per day adjustment payment equal to

11 the sum of $90 plus $2 for each one percent that the

12 hospital's Medicaid inpatient utilization rate exceeds 1.5

13 standard deviations above the mean Medicaid inpatient

14 utilization rate; and

15 (5) hospitals qualifying under clause (6) of paragraph

16 (b) shall have the rate assigned to the previously closed

17 hospital facility at the date of closure, until

18 utilization data for the new facility is available for the

19 Medicaid inpatient utilization rate calculation.

20 (c-1) Beginning October 1, 2026, for rate year 2027 and

21 thereafter, the Medicaid inpatient utilization rate used in

22 the determination of eligibility for payments under paragraph

23 (c) shall be modified to exclude from both the numerator and

24 denominator all days of care funded by the U.S. Department of

25 Veterans Affairs at a hospital approved to conduct its

26 operations from more than one location within contiguous

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1 counties under a single license, if at the time of its

2 licensing application the hospital was located in a county

3 with fewer than 125,000 inhabitants and the hospital's second

4 facility is located in a contiguous county with fewer than

5 235,000 inhabitants. For purposes of this subsection, days of

6 care funded by the U.S. Department of Veterans Affairs include

7 authorized VA community care provided at non-VA hospitals.

8 (d) Supplemental adjustment payments. In addition to the

9 adjustment payments described in paragraph (c), hospitals as

10 defined in clauses (1) through (6) of paragraph (b), excluding

11 county hospitals (as defined in subsection (c) of Section 15-1

12 of this Code) and a hospital organized under the University of

13 Illinois Hospital Act, shall be paid supplemental inpatient

14 adjustment payments of $60 per day. For purposes of Title XIX

15 of the federal Social Security Act, these supplemental

16 adjustment payments shall not be classified as adjustment

17 payments to disproportionate share hospitals.

18 (e) The inpatient adjustment payments described in

19 paragraphs (c) and (d) shall be increased on October 1, 1993

20 and annually thereafter by a percentage equal to the lesser of

21 (i) the increase in the DRI hospital cost index for the most

22 recent 12 month period for which data are available, or (ii)

23 the percentage increase in the statewide average hospital

24 payment rate over the previous year's statewide average

25 hospital payment rate. The sum of the inpatient adjustment

26 payments under paragraphs (c) and (d) to a hospital, other

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1 than a county hospital (as defined in subsection (c) of

2 Section 15-1 of this Code) or a hospital organized under the

3 University of Illinois Hospital Act, however, shall not exceed

4 $275 per day; that limit shall be increased on October 1, 1993

5 and annually thereafter by a percentage equal to the lesser of

6 (i) the increase in the DRI hospital cost index for the most

7 recent 12-month period for which data are available or (ii)

8 the percentage increase in the statewide average hospital

9 payment rate over the previous year's statewide average

10 hospital payment rate.

11 (f) Children's hospital inpatient adjustment payments. For

12 children's hospitals, as defined in clause (5) of paragraph

13 (b), the adjustment payments required pursuant to paragraphs

14 (c) and (d) shall be multiplied by 2.0.

15 (g) County hospital inpatient adjustment payments. For

16 county hospitals, as defined in subsection (c) of Section 15-1

17 of this Code, there shall be an adjustment payment as

18 determined by rules issued by the Illinois Department.

19 (h) For the purposes of this Section the following terms

20 shall be defined as follows:

21 (1) "Medicaid inpatient utilization rate" means a

22 fraction, the numerator of which is the number of a

23 hospital's inpatient days provided in a given 12-month

24 period to patients who, for such days, were eligible for

25 Medicaid under Title XIX of the federal Social Security

26 Act, and the denominator of which is the total number of

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1 the hospital's inpatient days in that same period.

2 (2) "Mean Medicaid inpatient utilization rate" means

3 the total number of Medicaid inpatient days provided by

4 all Illinois Medicaid-participating hospitals divided by

5 the total number of inpatient days provided by those same

6 hospitals.

7 (3) "Medicaid obstetrical inpatient utilization rate"

8 means the ratio of Medicaid obstetrical inpatient days to

9 total Medicaid inpatient days for all Illinois hospitals

10 receiving Medicaid payments from the Illinois Department.

11 (i) Inpatient adjustment payment limit. In order to meet

12 the limits of Public Law 102-234 and Public Law 103-66, the

13 Illinois Department shall by rule adjust disproportionate

14 share adjustment payments.

15 (j) University of Illinois Hospital inpatient adjustment

16 payments. For hospitals organized under the University of

17 Illinois Hospital Act, there shall be an adjustment payment as

18 determined by rules adopted by the Illinois Department.

19 (k) The Illinois Department may by rule establish criteria

20 for and develop methodologies for adjustment payments to

21 hospitals participating under this Article.

22 (l) On and after July 1, 2012, the Department shall reduce

23 any rate of reimbursement for services or other payments or

24 alter any methodologies authorized by this Code to reduce any

25 rate of reimbursement for services or other payments in

26 accordance with Section 5-5e.

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1 (m) The Department shall establish a cost-based

2 reimbursement methodology for determining payments to

3 hospitals for approved graduate medical education (GME)

4 programs for dates of service on and after July 1, 2018.

5 (1) As used in this subsection, "hospitals" means the

6 University of Illinois Hospital as defined in the

7 University of Illinois Hospital Act and a county hospital

8 in a county of over 3,000,000 inhabitants.

9 (2) An amendment to the Illinois Title XIX State Plan

10 defining GME shall maximize reimbursement, shall not be

11 limited to the education programs or special patient care

12 payments allowed under Medicare, and shall include:

13 (A) inpatient days;

14 (B) outpatient days;

15 (C) direct costs;

16 (D) indirect costs;

17 (E) managed care days;

18 (F) all stages of medical training and education

19 including students, interns, residents, and fellows

20 with no caps on the number of persons who may qualify;

21 and

22 (G) patient care payments related to the

23 complexities of treating Medicaid enrollees including

24 clinical and social determinants of health.

25 (3) The Department shall make all GME payments

26 directly to hospitals including such costs in support of

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1 clients enrolled in Medicaid managed care entities.

2 (4) The Department shall promptly take all actions

3 necessary for reimbursement to be effective for dates of

4 service on and after July 1, 2018 including publishing all

5 appropriate public notices, amendments to the Illinois

6 Title XIX State Plan, and adoption of administrative rules

7 if necessary.

8 (5) As used in this subsection, "managed care days"

9 means costs associated with services rendered to enrollees

10 of Medicaid managed care entities. "Medicaid managed care

11 entities" means any entity which contracts with the

12 Department to provide services paid for on a capitated

13 basis. "Medicaid managed care entities" includes a managed

14 care organization and a managed care community network.

15 (6) All payments under this Section are contingent

16 upon federal approval of changes to the Illinois Title XIX

17 State Plan, if that approval is required.

18 (7) The Department may adopt rules necessary to

19 implement Public Act 100-581 through the use of emergency

20 rulemaking in accordance with subsection (aa) of Section

21 5-45 of the Illinois Administrative Procedure Act. For

22 purposes of that Act, the General Assembly finds that the

23 adoption of rules to implement Public Act 100-581 is

24 deemed an emergency and necessary for the public interest,

25 safety, and welfare.

26 (Source: P.A. 101-81, eff. 7-12-19; 102-682, eff. 12-10-21;

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1 102-886, eff. 5-17-22.)

2 ARTICLE 85.

3 Section 85-5. The Illinois Act on the Aging is amended by

4 changing Section 4.02 as follows:

5 (20 ILCS 105/4.02)

6 Sec. 4.02. Community Care Program. The Department shall

7 establish a program of services to prevent unnecessary

8 institutionalization of persons age 60 and older in need of

9 long term care or who are established as persons who suffer

10 from Alzheimer's disease or a related disorder under the

11 Alzheimer's Disease Assistance Act, thereby enabling them to

12 remain in their own homes or in other living arrangements.

13 Such preventive services, which may be coordinated with other

14 programs for the aged, may include, but are not limited to, any

15 or all of the following:

16 (a) (blank);

17 (b) (blank);

18 (c) home care aide services;

19 (d) personal assistant services;

20 (e) adult day services;

21 (f) home-delivered meals;

22 (g) education in self-care;

23 (h) personal care services;

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1 (i) adult day health services;

2 (j) habilitation services;

3 (k) respite care;

4 (k-5) community reintegration services;

5 (k-6) flexible senior services;

6 (k-7) medication management;

7 (k-8) emergency home response;

8 (l) other nonmedical social services that may enable

9 the person to become self-supporting; or

10 (m) (blank).

11 The Department shall establish eligibility standards for

12 such services. In determining the amount and nature of

13 services for which a person may qualify, consideration shall

14 not be given to the value of cash, property, or other assets

15 held in the name of the person's spouse pursuant to a written

16 agreement dividing marital property into equal but separate

17 shares or pursuant to a transfer of the person's interest in a

18 home to his spouse, provided that the spouse's share of the

19 marital property is not made available to the person seeking

20 such services.

21 The Department shall require as a condition of eligibility

22 that all new financially eligible applicants apply for and

23 enroll in medical assistance under Article V of the Illinois

24 Public Aid Code in accordance with rules promulgated by the

25 Department.

26 The Department shall, in conjunction with the Department

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1 of Public Aid (now Department of Healthcare and Family

2 Services), seek appropriate amendments under Sections 1915 and

3 1924 of the Social Security Act. The purpose of the amendments

4 shall be to extend eligibility for home and community based

5 services under Sections 1915 and 1924 of the Social Security

6 Act to persons who transfer to or for the benefit of a spouse

7 those amounts of income and resources allowed under Section

8 1924 of the Social Security Act. Subject to the approval of

9 such amendments, the Department shall extend the provisions of

10 Section 5-4 of the Illinois Public Aid Code to persons who, but

11 for the provision of home or community-based services, would

12 require the level of care provided in an institution, as is

13 provided for in federal law. Those persons no longer found to

14 be eligible for receiving noninstitutional services due to

15 changes in the eligibility criteria shall be given 45 days

16 notice prior to actual termination. Those persons receiving

17 notice of termination may contact the Department and request

18 the determination be appealed at any time during the 45 day

19 notice period. The target population identified for the

20 purposes of this Section are persons age 60 and older with an

21 identified service need. Priority shall be given to those who

22 are at imminent risk of institutionalization. The services

23 shall be provided to eligible persons age 60 and older to the

24 extent that the cost of the services together with the other

25 personal maintenance expenses of the persons are reasonably

26 related to the standards established for care in a group

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1 facility appropriate to the person's condition. These

2 noninstitutional services, pilot projects, or experimental

3 facilities may be provided as part of or in addition to those

4 authorized by federal law or those funded and administered by

5 the Department of Human Services. The Departments of Human

6 Services, Healthcare and Family Services, Public Health,

7 Veterans' Affairs, and Commerce and Economic Opportunity and

8 other appropriate agencies of State, federal, and local

9 governments shall cooperate with the Department on Aging in

10 the establishment and development of the noninstitutional

11 services. The Department shall require an annual audit from

12 all personal assistant and home care aide vendors contracting

13 with the Department under this Section. The annual audit shall

14 assure that each audited vendor's procedures are in compliance

15 with Department's financial reporting guidelines requiring an

16 administrative and employee wage and benefits cost split as

17 defined in administrative rules. The audit is a public record

18 under the Freedom of Information Act. The Department shall

19 execute, relative to the nursing home prescreening project,

20 written inter-agency agreements with the Department of Human

21 Services and the Department of Healthcare and Family Services,

22 to effect the following: (1) intake procedures and common

23 eligibility criteria for those persons who are receiving

24 noninstitutional services; and (2) the establishment and

25 development of noninstitutional services in areas of the State

26 where they are not currently available or are undeveloped. On

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1 and after July 1, 1996, all nursing home prescreenings for

2 individuals 60 years of age or older shall be conducted by the

3 Department.

4 As part of the Department on Aging's routine training of

5 case managers and case manager supervisors, the Department may

6 include information on family futures planning for persons who

7 are age 60 or older and who are caregivers of their adult

8 children with developmental disabilities. The content of the

9 training shall be at the Department's discretion.

10 The Department is authorized to establish a system of

11 recipient copayment for services provided under this Section,

12 such copayment to be based upon the recipient's ability to pay

13 but in no case to exceed the actual cost of the services

14 provided. Additionally, any portion of a person's income which

15 is equal to or less than the federal poverty standard shall not

16 be considered by the Department in determining the copayment.

17 The level of such copayment shall be adjusted whenever

18 necessary to reflect any change in the officially designated

19 federal poverty standard.

20 The Department, or the Department's authorized

21 representative, may recover the amount of moneys expended for

22 services provided to or in behalf of a person under this

23 Section by a claim against the person's estate or against the

24 estate of the person's surviving spouse, but no recovery may

25 be had until after the death of the surviving spouse, if any,

26 and then only at such time when there is no surviving child who

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1 is under age 21 or blind or who has a permanent and total

2 disability. This paragraph, however, shall not bar recovery,

3 at the death of the person, of moneys for services provided to

4 the person or in behalf of the person under this Section to

5 which the person was not entitled; provided that such recovery

6 shall not be enforced against any real estate while it is

7 occupied as a homestead by the surviving spouse or other

8 dependent, if no claims by other creditors have been filed

9 against the estate, or, if such claims have been filed, they

10 remain dormant for failure of prosecution or failure of the

11 claimant to compel administration of the estate for the

12 purpose of payment. This paragraph shall not bar recovery from

13 the estate of a spouse, under Sections 1915 and 1924 of the

14 Social Security Act and Section 5-4 of the Illinois Public Aid

15 Code, who precedes a person receiving services under this

16 Section in death. All moneys for services paid to or in behalf

17 of the person under this Section shall be claimed for recovery

18 from the deceased spouse's estate. "Homestead", as used in

19 this paragraph, means the dwelling house and contiguous real

20 estate occupied by a surviving spouse or relative, as defined

21 by the rules and regulations of the Department of Healthcare

22 and Family Services, regardless of the value of the property.

23 The Department shall increase the effectiveness of the

24 existing Community Care Program by:

25 (1) ensuring that in-home services included in the

26 care plan are available on evenings and weekends;

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1 (2) ensuring that care plans contain the services that

2 eligible participants need based on the number of days in

3 a month, not limited to specific blocks of time, as

4 identified by the comprehensive assessment tool selected

5 by the Department for use statewide, not to exceed the

6 total monthly service cost maximum allowed for each

7 service; the Department shall develop administrative rules

8 to implement this item (2);

9 (3) ensuring that the participants have the right to

10 choose the services contained in their care plan and to

11 direct how those services are provided, based on

12 administrative rules established by the Department;

13 (4)(blank);

14 (5) ensuring that homemakers can provide personal care

15 services that may or may not involve contact with clients,

16 including, but not limited to:

17 (A) bathing;

18 (B) grooming;

19 (C) toileting;

20 (D) nail care;

21 (E) transferring;

22 (F) respiratory services;

23 (G) exercise; or

24 (H) positioning;

25 (6) ensuring that homemaker program vendors are not

26 restricted from hiring homemakers who are family members

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1 of clients or recommended by clients; the Department may

2 not, by rule or policy, require homemakers who are family

3 members of clients or recommended by clients to accept

4 assignments in homes other than the client;

5 (7) ensuring that the State may access maximum federal

6 matching funds by seeking approval for the Centers for

7 Medicare and Medicaid Services for modifications to the

8 State's home and community based services waiver and

9 additional waiver opportunities, including applying for

10 enrollment in the Balance Incentive Payment Program by May

11 1, 2013, in order to maximize federal matching funds; this

12 shall include, but not be limited to, modification that

13 reflects all changes in the Community Care Program

14 services and all increases in the services cost maximum;

15 (8) ensuring that the determination of need tool

16 accurately reflects the service needs of individuals with

17 Alzheimer's disease and related dementia disorders;

18 (9) ensuring that services are authorized accurately

19 and consistently for the Community Care Program (CCP); the

20 Department shall implement a Service Authorization policy

21 directive; the purpose shall be to ensure that eligibility

22 and services are authorized accurately and consistently in

23 the CCP program; the policy directive shall clarify

24 service authorization guidelines to Care Coordination

25 Units and Community Care Program providers no later than

26 May 1, 2013;

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1 (10) working in conjunction with Care Coordination

2 Units, the Department of Healthcare and Family Services,

3 the Department of Human Services, Community Care Program

4 providers, and other stakeholders to make improvements to

5 the Medicaid claiming processes and the Medicaid

6 enrollment procedures or requirements as needed,

7 including, but not limited to, specific policy changes or

8 rules to improve the up-front enrollment of participants

9 in the Medicaid program and specific policy changes or

10 rules to ensure ~~insure~~ more prompt submission of bills to

11 the federal government to secure maximum federal matching

12 dollars as promptly as possible; the Department on Aging

13 shall have at least 3 meetings with stakeholders by

14 January 1, 2014 in order to address these improvements;

15 (11) requiring home care service providers to comply

16 with the rounding of hours worked provisions under the

17 federal Fair Labor Standards Act (FLSA) and as set forth

18 in 29 CFR 785.48(b) by May 1, 2013;

19 (12) implementing any necessary policy changes or

20 promulgating any rules, no later than January 1, 2014, to

21 assist the Department of Healthcare and Family Services in

22 moving as many participants as possible, consistent with

23 federal regulations, into coordinated care plans if a care

24 coordination plan that covers long term care is available

25 in the recipient's area; and

26 (13) (blank).

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1 By January 1, 2009 or as soon after the end of the Cash and

2 Counseling Demonstration Project as is practicable, the

3 Department may, based on its evaluation of the demonstration

4 project, promulgate rules concerning personal assistant

5 services, to include, but need not be limited to,

6 qualifications, employment screening, rights under fair labor

7 standards, training, fiduciary agent, and supervision

8 requirements. All applicants shall be subject to the

9 provisions of the Health Care Worker Background Check Act.

10 The Department shall develop procedures to enhance

11 availability of services on evenings, weekends, and on an

12 emergency basis to meet the respite needs of caregivers.

13 Procedures shall be developed to permit the utilization of

14 services in successive blocks of 24 hours up to the monthly

15 maximum established by the Department. Workers providing these

16 services shall be appropriately trained.

17 No person may perform chore/housekeeping and home care

18 aide services under a program authorized by this Section

19 unless that person has been issued a certificate of

20 pre-service to do so by his or her employing agency.

21 Information gathered to effect such certification shall

22 include (i) the person's name, (ii) the date the person was

23 hired by his or her current employer, and (iii) the training,

24 including dates and levels. Persons engaged in the program

25 authorized by this Section before the effective date of this

26 amendatory Act of 1991 shall be issued a certificate of all

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1 pre-service and in-service training from his or her employer

2 upon submitting the necessary information. The employing

3 agency shall be required to retain records of all staff

4 pre-service and in-service training, and shall provide such

5 records to the Department upon request and upon termination of

6 the employer's contract with the Department. In addition, the

7 employing agency is responsible for the issuance of

8 certifications of in-service training completed to its ~~their~~

9 employees.

10 The Department is required to develop a system to ensure

11 that persons working as home care aides and personal

12 assistants receive increases in their wages when the federal

13 minimum wage is increased by requiring vendors to certify that

14 they are meeting the federal minimum wage statute for home

15 care aides and personal assistants. An employer that cannot

16 ensure that the minimum wage increase is being given to home

17 care aides and personal assistants shall be denied any

18 increase in reimbursement costs.

19 The Community Care Program Advisory Committee is created

20 in the Department on Aging. The Director shall appoint

21 individuals to serve in the Committee, who shall serve at

22 their own expense. Members of the Committee must abide by all

23 applicable ethics laws. The Committee shall advise the

24 Department on issues related to the Department's program of

25 services to prevent unnecessary institutionalization. The

26 Committee shall meet on a bi-monthly basis and shall serve to

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1 identify and advise the Department on present and potential

2 issues affecting the service delivery network, the program's

3 clients, and the Department and to recommend solution

4 strategies. Persons appointed to the Committee shall be

5 appointed on, but not limited to, their own and their agency's

6 experience with the program, geographic representation, and

7 willingness to serve. The Director shall appoint members to

8 the Committee to represent provider, advocacy, policy

9 research, and other constituencies committed to the delivery

10 of high quality home and community-based services to older

11 adults. Representatives shall be appointed to ensure

12 representation from community care providers, including, but

13 not limited to, adult day service providers, homemaker

14 providers, case coordination and case management units,

15 emergency home response providers, statewide trade or labor

16 unions that represent home care aides and direct care staff,

17 area agencies on aging, adults over age 60, membership

18 organizations representing older adults, and other

19 organizational entities, providers of care, or individuals

20 with demonstrated interest and expertise in the field of home

21 and community care as determined by the Director.

22 Nominations may be presented from any agency or State

23 association with interest in the program. The Director, or his

24 or her designee, shall serve as the permanent co-chair of the

25 advisory committee. One other co-chair shall be nominated and

26 approved by the members of the committee on an annual basis.

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1 Committee members' terms of appointment shall be for 4 years

2 with one-quarter of the appointees' terms expiring each year.

3 A member shall continue to serve until his or her replacement

4 is named. The Department shall fill vacancies that have a

5 remaining term of over one year, and this replacement shall

6 occur through the annual replacement of expiring terms. The

7 Director shall designate Department staff to provide technical

8 assistance and staff support to the committee. Department

9 representation shall not constitute membership of the

10 committee. All Committee papers, issues, recommendations,

11 reports, and meeting memoranda are advisory only. The

12 Director, or his or her designee, shall make a written report,

13 as requested by the Committee, regarding issues before the

14 Committee.

15 The Department on Aging and the Department of Human

16 Services shall cooperate in the development and submission of

17 an annual report on programs and services provided under this

18 Section. Such joint report shall be filed with the Governor

19 and the General Assembly on or before March 31 of the following

20 fiscal year.

21 The requirement for reporting to the General Assembly

22 shall be satisfied by filing copies of the report as required

23 by Section 3.1 of the General Assembly Organization Act and

24 filing such additional copies with the State Government Report

25 Distribution Center for the General Assembly as is required

26 under paragraph (t) of Section 7 of the State Library Act.

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1 Those persons previously found eligible for receiving

2 noninstitutional services whose services were discontinued

3 under the Emergency Budget Act of Fiscal Year 1992, and who do

4 not meet the eligibility standards in effect on or after July

5 1, 1992, shall remain ineligible on and after July 1, 1992.

6 Those persons previously not required to cost-share and who

7 were required to cost-share effective March 1, 1992, shall

8 continue to meet cost-share requirements on and after July 1,

9 1992. Beginning July 1, 1992, all clients will be required to

10 meet eligibility, cost-share, and other requirements and will

11 have services discontinued or altered when they fail to meet

12 these requirements.

13 For the purposes of this Section, "flexible senior

14 services" refers to services that require one-time or periodic

15 expenditures, including, but not limited to, respite care,

16 home modification, assistive technology, housing assistance,

17 and transportation.

18 The Department shall implement an electronic service

19 verification based on global positioning systems or other

20 cost-effective technology for the Community Care Program no

21 later than January 1, 2014.

22 The Department shall require, as a condition of

23 eligibility, application for the medical assistance program

24 under Article V of the Illinois Public Aid Code.

25 The Department may authorize Community Care Program

26 services until an applicant is determined eligible for medical

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1 assistance under Article V of the Illinois Public Aid Code.

2 The Department shall continue to provide Community Care

3 Program reports as required by statute, which shall include an

4 annual report on Care Coordination Unit performance and

5 adherence to service guidelines and a 6-month supplemental

6 report.

7 In regard to community care providers, failure to comply

8 with Department on Aging policies shall be cause for

9 disciplinary action, including, but not limited to,

10 disqualification from serving Community Care Program clients.

11 Each provider, upon submission of any bill or invoice to the

12 Department for payment for services rendered, shall include a

13 notarized statement, under penalty of perjury pursuant to

14 Section 1-109 of the Code of Civil Procedure, that the

15 provider has complied with all Department policies.

16 The Director of the Department on Aging shall make

17 information available to the State Board of Elections as may

18 be required by an agreement the State Board of Elections has

19 entered into with a multi-state voter registration list

20 maintenance system.

21 The Department shall pay an enhanced rate of at least

22 $1.77 per unit under the Community Care Program to those

23 in-home service provider agencies that offer health insurance

24 coverage as a benefit to their direct service worker employees

25 pursuant to rules adopted by the Department. The Department

26 shall review the enhanced rate as part of its process to rebase

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1 in-home service provider reimbursement rates pursuant to

2 federal waiver requirements. Subject to federal approval,

3 beginning on January 1, 2024, rates for adult day services

4 shall be increased to $16.84 per hour and rates for each way

5 transportation services for adult day services shall be

6 increased to $12.44 per unit transportation.

7 Subject to federal approval, on and after January 1, 2024,

8 rates for homemaker services shall be increased to $28.07 to

9 sustain a minimum wage of $17 per hour for direct service

10 workers. Rates in subsequent State fiscal years shall be no

11 lower than the rates put into effect upon federal approval.

12 Providers of in-home services shall be required to certify to

13 the Department that they remain in compliance with the

14 mandated wage increase for direct service workers. Fringe

15 benefits, including, but not limited to, paid time off and

16 payment for training, health insurance, travel, or

17 transportation, shall not be reduced in relation to the rate

18 increases described in this paragraph.

19 Subject to and upon federal approval, on and after January

20 1, 2025, rates for homemaker services shall be increased to

21 $29.63 to sustain a minimum wage of $18 per hour for direct

22 service workers. Rates in subsequent State fiscal years shall

23 be no lower than the rates put into effect upon federal

24 approval. Providers of in-home services shall be required to

25 certify to the Department that they remain in compliance with

26 the mandated wage increase for direct service workers. Fringe

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1 benefits, including, but not limited to, paid time off and

2 payment for training, health insurance, travel, or

3 transportation, shall not be reduced in relation to the rate

4 increases described in this paragraph.

5 Subject to and upon federal approval, on and after January

6 1, 2026, rates for homemaker services shall be increased to

7 $30.80 to sustain a minimum wage of $18.75 per hour for direct

8 service workers. Rates in subsequent State fiscal years shall

9 be no lower than the rates put into effect upon federal

10 approval. Providers of in-home services shall be required to

11 certify to the Department that they remain in compliance with

12 the mandated wage increase for direct service workers. Fringe

13 benefits, including, but not limited to, paid time off and

14 payment for training, health insurance, travel, or

15 transportation, shall not be reduced in relation to the rate

16 increases described in this paragraph.

17 Beginning January 1, 2027, subject to any necessary

18 federal approval, rates for adult day services shall be

19 increased to $17.84 per hour and rates for each way

20 transportation services for adult day services shall be

21 increased to $13.44 per unit transportation.

22 The General Assembly finds it necessary to authorize an

23 aggressive Medicaid enrollment initiative designed to maximize

24 federal Medicaid funding for the Community Care Program which

25 produces significant savings for the State of Illinois. The

26 Department on Aging shall establish and implement a Community

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1 Care Program Medicaid Initiative. Under the Initiative, the

2 Department on Aging shall, at a minimum: (i) provide an

3 enhanced rate to adequately compensate care coordination units

4 to enroll eligible Community Care Program clients into

5 Medicaid; (ii) use recommendations from a stakeholder

6 committee on how best to implement the Initiative; and (iii)

7 establish requirements for State agencies to make enrollment

8 in the State's Medical Assistance program easier for seniors.

9 The Community Care Program Medicaid Enrollment Oversight

10 Subcommittee is created as a subcommittee of the Older Adult

11 Services Advisory Committee established in Section 35 of the

12 Older Adult Services Act to make recommendations on how best

13 to increase the number of medical assistance recipients who

14 are enrolled in the Community Care Program. The Subcommittee

15 shall consist of all of the following persons who must be

16 appointed within 30 days after June 4, 2018 (the effective

17 date of Public Act 100-587):

18 (1) The Director of Aging, or his or her designee, who

19 shall serve as the chairperson of the Subcommittee.

20 (2) One representative of the Department of Healthcare

21 and Family Services, appointed by the Director of

22 Healthcare and Family Services.

23 (3) One representative of the Department of Human

24 Services, appointed by the Secretary of Human Services.

25 (4) One individual representing a care coordination

26 unit, appointed by the Director of Aging.

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1 (5) One individual from a non-governmental statewide

2 organization that advocates for seniors, appointed by the

3 Director of Aging.

4 (6) One individual representing Area Agencies on

5 Aging, appointed by the Director of Aging.

6 (7) One individual from a statewide association

7 dedicated to Alzheimer's care, support, and research,

8 appointed by the Director of Aging.

9 (8) One individual from an organization that employs

10 persons who provide services under the Community Care

11 Program, appointed by the Director of Aging.

12 (9) One member of a trade or labor union representing

13 persons who provide services under the Community Care

14 Program, appointed by the Director of Aging.

15 (10) One member of the Senate, who shall serve as

16 co-chairperson, appointed by the President of the Senate.

17 (11) One member of the Senate, who shall serve as

18 co-chairperson, appointed by the Minority Leader of the

19 Senate.

20 (12) One member of the House of Representatives, who

21 shall serve as co-chairperson, appointed by the Speaker of

22 the House of Representatives.

23 (13) One member of the House of Representatives, who

24 shall serve as co-chairperson, appointed by the Minority

25 Leader of the House of Representatives.

26 (14) One individual appointed by a labor organization

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1 representing frontline employees at the Department of

2 Human Services.

3 The Subcommittee shall provide oversight to the Community

4 Care Program Medicaid Initiative and shall meet quarterly. At

5 each Subcommittee meeting the Department on Aging shall

6 provide the following data sets to the Subcommittee: (A) the

7 number of Illinois residents, categorized by planning and

8 service area, who are receiving services under the Community

9 Care Program and are enrolled in the State's Medical

10 Assistance Program; (B) the number of Illinois residents,

11 categorized by planning and service area, who are receiving

12 services under the Community Care Program, but are not

13 enrolled in the State's Medical Assistance Program; and (C)

14 the number of Illinois residents, categorized by planning and

15 service area, who are receiving services under the Community

16 Care Program and are eligible for benefits under the State's

17 Medical Assistance Program, but are not enrolled in the

18 State's Medical Assistance Program. In addition to this data,

19 the Department on Aging shall provide the Subcommittee with

20 plans on how the Department on Aging will reduce the number of

21 Illinois residents who are not enrolled in the State's Medical

22 Assistance Program but who are eligible for medical assistance

23 benefits. The Department on Aging shall enroll in the State's

24 Medical Assistance Program those Illinois residents who

25 receive services under the Community Care Program and are

26 eligible for medical assistance benefits but are not enrolled

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1 in the State's Medical ~~Medicaid~~ Assistance Program. The data

2 provided to the Subcommittee shall be made available to the

3 public via the Department on Aging's website.

4 The Department on Aging, with the involvement of the

5 Subcommittee, shall collaborate with the Department of Human

6 Services and the Department of Healthcare and Family Services

7 on how best to achieve the responsibilities of the Community

8 Care Program Medicaid Initiative.

9 The Department on Aging, the Department of Human Services,

10 and the Department of Healthcare and Family Services shall

11 coordinate and implement a streamlined process for seniors to

12 access benefits under the State's Medical Assistance Program.

13 The Subcommittee shall collaborate with the Department of

14 Human Services on the adoption of a uniform application

15 submission process. The Department of Human Services and any

16 other State agency involved with processing the medical

17 assistance application of any person enrolled in the Community

18 Care Program shall include the appropriate care coordination

19 unit in all communications related to the determination or

20 status of the application.

21 The Community Care Program Medicaid Initiative shall

22 provide targeted funding to care coordination units to help

23 seniors complete their applications for medical assistance

24 benefits. On and after July 1, 2019, care coordination units

25 shall receive no less than $200 per completed application,

26 which rate may be included in a bundled rate for initial intake

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1 services when Medicaid application assistance is provided in

2 conjunction with the initial intake process for new program

3 participants.

4 The Community Care Program Medicaid Initiative shall cease

5 operation 5 years after June 4, 2018 (the effective date of

6 Public Act 100-587), after which the Subcommittee shall

7 dissolve.

8 Effective July 1, 2023, subject to federal approval, the

9 Department on Aging shall reimburse Care Coordination Units at

10 the following rates for case management services: $252.40 for

11 each initial assessment; $366.40 for each initial assessment

12 with translation; $229.68 for each redetermination assessment;

13 $313.68 for each redetermination assessment with translation;

14 $200.00 for each completed application for medical assistance

15 benefits; $132.26 for each face-to-face, choices-for-care

16 screening; $168.26 for each face-to-face, choices-for-care

17 screening with translation; $124.56 for each 6-month,

18 face-to-face visit; $132.00 for each MCO participant

19 eligibility determination; and $157.00 for each MCO

20 participant eligibility determination with translation.

21 (Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section

22 45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.

23 1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;

24 103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.

25 1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)

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1 ARTICLE 145.

2 Section 145-5. The Illinois Public Aid Code is amended by

3 changing Section 14-12.5 as follows:

4 (305 ILCS 5/14-12.5)

5 Sec. 14-12.5. Hospital rate updates.

6 (a) Notwithstanding any other provision of this Code, the

7 hospital rates of reimbursement authorized under Sections

8 5-5.05, 14-12, and 14-13 of this Code shall be adjusted in

9 accordance with the provisions of this Section.

10 (b) Notwithstanding any other provision of this Code,

11 effective for dates of service on and after January 1, 2024,

12 subject to federal approval, hospital reimbursement rates

13 shall be revised as follows:

14 (1) For inpatient general acute care services, the

15 statewide-standardized amount and the per diem rates for

16 hospitals exempt from the APR-DRG reimbursement system, in

17 effect January 1, 2023, shall be increased by 10%.

18 (2) For inpatient psychiatric services:

19 (A) For safety-net hospitals, the hospital

20 specific per diem rate in effect January 1, 2023 and

21 the minimum per diem rate of $630, authorized in

22 subsection (b-5) of Section 5-5.05 of this Code, shall

23 be increased by 10%.

24 (B) For all general acute care hospitals that are

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1 not safety-net hospitals, the inpatient psychiatric

2 care per diem rates in effect January 1, 2023 shall be

3 increased by 10%, except that all rates shall be at

4 least 90% of the minimum inpatient psychiatric care

5 per diem rate for safety-net hospitals as authorized

6 in subsection (b-5) of Section 5-5.05 of this Code

7 including the adjustments authorized in this Section.

8 The statewide default per diem rate for a hospital

9 opening a new psychiatric distinct part unit, shall be

10 set at 90% of the minimum inpatient psychiatric care

11 per diem rate for safety-net hospitals as authorized

12 in subsection (b-5) of Section 5-5.05 of this Code,

13 including the adjustment authorized in this Section.

14 (C) For all psychiatric specialty hospitals, the

15 per diem rates in effect January 1, 2023, shall be

16 increased by 10%, except that all rates shall be at

17 least 90% of the minimum inpatient per diem rate for

18 safety-net hospitals as authorized in subsection (b-5)

19 of Section 5-5.05 of this Code, including the

20 adjustments authorized in this Section. The statewide

21 default per diem rate for a new psychiatric specialty

22 hospital shall be set at 90% of the minimum inpatient

23 psychiatric care per diem rate for safety-net

24 hospitals as authorized in subsection (b-5) of Section

25 5-5.05 of this Code, including the adjustment

26 authorized in this Section.

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1 (3) For inpatient rehabilitative services, all

2 hospital specific per diem rates in effect January 1,

3 2023, shall be increased by 10%. The statewide default

4 inpatient rehabilitative services per diem rates, for

5 general acute care hospitals and for rehabilitation

6 specialty hospitals respectively, shall be increased by

7 10%.

8 (4) The statewide-standardized amount for outpatient

9 general acute care services in effect January 1, 2023,

10 shall be increased by 10%.

11 (5) The statewide-standardized amount for outpatient

12 psychiatric care services in effect January 1, 2023, shall

13 be increased by 10%.

14 (6) The statewide-standardized amount for outpatient

15 rehabilitative care services in effect January 1, 2023,

16 shall be increased by 10%.

17 (7) The per diem rate in effect January 1, 2023, as

18 authorized in subsection (a) of Section 14-13 of this

19 Article shall be increased by 10%.

20 (8) For services provided on and after January 1, 2024

21 through June 30, 2024, and on and after January 1, 2029

22 ~~2027~~, subject to federal approval, in addition to the

23 statewide standardized amount, an add-on payment of at

24 least $210 shall be paid for each inpatient General Acute

25 and Psychiatric day of care, excluding Medicare-Medicaid

26 dual eligible crossover days, for all safety-net hospitals

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1 defined in Section 5-5e.1 of this Code.

2 (A) For Psychiatric days of care, the Department

3 may implement payment of this add-on by increasing the

4 hospital specific psychiatric per diem rate, adjusted

5 in accordance with subparagraph (A) of paragraph (2)

6 of subsection (b) by $210, or by a separate add-on

7 payment.

8 (B) If the add-on adjustment is added to the

9 hospital specific psychiatric per diem rate to

10 operationalize payment, the Department shall provide a

11 rate sheet to each safety-net hospital, which

12 identifies the hospital psychiatric per diem rate

13 before and after the adjustment.

14 (C) The add-on adjustment shall not be considered

15 when setting the 90% minimum rate identified in

16 paragraph (2) of subsection (b).

17 (9) For services provided on and after July 1, 2024,

18 and on or before December 31, 2028 ~~2026~~, subject to

19 federal approval, in addition to the statewide

20 standardized amount and any other payments authorized

21 under this Code, a safety-net hospital health care equity

22 add-on payment shall be paid for each inpatient General

23 Acute and Psychiatric day of care, excluding

24 Medicare-Medicaid dual eligible crossover days, for

25 safety-net hospitals defined in Section 5-5e.1 of this

26 Code, as follows:

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1 (A) if the safety-net hospital's Medicaid

2 inpatient utilization rate, as calculated under

3 Section 5-5e.1 of this Code, is equal to or greater

4 than 70%, the add-on payment shall be $425;

5 (B) if the safety-net hospital's Medicaid

6 inpatient utilization rate, as calculated under

7 Section 5-5e.1 of this Code, is equal to or greater

8 than 50% and less than 70%, the add-on payment shall be

9 $300;

10 (C) if the safety-net hospital's Medicaid

11 inpatient utilization rate, as calculated under

12 Section 5-5e.1 of this Code, is equal to or greater

13 than 40% and less than 50%, the add-on payment shall be

14 $225; and

15 (D) if the safety-net hospital's Medicaid

16 inpatient utilization rate, as calculated under

17 Section 5-5e.1 of this Code, is less than 40%, the

18 add-on payment shall be $210.

19 Qualification for the safety-net hospital health care

20 equity add-on payment shall be updated January 1, 2026,

21 and each January 1 thereafter based on the MIUR

22 determination effective 3 months prior to the start of

23 each ~~the January 1, 2026~~ calendar year, ending in 2028.

24 Rates described in subparagraphs (A) through (C) shall

25 be adjusted annually beginning January 1, 2026 by applying

26 a uniform factor to each rate to spend an approximate

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1 amount of $50,000,000 annually per year using State fiscal

2 year 2024 days as a basis for calendar year 2026 rates.

3 The add-on adjustment under this paragraph shall not

4 be considered when setting the 90% minimum rate identified

5 in subparagraph (B) of paragraph (2).

6 (10) For services provided on and after July 1, 2024,

7 and on or before December 31, 2028 ~~2026~~, subject to

8 federal approval, in addition to the statewide

9 standardized amount and any other payments authorized

10 under this Code, a safety-net hospital low volume add-on

11 payment of the lesser of $200 or the annually recalculated

12 amount described below shall be paid for each inpatient

13 General Acute and Psychiatric day of care, excluding

14 Medicare-Medicaid dual eligible crossover days, for any

15 safety-net hospital as defined in Section 5-5e.1 that

16 provided less than 11,000 Medicaid inpatient days of care,

17 excluding Medicare-Medicaid dual eligible crossover days,

18 in the base period. As used in this paragraph, "base

19 period" means State fiscal year 2022 admissions received

20 by the Department prior to October 1, 2023 for the payment

21 period July 1, 2024 through December 31, 2025, and

22 beginning in calendar year 2026, the State fiscal year

23 that ends 30 months before the applicable calendar year,

24 such as State fiscal year 2023 admissions received by the

25 Department prior to October 1, 2024, for calendar year

26 2026. The low volume add-on payment amount of $200 shall

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1 be adjusted annually beginning January 1, 2027 if

2 projected overall payment exceeds $30,000,000 by setting a

3 rate to spend an approximate amount of $30,000,000

4 annually using the most recent complete State fiscal year

5 inpatient General Acute and Psychiatric day of care data,

6 excluding Medicare-Medicaid dual eligible crossover days

7 for qualifying hospitals. State Fiscal Year 2025 data

8 shall be used as the basis for the Calendar Year 2027 rate,

9 and State Fiscal Year 2026 data shall be used as the basis

10 for the Calendar Year 2028 rate.

11 (c) The Department shall take all actions necessary to

12 ensure the changes authorized in Public Act 103-102 and this

13 amendatory Act of the 103rd General Assembly are in effect for

14 dates of service on and after the effective date of the changes

15 made to this Section by this amendatory Act of the 103rd

16 General Assembly, including publishing all appropriate public

17 notices, applying for federal approval of amendments to the

18 Illinois Title XIX State Plan, and adopting administrative

19 rules if necessary.

20 (d) The Department of Healthcare and Family Services may

21 adopt rules necessary to implement the changes made by Public

22 Act 103-102 and this amendatory Act of the 103rd General

23 Assembly through the use of emergency rulemaking in accordance

24 with Section 5-45 of the Illinois Administrative Procedure

25 Act. The 24-month limitation on the adoption of emergency

26 rules does not apply to rules adopted under this Section. The

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1 General Assembly finds that the adoption of rules to implement

2 the changes made by Public Act 103-102 and this amendatory Act

3 of the 103rd General Assembly is deemed an emergency and

4 necessary for the public interest, safety, and welfare.

5 (e) The Department shall ensure that all necessary

6 adjustments to the managed care organization capitation base

7 rates necessitated by the adjustments in this Section are

8 completed, published, and applied in accordance with Section

9 5-30.8 of this Code 90 days prior to the implementation date of

10 the changes required under Public Act 103-102 and this

11 amendatory Act of the 103rd General Assembly.

12 (f) The Department shall publish updated rate sheets or

13 add-on payment amounts, as applicable, for all hospitals 30

14 days prior to the effective date of the rate increase, or

15 within 30 days after federal approval by the Centers for

16 Medicare and Medicaid Services, whichever is later.

17 (Source: P.A. 103-102, eff. 6-16-23; 103-593, eff. 6-7-24.)

18 ARTICLE 170.

19 Section 170-5. The Illinois Public Aid Code is amended by

20 changing Section 1-8.5 as follows:

21 (305 ILCS 5/1-8.5)

22 Sec. 1-8.5. Eligibility for medical assistance during

23 periods of incarceration or detention.

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1 (a) To the extent permitted by federal law and

2 notwithstanding any other provision of this Code, the

3 Department of Healthcare and Family Services shall not cancel

4 a person's eligibility for medical assistance, nor shall the

5 Department deny a person's application for medical assistance,

6 solely because that person has become or is an inmate of a

7 public institution, including, but not limited to, a county

8 jail, juvenile detention center, or State correctional

9 facility. The person may be and remain enrolled for medical

10 assistance as long as all other eligibility criteria are met.

11 (b) The Department may adopt rules to permit a person to

12 apply for medical assistance while he or she is an inmate of a

13 public institution as described in subsection (a). The rules

14 may limit applications to persons who would be likely to

15 qualify for medical assistance if they resided in the

16 community. Any such person who is not already enrolled for

17 medical assistance may apply for medical assistance prior to

18 the date of scheduled release or discharge from a penal

19 institution or county jail or similar status.

20 (c) Except as provided under Section 17 of the County Jail

21 Act, the Department shall not be responsible to provide

22 medical assistance under this Code for any medical care,

23 services, or supplies provided to a person while he or she is

24 an inmate of a public institution as described in subsection

25 (a). The responsibility for providing medical care shall

26 remain as otherwise provided by law with the Department of

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1 Corrections, county, or other arresting authority. The

2 Department may seek federal financial participation, to the

3 extent that it is available and with the cooperation of the

4 Department of Juvenile Justice, the Department of Corrections,

5 or the relevant county, for the costs of those services.

6 (c-1) Notwithstanding subsection (c), the Department may

7 provide medical assistance under this Code for medical care,

8 services, and supplies provided to a person while he or she is

9 an inmate of a public institution as described in subsection

10 (a) to the extent authorized under a federally approved 1115

11 Waiver or other federal authority. The medical care, services,

12 and supplies covered, and any other standards, limitations, or

13 conditions for coverage, shall be established by rule by the

14 Department in accordance with the federal authority obtained.

15 (d) To the extent permitted under State and federal law,

16 the Department shall develop procedures to expedite required

17 periodic reviews of continued eligibility for persons

18 described in subsection (a).

19 (e) Counties, the Department of Juvenile Justice, the

20 Department of Human Services, and the Department of

21 Corrections shall cooperate with the Department in

22 administering this Section. That cooperation shall include

23 managing eligibility processing and sharing information

24 sufficient to inform the Department, in a manner established

25 by the Department, that a person enrolled in the medical

26 assistance program has been detained or incarcerated.

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1 (f) The Department shall resume responsibility for

2 providing medical assistance upon release of the person to the

3 community as long as all of the following apply:

4 (1) The person is enrolled for medical assistance at

5 the time of release.

6 (2) Neither a county, the Department of Juvenile

7 Justice, the Department of Corrections, nor any other

8 criminal justice authority continues to bear

9 responsibility for the person's medical care.

10 (3) The county, the Department of Juvenile Justice, or

11 the Department of Corrections provides timely notice of

12 the date of release in a manner established by the

13 Department.

14 (g) This Section applies on and after December 31, 2011.

15 (Source: P.A. 98-139, eff. 1-1-14; 99-415, eff. 8-20-15.)

16 ARTICLE 175.

17 Section 175-5. The Illinois Public Aid Code is amended by

18 changing Section 5-30.1 as follows:

19 (305 ILCS 5/5-30.1)

20 Sec. 5-30.1. Managed care protections.

21 (a) As used in this Section:

22 "Managed care organization" or "MCO" means any entity

23 which contracts with the Department to provide services where

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1 payment for medical services is made on a capitated basis.

2 "Emergency services" means health care items and services,

3 including inpatient and outpatient hospital services,

4 furnished or required to evaluate and stabilize an emergency

5 medical condition. "Emergency services" include inpatient

6 stabilization services furnished during the inpatient

7 stabilization period. "Emergency services" do not include

8 post-stabilization medical services.

9 "Emergency medical condition" means a medical condition

10 manifesting itself by acute symptoms of sufficient severity,

11 regardless of the final diagnosis given, such that a prudent

12 layperson, who possesses an average knowledge of health and

13 medicine, could reasonably expect the absence of immediate

14 medical attention to result in:

15 (1) placing the health of the individual (or, with

16 respect to a pregnant woman, the health of the woman or her

17 unborn child) in serious jeopardy;

18 (2) serious impairment to bodily functions;

19 (3) serious dysfunction of any bodily organ or part;

20 (4) inadequately controlled pain; or

21 (5) with respect to a pregnant woman who is having

22 contractions:

23 (A) inadequate time to complete a safe transfer to

24 another hospital before delivery; or

25 (B) a transfer to another hospital may pose a

26 threat to the health or safety of the woman or unborn

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1 child.

2 "Emergency medical screening examination" means a medical

3 screening examination and evaluation by a physician licensed

4 to practice medicine in all its branches or, to the extent

5 permitted by applicable laws, by other appropriately licensed

6 personnel under the supervision of or in collaboration with a

7 physician licensed to practice medicine in all its branches to

8 determine whether the need for emergency services exists.

9 "Health care services" means ~~mean~~ any medical or

10 behavioral health services covered under the medical

11 assistance program that are subject to review under a service

12 authorization program.

13 "Inpatient stabilization period" means the initial 72

14 hours of inpatient stabilization services, beginning from the

15 date and time of the order for inpatient admission to the

16 hospital.

17 "Inpatient stabilization services" means ~~mean~~ emergency

18 services furnished in the inpatient setting at a hospital

19 pursuant to an order for inpatient admission by a physician or

20 other qualified practitioner who has admitting privileges at

21 the hospital, as permitted by State law, to stabilize an

22 emergency medical condition following an emergency medical

23 screening examination.

24 "Post-stabilization medical services" means health care

25 services provided to an enrollee that are furnished in a

26 hospital by a provider that is qualified to furnish such

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1 services and determined to be medically necessary by the

2 provider and directly related to the emergency medical

3 condition following stabilization.

4 "Provider" means a facility or individual who is actively

5 enrolled in the medical assistance program and licensed or

6 otherwise authorized to order, prescribe, refer, or render

7 health care services in this State.

8 "Service authorization determination" means a decision

9 made by a service authorization program in advance of,

10 concurrent to, or after the provision of a health care service

11 to approve, change the level of care, partially deny, deny, or

12 otherwise limit coverage and reimbursement for a health care

13 service upon review of a service authorization request.

14 "Service authorization program" means any utilization

15 review, utilization management, peer review, quality review,

16 or other medical management activity conducted by an MCO, or

17 its contracted utilization review organization, including, but

18 not limited to, prior authorization, prior approval,

19 pre-certification, concurrent review, retrospective review, or

20 certification of admission, of health care services provided

21 in the inpatient or outpatient hospital setting.

22 "Service authorization request" means a request by a

23 provider to a service authorization program to determine

24 whether a health care service meets the reimbursement

25 eligibility requirements for medically necessary, clinically

26 appropriate care, resulting in the issuance of a service

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1 authorization determination.

2 "Utilization review organization" or "URO" means an MCO's

3 utilization review department or a peer review organization or

4 quality improvement organization that contracts with an MCO to

5 administer a service authorization program and make service

6 authorization determinations.

7 (b) As provided by Section 5-16.12, managed care

8 organizations are subject to the provisions of the Managed

9 Care Reform and Patient Rights Act.

10 (c) An MCO shall pay any provider of emergency services,

11 including for inpatient stabilization services provided during

12 the inpatient stabilization period, that does not have in

13 effect a contract with the contracted Medicaid MCO. The

14 default rate of reimbursement shall be the rate paid under

15 Illinois Medicaid fee-for-service program methodology,

16 including all policy adjusters, including but not limited to

17 Medicaid High Volume Adjustments, Medicaid Percentage

18 Adjustments, Outpatient High Volume Adjustments, and all

19 outlier add-on adjustments to the extent such adjustments are

20 incorporated in the development of the applicable MCO

21 capitated rates.

22 (d) (Blank).

23 (e) Notwithstanding any other provision of law, the

24 following requirements apply to MCOs in determining payment

25 for all emergency services, including inpatient stabilization

26 services provided during the inpatient stabilization period:

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1 (1) The MCO shall not impose any service authorization

2 program requirements for emergency services, including,

3 but not limited to, prior authorization, prior approval,

4 pre-certification, certification of admission, concurrent

5 review, or retrospective review.

6 (A) Notification period: Hospitals shall notify

7 the enrollee's Medicaid MCO within 48 hours of the

8 date and time the order for inpatient admission is

9 written. Notification shall be limited to advising the

10 MCO that the patient has been admitted to a hospital

11 inpatient level of care.

12 (B) If the admitting hospital complies with the

13 notification provisions of subparagraph (A), the

14 Medicaid MCO may not initiate concurrent review before

15 the end of the inpatient stabilization period. If the

16 admitting hospital does not comply with the

17 notification requirements in subparagraph (A), the

18 Medicaid MCO may initiate concurrent review for the

19 continuation of the stay beginning at the end of the

20 48-hour notification period.

21 (C) Coverage for services provided during the

22 48-hour notification period may not be retrospectively

23 denied.

24 (2) The MCO shall cover emergency services provided to

25 enrollees who are temporarily away from their residence

26 and outside the contracting area to the extent that the

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1 enrollees would be entitled to the emergency services if

2 they still were within the contracting area.

3 (3) The MCO shall have no obligation to cover

4 emergency services provided on an emergency basis that are

5 not covered services under the contract between the MCO

6 and the Department.

7 (4) The MCO shall not condition coverage for emergency

8 services on the treating provider notifying the MCO of the

9 enrollee's emergency medical screening examination and

10 treatment within 10 days after presentation for emergency

11 services.

12 (5) The determination of the attending emergency

13 physician, or the practitioner responsible for the

14 enrollee's care at the hospital, of whether an enrollee

15 requires inpatient stabilization services, can be

16 stabilized in the outpatient setting, or is sufficiently

17 stabilized for discharge or transfer to another setting,

18 shall be binding on the MCO. The MCO shall cover and

19 reimburse providers for emergency services as billed by

20 the provider for all enrollees whether the emergency

21 services are provided by an affiliated or non-affiliated

22 provider, except in cases of fraud. The MCO shall

23 reimburse inpatient stabilization services provided during

24 the inpatient stabilization period and billed as inpatient

25 level of care based on the appropriate inpatient

26 reimbursement methodology.

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1 (6) The MCO's financial responsibility for

2 post-stabilization medical services it has not

3 pre-approved ends when:

4 (A) a plan physician with privileges at the

5 treating hospital assumes responsibility for the

6 enrollee's care;

7 (B) a plan physician assumes responsibility for

8 the enrollee's care through transfer;

9 (C) a contracting entity representative and the

10 treating physician reach an agreement concerning the

11 enrollee's care; or

12 (D) the enrollee is discharged.

13 (e-5) An MCO shall pay for all post-stabilization medical

14 services as a covered service in any of the following

15 situations:

16 (1) the MCO or its URO authorized such services;

17 (2) such services were administered to maintain the

18 enrollee's stabilized condition within one hour after a

19 request to the MCO for authorization of further

20 post-stabilization services;

21 (3) the MCO or its URO did not respond to a request to

22 authorize such services within one hour;

23 (4) the MCO or its URO could not be contacted; or

24 (5) the MCO or its URO and the treating provider, if

25 the treating provider is a non-affiliated provider, could

26 not reach an agreement concerning the enrollee's care and

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1 an affiliated provider was unavailable for a consultation,

2 in which case the MCO must pay for such services rendered

3 by the treating non-affiliated provider until an

4 affiliated provider was reached and either concurred with

5 the treating non-affiliated provider's plan of care or

6 assumed responsibility for the enrollee's care. Such

7 payment shall be made at the default rate of reimbursement

8 paid under the State's Medicaid fee-for-service program

9 methodology, including all policy adjusters, including,

10 but not limited to, Medicaid High Volume Adjustments,

11 Medicaid Percentage Adjustments, Outpatient High Volume

12 Adjustments, and all outlier add-on adjustments to the

13 extent that such adjustments are incorporated in the

14 development of the applicable MCO capitated rates.

15 (f) Network adequacy and transparency.

16 (1) The Department shall:

17 (A) ensure that an adequate provider network is in

18 place, taking into consideration health professional

19 shortage areas and medically underserved areas;

20 (B) publicly release an explanation of its process

21 for analyzing network adequacy;

22 (C) periodically ensure that an MCO continues to

23 have an adequate network in place;

24 (D) require MCOs, including Medicaid Managed Care

25 Entities as defined in Section 5-30.2, to meet

26 provider directory requirements under Section 5-30.3;

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1 (E) require MCOs to ensure that any

2 Medicaid-certified provider under contract with an MCO

3 and previously submitted on a roster on the date of

4 service is paid for any medically necessary,

5 Medicaid-covered, and authorized service rendered to

6 any of the MCO's enrollees, regardless of inclusion on

7 the MCO's published and publicly available directory

8 of available providers; and

9 (F) require MCOs, including Medicaid Managed Care

10 Entities as defined in Section 5-30.2, to meet each of

11 the requirements under subsection (d-5) of Section 10

12 of the Network Adequacy and Transparency Act; with

13 necessary exceptions to the MCO's network to ensure

14 that admission and treatment with a provider or at a

15 treatment facility in accordance with the network

16 adequacy standards in paragraph (3) of subsection

17 (d-5) of Section 10 of the Network Adequacy and

18 Transparency Act is limited to providers or facilities

19 that are Medicaid certified.

20 (2) Each MCO shall confirm its receipt of information

21 submitted specific to physician or dentist additions or

22 physician or dentist deletions from the MCO's provider

23 network within 3 days after receiving all required

24 information from contracted physicians or dentists, and

25 electronic physician and dental directories must be

26 updated consistent with current rules as published by the

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1 Centers for Medicare and Medicaid Services or its

2 successor agency.

3 (g) Timely payment of claims.

4 (1) The MCO shall pay a claim within 30 days of

5 receiving a claim that contains all the essential

6 information needed to adjudicate the claim.

7 (2) The MCO shall notify the billing party of its

8 inability to adjudicate a claim within 30 days of

9 receiving that claim.

10 (3) The MCO shall pay a penalty that is at least equal

11 to the timely payment interest penalty imposed under

12 Section 368a of the Illinois Insurance Code for any claims

13 not timely paid.

14 (A) When an MCO is required to pay a timely payment

15 interest penalty to a provider, the MCO must calculate

16 and pay the timely payment interest penalty that is

17 due to the provider within 30 days after the payment of

18 the claim. In no event shall a provider be required to

19 request or apply for payment of any owed timely

20 payment interest penalties.

21 (B) Such payments shall be reported separately

22 from the claim payment for services rendered to the

23 MCO's enrollee and clearly identified as interest

24 payments.

25 (4)(A) The Department shall require MCOs to expedite

26 payments to providers identified on the Department's

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1 expedited provider list, determined in accordance with 89

2 Ill. Adm. Code 140.71(b), on a schedule at least as

3 frequently as the providers are paid under the

4 Department's fee-for-service expedited provider schedule.

5 (B) Compliance with the expedited provider requirement

6 may be satisfied by an MCO through the use of a Periodic

7 Interim Payment (PIP) program that has been mutually

8 agreed to and documented between the MCO and the provider,

9 if the PIP program ensures that any expedited provider

10 receives regular and periodic payments based on prior

11 period payment experience from that MCO. Total payments

12 under the PIP program may be reconciled against future PIP

13 payments on a schedule mutually agreed to between the MCO

14 and the provider.

15 (C) The Department shall share at least monthly its

16 expedited provider list and the frequency with which it

17 pays providers on the expedited list.

18 (g-5) Recognizing that the rapid transformation of the

19 Illinois Medicaid program may have unintended operational

20 challenges for both payers and providers:

21 (1) in no instance shall a medically necessary covered

22 service rendered in good faith, based upon eligibility

23 information documented by the provider, be denied coverage

24 or diminished in payment amount if the eligibility or

25 coverage information available at the time the service was

26 rendered is later found to be inaccurate in the assignment

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1 of coverage responsibility between MCOs or the

2 fee-for-service system, except for instances when an

3 individual is deemed to have not been eligible for

4 coverage under the Illinois Medicaid program; and

5 (2) the Department shall, by December 31, 2016, adopt

6 rules establishing policies that shall be included in the

7 Medicaid managed care policy and procedures manual

8 addressing payment resolutions in situations in which a

9 provider renders services based upon information obtained

10 after verifying a patient's eligibility and coverage plan

11 through either the Department's current enrollment system

12 or a system operated by the coverage plan identified by

13 the patient presenting for services:

14 (A) such medically necessary covered services

15 shall be considered rendered in good faith;

16 (B) such policies and procedures shall be

17 developed in consultation with industry

18 representatives of the Medicaid managed care health

19 plans and representatives of provider associations

20 representing the majority of providers within the

21 identified provider industry; and

22 (C) such rules shall be published for a review and

23 comment period of no less than 30 days on the

24 Department's website with final rules remaining

25 available on the Department's website.

26 The rules on payment resolutions shall include, but

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1 not be limited to:

2 (A) the extension of the timely filing period;

3 (B) retroactive prior authorizations; and

4 (C) guaranteed minimum payment rate of no less

5 than the current, as of the date of service,

6 fee-for-service rate, plus all applicable add-ons,

7 when the resulting service relationship is out of

8 network.

9 The rules shall be applicable for both MCO coverage

10 and fee-for-service coverage.

11 If the fee-for-service system is ultimately determined to

12 have been responsible for coverage on the date of service, the

13 Department shall provide for an extended period for claims

14 submission outside the standard timely filing requirements.

15 (g-6) MCO Performance Metrics Report.

16 (1) The Department shall publish, on at least a

17 quarterly basis, each MCO's operational performance,

18 including, but not limited to, the following categories of

19 metrics:

20 (A) claims payment, including timeliness and

21 accuracy;

22 (B) prior authorizations;

23 (C) grievance and appeals;

24 (D) utilization statistics;

25 (E) provider disputes;

26 (F) provider credentialing; and

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1 (G) member and provider customer service.

2 (2) The Department shall ensure that the metrics

3 report is accessible to providers online by January 1,

4 2017.

5 (3) The metrics shall be developed in consultation

6 with industry representatives of the Medicaid managed care

7 health plans and representatives of associations

8 representing the majority of providers within the

9 identified industry.

10 (4) Metrics shall be defined and incorporated into the

11 applicable Managed Care Policy Manual issued by the

12 Department.

13 (g-7) MCO claims processing and performance analysis. In

14 order to monitor MCO payments to hospital providers, pursuant

15 to Public Act 100-580, the Department shall post an analysis

16 of MCO claims processing and payment performance on its

17 website every 6 months. Such analysis shall include a review

18 and evaluation of a representative sample of hospital claims

19 that are rejected and denied for clean and unclean claims and

20 the top 5 reasons for such actions and timeliness of claims

21 adjudication, which identifies the percentage of claims

22 adjudicated within 30, 60, 90, and over 90 days, and the dollar

23 amounts associated with those claims.

24 (g-8) Dispute resolution process. The Department shall

25 maintain a provider complaint portal through which a provider

26 can submit to the Department unresolved disputes with an MCO.

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1 An unresolved dispute means an MCO's decision that denies in

2 whole or in part a claim for reimbursement to a provider for

3 health care services rendered by the provider to an enrollee

4 of the MCO with which the provider disagrees. Disputes shall

5 not be submitted to the portal until the provider has availed

6 itself of the MCO's internal dispute resolution process.

7 Disputes that are submitted to the MCO internal dispute

8 resolution process may be submitted to the Department of

9 Healthcare and Family Services' complaint portal no sooner

10 than 30 days after submitting to the MCO's internal process

11 and not later than 30 days after the unsatisfactory resolution

12 of the internal MCO process or 60 days after submitting the

13 dispute to the MCO internal process. Multiple claim disputes

14 involving the same MCO may be submitted in one complaint,

15 regardless of whether the claims are for different enrollees,

16 when the specific reason for non-payment of the claims

17 involves a common question of fact or policy. Within 10

18 business days of receipt of a complaint, the Department shall

19 present such disputes to the appropriate MCO, which shall then

20 have 30 days to issue its written proposal to resolve the

21 dispute. The Department may grant one 30-day extension of this

22 time frame to one of the parties to resolve the dispute. If the

23 dispute remains unresolved at the end of this time frame or the

24 provider is not satisfied with the MCO's written proposal to

25 resolve the dispute, the provider may, within 30 days, request

26 the Department to review the dispute and make a final

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1 determination. Within 30 days of the request for Department

2 review of the dispute, both the provider and the MCO shall

3 present all relevant information to the Department for

4 resolution and make individuals with knowledge of the issues

5 available to the Department for further inquiry if needed.

6 Within 30 days of receiving the relevant information on the

7 dispute, or the lapse of the period for submitting such

8 information, the Department shall issue a written decision on

9 the dispute based on contractual terms between the provider

10 and the MCO, contractual terms between the MCO and the

11 Department of Healthcare and Family Services and applicable

12 Medicaid policy. The decision of the Department shall be

13 final. By January 1, 2020, the Department shall establish by

14 rule further details of this dispute resolution process.

15 Disputes between MCOs and providers presented to the

16 Department for resolution are not contested cases, as defined

17 in Section 1-30 of the Illinois Administrative Procedure Act,

18 conferring any right to an administrative hearing.

19 (g-9)(1) The Department shall publish annually on its

20 website a report on the calculation of each managed care

21 organization's medical loss ratio showing the following:

22 (A) Premium revenue, with appropriate adjustments.

23 (B) Benefit expense, setting forth the aggregate

24 amount spent for the following:

25 (i) Direct paid claims.

26 (ii) Subcapitation payments.

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1 (iii) Other claim payments.

2 (iv) Direct reserves.

3 (v) Gross recoveries.

4 (vi) Expenses for activities that improve health

5 care quality as allowed by the Department.

6 (2) The medical loss ratio shall be calculated consistent

7 with federal law and regulation following a claims runout

8 period determined by the Department.

9 (g-10)(1) "Liability effective date" means the date on

10 which an MCO becomes responsible for payment for medically

11 necessary and covered services rendered by a provider to one

12 of its enrollees in accordance with the contract terms between

13 the MCO and the provider. The liability effective date shall

14 be the later of:

15 (A) The execution date of a network participation

16 contract agreement.

17 (B) The date the provider or its representative

18 submits to the MCO the complete and accurate standardized

19 roster form for the provider in the format approved by the

20 Department.

21 (C) The provider effective date contained within the

22 Department's provider enrollment subsystem within the

23 Illinois Medicaid Program Advanced Cloud Technology

24 (IMPACT) System.

25 (2) The standardized roster form may be submitted to the

26 MCO at the same time that the provider submits an enrollment

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1 application to the Department through IMPACT.

2 (3) By October 1, 2019, the Department shall require all

3 MCOs to update their provider directory with information for

4 new practitioners of existing contracted providers within 30

5 days of receipt of a complete and accurate standardized roster

6 template in the format approved by the Department provided

7 that the provider is effective in the Department's provider

8 enrollment subsystem within the IMPACT system. Such provider

9 directory shall be readily accessible for purposes of

10 selecting an approved health care provider and comply with all

11 other federal and State requirements.

12 (g-11) The Department shall work with relevant

13 stakeholders on the development of operational guidelines to

14 enhance and improve operational performance of Illinois'

15 Medicaid managed care program, including, but not limited to,

16 improving provider billing practices, reducing claim

17 rejections and inappropriate payment denials, and

18 standardizing processes, procedures, definitions, and response

19 timelines, with the goal of reducing provider and MCO

20 administrative burdens and conflict. The Department shall

21 include a report on the progress of these program improvements

22 and other topics in its Fiscal Year 2020 annual report to the

23 General Assembly.

24 (g-12) Notwithstanding any other provision of law, if the

25 Department or an MCO requires submission of a claim for

26 payment in a non-electronic format, a provider shall always be

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1 afforded a period of no less than 90 business days, as a

2 correction period, following any notification of rejection by

3 either the Department or the MCO to correct errors or

4 omissions in the original submission.

5 Under no circumstances, either by an MCO or under the

6 State's fee-for-service system, shall a provider be denied

7 payment for failure to comply with any timely submission

8 requirements under this Code or under any existing contract,

9 unless the non-electronic format claim submission occurs after

10 the initial 180 days following the latest date of service on

11 the claim, or after the 90 business days correction period

12 following notification to the provider of rejection or denial

13 of payment.

14 (g-13) Utilization Review Standardization and

15 Transparency.

16 (1) To ensure greater standardization and transparency

17 related to service authorization determinations, for all

18 individuals covered under the medical assistance program

19 and enrolled in the managed care program ~~, including both~~

20 ~~the fee-for-service and managed care programs,~~ the

21 Department shall, in consultation with the MCOs, a

22 statewide association representing the MCOs, a statewide

23 association representing the majority of Illinois

24 hospitals, a statewide association representing

25 physicians, or any other interested parties deemed

26 appropriate by the Department, adopt administrative rules

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1 consistent with this subsection, in accordance with the

2 Illinois Administrative Procedure Act.

3 (2) No later than July 1, 2025, the Department shall

4 in accordance with the Illinois Administrative Procedure

5 Act file emergency rules, and adopt permanent rules no

6 later than November 28, 2025 ~~October 1, 2025~~, which govern

7 MCO practices for dates of services on and after July 1,

8 2025, as follows:

9 (A) guidelines related to the publication of MCO

10 service authorization policies;

11 (B) procedures listed on the Medicare Inpatient

12 Only list published on January 1, 2025 by the Centers

13 for Medicare and Medicaid Services in Addendum B to

14 CMS-1809-FC that, due to medical complexity, must be

15 reimbursed under the applicable inpatient methodology,

16 when provided in the inpatient setting and billed as

17 an inpatient service;

18 (C) standardization of administrative forms used

19 in the member appeal process;

20 (D) limitations on second or subsequent medical

21 necessity review of a health care service already

22 authorized by the MCO or URO under a service

23 authorization program;

24 (E) standardization of peer-to-peer processes and

25 timelines;

26 (F) defined criteria for urgent and standard

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1 post-acute care and long-term acute care service

2 authorization requests; and

3 (G) standardized criteria for service

4 authorization programs for authorization of admission

5 to a long-term acute care hospital.

6 (3) The Department shall expand the scope of the

7 quality and compliance audits conducted by its contracted

8 external quality review organization to include, but not

9 be limited to:

10 (A) an analysis of the Medicaid MCO's compliance

11 with nationally recognized clinical decision

12 guidelines for inpatient and outpatient hospital

13 services;

14 (B) an analysis that compares and contrasts the

15 Medicaid MCO's service authorization determination

16 outcomes for inpatient and outpatient hospital

17 services to the outcomes of each other MCO plan and the

18 State's fee-for-service program model to evaluate

19 whether service authorization determinations are being

20 made consistently by all Medicaid MCOs to ensure that

21 all individuals are being treated in accordance with

22 equitable standards of care;

23 (C) an analysis, for each Medicaid MCO, of the

24 number of service authorization requests, including

25 requests for concurrent review of inpatient hospital

26 admissions and certification of inpatient hospital

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1 admissions, received, initially denied, overturned

2 through any post-denial process including, but not

3 limited to, enrollee or provider appeal, peer-to-peer

4 review, or the provider dispute resolution process,

5 denied but approved for a lower or different level of

6 care, and the number denied on final determination;

7 and

8 (D) provide a written report to the General

9 Assembly, detailing the items listed in this

10 subsection and any other metrics deemed necessary by

11 the Department, by the second April, following June 7,

12 2025 ~~2024 (the effective date of Public Act 103-593)~~,

13 and each April thereafter. The Department shall make

14 this report available within 30 days of delivery to

15 the General Assembly, on its public facing website.

16 (h) The Department shall not expand mandatory MCO

17 enrollment into new counties beyond those counties already

18 designated by the Department as of June 1, 2014 for the

19 individuals whose eligibility for medical assistance is not

20 the seniors or people with disabilities population until the

21 Department provides an opportunity for accountable care

22 entities and MCOs to participate in such newly designated

23 counties.

24 (h-5) Leading indicator data sharing. By January 1, 2024,

25 the Department shall obtain input from the Department of Human

26 Services, the Department of Juvenile Justice, the Department

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1 of Children and Family Services, the State Board of Education,

2 managed care organizations, providers, and clinical experts to

3 identify and analyze key indicators and data elements that can

4 be used in an analysis of lead indicators from assessments and

5 data sets available to the Department that can be shared with

6 managed care organizations and similar care coordination

7 entities contracted with the Department as leading indicators

8 for elevated behavioral health crisis risk for children,

9 including data sets such as the Illinois Medicaid

10 Comprehensive Assessment of Needs and Strengths (IM-CANS),

11 calls made to the State's Crisis and Referral Entry Services

12 (CARES) hotline, health services information from Health and

13 Human Services Innovators, or other data sets that may include

14 key indicators. The workgroup shall complete its

15 recommendations for leading indicator data elements on or

16 before September 1, 2024. To the extent permitted by State and

17 federal law, the identified leading indicators shall be shared

18 with managed care organizations and similar care coordination

19 entities contracted with the Department on or before December

20 1, 2024 for the purpose of improving care coordination with

21 the early detection of elevated risk. Leading indicators shall

22 be reassessed annually with stakeholder input. The Department

23 shall implement guidance to managed care organizations and

24 similar care coordination entities contracted with the

25 Department, so that the managed care organizations and care

26 coordination entities respond to lead indicators with services

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1 and interventions that are designed to help stabilize the

2 child.

3 (i) The requirements of this Section apply to contracts

4 with accountable care entities and MCOs entered into, amended,

5 or renewed after June 16, 2014 (the effective date of Public

6 Act 98-651).

7 (j) Health care information released to managed care

8 organizations. A health care provider shall release to a

9 Medicaid managed care organization, upon request, and subject

10 to the Health Insurance Portability and Accountability Act of

11 1996 and any other law applicable to the release of health

12 information, the health care information of the MCO's

13 enrollee, if the enrollee has completed and signed a general

14 release form that grants to the health care provider

15 permission to release the recipient's health care information

16 to the recipient's insurance carrier.

17 (k) The Department of Healthcare and Family Services,

18 managed care organizations, a statewide organization

19 representing hospitals, and a statewide organization

20 representing safety-net hospitals shall explore ways to

21 support billing departments in safety-net hospitals.

22 (l) The requirements of this Section added by Public Act

23 102-4 shall apply to services provided on or after the first

24 day of the month that begins 60 days after April 27, 2021 (the

25 effective date of Public Act 102-4).

26 (m) Except where otherwise expressly specified, the

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1 requirements of this Section added by Public Act 103-593 shall

2 apply to services provided on and after July 1, 2026.

3 (Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;

4 103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.

5 8-15-25.)

6 ARTICLE 180.

7 Section 180-5. The Psychiatric Residential Treatment

8 Facilities (PRTF) Act is amended by changing Sections 10 and

9 15 as follows:

10 (405 ILCS 142/10)

11 Sec. 10. PRTF services.

12 (a) The Department shall establish an Illinois Psychiatric

13 Residential Treatment Facilities (PRTF) program that is

14 family-driven, youth-guided, and trauma-informed, and includes

15 youth and family involvement in all aspects of care planning.

16 The Illinois PRTF program design shall establish meaningful

17 opportunities for youth and families to be involved in the

18 design, monitoring, and oversight of PRTF services.

19 (b) By September 1, 2027 ~~By January 1, 2026~~, the

20 Department shall submit a State Plan Amendment to the Centers

21 for Medicare and Medicaid Services to establish coverage of

22 federally authorized, medically necessary inpatient

23 psychiatric services delivered by a certified PRTF to medical

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1 assistance beneficiaries under 21 years of age.

2 (c) The Department shall adopt rules to implement the

3 Illinois PRTF program. The rules may establish the services,

4 standards, and requirements for participation in the program

5 to comply with all applicable federal statutes, regulations,

6 requirements, and policies. The rules proposed by the

7 Department may take into consideration the recommendations of

8 the PRTF Advisory Committee, as outlined in Section 20. At a

9 minimum, the rules shall include the following:

10 (1) Certification and participation requirements for

11 PRTF providers in compliance with all applicable federal

12 laws, regulations, requirements, and policies, including

13 those found at 42 CFR 441, Subpart D and 42 CFR 483,

14 Subpart G or any successor regulations.

15 (2) Monitoring and oversight of PRTF services,

16 including on-site review protocols that include scheduled

17 and unannounced on-site visits. Each provider seeking PRTF

18 certification shall minimally have an on-site review prior

19 to initiating services and all PRTFs shall have at least

20 one on-site review annually thereafter.

21 (3) Utilization management criteria to ensure that

22 PRTF services are provided as medically necessary and

23 emphasize clinically appropriate patient transitions back

24 to the community, including, but not limited to, service

25 authorization, documentation, and treatment plan

26 requirements for initial stay reviews and continued stay

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1 reviews.

2 (4) A limit on allowable beds at any one PRTF, not to

3 exceed 40 total beds, unless waived in writing by the

4 Director of the Department.

5 (5) A limit on the number of new PRTF facilities to be

6 certified in any State fiscal year.

7 (6) A requirement that PRTFs are distinct, standalone

8 non-hospital entities not physically attached or adjacent

9 to any other type of facility engaged in providing

10 congregate care.

11 (7) A requirement that, in order to obtain PRTF

12 certification, providers must undergo a survey from the

13 State Survey Agency, the Department of Public Health, to

14 establish the provider's compliance with the Conditions of

15 Participation for PRTFs outlined in 42 CFR 483, Subpart G

16 and the Interpretive Guidelines issued by the Centers for

17 Medicare and Medicaid Services.

18 (8) A requirement that, in order to obtain PRTF

19 certification, providers be accredited from one of the

20 following organizations identified in 42 CFR 441.151, or

21 any successor regulations:

22 (i) Joint Commission on Accreditation of

23 Healthcare Organizations.

24 (ii) The Commission on Accreditation of

25 Rehabilitation Facilities.

26 (iii) The Council on Accreditation of Services for

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1 Families and Children.

2 (iv) Any other accrediting organization with

3 comparable standards recognized by the Department.

4 (9) Requirements for the reporting of emergency safety

5 interventions and serious occurrences to the Department

6 and the State-designated Protection and Advocacy System no

7 later than the close of business the next business day

8 after the intervention or occurrence.

9 (Source: P.A. 104-147, eff. 8-1-25.)

10 (405 ILCS 142/15)

11 Sec. 15. PRTF capacity analysis.

12 (a) The Department shall establish, and update as needed,

13 a methodology for completing a statewide PRTF capacity

14 analysis for the purposes of identifying capacity needs for

15 PRTF services under the Illinois Medical Assistance Program.

16 The Department shall utilize the PRTF capacity analysis to

17 inform its certification and enrollment of PRTF providers. The

18 capacity analysis shall minimally include:

19 (1) An analysis of aggregate service utilization data

20 for Medicaid eligible individuals under the age of 21,

21 including community-based services, behavioral health

22 crisis services, and inpatient psychiatric hospitalization

23 services.

24 (2) Identification of locations across the State with

25 demonstrated need for PRTF services and locations with

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1 demonstrated surplus of PRTF service capacity.

2 (3) Consideration of specialized treatment needs based

3 on increased utilization of out-of-state facilities to

4 address specialized treatment needs.

5 (4) Other factors of consideration identified by the

6 Department as necessary to support access to care,

7 compliance with the federal Medicaid program, and all

8 other applicable federal or State laws, regulations,

9 policies, requirements, and programs impacting Illinois'

10 children's behavioral health service delivery system.

11 (5) Recommendations to the Department and the PRTF

12 Advisory Committee on capacity needs within the Illinois

13 PRTF program. The recommendations shall seek to avoid the

14 concentration of PRTF facilities in any particular

15 community or area of the State to promote access for

16 families or guardians to visit patients when appropriate.

17 (b) The Department's methodology, completed analyses, and

18 outcomes shall be published on its website, with an initial

19 PRTF capacity analysis to be published by no later than April

20 1, 2027 ~~January 1, 2026~~.

21 (c) The Department's PRTF capacity analysis shall be

22 updated at a minimum of every 5 years and shall be performed

23 consistent with the Department's published methodology.

24 (Source: P.A. 104-147, eff. 8-1-25.)

25 ARTICLE 185.

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1 Section 185-5. The Illinois Public Aid Code is amended by

2 changing Section 1-8.5 as follows:

3 (305 ILCS 5/1-8.5)

4 Sec. 1-8.5. Eligibility for medical assistance during

5 periods of incarceration or detention.

6 (a) To the extent permitted by federal law and

7 notwithstanding any other provision of this Code, the

8 Department of Healthcare and Family Services shall not cancel

9 a person's eligibility for medical assistance, nor shall the

10 Department deny a person's application for medical assistance,

11 solely because that person has become or is an inmate of a

12 public institution, including, but not limited to, a county

13 jail, juvenile detention center, or State correctional

14 facility. The person may be and remain enrolled for medical

15 assistance as long as all other eligibility criteria are met.

16 (b) The Department may adopt rules to permit a person to

17 apply for medical assistance while he or she is an inmate of a

18 public institution as described in subsection (a). The rules

19 may limit applications to persons who would be likely to

20 qualify for medical assistance if they resided in the

21 community. Any such person who is not already enrolled for

22 medical assistance may apply for medical assistance prior to

23 the date of scheduled release or discharge from a penal

24 institution or county jail or similar status.

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1 (c) Except as provided under Section 17 of the County Jail

2 Act, the Department shall not be responsible to provide

3 medical assistance under this Code for any medical care,

4 services, or supplies provided to a person while he or she is

5 an inmate of a public institution as described in subsection

6 (a). The responsibility for providing medical care shall

7 remain as otherwise provided by law with the Department of

8 Corrections, county, or other arresting authority. The

9 Department may seek federal financial participation, to the

10 extent that it is available and with the cooperation of the

11 Department of Juvenile Justice, the Department of Corrections,

12 or the relevant county, for the costs of those services.

13 (c-1) Notwithstanding subsection (c), the Department may

14 provide medical assistance under this Code for medical care,

15 services, and supplies provided to a person while he or she is

16 an inmate of a public institution as described in subsection

17 (a) only to the extent required by the federal Medicaid

18 program, the Children's Health Insurance Program, or otherwise

19 authorized under a federally approved 1115 Waiver, State Plan

20 Amendment, or other federal authority. The medical care,

21 services, and supplies covered, and any other standards,

22 limitations, or conditions for eligibility and coverage, shall

23 be established by rule by the Department in accordance with

24 the applicable federal requirement, waiver, State Plan

25 amendment, or other authority.

26 (d) To the extent permitted under State and federal law,

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1 the Department shall develop procedures to expedite required

2 periodic reviews of continued eligibility for persons

3 described in subsection (a).

4 (e) Counties, the Department of Juvenile Justice, the

5 Department of Human Services, and the Department of

6 Corrections shall cooperate with the Department in

7 administering this Section. That cooperation shall include

8 managing eligibility processing and sharing information

9 sufficient to inform the Department, in a manner established

10 by the Department, that a person enrolled in the medical

11 assistance program has been detained or incarcerated.

12 (f) The Department shall resume responsibility for

13 providing medical assistance upon release of the person to the

14 community as long as all of the following apply:

15 (1) The person is enrolled for medical assistance at

16 the time of release.

17 (2) Neither a county, the Department of Juvenile

18 Justice, the Department of Corrections, nor any other

19 criminal justice authority continues to bear

20 responsibility for the person's medical care.

21 (3) The county, the Department of Juvenile Justice, or

22 the Department of Corrections provides timely notice of

23 the date of release in a manner established by the

24 Department.

25 (g) This Section applies on and after December 31, 2011.

26 (Source: P.A. 98-139, eff. 1-1-14; 99-415, eff. 8-20-15.)

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1 ARTICLE 190.

2 Section 190-5. The Illinois Public Aid Code is amended by

3 changing Sections 5-30.1 and 5-30.18 as follows:

4 (305 ILCS 5/5-30.1)

5 Sec. 5-30.1. Managed care protections.

6 (a) As used in this Section:

7 "Managed care organization" or "MCO" means any entity

8 which contracts with the Department to provide services where

9 payment for medical services is made on a capitated basis.

10 "Emergency services" means health care items and services,

11 including inpatient and outpatient hospital services,

12 furnished or required to evaluate and stabilize an emergency

13 medical condition. "Emergency services" include inpatient

14 stabilization services furnished during the inpatient

15 stabilization period. "Emergency services" do not include

16 post-stabilization medical services.

17 "Emergency medical condition" means a medical condition

18 manifesting itself by acute symptoms of sufficient severity,

19 regardless of the final diagnosis given, such that a prudent

20 layperson, who possesses an average knowledge of health and

21 medicine, could reasonably expect the absence of immediate

22 medical attention to result in:

23 (1) placing the health of the individual (or, with

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1 respect to a pregnant woman, the health of the woman or her

2 unborn child) in serious jeopardy;

3 (2) serious impairment to bodily functions;

4 (3) serious dysfunction of any bodily organ or part;

5 (4) inadequately controlled pain; or

6 (5) with respect to a pregnant woman who is having

7 contractions:

8 (A) inadequate time to complete a safe transfer to

9 another hospital before delivery; or

10 (B) a transfer to another hospital may pose a

11 threat to the health or safety of the woman or unborn

12 child.

13 "Emergency medical screening examination" means a medical

14 screening examination and evaluation by a physician licensed

15 to practice medicine in all its branches or, to the extent

16 permitted by applicable laws, by other appropriately licensed

17 personnel under the supervision of or in collaboration with a

18 physician licensed to practice medicine in all its branches to

19 determine whether the need for emergency services exists.

20 "Health care services" means ~~mean~~ any medical or

21 behavioral health services covered under the medical

22 assistance program that are subject to review under a service

23 authorization program.

24 "Inpatient stabilization period" means the initial 72

25 hours of inpatient stabilization services, beginning from the

26 date and time of the order for inpatient admission to the

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1 hospital.

2 "Inpatient stabilization services" means ~~mean~~ emergency

3 services furnished in the inpatient setting at a hospital

4 pursuant to an order for inpatient admission by a physician or

5 other qualified practitioner who has admitting privileges at

6 the hospital, as permitted by State law, to stabilize an

7 emergency medical condition following an emergency medical

8 screening examination.

9 "Post-stabilization medical services" means health care

10 services provided to an enrollee that are furnished in a

11 hospital by a provider that is qualified to furnish such

12 services and determined to be medically necessary by the

13 provider and directly related to the emergency medical

14 condition following stabilization.

15 "Provider" means a facility or individual who is actively

16 enrolled in the medical assistance program and licensed or

17 otherwise authorized to order, prescribe, refer, or render

18 health care services in this State.

19 "Service authorization determination" means a decision

20 made by a service authorization program in advance of,

21 concurrent to, or after the provision of a health care service

22 to approve, change the level of care, partially deny, deny, or

23 otherwise limit coverage and reimbursement for a health care

24 service upon review of a service authorization request.

25 "Service authorization program" means any utilization

26 review, utilization management, peer review, quality review,

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1 or other medical management activity conducted by an MCO, or

2 its contracted utilization review organization, including, but

3 not limited to, prior authorization, prior approval,

4 pre-certification, concurrent review, retrospective review, or

5 certification of admission, of health care services provided

6 in the inpatient or outpatient hospital setting.

7 "Service authorization request" means a request by a

8 provider to a service authorization program to determine

9 whether a health care service meets the reimbursement

10 eligibility requirements for medically necessary, clinically

11 appropriate care, resulting in the issuance of a service

12 authorization determination.

13 "Utilization review organization" or "URO" means an MCO's

14 utilization review department or a peer review organization or

15 quality improvement organization that contracts with an MCO to

16 administer a service authorization program and make service

17 authorization determinations.

18 (b) As provided by Section 5-16.12, managed care

19 organizations are subject to the provisions of the Managed

20 Care Reform and Patient Rights Act.

21 (c) An MCO shall pay any provider of emergency services,

22 including for inpatient stabilization services provided during

23 the inpatient stabilization period, that does not have in

24 effect a contract with the contracted Medicaid MCO. The

25 default rate of reimbursement shall be the rate paid under

26 Illinois Medicaid fee-for-service program methodology,

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1 including all policy adjusters, including but not limited to

2 Medicaid High Volume Adjustments, Medicaid Percentage

3 Adjustments, Outpatient High Volume Adjustments, and all

4 outlier add-on adjustments to the extent such adjustments are

5 incorporated in the development of the applicable MCO

6 capitated rates.

7 (d) (Blank).

8 (e) Notwithstanding any other provision of law, the

9 following requirements apply to MCOs in determining payment

10 for all emergency services, including inpatient stabilization

11 services provided during the inpatient stabilization period:

12 (1) The MCO shall not impose any service authorization

13 program requirements for emergency services, including,

14 but not limited to, prior authorization, prior approval,

15 pre-certification, certification of admission, concurrent

16 review, or retrospective review.

17 (A) Notification period: Hospitals shall notify

18 the enrollee's Medicaid MCO within 48 hours of the

19 date and time the order for inpatient admission is

20 written. Notification shall be limited to advising the

21 MCO that the patient has been admitted to a hospital

22 inpatient level of care.

23 (B) If the admitting hospital complies with the

24 notification provisions of subparagraph (A), the

25 Medicaid MCO may not initiate concurrent review before

26 the end of the inpatient stabilization period. If the

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1 admitting hospital does not comply with the

2 notification requirements in subparagraph (A), the

3 Medicaid MCO may initiate concurrent review for the

4 continuation of the stay beginning at the end of the

5 48-hour notification period.

6 (C) Coverage for services provided during the

7 48-hour notification period may not be retrospectively

8 denied.

9 (2) The MCO shall cover emergency services provided to

10 enrollees who are temporarily away from their residence

11 and outside the contracting area to the extent that the

12 enrollees would be entitled to the emergency services if

13 they still were within the contracting area.

14 (3) The MCO shall have no obligation to cover

15 emergency services provided on an emergency basis that are

16 not covered services under the contract between the MCO

17 and the Department.

18 (4) The MCO shall not condition coverage for emergency

19 services on the treating provider notifying the MCO of the

20 enrollee's emergency medical screening examination and

21 treatment within 10 days after presentation for emergency

22 services.

23 (5) The determination of the attending emergency

24 physician, or the practitioner responsible for the

25 enrollee's care at the hospital, of whether an enrollee

26 requires inpatient stabilization services, can be

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1 stabilized in the outpatient setting, or is sufficiently

2 stabilized for discharge or transfer to another setting,

3 shall be binding on the MCO. The MCO shall cover and

4 reimburse providers for emergency services as billed by

5 the provider for all enrollees whether the emergency

6 services are provided by an affiliated or non-affiliated

7 provider, except in cases of fraud. The MCO shall

8 reimburse inpatient stabilization services provided during

9 the inpatient stabilization period and billed as inpatient

10 level of care based on the appropriate inpatient

11 reimbursement methodology.

12 (6) The MCO's financial responsibility for

13 post-stabilization medical services it has not

14 pre-approved ends when:

15 (A) a plan physician with privileges at the

16 treating hospital assumes responsibility for the

17 enrollee's care;

18 (B) a plan physician assumes responsibility for

19 the enrollee's care through transfer;

20 (C) a contracting entity representative and the

21 treating physician reach an agreement concerning the

22 enrollee's care; or

23 (D) the enrollee is discharged.

24 (e-5) An MCO shall pay for all post-stabilization medical

25 services as a covered service in any of the following

26 situations:

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1 (1) the MCO or its URO authorized such services;

2 (2) such services were administered to maintain the

3 enrollee's stabilized condition within one hour after a

4 request to the MCO for authorization of further

5 post-stabilization services;

6 (3) the MCO or its URO did not respond to a request to

7 authorize such services within one hour;

8 (4) the MCO or its URO could not be contacted; or

9 (5) the MCO or its URO and the treating provider, if

10 the treating provider is a non-affiliated provider, could

11 not reach an agreement concerning the enrollee's care and

12 an affiliated provider was unavailable for a consultation,

13 in which case the MCO must pay for such services rendered

14 by the treating non-affiliated provider until an

15 affiliated provider was reached and either concurred with

16 the treating non-affiliated provider's plan of care or

17 assumed responsibility for the enrollee's care. Such

18 payment shall be made at the default rate of reimbursement

19 paid under the State's Medicaid fee-for-service program

20 methodology, including all policy adjusters, including,

21 but not limited to, Medicaid High Volume Adjustments,

22 Medicaid Percentage Adjustments, Outpatient High Volume

23 Adjustments, and all outlier add-on adjustments to the

24 extent that such adjustments are incorporated in the

25 development of the applicable MCO capitated rates.

26 (f) Network adequacy and transparency.

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1 (1) The Department shall:

2 (A) ensure that an adequate provider network is in

3 place, taking into consideration health professional

4 shortage areas and medically underserved areas;

5 (B) publicly release an explanation of its process

6 for analyzing network adequacy;

7 (C) periodically ensure that an MCO continues to

8 have an adequate network in place;

9 (D) require MCOs, including Medicaid Managed Care

10 Entities as defined in Section 5-30.2, to meet

11 provider directory requirements under Section 5-30.3;

12 (E) require MCOs to ensure that any

13 Medicaid-certified provider under contract with an MCO

14 and previously submitted on a roster on the date of

15 service is paid for any medically necessary,

16 Medicaid-covered, and authorized service rendered to

17 any of the MCO's enrollees, regardless of inclusion on

18 the MCO's published and publicly available directory

19 of available providers; and

20 (F) require MCOs, including Medicaid Managed Care

21 Entities as defined in Section 5-30.2, to meet each of

22 the requirements under subsection (d-5) of Section 10

23 of the Network Adequacy and Transparency Act; with

24 necessary exceptions to the MCO's network to ensure

25 that admission and treatment with a provider or at a

26 treatment facility in accordance with the network

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1 adequacy standards in paragraph (3) of subsection

2 (d-5) of Section 10 of the Network Adequacy and

3 Transparency Act is limited to providers or facilities

4 that are Medicaid certified.

5 (2) Each MCO shall confirm its receipt of information

6 submitted specific to physician or dentist additions or

7 physician or dentist deletions from the MCO's provider

8 network within 3 days after receiving all required

9 information from contracted physicians or dentists, and

10 electronic physician and dental directories must be

11 updated consistent with current rules as published by the

12 Centers for Medicare and Medicaid Services or its

13 successor agency.

14 (g) Timely payment of claims.

15 (1) The MCO shall pay a claim within 30 days of

16 receiving a claim that contains all the essential

17 information needed to adjudicate the claim.

18 (2) The MCO shall notify the billing party of its

19 inability to adjudicate a claim within 30 days of

20 receiving that claim.

21 (3) The MCO shall pay a penalty that is at least equal

22 to the timely payment interest penalty imposed under

23 Section 368a of the Illinois Insurance Code for any claims

24 not timely paid.

25 (A) When an MCO is required to pay a timely payment

26 interest penalty to a provider, the MCO must calculate

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1 and pay the timely payment interest penalty that is

2 due to the provider within 30 days after the payment of

3 the claim. In no event shall a provider be required to

4 request or apply for payment of any owed timely

5 payment interest penalties.

6 (B) Such payments shall be reported separately

7 from the claim payment for services rendered to the

8 MCO's enrollee and clearly identified as interest

9 payments.

10 (4)(A) The Department shall require MCOs to expedite

11 payments to providers identified on the Department's

12 expedited provider list, determined in accordance with 89

13 Ill. Adm. Code 140.71(b), on a schedule at least as

14 frequently as the providers are paid under the

15 Department's fee-for-service expedited provider schedule.

16 (B) Compliance with the expedited provider requirement

17 may be satisfied by an MCO through the use of a Periodic

18 Interim Payment (PIP) program that has been mutually

19 agreed to and documented between the MCO and the provider,

20 if the PIP program ensures that any expedited provider

21 receives regular and periodic payments based on prior

22 period payment experience from that MCO. Total payments

23 under the PIP program may be reconciled against future PIP

24 payments on a schedule mutually agreed to between the MCO

25 and the provider.

26 (C) The Department shall share at least monthly its

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1 expedited provider list and the frequency with which it

2 pays providers on the expedited list.

3 (g-5) Recognizing that the rapid transformation of the

4 Illinois Medicaid program may have unintended operational

5 challenges for both payers and providers:

6 (1) in no instance shall a medically necessary covered

7 service rendered in good faith, based upon eligibility

8 information documented by the provider, be denied coverage

9 or diminished in payment amount if the eligibility or

10 coverage information available at the time the service was

11 rendered is later found to be inaccurate in the assignment

12 of coverage responsibility between MCOs or the

13 fee-for-service system, except for instances when an

14 individual is deemed to have not been eligible for

15 coverage under the Illinois Medicaid program; and

16 (2) the Department shall, by December 31, 2016, adopt

17 rules establishing policies that shall be included in the

18 Medicaid managed care policy and procedures manual

19 addressing payment resolutions in situations in which a

20 provider renders services based upon information obtained

21 after verifying a patient's eligibility and coverage plan

22 through either the Department's current enrollment system

23 or a system operated by the coverage plan identified by

24 the patient presenting for services:

25 (A) such medically necessary covered services

26 shall be considered rendered in good faith;

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1 (B) such policies and procedures shall be

2 developed in consultation with industry

3 representatives of the Medicaid managed care health

4 plans and representatives of provider associations

5 representing the majority of providers within the

6 identified provider industry; and

7 (C) such rules shall be published for a review and

8 comment period of no less than 30 days on the

9 Department's website with final rules remaining

10 available on the Department's website.

11 The rules on payment resolutions shall include, but

12 not be limited to:

13 (A) the extension of the timely filing period;

14 (B) retroactive prior authorizations; and

15 (C) guaranteed minimum payment rate of no less

16 than the current, as of the date of service,

17 fee-for-service rate, plus all applicable add-ons,

18 when the resulting service relationship is out of

19 network.

20 The rules shall be applicable for both MCO coverage

21 and fee-for-service coverage.

22 If the fee-for-service system is ultimately determined to

23 have been responsible for coverage on the date of service, the

24 Department shall provide for an extended period for claims

25 submission outside the standard timely filing requirements.

26 (g-6) MCO Performance Metrics Report.

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1 (1) The Department shall publish, on at least a

2 quarterly basis, each MCO's operational performance,

3 including, but not limited to, the following categories of

4 metrics:

5 (A) claims payment, including timeliness and

6 accuracy;

7 (B) prior authorizations;

8 (C) grievance and appeals;

9 (D) utilization statistics;

10 (E) provider disputes;

11 (F) provider credentialing; and

12 (G) member and provider customer service.

13 (2) The Department shall ensure that the metrics

14 report is accessible to providers online by January 1,

15 2017.

16 (3) The metrics shall be developed in consultation

17 with industry representatives of the Medicaid managed care

18 health plans and representatives of associations

19 representing the majority of providers within the

20 identified industry.

21 (4) Metrics shall be defined and incorporated into the

22 applicable Managed Care Policy Manual issued by the

23 Department.

24 (g-7) MCO claims processing and performance analysis. In

25 order to monitor MCO payments to hospital providers, pursuant

26 to Public Act 100-580, the Department shall post an analysis

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1 of MCO claims processing and payment performance on its

2 website every 6 months. Such analysis shall include a review

3 and evaluation of a representative sample of hospital claims

4 that are rejected and denied for clean and unclean claims and

5 the top 5 reasons for such actions and timeliness of claims

6 adjudication, which identifies the percentage of claims

7 adjudicated within 30, 60, 90, and over 90 days, and the dollar

8 amounts associated with those claims.

9 (g-8) Dispute resolution process. The Department shall

10 maintain a provider complaint portal through which a provider

11 can submit to the Department unresolved disputes with an MCO.

12 An unresolved dispute means an MCO's decision that denies in

13 whole or in part a claim for reimbursement to a provider for

14 health care services rendered by the provider to an enrollee

15 of the MCO with which the provider disagrees. Disputes shall

16 not be submitted to the portal until the provider has availed

17 itself of the MCO's internal dispute resolution process.

18 Disputes that are submitted to the MCO internal dispute

19 resolution process may be submitted to the Department of

20 Healthcare and Family Services' complaint portal no sooner

21 than 30 days after submitting to the MCO's internal process

22 and not later than 30 days after the unsatisfactory resolution

23 of the internal MCO process or 60 days after submitting the

24 dispute to the MCO internal process. Multiple claim disputes

25 involving the same MCO may be submitted in one complaint,

26 regardless of whether the claims are for different enrollees,

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1 when the specific reason for non-payment of the claims

2 involves a common question of fact or policy. Within 10

3 business days of receipt of a complaint, the Department shall

4 present such disputes to the appropriate MCO, which shall then

5 have 30 days to issue its written proposal to resolve the

6 dispute. The Department may grant one 30-day extension of this

7 time frame to one of the parties to resolve the dispute. If the

8 dispute remains unresolved at the end of this time frame or the

9 provider is not satisfied with the MCO's written proposal to

10 resolve the dispute, the provider may, within 30 days, request

11 the Department to review the dispute and make a final

12 determination. Within 30 days of the request for Department

13 review of the dispute, both the provider and the MCO shall

14 present all relevant information to the Department for

15 resolution and make individuals with knowledge of the issues

16 available to the Department for further inquiry if needed.

17 Within 30 days of receiving the relevant information on the

18 dispute, or the lapse of the period for submitting such

19 information, the Department shall issue a written decision on

20 the dispute based on contractual terms between the provider

21 and the MCO, contractual terms between the MCO and the

22 Department of Healthcare and Family Services and applicable

23 Medicaid policy. The decision of the Department shall be

24 final. By January 1, 2020, the Department shall establish by

25 rule further details of this dispute resolution process.

26 Disputes between MCOs and providers presented to the

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1 Department for resolution are not contested cases, as defined

2 in Section 1-30 of the Illinois Administrative Procedure Act,

3 conferring any right to an administrative hearing.

4 (g-9)(1) The Department shall publish annually on its

5 website a report on the calculation of each managed care

6 organization's medical loss ratio showing the following:

7 (A) Premium revenue, with appropriate adjustments.

8 (B) Benefit expense, setting forth the aggregate

9 amount spent for the following:

10 (i) Direct paid claims.

11 (ii) Subcapitation payments.

12 (iii) Other claim payments.

13 (iv) Direct reserves.

14 (v) Gross recoveries.

15 (vi) Expenses for activities that improve health

16 care quality as allowed by the Department.

17 (2) The medical loss ratio shall be calculated consistent

18 with federal law and regulation following a claims runout

19 period determined by the Department.

20 (g-10)(1) "Liability effective date" means the date on

21 which an MCO becomes responsible for payment for medically

22 necessary and covered services rendered by a provider to one

23 of its enrollees in accordance with the contract terms between

24 the MCO and the provider. The liability effective date shall

25 be the later of:

26 (A) The execution date of a network participation

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1 contract agreement.

2 (B) The date the provider or its representative

3 submits to the MCO the complete and accurate standardized

4 roster form for the provider in the format approved by the

5 Department.

6 (C) The provider effective date contained within the

7 Department's provider enrollment subsystem within the

8 Illinois Medicaid Program Advanced Cloud Technology

9 (IMPACT) System.

10 (2) The standardized roster form may be submitted to the

11 MCO at the same time that the provider submits an enrollment

12 application to the Department through IMPACT.

13 (3) By October 1, 2019, the Department shall require all

14 MCOs to update their provider directory with information for

15 new practitioners of existing contracted providers within 30

16 days of receipt of a complete and accurate standardized roster

17 template in the format approved by the Department provided

18 that the provider is effective in the Department's provider

19 enrollment subsystem within the IMPACT system. Such provider

20 directory shall be readily accessible for purposes of

21 selecting an approved health care provider and comply with all

22 other federal and State requirements.

23 (g-11) The Department shall work with relevant

24 stakeholders on the development of operational guidelines to

25 enhance and improve operational performance of Illinois'

26 Medicaid managed care program, including, but not limited to,

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1 improving provider billing practices, reducing claim

2 rejections and inappropriate payment denials, and

3 standardizing processes, procedures, definitions, and response

4 timelines, with the goal of reducing provider and MCO

5 administrative burdens and conflict. The Department shall

6 include a report on the progress of these program improvements

7 and other topics in its Fiscal Year 2020 annual report to the

8 General Assembly.

9 (g-12) Notwithstanding any other provision of law, if the

10 Department or an MCO requires submission of a claim for

11 payment in a non-electronic format, a provider shall always be

12 afforded a period of no less than 90 business days, as a

13 correction period, following any notification of rejection by

14 either the Department or the MCO to correct errors or

15 omissions in the original submission.

16 Under no circumstances, either by an MCO or under the

17 State's fee-for-service system, shall a provider be denied

18 payment for failure to comply with any timely submission

19 requirements under this Code or under any existing contract,

20 unless the non-electronic format claim submission occurs after

21 the initial 180 days following the latest date of service on

22 the claim, or after the 90 business days correction period

23 following notification to the provider of rejection or denial

24 of payment.

25 (g-13) Utilization Review Standardization and

26 Transparency.

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1 (1) To ensure greater standardization and transparency

2 related to service authorization determinations, for all

3 individuals covered under the medical assistance program,

4 including both the fee-for-service and managed care

5 programs, the Department shall, in consultation with the

6 MCOs, a statewide association representing the MCOs, a

7 statewide association representing the majority of

8 Illinois hospitals, a statewide association representing

9 physicians, or any other interested parties deemed

10 appropriate by the Department, adopt administrative rules

11 consistent with this subsection, in accordance with the

12 Illinois Administrative Procedure Act.

13 (2) No later than July 1, 2025, the Department shall

14 in accordance with the Illinois Administrative Procedure

15 Act file emergency rules, and adopt permanent rules no

16 later than October 1, 2025, which govern MCO practices for

17 dates of services on and after July 1, 2025, as follows:

18 (A) guidelines related to the publication of MCO

19 authorization policies;

20 (B) procedures that, due to medical complexity,

21 must be reimbursed under the applicable inpatient

22 methodology, when provided in the inpatient setting

23 and billed as an inpatient service;

24 (C) standardization of administrative forms used

25 in the member appeal process;

26 (D) limitations on second or subsequent medical

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1 necessity review of a health care service already

2 authorized by the MCO or URO under a service

3 authorization program;

4 (E) standardization of peer-to-peer processes and

5 timelines;

6 (F) defined criteria for urgent and standard

7 post-acute care and long-term acute care service

8 authorization requests; and

9 (G) standardized criteria for service

10 authorization programs for authorization of admission

11 to a long-term acute care hospital.

12 (3) The Department shall expand the scope of the

13 quality and compliance audits conducted by its contracted

14 external quality review organization to include, but not

15 be limited to:

16 (A) an analysis of the Medicaid MCO's compliance

17 with nationally recognized clinical decision

18 guidelines;

19 (B) an analysis that compares and contrasts the

20 Medicaid MCO's service authorization determination

21 outcomes to the outcomes of each other MCO plan and the

22 State's fee-for-service program model to evaluate

23 whether service authorization determinations are being

24 made consistently by all Medicaid MCOs to ensure that

25 all individuals are being treated in accordance with

26 equitable standards of care;

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1 (C) an analysis, for each Medicaid MCO, of the

2 number of service authorization requests, including

3 requests for concurrent review and certification of

4 admissions, received, initially denied, overturned

5 through any post-denial process including, but not

6 limited to, enrollee or provider appeal, peer-to-peer

7 review, or the provider dispute resolution process,

8 denied but approved for a lower or different level of

9 care, and the number denied on final determination;

10 and

11 (D) provide a written report to the General

12 Assembly, detailing the items listed in this

13 subsection and any other metrics deemed necessary by

14 the Department, by the second April, following June 7,

15 2024 (the effective date of Public Act 103-593), and

16 each April thereafter. The Department shall make this

17 report available within 30 days of delivery to the

18 General Assembly, on its public facing website.

19 (h) The Department shall not expand mandatory MCO

20 enrollment into new counties beyond those counties already

21 designated by the Department as of June 1, 2014 for the

22 individuals whose eligibility for medical assistance is not

23 the seniors or people with disabilities population until the

24 Department provides an opportunity for accountable care

25 entities and MCOs to participate in such newly designated

26 counties.

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1 (h-5) Leading indicator data sharing. By January 1, 2024,

2 the Department shall obtain input from the Department of Human

3 Services, the Department of Juvenile Justice, the Department

4 of Children and Family Services, the State Board of Education,

5 managed care organizations, providers, and clinical experts to

6 identify and analyze key indicators and data elements that can

7 be used in an analysis of lead indicators from assessments and

8 data sets available to the Department that can be shared with

9 managed care organizations and similar care coordination

10 entities contracted with the Department as leading indicators

11 for elevated behavioral health crisis risk for children,

12 including data sets such as the Illinois Medicaid

13 Comprehensive Assessment of Needs and Strengths (IM-CANS),

14 calls made to the State's Crisis and Referral Entry Services

15 (CARES) hotline, health services information from Health and

16 Human Services Innovators, or other data sets that may include

17 key indicators. The workgroup shall complete its

18 recommendations for leading indicator data elements on or

19 before September 1, 2024. To the extent permitted by State and

20 federal law, the identified leading indicators shall be shared

21 with managed care organizations and similar care coordination

22 entities contracted with the Department on or before December

23 1, 2024 for the purpose of improving care coordination with

24 the early detection of elevated risk. Leading indicators shall

25 be reassessed annually with stakeholder input. The Department

26 shall implement guidance to managed care organizations and

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1 similar care coordination entities contracted with the

2 Department, so that the managed care organizations and care

3 coordination entities respond to lead indicators with services

4 and interventions that are designed to help stabilize the

5 child.

6 (i) The requirements of this Section apply to contracts

7 with accountable care entities and MCOs entered into, amended,

8 or renewed after June 16, 2014 (the effective date of Public

9 Act 98-651).

10 (j) Health care information released to managed care

11 organizations. A health care provider shall release to a

12 Medicaid managed care organization, upon request, and subject

13 to the Health Insurance Portability and Accountability Act of

14 1996 and any other law applicable to the release of health

15 information, the health care information of the MCO's

16 enrollee, if the enrollee has completed and signed a general

17 release form that grants to the health care provider

18 permission to release the recipient's health care information

19 to the recipient's insurance carrier.

20 (k) The Department of Healthcare and Family Services,

21 managed care organizations, a statewide organization

22 representing hospitals, and a statewide organization

23 representing safety-net hospitals shall explore ways to

24 support billing departments in safety-net hospitals.

25 (l) The requirements of this Section added by Public Act

26 102-4 shall apply to services provided on or after the first

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1 day of the month that begins 60 days after April 27, 2021 (the

2 effective date of Public Act 102-4).

3 (m) Except where otherwise expressly specified, the

4 requirements of this Section added by Public Act 103-593 shall

5 apply to services provided on and after July 1, 2027 ~~July 1,~~

6 ~~2026~~.

7 (Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;

8 103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.

9 8-15-25.)

10 (305 ILCS 5/5-30.18)

11 (Section scheduled to be repealed on December 31, 2030)

12 Sec. 5-30.18. Service authorization program performance.

13 (a) Definitions. As used in this Section:

14 "Gold Card provider" means a provider identified by each

15 Medicaid Managed Care Organization (MCO) as qualified under

16 the guidelines outlined by the Department in accordance with

17 subsection (c) and thereby granted a service authorization

18 exemption when ordering a health care service.

19 "Health care service" means any medical or behavioral

20 health service covered under the medical assistance program

21 that is rendered in the inpatient or outpatient hospital

22 setting, including hospital-based clinics, and subject to

23 review under a service authorization program.

24 "Provider" means an individual actively enrolled in the

25 medical assistance program and licensed or otherwise

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1 authorized to order, prescribe, refer, or render health care

2 services in this State, and, as determined by the Department,

3 may also include hospitals that submit service authorization

4 requests.

5 "Service authorization exemption" means an exception

6 granted by a Medicaid MCO to a provider under which all service

7 authorization requests for covered health care services,

8 excluding pharmacy services and durable medical equipment, are

9 automatically deemed to be medically necessary, clinically

10 appropriate, and approved for reimbursement as ordered.

11 "Service authorization program" means any utilization

12 review, utilization management, peer review, quality review,

13 or other medical management activity conducted in advance of,

14 concurrent to, or after the provision of a health care service

15 by a Medicaid MCO, either directly or through a contracted

16 utilization review organization (URO), including, but not

17 limited to, prior authorization, pre-certification,

18 certification of admission, concurrent review, and

19 retrospective review of health care services.

20 "Service authorization request" means a request by a

21 provider to a service authorization program to determine

22 whether a health care service that is otherwise covered under

23 the medical assistance program meets the reimbursement

24 requirements established by the Medicaid MCO, or its

25 contracted URO, for medically necessary, clinically

26 appropriate care and to issue a service authorization

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1 determination.

2 "Utilization review organization" or "URO" means a managed

3 care organization or other entity that has established or

4 administers one or more service authorization programs.

5 (b) In consultation with the Medicaid MCOs, a statewide

6 association representing managed care organizations, a

7 statewide association representing the majority of Illinois

8 hospitals, and a statewide association representing

9 physicians, the Department shall in accordance with the

10 Illinois Administrative Procedure Act, adopt administrative

11 rules no later than October ~~July~~ 1, 2026, consistent with this

12 Section, to require each Medicaid MCO to identify Gold Card

13 providers with such identification initially being effective

14 for health care services provided on and after January 1, 2027

15 ~~July 1, 2026~~.

16 (c) The Department shall adopt rules, in accordance with

17 the Illinois Administrative Procedure Act, to implement this

18 Section that include, but are not limited to, the following

19 provisions:

20 (1) Require each Medicaid MCO to provide a service

21 authorization exemption to a provider if the provider has

22 submitted at least 50 service authorization requests to

23 its service authorization program in the preceding

24 calendar year and the service authorization program

25 approved at least 90% of all service authorization

26 requests, regardless of the type of health care services

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1 requested.

2 (2) Require that service authorization exemptions be

3 limited to services provided in an inpatient or outpatient

4 hospital setting inclusive of hospital-based clinics.

5 Service authorization exemptions under this Section shall

6 not pertain to pharmacy services and durable medical

7 equipment and supplies.

8 (3) The service authorization exemption shall be valid

9 for at least one year, shall be made by each Medicaid MCO

10 or its URO, and shall be binding on the Medicaid MCO and

11 its URO.

12 (4) The provider shall be required to continue to

13 document medically necessary, clinically appropriate care

14 and submit such documentation to the Medicaid MCO for the

15 purpose of continuous performance monitoring. If a

16 provider fails to maintain the 90% service authorization

17 standard, as determined on no more frequent a basis than

18 bi-annually, the provider's service authorization

19 exemption is subject to temporary or permanent suspension.

20 (5) Require that each Medicaid MCO publish on its

21 provider portal a list of all providers that have

22 qualified for a service authorization exemption or

23 indicate that a provider has qualified for a service

24 authorization exemption on its provider-facing provider

25 roster.

26 (6) Require that no later than June 1 of each calendar

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1 year, each Medicaid MCO shall provide written notification

2 to all providers who qualify for a service authorization

3 exemption, for the subsequent State fiscal year.

4 (7) Require that each Medicaid MCO or its URO use the

5 policies and guidelines published by the Department to

6 evaluate whether a provider meets the criteria to qualify

7 for a service authorization exemption and the conditions

8 under which a service authorization exemption may be

9 rescinded, including review of the provider's service

10 authorization determinations during the preceding calendar

11 year.

12 (8) Require each Medicaid MCO to provide the

13 Department a list of all providers who were denied a

14 service authorization exemption or had a previously

15 granted service authorization exemption suspended, with

16 such denials being subject to an annual audit conducted by

17 an independent third-party URO to ensure their

18 appropriateness.

19 (A) The independent third-party URO shall issue a

20 written report consistent with this paragraph.

21 (B) The independent third-party URO shall not be

22 owned by, affiliated with, or employed by any Medicaid

23 MCO or its contracted URO, nor shall it have any

24 financial interest in the Medicaid MCO's service

25 authorization exemption program.

26 (d) Each Medicaid MCO must have a standard method to

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1 accept and process professional claims and facility claims, as

2 billed by the provider, for a health care service that is

3 rendered, prescribed, or ordered by a provider granted a

4 service authorization exemption, except in cases of fraud.

5 (e) A service authorization program shall not deny,

6 partially deny, reduce the level of care, or otherwise limit

7 reimbursement to the rendering or supervising provider,

8 including the rendering facility, for health care services

9 ordered by a provider who qualifies for a service

10 authorization exemption, except in cases of fraud.

11 (f) This Section is repealed on December 31, 2030.

12 (Source: P.A. 103-593, eff. 6-7-24; 104-9, eff. 6-16-25.)

13 ARTICLE 195.

14 Section 195-5. The Illinois Insurance Code is amended by

15 changing Section 370c.1 as follows:

16 (215 ILCS 5/370c.1)

17 Sec. 370c.1. Mental, emotional, nervous, or substance use

18 disorder or condition parity.

19 (a) On and after July 23, 2021 (the effective date of

20 Public Act 102-135), every insurer that amends, delivers,

21 issues, or renews a group or individual policy of accident and

22 health insurance or a qualified health plan offered through

23 the Health Insurance Marketplace in this State providing

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1 coverage for hospital or medical treatment and for the

2 treatment of mental, emotional, nervous, or substance use

3 disorders or conditions shall ensure prior to policy issuance

4 that:

5 (1) the financial requirements applicable to such

6 mental, emotional, nervous, or substance use disorder or

7 condition benefits are no more restrictive than the

8 predominant financial requirements applied to

9 substantially all hospital and medical benefits covered by

10 the policy and that there are no separate cost-sharing

11 requirements that are applicable only with respect to

12 mental, emotional, nervous, or substance use disorder or

13 condition benefits; and

14 (2) the treatment limitations applicable to such

15 mental, emotional, nervous, or substance use disorder or

16 condition benefits are no more restrictive than the

17 predominant treatment limitations applied to substantially

18 all hospital and medical benefits covered by the policy

19 and that there are no separate treatment limitations that

20 are applicable only with respect to mental, emotional,

21 nervous, or substance use disorder or condition benefits.

22 (b) The following provisions shall apply concerning

23 aggregate lifetime limits:

24 (1) In the case of a group or individual policy of

25 accident and health insurance or a qualified health plan

26 offered through the Health Insurance Marketplace amended,

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1 delivered, issued, or renewed in this State on or after

2 September 9, 2015 (the effective date of Public Act

3 99-480) that provides coverage for hospital or medical

4 treatment and for the treatment of mental, emotional,

5 nervous, or substance use disorders or conditions the

6 following provisions shall apply:

7 (A) if the policy does not include an aggregate

8 lifetime limit on substantially all hospital and

9 medical benefits, then the policy may not impose any

10 aggregate lifetime limit on mental, emotional,

11 nervous, or substance use disorder or condition

12 benefits; or

13 (B) if the policy includes an aggregate lifetime

14 limit on substantially all hospital and medical

15 benefits (in this subsection referred to as the

16 "applicable lifetime limit"), then the policy shall

17 either:

18 (i) apply the applicable lifetime limit both

19 to the hospital and medical benefits to which it

20 otherwise would apply and to mental, emotional,

21 nervous, or substance use disorder or condition

22 benefits and not distinguish in the application of

23 the limit between the hospital and medical

24 benefits and mental, emotional, nervous, or

25 substance use disorder or condition benefits; or

26 (ii) not include any aggregate lifetime limit

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1 on mental, emotional, nervous, or substance use

2 disorder or condition benefits that is less than

3 the applicable lifetime limit.

4 (2) In the case of a policy that is not described in

5 paragraph (1) of subsection (b) of this Section and that

6 includes no or different aggregate lifetime limits on

7 different categories of hospital and medical benefits, the

8 Director shall establish rules under which subparagraph

9 (B) of paragraph (1) of subsection (b) of this Section is

10 applied to such policy with respect to mental, emotional,

11 nervous, or substance use disorder or condition benefits

12 by substituting for the applicable lifetime limit an

13 average aggregate lifetime limit that is computed taking

14 into account the weighted average of the aggregate

15 lifetime limits applicable to such categories.

16 (c) The following provisions shall apply concerning annual

17 limits:

18 (1) In the case of a group or individual policy of

19 accident and health insurance or a qualified health plan

20 offered through the Health Insurance Marketplace amended,

21 delivered, issued, or renewed in this State on or after

22 September 9, 2015 (the effective date of Public Act

23 99-480) that provides coverage for hospital or medical

24 treatment and for the treatment of mental, emotional,

25 nervous, or substance use disorders or conditions the

26 following provisions shall apply:

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1 (A) if the policy does not include an annual limit

2 on substantially all hospital and medical benefits,

3 then the policy may not impose any annual limits on

4 mental, emotional, nervous, or substance use disorder

5 or condition benefits; or

6 (B) if the policy includes an annual limit on

7 substantially all hospital and medical benefits (in

8 this subsection referred to as the "applicable annual

9 limit"), then the policy shall either:

10 (i) apply the applicable annual limit both to

11 the hospital and medical benefits to which it

12 otherwise would apply and to mental, emotional,

13 nervous, or substance use disorder or condition

14 benefits and not distinguish in the application of

15 the limit between the hospital and medical

16 benefits and mental, emotional, nervous, or

17 substance use disorder or condition benefits; or

18 (ii) not include any annual limit on mental,

19 emotional, nervous, or substance use disorder or

20 condition benefits that is less than the

21 applicable annual limit.

22 (2) In the case of a policy that is not described in

23 paragraph (1) of subsection (c) of this Section and that

24 includes no or different annual limits on different

25 categories of hospital and medical benefits, the Director

26 shall establish rules under which subparagraph (B) of

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1 paragraph (1) of subsection (c) of this Section is applied

2 to such policy with respect to mental, emotional, nervous,

3 or substance use disorder or condition benefits by

4 substituting for the applicable annual limit an average

5 annual limit that is computed taking into account the

6 weighted average of the annual limits applicable to such

7 categories.

8 (d) With respect to mental, emotional, nervous, or

9 substance use disorders or conditions, an insurer shall use

10 policies and procedures for the election and placement of

11 mental, emotional, nervous, or substance use disorder or

12 condition treatment drugs on its ~~their~~ formulary that are no

13 less favorable to the insured as those policies and procedures

14 the insurer uses for the selection and placement of drugs for

15 medical or surgical conditions and shall follow the expedited

16 coverage determination requirements for substance abuse

17 treatment drugs set forth in Section 45.2 of the Managed Care

18 Reform and Patient Rights Act.

19 (e) This Section shall be interpreted in a manner

20 consistent with all applicable federal parity regulations

21 including, but not limited to, the Paul Wellstone and Pete

22 Domenici Mental Health Parity and Addiction Equity Act of

23 2008, final regulations issued under the Paul Wellstone and

24 Pete Domenici Mental Health Parity and Addiction Equity Act of

25 2008 and final regulations applying the Paul Wellstone and

26 Pete Domenici Mental Health Parity and Addiction Equity Act of

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1 2008 to Medicaid managed care organizations, the Children's

2 Health Insurance Program, and alternative benefit plans.

3 (f) The provisions of subsections (b) and (c) of this

4 Section shall not be interpreted to allow the use of lifetime

5 or annual limits otherwise prohibited by State or federal law.

6 (g) As used in this Section:

7 "Financial requirement" includes deductibles, copayments,

8 coinsurance, and out-of-pocket maximums, but does not include

9 an aggregate lifetime limit or an annual limit subject to

10 subsections (b) and (c).

11 "Mental, emotional, nervous, or substance use disorder or

12 condition" means a condition or disorder that involves a

13 mental health condition or substance use disorder that falls

14 under any of the diagnostic categories listed in the mental

15 and behavioral disorders chapter of the current edition of the

16 International Classification of Disease or that is listed in

17 the most recent version of the Diagnostic and Statistical

18 Manual of Mental Disorders.

19 "Treatment limitation" includes limits on benefits based

20 on the frequency of treatment, number of visits, days of

21 coverage, days in a waiting period, or other similar limits on

22 the scope or duration of treatment. "Treatment limitation"

23 includes both quantitative treatment limitations, which are

24 expressed numerically (such as 50 outpatient visits per year),

25 and nonquantitative treatment limitations, which otherwise

26 limit the scope or duration of treatment. A permanent

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1 exclusion of all benefits for a particular condition or

2 disorder shall not be considered a treatment limitation.

3 "Nonquantitative treatment limitations" means those

4 limitations as described under federal regulations (26 CFR

5 54.9812-1). "Nonquantitative treatment limitations" include,

6 but are not limited to, those limitations described under

7 federal regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45

8 CFR 146.136.

9 (h) The Department of Insurance shall implement the

10 following education initiatives:

11 (1) By January 1, 2016, the Department shall develop a

12 plan for a Consumer Education Campaign on parity. The

13 Consumer Education Campaign shall focus its efforts

14 throughout the State and include trainings in the

15 northern, southern, and central regions of the State, as

16 defined by the Department, as well as each of the 5 managed

17 care regions of the State as identified by the Department

18 of Healthcare and Family Services. Under this Consumer

19 Education Campaign, the Department shall: (1) by January

20 1, 2017, provide at least one live training in each region

21 on parity for consumers and providers and one webinar

22 training to be posted on the Department website and (2)

23 establish a consumer hotline to assist consumers in

24 navigating the parity process by March 1, 2017. By January

25 1, 2018 the Department shall issue a report to the General

26 Assembly on the success of the Consumer Education

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1 Campaign, which shall indicate whether additional training

2 is necessary or would be recommended.

3 (2) (Blank).

4 (3) Not later than March ~~January~~ 1 of each year,

5 beginning in calendar year 2027, the Department, in

6 conjunction with the Department of Healthcare and Family

7 Services, shall issue a joint report to the General

8 Assembly. The joint report shall be posted on each

9 respective department's website ~~and provide an educational~~

10 ~~presentation to the General Assembly~~. The report and

11 presentation shall:

12 (A) Cover the methodology the Departments use to

13 check for compliance with the federal Paul Wellstone

14 and Pete Domenici Mental Health Parity and Addiction

15 Equity Act of 2008, 42 U.S.C. 18031(j), and any

16 federal regulations or guidance relating to the

17 compliance and oversight of the federal Paul Wellstone

18 and Pete Domenici Mental Health Parity and Addiction

19 Equity Act of 2008 and 42 U.S.C. 18031(j).

20 (B) Cover the methodology the Departments use to

21 check for compliance with this Section and Sections

22 356z.23 and 370c of this Code.

23 (C) Identify market conduct examinations or, in

24 the case of the Department of Healthcare and Family

25 Services, audits conducted or completed during the

26 preceding 12-month period regarding compliance with

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1 parity in mental, emotional, nervous, and substance

2 use disorder or condition benefits under State and

3 federal laws and summarize the results of such market

4 conduct examinations and audits. This shall include:

5 (i) the number of market conduct examinations

6 and audits initiated and completed;

7 (ii) the benefit classifications examined by

8 each market conduct examination and audit;

9 (iii) the subject matter of each market

10 conduct examination and audit, including

11 quantitative and nonquantitative treatment

12 limitations; and

13 (iv) a summary of the basis for the final

14 decision rendered in each market conduct

15 examination and audit.

16 Individually identifiable information shall be

17 excluded from the reports consistent with federal

18 privacy protections.

19 (D) Detail any educational or corrective actions

20 the Departments have taken to ensure compliance with

21 the federal Paul Wellstone and Pete Domenici Mental

22 Health Parity and Addiction Equity Act of 2008, 42

23 U.S.C. 18031(j), this Section, and Sections 356z.23

24 and 370c of this Code.

25 (E) The report must be written in non-technical,

26 readily understandable language and shall be made

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1 available to the public by, among such other means as

2 the Departments find appropriate, posting the report

3 on the Departments' websites.

4 (i) The Parity Advancement Fund is created as a special

5 fund in the State treasury. Moneys from fines and penalties

6 collected from insurers for violations of this Section shall

7 be deposited into the Fund. Moneys deposited into the Fund for

8 appropriation by the General Assembly to the Department shall

9 be used for the purpose of providing financial support of the

10 Consumer Education Campaign, parity compliance advocacy, and

11 other initiatives that support parity implementation and

12 enforcement on behalf of consumers.

13 (j) (Blank).

14 (j-5) The Department of Insurance shall collect the

15 following information:

16 (1) The number of employment disability insurance

17 plans offered in this State, including, but not limited

18 to:

19 (A) individual short-term policies;

20 (B) individual long-term policies;

21 (C) group short-term policies; and

22 (D) group long-term policies.

23 (2) The number of policies referenced in paragraph (1)

24 of this subsection that limit mental health and substance

25 use disorder benefits.

26 (3) The average defined benefit period for the

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1 policies referenced in paragraph (1) of this subsection,

2 both for those policies that limit and those policies that

3 have no limitation on mental health and substance use

4 disorder benefits.

5 (4) Whether the policies referenced in paragraph (1)

6 of this subsection are purchased on a voluntary or

7 non-voluntary basis.

8 (5) The identities of the individuals, entities, or a

9 combination of the 2 that assume the cost associated with

10 covering the policies referenced in paragraph (1) of this

11 subsection.

12 (6) The average defined benefit period for plans that

13 cover physical disability and mental health and substance

14 abuse without limitation, including, but not limited to:

15 (A) individual short-term policies;

16 (B) individual long-term policies;

17 (C) group short-term policies; and

18 (D) group long-term policies.

19 (7) The average premiums for disability income

20 insurance issued in this State for:

21 (A) individual short-term policies that limit

22 mental health and substance use disorder benefits;

23 (B) individual long-term policies that limit

24 mental health and substance use disorder benefits;

25 (C) group short-term policies that limit mental

26 health and substance use disorder benefits;

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1 (D) group long-term policies that limit mental

2 health and substance use disorder benefits;

3 (E) individual short-term policies that include

4 mental health and substance use disorder benefits

5 without limitation;

6 (F) individual long-term policies that include

7 mental health and substance use disorder benefits

8 without limitation;

9 (G) group short-term policies that include mental

10 health and substance use disorder benefits without

11 limitation; and

12 (H) group long-term policies that include mental

13 health and substance use disorder benefits without

14 limitation.

15 The Department shall present its findings regarding

16 information collected under this subsection (j-5) to the

17 General Assembly no later than April 30, 2024. Information

18 regarding a specific insurance provider's contributions to the

19 Department's report shall be exempt from disclosure under

20 paragraph (t) of subsection (1) of Section 7 of the Freedom of

21 Information Act. The aggregated information gathered by the

22 Department shall not be exempt from disclosure under paragraph

23 (t) of subsection (1) of Section 7 of the Freedom of

24 Information Act.

25 (k) An insurer that amends, delivers, issues, or renews a

26 group or individual policy of accident and health insurance or

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1 a qualified health plan offered through the health insurance

2 marketplace in this State providing coverage for hospital or

3 medical treatment and for the treatment of mental, emotional,

4 nervous, or substance use disorders or conditions shall submit

5 an annual report, the format and definitions for which will be

6 determined by the Department and the Department of Healthcare

7 and Family Services and posted on their respective websites,

8 starting on September 1, 2023 and annually thereafter, that

9 contains the following information separately for inpatient

10 in-network benefits, inpatient out-of-network benefits,

11 outpatient in-network benefits, outpatient out-of-network

12 benefits, emergency care benefits, and prescription drug

13 benefits in the case of accident and health insurance or

14 qualified health plans, or inpatient, outpatient, emergency

15 care, and prescription drug benefits in the case of medical

16 assistance:

17 (1) A summary of the plan's pharmacy management

18 processes for mental, emotional, nervous, or substance use

19 disorder or condition benefits compared to those for other

20 medical benefits.

21 (2) A summary of the internal processes of review for

22 experimental benefits and unproven technology for mental,

23 emotional, nervous, or substance use disorder or condition

24 benefits and those for other medical benefits.

25 (3) A summary of how the plan's policies and

26 procedures for utilization management for mental,

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1 emotional, nervous, or substance use disorder or condition

2 benefits compare to those for other medical benefits.

3 (4) A description of the process used to develop or

4 select the medical necessity criteria for mental,

5 emotional, nervous, or substance use disorder or condition

6 benefits and the process used to develop or select the

7 medical necessity criteria for medical and surgical

8 benefits.

9 (5) Identification of all nonquantitative treatment

10 limitations that are applied to both mental, emotional,

11 nervous, or substance use disorder or condition benefits

12 and medical and surgical benefits within each

13 classification of benefits.

14 (6) The results of an analysis that demonstrates that

15 for the medical necessity criteria described in

16 subparagraph (A) and for each nonquantitative treatment

17 limitation identified in subparagraph (B), as written and

18 in operation, the processes, strategies, evidentiary

19 standards, or other factors used in applying the medical

20 necessity criteria and each nonquantitative treatment

21 limitation to mental, emotional, nervous, or substance use

22 disorder or condition benefits within each classification

23 of benefits are comparable to, and are applied no more

24 stringently than, the processes, strategies, evidentiary

25 standards, or other factors used in applying the medical

26 necessity criteria and each nonquantitative treatment

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1 limitation to medical and surgical benefits within the

2 corresponding classification of benefits; at a minimum,

3 the results of the analysis shall:

4 (A) identify the factors used to determine that a

5 nonquantitative treatment limitation applies to a

6 benefit, including factors that were considered but

7 rejected;

8 (B) identify and define the specific evidentiary

9 standards used to define the factors and any other

10 evidence relied upon in designing each nonquantitative

11 treatment limitation;

12 (C) provide the comparative analyses, including

13 the results of the analyses, performed to determine

14 that the processes and strategies used to design each

15 nonquantitative treatment limitation, as written, for

16 mental, emotional, nervous, or substance use disorder

17 or condition benefits are comparable to, and are

18 applied no more stringently than, the processes and

19 strategies used to design each nonquantitative

20 treatment limitation, as written, for medical and

21 surgical benefits;

22 (D) provide the comparative analyses, including

23 the results of the analyses, performed to determine

24 that the processes and strategies used to apply each

25 nonquantitative treatment limitation, in operation,

26 for mental, emotional, nervous, or substance use

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1 disorder or condition benefits are comparable to, and

2 applied no more stringently than, the processes or

3 strategies used to apply each nonquantitative

4 treatment limitation, in operation, for medical and

5 surgical benefits; and

6 (E) disclose the specific findings and conclusions

7 reached by the insurer that the results of the

8 analyses described in subparagraphs (C) and (D)

9 indicate that the insurer is in compliance with this

10 Section and the Mental Health Parity and Addiction

11 Equity Act of 2008 and its implementing regulations,

12 which include ~~includes~~ 42 CFR Parts 438, 440, and 457

13 and 45 CFR 146.136 and any other related federal

14 regulations found in the Code of Federal Regulations.

15 (7) Any other information necessary to clarify data

16 provided in accordance with this Section requested by the

17 Director, including information that may be proprietary or

18 have commercial value, under the requirements of Section

19 30 of the Viatical Settlements Act of 2009.

20 (l) An insurer that amends, delivers, issues, or renews a

21 group or individual policy of accident and health insurance or

22 a qualified health plan offered through the health insurance

23 marketplace in this State providing coverage for hospital or

24 medical treatment and for the treatment of mental, emotional,

25 nervous, or substance use disorders or conditions on or after

26 January 1, 2019 (the effective date of Public Act 100-1024)

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1 shall, in advance of the plan year, make available to the

2 Department or, with respect to medical assistance, the

3 Department of Healthcare and Family Services and to all plan

4 participants and beneficiaries the information required in

5 subparagraphs (C) through (E) of paragraph (6) of subsection

6 (k). For plan participants and medical assistance

7 beneficiaries, the information required in subparagraphs (C)

8 through (E) of paragraph (6) of subsection (k) shall be made

9 available on a publicly available website whose web address is

10 prominently displayed in plan and managed care organization

11 informational and marketing materials.

12 (m) In conjunction with its compliance examination program

13 conducted in accordance with the Illinois State Auditing Act,

14 the Auditor General shall undertake a review of compliance by

15 the Department and the Department of Healthcare and Family

16 Services with Section 370c and this Section. Any findings

17 resulting from the review conducted under this Section shall

18 be included in the applicable State agency's compliance

19 examination report. Each compliance examination report shall

20 be issued in accordance with Section 3-14 of the Illinois

21 State Auditing Act. A copy of each report shall also be

22 delivered to the head of the applicable State agency and

23 posted on the Auditor General's website.

24 (Source: P.A. 103-94, eff. 1-1-24; 103-105, eff. 6-27-23;

25 103-605, eff. 7-1-24; 104-334, eff. 8-15-25.)

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1 ARTICLE 200.

2 Section 200-5. The Illinois Public Aid Code is amended by

3 changing Sections 5F-10, 5F-15, and 5F-35 as follows:

4 (305 ILCS 5/5F-10)

5 Sec. 5F-10. Scope. This Article applies to policies and

6 contracts amended, delivered, issued, or renewed on or after

7 the effective date of this amendatory Act of the 98th General

8 Assembly for the nursing home component of the

9 Medicare-Medicaid Alignment Initiative and the Managed

10 Long-Term Services and Support Program, a fully integrated

11 dual eligible special needs plan, or any managed care plan for

12 persons who are dually eligible for Medicare and Medicaid.

13 This Article does not diminish a managed care organization's

14 duties and responsibilities under other federal or State laws

15 or rules adopted under those laws and the 3-way

16 Medicare-Medicaid Alignment Initiative contract and the

17 Managed Long-Term Services and Support Program contract.

18 (Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)

19 (305 ILCS 5/5F-15)

20 Sec. 5F-15. Definitions. As used in this Article:

21 "Appeal" means any of the procedures that deal with the

22 review of adverse organization determinations on the health

23 care services the enrollee believes he or she is entitled to

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1 receive, including delay in providing, arranging for, or

2 approving the health care services, such that a delay would

3 adversely affect the health of the enrollee or on any amounts

4 the enrollee must pay for a service, as defined under 42 CFR

5 422.566(b). These procedures include reconsiderations by the

6 managed care organization and, if necessary, an independent

7 review entity as provided by the Health Carrier External

8 Review Act, hearings before administrative law judges, review

9 by the Medicare Appeals Council, and judicial review.

10 "Demonstration Project" means the nursing home component

11 of the Medicare-Medicaid Alignment Initiative Demonstration

12 Project, a fully integrated dual eligible special needs plan,

13 or any managed care plan for persons who are dually eligible

14 for Medicare and Medicaid.

15 "Department" means the Department of Healthcare and Family

16 Services.

17 "Enrollee" means an individual who resides in a nursing

18 home or is qualified to be admitted to a nursing home and is

19 enrolled with a managed care organization participating in the

20 Demonstration Project.

21 "Health care services" means the diagnosis, treatment, and

22 prevention of disease and includes medication, primary care,

23 nursing or medical care, mental health treatment, psychiatric

24 rehabilitation, memory loss services, physical, occupational,

25 and speech rehabilitation, enhanced care, medical supplies and

26 equipment and the repair of such equipment, and assistance

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1 with activities of daily living.

2 "Managed care organization" or "MCO" means an entity that

3 meets the definition of health maintenance organization as

4 defined in the Health Maintenance Organization Act, is

5 licensed, regulated and in good standing with the Department

6 of Insurance, and is authorized to participate in the nursing

7 home component of the Medicare-Medicaid Alignment Initiative

8 Demonstration Project by a 3-way contract with the Department

9 of Healthcare and Family Services and the Centers for Medicare

10 and Medicaid Services.

11 "Medical professional" means a physician, physician

12 assistant, or nurse practitioner.

13 "Medically necessary" means health care services that a

14 medical professional, exercising prudent clinical judgment,

15 would provide to a patient for the purpose of preventing,

16 evaluating, diagnosing, or treating an illness, injury, or

17 disease or its symptoms, and that are: (i) in accordance with

18 the generally accepted standards of medical practice; (ii)

19 clinically appropriate, in terms of type, frequency, extent,

20 site, and duration, and considered effective for the patient's

21 illness, injury, or disease; and (iii) not primarily for the

22 convenience of the patient, a medical professional, other

23 health care provider, caregiver, family member, or other

24 interested party.

25 "Nursing home" means a facility licensed under the Nursing

26 Home Care Act.

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1 "Nurse practitioner" means an individual properly licensed

2 as a nurse practitioner under the Nurse Practice Act.

3 "Physician" means an individual licensed to practice in

4 all branches of medicine under the Medical Practice Act of

5 1987.

6 "Physician assistant" means an individual properly

7 licensed under the Physician Assistant Practice Act of 1987.

8 "Resident" means an enrollee who is receiving personal or

9 medical care, including, but not limited to, mental health

10 treatment, psychiatric rehabilitation, physical

11 rehabilitation, and assistance with activities of daily

12 living, from a nursing home.

13 "RAI Manual" means the most recent Resident Assessment

14 Instrument Manual, published by the Centers for Medicare and

15 Medicaid Services.

16 "Resident's representative" means a person designated in

17 writing by a resident to be the resident's representative or

18 the resident's guardian, as described by the Nursing Home Care

19 Act.

20 "SNFist" means a medical professional specializing in the

21 care of individuals residing in nursing homes employed by or

22 under contract with an ~~a~~ MCO.

23 "Transition period" means a period of time immediately

24 following enrollment into the Demonstration Project or an

25 enrollee's movement from one managed care organization to

26 another managed care organization or one care setting to

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1 another care setting.

2 (Source: P.A. 98-651, eff. 6-16-14.)

3 (305 ILCS 5/5F-35)

4 Sec. 5F-35. Reimbursement. The Department shall provide

5 each managed care organization with the quarterly

6 facility-specific ~~RUG-IV~~ nursing component per diem along with

7 any add-ons for enhanced care services, support component per

8 diem, and capital component per diem effective for each

9 nursing home under contract with the managed care

10 organization.

11 (Source: P.A. 98-651, eff. 6-16-14.)

12 ARTICLE 210.

13 Section 210-5. The Nursing Home Care Act is amended by

14 adding Article IIIB as follows:

15 (210 ILCS 45/Art. IIIB heading new)

16 ARTICLE IIIB. COTTAGE STYLE NURSING HOMES

17 (210 ILCS 45/3B-100 new)

18 Sec. 3B-100. Definitions. As used in this Article:

19 "Clinical support team" (CST) means non-universal team

20 members who provide support services throughout the campus.

21 The CST provides support to self-directed or self-managed work

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1 teams. The CST includes, but is not limited to, the

2 Administrator, Director of Nursing, Assistant Director of

3 Nursing, and Minimum Data Set nurse.

4 "Cottage style" or "cottage style facilities" means small,

5 free-standing, self-contained homes that:

6 (1) Surround or are adjacent to a central

7 administration unit.

8 (2) Provide up to 12 private residents' rooms that are

9 shared only at the request of a resident to accommodate a

10 spouse, partner, or family member. A spouse that does not

11 meet medical criteria for nursing facility placement may

12 reside in the room assigned to a spouse who is admitted to

13 the facility and who meets medical criteria for admission.

14 The facility may charge the spouse who does not meet

15 medical criteria for room and board, as well as other

16 services so long as the facility meets all requirements or

17 cost reporting.

18 (3) Have a full, accessible private bathroom for each

19 resident room that contains, at a minimum, a toilet, sink,

20 and shower.

21 (4) Have the appearance of a residential dwelling for

22 both the exterior and the interior.

23 (5) Have residents' rooms constructed around a

24 central, communal, family-style open space that includes a

25 hearth room, dining area, and residential-style kitchen.

26 The central communal area shall contain a living area

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1 where residents and staff may socialize, dine, and prepare

2 food together that, at a minimum, provides a living room

3 seating area, a dining area large enough for a single

4 table serving all residents in the home plus 2 staff

5 members, and an open full kitchen. The communal area may

6 include a gas fireplace with a fixed, "stay-cool" glass

7 screen.

8 (6) Have all residents' room entrances visible from

9 the central communal area.

10 (7) Each communal area may not exceed a ratio of one

11 communal area to 12 resident rooms.

12 (8) Two cottages may share a centralized kitchen and

13 laundry, but each may not exceed a ratio of one

14 kitchen/laundry to 24 resident rooms.

15 (9) Contains residential-style design approach, scale,

16 details, and materials throughout the home that are

17 similar to the typical residential designs and finishes in

18 the immediate surrounding community and does not contain

19 or utilize commercial and institutional elements and

20 products such as a nurse station, medication carts,

21 hospital or office type fluorescent lighting, acoustical

22 tile ceilings, institutional-style railings, room

23 numbering, and labeling and signage that would not

24 normally be found in a private home setting.

25 Where rules require specific institutional elements,

26 every effort shall be made to provide the institutional

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1 elements in a manner consistent with what might be found

2 in a new private home in the community (such as

3 residential wall sconces used for required nurse call

4 lights).

5 (10) Have outdoor space that:

6 (A) allows residents to ambulate, with or without

7 assistive devices such as wheelchairs or walkers;

8 (B) signals staff wirelessly when someone enters

9 the outdoor space from the cottage style home;

10 (C) is partially covered to protect from sun and

11 elements under the covered area; and

12 (D) provides for outdoor activities.

13 (11) Utilize a wireless alert or call system. The

14 system shall also include, for residents who have been

15 care planned to be at risk for wandering or elopement,

16 location bracelets that permit residents to signal for

17 assistance and enable staff to locate residents. Wired

18 call or alert systems and overhead paging are not

19 permitted.

20 (12) Utilize a wireless communication and notification

21 system for staff. The system shall provide a means for

22 notification of staff both in the home and in other homes

23 or other areas of the facility occupied by other staff.

24 (13) Contain ample natural light in each habitable

25 space provided through exterior windows and other means,

26 with window areas, exclusive of skylights and

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1 clerestories, being a minimum of 10% of the area of the

2 room.

3 (14) Have built-in safety features (such as magnetic

4 locks on cabinets with chemicals or knives) to allow all

5 areas of the house, including the kitchen and any staff

6 office, to be accessible to the residents during the

7 majority of the day and night.

8 (15) Provide self-directed care for residents through

9 the establishment of self-managed or self-directed work

10 teams consisting of certified nursing assistants.

11 (16) Prepare and cook at least 80% of resident meals

12 in the cottage style home. Nothing in this item (16)

13 prohibits the consumption of foods that are:

14 (A) prepared outside the cottage style home by

15 family, acquaintances, or social organizations such as

16 churches;

17 (B) grown in or on the grounds of the cottage style

18 home by residents or staff; or

19 (C) prepared by local retail eating establishments

20 that are licensed or inspected based on local, State,

21 or federal laws.

22 (17) Train all staff involved in the operation of the

23 project in the philosophy, operations, and skills required

24 to implement and maintain self-directed care,

25 self-directed or self-managed work teams, a

26 non-institutional approach to life and care in long-term

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1 care, appropriate safety and emergency skills, and other

2 elements required for successful operations and outcomes

3 of the project.

4 (18) Are designed to be fully accessible for persons

5 with disabilities.

6 (19) Have overhead lift tracks that run from the bed

7 into the bathroom in at least 30% of resident rooms.

8 (20) Have at least one lift motor for each cottage

9 style home.

10 (21) Have separate slings for each resident in the

11 facility who requires a lift.

12 (22) Are not connected to, or share, any area that

13 would not typically be connected or shared between private

14 homes in the surrounding community (such as a driveway).

15 (23) Provide the necessary care and services to attain

16 or maintain the highest practicable physical, mental, and

17 psychological well-being of the resident, in accordance

18 with each resident's comprehensive resident care plan.

19 (24) Maintain a staffing plan compliant with the

20 minimum direct care staffing ratios required by this Act,

21 the Illinois Administrative Code, and any other applicable

22 State or federal law.

23 (25) Maintain all professional licensure for staff and

24 employees in accordance with applicable State laws,

25 including, but not limited to, Department of Financial and

26 Professional Regulation requirements.

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1 (26) Comply with any applicable State and federal

2 consent decrees.

3 (27) Obtain proof and documentation of federal

4 approval by the Centers for Medicare and Medicaid

5 Services.

6 "Home" means each discrete cottage style unit housing up

7 to 12 private residents' rooms.

8 "Person-directed care" means a holistic model that takes

9 into consideration each resident's physical, mental, and

10 social needs in the development of a care and treatment plan

11 and the delivery of services that is driven to the greatest

12 extent possible by resident choice, as opposed to an

13 institutional medical model that is schedule and task driven.

14 "Self-managed or self-directed work team" means the

15 universal workers assigned to a specific cottage style home

16 and who determine, plan, and manage day-to-day activities in

17 the house with little or no direct supervision.

18 "Food safety" means a method of ensuring safe preparation

19 and delivery of food for and to residents.

20 "Family-style dining" means residential-style dining, in

21 which all food is placed in serving bowls, platters, and

22 similar residential serving dishes on the table, residents and

23 staff dine together, and residents are encouraged to serve

24 themselves or serve themselves with help from staff.

25 "Universal or flexible worker" means a certified nursing

26 assistant who has received additional training in the areas of

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1 dietary, housekeeping, activities, and laundry and is a member

2 of the self-managed or self-directed work team.

3 (210 ILCS 45/3B-105 new)

4 Sec. 3B-105. Intent. This Article creates a framework that

5 encourages the construction and operation of skilled nursing

6 facilities that are consistent with State and federal laws and

7 referred to as "cottage style". The cottage style model is a

8 facility model resulting in a residential-style physical plant

9 and specific principles of staff interaction. The cottage

10 style model utilizes small, free-standing, self-contained

11 homes. A single cottage consists of up to 12 private rooms,

12 each with full bathrooms. Two cottages may share a common

13 kitchen and laundry but the maximum ratio of 1 kitchen and

14 laundry per 24 rooms must be maintained. The residents' rooms

15 are constructed around a central, communal, family-style open

16 space that includes a hearth room and dining area. All

17 residents' room entrances are visible from the central

18 communal area. The maximum ratio of one communal area per 12

19 rooms must be maintained. Each home is built to blend

20 architecturally with neighboring homes.

21 (210 ILCS 45/3B-110 new)

22 Sec. 3B-110. Applicability. Nursing homes that meet the

23 requirements of this Article to be designated as a cottage

24 style nursing home are still subject to all requirements of

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1 this Act, administrative rules, and applicable State or

2 federal laws. All requirements of this Article are additional

3 requirements necessary to be designated as cottage style as

4 defined in Section 3B-100.

5 (210 ILCS 45/3B-115 new)

6 Sec. 3B-115. License designation. During the initial

7 licensure survey required under Section 3-109 of this Act, the

8 Department must also review compliance with this Article. The

9 Department must indicate, on licenses issued under this Act,

10 "cottage style" for nursing homes that meet the requirements

11 of this Article.

12 (210 ILCS 45/3B-120 new)

13 Sec. 3B-120. Staff Training.

14 (a) In addition to any State or federal training

15 requirements pertaining to long-term care facilities, each

16 certified nursing assistant (CNA) working in a cottage style

17 home shall complete the following 40 hours of training, to

18 include, but not be limited to:

19 (1) Cottage Style Model v. Traditional Model, a

20 minimum of 2 hours covering at least the following topics:

21 (A) Meaningful Engagement. Development of, and

22 appreciation for, activities designed to meet the

23 individual's personal preferences and needs.

24 (B) Organizational Culture Change.

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1 (2) Universal or Flexible Worker, a minimum of 2 hours

2 covering at least the following topics:

3 (A) Concept.

4 (B) Responsibilities of the Worker.

5 (3) Person-Directed Care, a minimum of 2 hours

6 covering at least the following topics:

7 (A) Concepts and Relationship Building.

8 (B) Execution. How elder preferences shape

9 workflow.

10 (4) Self-Managed or Self-Directed Work Team, a minimum

11 of 4 hours covering at least the following topics:

12 (A) Concept.

13 (B) Responsibilities.

14 (C) Conflict Resolution and Learning Circles.

15 (5) Food Safety, a minimum of 22 hours covering at

16 least the following topics:

17 (A) Safety.

18 (B) Contamination.

19 (C) Allergies.

20 (D) Therapeutic Diets.

21 (E) Thickening Agents.

22 (F) Food Preparation.

23 (G) Family Style Dining.

24 (H) Cottage Equipment Use. Appliance usage and

25 safety.

26 (6) Emergency Situations and Evacuation, a minimum of

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1 2 hours covering at least the following topics:

2 (A) Fire Drills.

3 (B) Tornado Drills.

4 (C) Disaster Drills.

5 (D) Evacuation.

6 (E) Environmental Policy.

7 (7) Cottage Orientation, a minimum of 2 hours covering

8 at least the following topics:

9 (A) Phone System.

10 (B) Call System.

11 (C) Cleaning Supply Storage.

12 (D) Cleaning Supply Usage.

13 (E) Workplace Organization.

14 (8) Communication, a minimum of 2 hours covering at

15 least the following topics:

16 (A) Communication Skills.

17 (B) Coaching Skills.

18 (C) Accountability.

19 (D) Support.

20 (9) Observation Skills, a minimum of 2 hours covering

21 at least the following topics:

22 (A) How to obtain a history from family.

23 (B) How to modify a care plan.

24 (C) How to identify a resident's change in

25 condition.

26 (b) Upon opening and for the first 90 days of continuous

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1 operation of a cottage style home, all CNAs working in that

2 home shall complete all of the required training listed in

3 subsection (a) prior to providing services in the cottage

4 style home.

5 (c) After a cottage style home has been in continuous

6 operation servicing residents for at least 90 days, each CNA

7 assigned to the cottage style home for the first time, and who

8 has not been trained in accordance with subsections (a) and

9 (b), shall complete the following 16-hour training schedule

10 before working with residents:

11 (1) Cottage Style Model v. Traditional Model, a

12 minimum of 1.5 hours.

13 (2) Universal or Flexible Worker, a minimum of 1.5

14 hours.

15 (3) Person-Directed Care, a minimum of 3 hours.

16 (4) Self-Managed or Self-Directed Work Team, a minimum

17 of 3 hours.

18 (5) Food Safety, a minimum of 3 hours.

19 (6) Family Style Dining, a minimum of one hour.

20 (7) Emergency Situations and Evacuations, a minimum of

21 one hour.

22 (8) Cottage Equipment Use, a minimum of one hour.

23 (9) Cottage Orientation, a minimum of one hour.

24 Following the 16-hour training the CNA shall complete the

25 remaining 24 hours of training listed in subsection (a) within

26 90 days.

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1 (d) All shared common staff shall undergo the following

2 training within 45 days of the opening of the first cottage

3 style home:

4 (1) Cottage Style Model v. Traditional Model, a

5 minimum of 1.5 hours.

6 (2) Clinical Support Team, a minimum of one hour.

7 (3) Universal or Flexible Worker, a minimum of one

8 hour.

9 (4) Self-Managed or Self-Directed Work Team, a minimum

10 of 3 hours.

11 (5) Person-Directed Care, a minimum of 3 hours.

12 (6) Team Communication, a minimum of one hour.

13 (7) Learning Circles, a minimum of one hour.

14 (8) Understanding Aging in the Elderly, a minimum of

15 one hour.

16 (9) Cottage Systems, a minimum of 2 hours.

17 (e) Each facility seeking designation as a cottage style

18 facility shall provide to the Department a syllabus, a list of

19 required reference and study materials, and a proposed

20 curriculum of training as required under this Section. As used

21 in this Section, "curriculum" means a detailed study guide

22 that states the learning objectives and provides information

23 or materials designed to impart to the student or trainee the

24 necessary skills, knowledge, or ability required under the

25 learning objectives.

26 (f) Facilities must keep all trainings current with all

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1 changes in best practices and local, State, and federal laws,

2 rules, regulations, and guidance.

3 (210 ILCS 45/3B-125 new)

4 Sec. 3B-125. Implementation. The Department may adopt

5 administrative rules to implement any part of this Article;

6 however, all provisions of this Article are fully effective

7 upon taking effect even if administrative rules have not been

8 adopted.

9 Section 210-10. The Illinois Public Aid Code is amended by

10 adding Section 5-5.2a as follows:

11 (305 ILCS 5/5-5.2a new)

12 Sec. 5-5.2a. Cottage style nursing home reimbursement

13 adjustment.

14 (a) As used in this Section, "cottage style nursing home"

15 means a nursing home meeting the requirements under Article

16 IIIB of the Nursing Home Care Act.

17 (b) Subject to any necessary federal approval, for dates

18 of service on and after July 1, 2027, the Department shall

19 reimburse cottage style nursing homes with a per diem add-on

20 of at least $50.

21 (c) This per diem add-on amount is in addition to all

22 amounts reimbursed to a nursing home under this Code. To

23 account for the unique person-directed care model in cottage

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1 style nursing homes, the Department may increase the initial

2 default rates of a new cottage style nursing home until data

3 required to calculate those rates are available.

4 ARTICLE 215.

5 Section 215-5. The Illinois Public Aid Code is amended by

6 changing Section 5-5e.1 as follows:

7 (305 ILCS 5/5-5e.1)

8 Sec. 5-5e.1. Safety-Net Hospitals.

9 (a) A Safety-Net Hospital is an Illinois hospital that:

10 (1) is licensed by the Department of Public Health as

11 a general acute care or pediatric hospital; and

12 (2) is a disproportionate share hospital, as described

13 in Section 1923 of the federal Social Security Act, as

14 determined by the Department; and

15 (3) meets one of the following:

16 (A) has a MIUR of at least 40% and a charity

17 percent of at least 4%; or

18 (B) has a MIUR of at least 50%.

19 (b) Definitions. As used in this Section:

20 (1) "Charity percent" means the ratio of (i) the

21 hospital's charity charges for services provided to

22 individuals without health insurance or another source of

23 third party coverage to (ii) the Illinois total hospital

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1 charges, each as reported on the hospital's OBRA form.

2 (2) "MIUR" means Medicaid Inpatient Utilization Rate

3 and is defined as a fraction, the numerator of which is the

4 number of a hospital's inpatient days provided in the

5 hospital's fiscal year ending 3 years prior to the rate

6 year, to patients who, for such days, were eligible for

7 Medicaid under Title XIX of the federal Social Security

8 Act, 42 USC 1396a et seq., excluding those persons

9 eligible for medical assistance pursuant to 42 U.S.C.

10 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of

11 Section 5-2 of this Article, and the denominator of which

12 is the total number of the hospital's inpatient days in

13 that same period, excluding those persons eligible for

14 medical assistance pursuant to 42 U.S.C.

15 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of

16 Section 5-2 of this Article.

17 (3) "OBRA form" means form HFS-3834, OBRA '93 data

18 collection form, for the rate year.

19 (4) "Rate year" means the 12-month period beginning on

20 October 1.

21 (c) Beginning July 1, 2012 and ending on December 31, 2028

22 ~~2026~~, a hospital that would have qualified for the rate year

23 beginning October 1, 2011 or October 1, 2012 shall be a

24 Safety-Net Hospital.

25 (c-5) Beginning July 1, 2020 and ending on December 31,

26 2028 ~~2026~~, a hospital that would have qualified for the rate

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1 year beginning October 1, 2020 and was designated a federal

2 rural referral center under 42 CFR 412.96 as of October 1, 2020

3 shall be a Safety-Net Hospital.

4 (d) No later than August 15 preceding the rate year, each

5 hospital shall submit the OBRA form to the Department. Prior

6 to October 1, the Department shall notify each hospital

7 whether it has qualified as a Safety-Net Hospital.

8 (e) The Department may promulgate rules in order to

9 implement this Section.

10 (f) Nothing in this Section shall be construed as limiting

11 the ability of the Department to include the Safety-Net

12 Hospitals in the hospital rate reform mandated by Section

13 14-11 of this Code and implemented under Section 14-12 of this

14 Code and by administrative rulemaking.

15 (Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;

16 102-886, eff. 5-17-22.)

17 ARTICLE 220.

18 Section 220-5. The Illinois Administrative Procedure Act

19 is amended by adding Section 5-45.72 as follows:

20 (5 ILCS 100/5-45.72 new)

21 Sec. 5-45.72. Emergency rulemaking; Department of

22 Healthcare and Family Services. In order to provide for the

23 expeditious and timely implementation of the federal Medicaid

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1 provisions contained in Public Law 119-21, including all

2 corresponding federal regulations and requirements issued by

3 the federal Centers for Medicare and Medicaid Services, the

4 Department of Healthcare and Family Services may adopt

5 emergency rules during fiscal year 2027. Emergency rulemaking

6 authority will pertain to changes in Public Law 119-21 with

7 implementation dates on or before January 1, 2027, which are

8 addressed in this amendatory Act of the 104th General

9 Assembly. During the 12-month period in which this Section is

10 in effect, the 24-month limitation on the adoption of

11 emergency rules does not apply to the rules adopted under this

12 subsection if such an amendment is due to subsequent federal

13 guidance or other federal requirements pertaining to changes

14 in federal law or regulation. The adoption of emergency rules

15 authorized by this Section shall be deemed to be necessary for

16 the public interest, safety, and welfare.

17 This Section is repealed one year after the effective date

18 of this amendatory Act of the 104th General Assembly.

19 Section 220-10. The Illinois Public Aid Code is amended by

20 changing Sections 1-11, 5-2, 5-2.1d, 11-4, 11-5.1, and 11-5.4

21 as follows:

22 (305 ILCS 5/1-11)

23 Sec. 1-11. Citizenship. To the extent not otherwise

24 provided in this Code or federal law, all clients who receive

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1 cash or medical assistance under Article III, IV, V, or VI of

2 this Code must meet the citizenship requirements as

3 established in this Section. To be eligible for assistance an

4 individual, who is otherwise eligible, must be either a United

5 States citizen or included in one of the following categories

6 of non-citizens:

7 (1) United States veterans honorably discharged and

8 persons on active military duty, and the spouse and

9 unmarried dependent children of these persons;

10 (2) Refugees under Section 207 of the Immigration and

11 Nationality Act;

12 (3) Asylees under Section 208 of the Immigration and

13 Nationality Act;

14 (4) Persons for whom deportation has been withheld

15 under Section 243(h) of the Immigration and Nationality

16 Act;

17 (5) Persons granted conditional entry under Section

18 203(a)(7) of the Immigration and Nationality Act as in

19 effect prior to April 1, 1980;

20 (6) Persons lawfully admitted for permanent residence

21 under the Immigration and Nationality Act;

22 (7) Parolees, for at least one year, under Section

23 212(d)(5) of the Immigration and Nationality Act;

24 (8) Nationals of Cuba or Haiti admitted on or after

25 April 21, 1980;

26 (9) Amerasians from Vietnam, and their close family

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1 members, admitted through the Orderly Departure Program

2 beginning on March 20, 1988;

3 (10) Persons identified by the federal Office of

4 Refugee Resettlement (ORR) as victims of trafficking;

5 (11) Persons legally residing in the United States who

6 were members of a Hmong or Highland Laotian tribe when the

7 tribe helped United States personnel by taking part in a

8 military or rescue operation during the Vietnam era

9 (between August 5, 1965 and May 7, 1975); this also

10 includes the person's spouse, a widow or widower who has

11 not remarried, and unmarried dependent children;

12 (12) American Indians born in Canada under Section 289

13 of the Immigration and Nationality Act and members of an

14 Indian tribe as defined in Section 4e of the Indian

15 Self-Determination and Education Assistance Act;

16 (13) Persons who are a spouse, widow, or child of a

17 U.S. citizen or a spouse or child of a legal permanent

18 resident (LPR) who have been battered or subjected to

19 extreme cruelty by the U.S. citizen or LPR or a member of

20 that relative's family who lived with them, who no longer

21 live with the abuser or plan to live separately within one

22 month of receipt of assistance and whose need for

23 assistance is due, at least in part, to the abuse; and

24 (14) Persons who are foreign-born victims of

25 trafficking, torture, or other serious crimes as defined

26 in Section 2-19 of this Code.

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1 Those persons who are in the categories set forth in

2 paragraphs ~~subdivisions~~ (6) and (7) of this Section, who enter

3 the United States on or after August 22, 1996, shall not be

4 eligible for 5 years beginning on the date the person entered

5 the United States.

6 The Illinois Department may, by rule, cover prenatal care

7 or emergency medical care for non-citizens who are not

8 otherwise eligible under this Section. Local governmental

9 units which do not receive State funds may impose their own

10 citizenship requirements and are authorized to provide any

11 benefits and impose any citizenship requirements as are

12 allowed under the Personal Responsibility and Work Opportunity

13 Reconciliation Act of 1996 (P.L. 104-193).

14 In order to implement the federal Medicaid provisions

15 contained in Public Law 119-21, and notwithstanding any other

16 provision of this Section, any category of non-citizens or

17 part thereof listed in paragraphs (1) through (14) of this

18 Section shall not be eligible for medical assistance under

19 Article V of this Code to the extent Public Law 119-21 and any

20 corresponding federal regulations or requirements issued by

21 the federal Centers for Medicare and Medicaid Services

22 excludes such category of non-citizens or part thereof from

23 eligibility, federal financial participation, or other federal

24 funding. This Section shall not require any category of

25 non-citizens or part thereof to be funded at state-only cost

26 under Article V of this Code, unless otherwise provided by

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1 State law. The Department shall amend 89 Ill. Adm. Code

2 120.310 to conform to the provisions of this paragraph

3 effective October 1, 2026.

4 (Source: P.A. 99-870, eff. 8-22-16.)

5 (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)

6 Sec. 5-2. Classes of persons eligible. Medical assistance

7 under this Article shall be available to any of the following

8 classes of persons in respect to whom a plan for coverage has

9 been submitted to the Governor by the Illinois Department and

10 approved by him. If changes made in this Section 5-2 require

11 federal approval, they shall not take effect until such

12 approval has been received:

13 1. Recipients of basic maintenance grants under

14 Articles III and IV.

15 2. Beginning January 1, 2014, persons otherwise

16 eligible for basic maintenance under Article III,

17 excluding any eligibility requirements that are

18 inconsistent with any federal law or federal regulation,

19 as interpreted by the U.S. Department of Health and Human

20 Services, but who fail to qualify thereunder on the basis

21 of need, and who have insufficient income and resources to

22 meet the costs of necessary medical care, including, but

23 not limited to, the following:

24 (a) All persons otherwise eligible for basic

25 maintenance under Article III but who fail to qualify

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1 under that Article on the basis of need and who meet

2 either of the following requirements:

3 (i) their income, as determined by the

4 Illinois Department in accordance with any federal

5 requirements, is equal to or less than 100% of the

6 federal poverty level; or

7 (ii) their income, after the deduction of

8 costs incurred for medical care and for other

9 types of remedial care, is equal to or less than

10 100% of the federal poverty level.

11 (b) (Blank).

12 3. (Blank).

13 4. Persons not eligible under any of the preceding

14 paragraphs who fall sick, are injured, or die, not having

15 sufficient money, property or other resources to meet the

16 costs of necessary medical care or funeral and burial

17 expenses.

18 5.(a) Beginning January 1, 2020, individuals during

19 pregnancy and during the 12-month period beginning on the

20 last day of the pregnancy, together with their infants,

21 whose income is at or below 200% of the federal poverty

22 level. Until September 30, 2019, or sooner if the

23 maintenance of effort requirements under the Patient

24 Protection and Affordable Care Act are eliminated or may

25 be waived before then, individuals during pregnancy and

26 during the 12-month period beginning on the last day of

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1 the pregnancy, whose countable monthly income, after the

2 deduction of costs incurred for medical care and for other

3 types of remedial care as specified in administrative

4 rule, is equal to or less than the Medical Assistance-No

5 Grant(C) (MANG(C)) Income Standard in effect on April 1,

6 2013 as set forth in administrative rule.

7 (b) The plan for coverage shall provide ambulatory

8 prenatal care to pregnant individuals during a presumptive

9 eligibility period and establish an income eligibility

10 standard that is equal to 200% of the federal poverty

11 level, provided that costs incurred for medical care are

12 not taken into account in determining such income

13 eligibility.

14 (c) The Illinois Department may conduct a

15 demonstration in at least one county that will provide

16 medical assistance to pregnant individuals together with

17 their infants and children up to one year of age, where the

18 income eligibility standard is set up to 185% of the

19 nonfarm income official poverty line, as defined by the

20 federal Office of Management and Budget. The Illinois

21 Department shall seek and obtain necessary authorization

22 provided under federal law to implement such a

23 demonstration. Such demonstration may establish resource

24 standards that are not more restrictive than those

25 established under Article IV of this Code.

26 6. (a) Subject to federal approval, children younger

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1 than age 19 when countable income is at or below 313% of

2 the federal poverty level, as determined by the Department

3 and in accordance with all applicable federal

4 requirements. The Department is authorized to adopt

5 emergency rules to implement the changes made to this

6 paragraph by Public Act 102-43. Until September 30, 2019,

7 or sooner if the maintenance of effort requirements under

8 the Patient Protection and Affordable Care Act are

9 eliminated or may be waived before then, children younger

10 than age 19 whose countable monthly income, after the

11 deduction of costs incurred for medical care and for other

12 types of remedial care as specified in administrative

13 rule, is equal to or less than the Medical Assistance-No

14 Grant(C) (MANG(C)) Income Standard in effect on April 1,

15 2013 as set forth in administrative rule.

16 (b) Children and youth who are under temporary custody

17 or guardianship of the Department of Children and Family

18 Services or who receive financial assistance in support of

19 an adoption or guardianship placement from the Department

20 of Children and Family Services.

21 7. (Blank).

22 8. As required under federal law, persons who are

23 eligible for Transitional Medical Assistance as a result

24 of an increase in earnings or child or spousal support

25 received. The plan for coverage for this class of persons

26 shall:

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1 (a) extend the medical assistance coverage to the

2 extent required by federal law; and

3 (b) offer persons who have initially received 6

4 months of the coverage provided in paragraph (a)

5 above, the option of receiving an additional 6 months

6 of coverage, subject to the following:

7 (i) such coverage shall be pursuant to

8 provisions of the federal Social Security Act;

9 (ii) such coverage shall include all services

10 covered under Illinois' State Medicaid Plan;

11 (iii) no premium shall be charged for such

12 coverage; and

13 (iv) such coverage shall be suspended in the

14 event of a person's failure without good cause to

15 file in a timely fashion reports required for this

16 coverage under the Social Security Act and

17 coverage shall be reinstated upon the filing of

18 such reports if the person remains otherwise

19 eligible.

20 9. Persons with acquired immunodeficiency syndrome

21 (AIDS) or with AIDS-related conditions with respect to

22 whom there has been a determination that but for home or

23 community-based services such individuals would require

24 the level of care provided in an inpatient hospital,

25 skilled nursing facility or intermediate care facility the

26 cost of which is reimbursed under this Article. Assistance

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1 shall be provided to such persons to the maximum extent

2 permitted under Title XIX of the Federal Social Security

3 Act.

4 10. Participants in the long-term care insurance

5 partnership program established under the Illinois

6 Long-Term Care Partnership Program Act who meet the

7 qualifications for protection of resources described in

8 Section 15 of that Act.

9 11. Persons with disabilities who are employed and

10 eligible for Medicaid, pursuant to Section

11 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,

12 subject to federal approval, persons with a medically

13 improved disability who are employed and eligible for

14 Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of

15 the Social Security Act, as provided by the Illinois

16 Department by rule. In establishing eligibility standards

17 under this paragraph 11, the Department shall, subject to

18 federal approval:

19 (a) set the income eligibility standard at not

20 lower than 350% of the federal poverty level;

21 (b) exempt retirement accounts that the person

22 cannot access without penalty before the age of 59

23 1/2, and medical savings accounts established pursuant

24 to 26 U.S.C. 220;

25 (c) allow non-exempt assets up to $25,000 as to

26 those assets accumulated during periods of eligibility

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1 under this paragraph 11; and

2 (d) continue to apply subparagraphs (b) and (c) in

3 determining the eligibility of the person under this

4 Article even if the person loses eligibility under

5 this paragraph 11.

6 12. Subject to federal approval, persons who are

7 eligible for medical assistance coverage under applicable

8 provisions of the federal Social Security Act and the

9 federal Breast and Cervical Cancer Prevention and

10 Treatment Act of 2000. Those eligible persons are defined

11 to include, but not be limited to, the following persons:

12 (1) persons who have been screened for breast or

13 cervical cancer under the U.S. Centers for Disease

14 Control and Prevention Breast and Cervical Cancer

15 Program established under Title XV of the federal

16 Public Health Service Act in accordance with the

17 requirements of Section 1504 of that Act as

18 administered by the Illinois Department of Public

19 Health; and

20 (2) persons whose screenings under the above

21 program were funded in whole or in part by funds

22 appropriated to the Illinois Department of Public

23 Health for breast or cervical cancer screening.

24 "Medical assistance" under this paragraph 12 shall be

25 identical to the benefits provided under the State's

26 approved plan under Title XIX of the Social Security Act.

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1 The Department must request federal approval of the

2 coverage under this paragraph 12 within 30 days after July

3 3, 2001 (the effective date of Public Act 92-47).

4 In addition to the persons who are eligible for

5 medical assistance pursuant to subparagraphs (1) and (2)

6 of this paragraph 12, and to be paid from funds

7 appropriated to the Department for its medical programs,

8 any uninsured person as defined by the Department in rules

9 residing in Illinois who is younger than 65 years of age,

10 who has been screened for breast and cervical cancer in

11 accordance with standards and procedures adopted by the

12 Department of Public Health for screening, and who is

13 referred to the Department by the Department of Public

14 Health as being in need of treatment for breast or

15 cervical cancer is eligible for medical assistance

16 benefits that are consistent with the benefits provided to

17 those persons described in subparagraphs (1) and (2).

18 Medical assistance coverage for the persons who are

19 eligible under the preceding sentence is not dependent on

20 federal approval, but federal moneys may be used to pay

21 for services provided under that coverage upon federal

22 approval.

23 13. Subject to appropriation and to federal approval,

24 persons living with HIV/AIDS who are not otherwise

25 eligible under this Article and who qualify for services

26 covered under Section 5-5.04 as provided by the Illinois

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1 Department by rule.

2 14. Subject to the availability of funds for this

3 purpose, the Department may provide coverage under this

4 Article to persons who

5 (a) reside in Illinois;

6 (b) are not eligible under any of the preceding

7 paragraphs of this Section;

8 (c) meet the income guidelines of paragraph 2(a)

9 of this Section; and

10 (d) meet one of the following conditions:

11 (i) have filed an application for asylum

12 status under 8 U.S.C. 1158 that is pending with

13 the appropriate federal agency or have a pending

14 appeal of such an application before a court of

15 competent jurisdiction and are represented either

16 by counsel or by an advocate accredited by the

17 appropriate federal agency and employed by a

18 not-for-profit organization in regard to that

19 application or appeal;

20 (ii) are receiving services through a

21 federally funded torture treatment center;

22 (iii) have filed a pending application for T

23 nonimmigrant status pursuant to 8 U.S.C.

24 1101(a)(15)(T);

25 (iv) have filed a pending application for U

26 nonimmigrant status pursuant to 8 U.S.C.

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1 1101(a)(15)(U); or

2 (v) have filed as a derivative family member

3 or are included in the application for item (i),

4 (iii), or (iv) as provided by Department rule.

5 Medical coverage under this paragraph 14 may be

6 provided for up to 24 continuous months from the initial

7 eligibility date so long as an individual continues to

8 satisfy the criteria of this paragraph 14. If an

9 individual has an application or appeal pending regarding

10 an application for asylum, T nonimmigrant status, or U

11 nonimmigrant status before the appropriate federal agency

12 for such applications or appeals, eligibility under this

13 paragraph 14 may be extended until a final decision is

14 rendered with respect to the application or appeal, except

15 that an individual who is approved for a U visa continues

16 to qualify for medical coverage under this paragraph 14 as

17 long as the individual meets all other eligibility

18 criteria. The Department shall adopt rules governing the

19 implementation of this paragraph 14.

20 15. Family Care Eligibility.

21 (a) On and after July 1, 2012, a parent or other

22 caretaker relative who is 19 years of age or older when

23 countable income is at or below 133% of the federal

24 poverty level. A person may not spend down to become

25 eligible under this paragraph 15.

26 (b) Eligibility shall be reviewed annually.

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1 (c) (Blank).

2 (d) (Blank).

3 (e) (Blank).

4 (f) (Blank).

5 (g) (Blank).

6 (h) (Blank).

7 (i) Following termination of an individual's

8 coverage under this paragraph 15, the individual must

9 be determined eligible before the person can be

10 re-enrolled.

11 16. Subject to appropriation, uninsured persons who

12 are not otherwise eligible under this Section who have

13 been certified and referred by the Department of Public

14 Health as having been screened and found to need

15 diagnostic evaluation or treatment, or both diagnostic

16 evaluation and treatment, for prostate or testicular

17 cancer. For the purposes of this paragraph 16, uninsured

18 persons are those who do not have creditable coverage, as

19 defined under the Health Insurance Portability and

20 Accountability Act, or have otherwise exhausted any

21 insurance benefits they may have had, for prostate or

22 testicular cancer diagnostic evaluation or treatment, or

23 both diagnostic evaluation and treatment. To be eligible,

24 a person must furnish a Social Security number. A person's

25 assets are exempt from consideration in determining

26 eligibility under this paragraph 16. Such persons shall be

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1 eligible for medical assistance under this paragraph 16

2 for so long as they need treatment for the cancer. A person

3 shall be considered to need treatment if, in the opinion

4 of the person's treating physician, the person requires

5 therapy directed toward cure or palliation of prostate or

6 testicular cancer, including recurrent metastatic cancer

7 that is a known or presumed complication of prostate or

8 testicular cancer and complications resulting from the

9 treatment modalities themselves. Persons who require only

10 routine monitoring services are not considered to need

11 treatment. "Medical assistance" under this paragraph 16

12 shall be identical to the benefits provided under the

13 State's approved plan under Title XIX of the Social

14 Security Act. Notwithstanding any other provision of law,

15 the Department (i) does not have a claim against the

16 estate of a deceased recipient of services under this

17 paragraph 16 and (ii) does not have a lien against any

18 homestead property or other legal or equitable real

19 property interest owned by a recipient of services under

20 this paragraph 16.

21 17. Persons who, pursuant to a waiver approved by the

22 Secretary of the U.S. Department of Health and Human

23 Services, are eligible for medical assistance under Title

24 XIX or XXI of the federal Social Security Act.

25 Notwithstanding any other provision of this Code and

26 consistent with the terms of the approved waiver, the

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1 Illinois Department, may by rule:

2 (a) Limit the geographic areas in which the waiver

3 program operates.

4 (b) Determine the scope, quantity, duration, and

5 quality, and the rate and method of reimbursement, of

6 the medical services to be provided, which may differ

7 from those for other classes of persons eligible for

8 assistance under this Article.

9 (c) Restrict the persons' freedom in choice of

10 providers.

11 18. Beginning January 1, 2014, persons aged 19 or

12 older, but younger than 65, who are not otherwise eligible

13 for medical assistance under this Section 5-2, who qualify

14 for medical assistance pursuant to 42 U.S.C.

15 1396a(a)(10)(A)(i)(VIII) to the extent permitted under

16 federal law ~~and applicable federal regulations~~, and who

17 have income at or below 133% of the federal poverty level

18 plus 5% for the applicable family size as determined

19 pursuant to 42 U.S.C. 1396a(e)(14) and applicable federal

20 regulations. Persons eligible for medical assistance under

21 this paragraph 18 shall receive coverage for the Health

22 Benefits Service Package as that term is defined in

23 subsection (m) of Section 5-1.1 of this Code. If Illinois'

24 federal medical assistance percentage (FMAP) is reduced

25 below 90% for persons eligible for medical assistance

26 under this paragraph 18, eligibility under this paragraph

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1 18 shall cease no later than the end of the third month

2 following the month in which the reduction in FMAP takes

3 effect.

4 19. Beginning January 1, 2014, as required under 42

5 U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18

6 and younger than age 26 who are not otherwise eligible for

7 medical assistance under paragraphs (1) through (17) of

8 this Section who (i) were in foster care under the

9 responsibility of the State on the date of attaining age

10 18 or on the date of attaining age 21 when a court has

11 continued wardship for good cause as provided in Section

12 2-31 of the Juvenile Court Act of 1987 and (ii) received

13 medical assistance under the Illinois Title XIX State Plan

14 or waiver of such plan while in foster care.

15 20. (Blank).

16 21. Persons who are not otherwise eligible for medical

17 assistance under this Section who may qualify for medical

18 assistance pursuant to 42 U.S.C.

19 1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the

20 duration of any federal or State declared emergency due to

21 COVID-19. Medical assistance to persons eligible for

22 medical assistance solely pursuant to this paragraph 21

23 shall be limited to any in vitro diagnostic product (and

24 the administration of such product) described in 42 U.S.C.

25 1396d(a)(3)(B) on or after March 18, 2020, any visit

26 described in 42 U.S.C. 1396o(a)(2)(G), or any other

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1 medical assistance that may be federally authorized for

2 this class of persons. The Department may also cover

3 treatment of COVID-19 for this class of persons, or any

4 similar category of uninsured individuals, to the extent

5 authorized under a federally approved 1115 Waiver or other

6 federal authority. Notwithstanding the provisions of

7 Section 1-11 of this Code, due to the nature of the

8 COVID-19 public health emergency, the Department may cover

9 and provide the medical assistance described in this

10 paragraph 21 to noncitizens who would otherwise meet the

11 eligibility requirements for the class of persons

12 described in this paragraph 21 for the duration of the

13 State emergency period.

14 In implementing the provisions of Public Act 96-20, the

15 Department is authorized to adopt only those rules necessary,

16 including emergency rules. Nothing in Public Act 96-20 permits

17 the Department to adopt rules or issue a decision that expands

18 eligibility for the FamilyCare Program to a person whose

19 income exceeds 185% of the Federal Poverty Level as determined

20 from time to time by the U.S. Department of Health and Human

21 Services, unless the Department is provided with express

22 statutory authority.

23 The eligibility of any such person for medical assistance

24 under this Article is not affected by the payment of any grant

25 under the Senior Citizens and Persons with Disabilities

26 Property Tax Relief Act or any distributions or items of

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1 income described under subparagraph (X) of paragraph (2) of

2 subsection (a) of Section 203 of the Illinois Income Tax Act.

3 The Department shall by rule establish the amounts of

4 assets to be disregarded in determining eligibility for

5 medical assistance, which shall at a minimum equal the amounts

6 to be disregarded under the Federal Supplemental Security

7 Income Program. The amount of assets of a single person to be

8 disregarded shall not be less than $2,000, and the amount of

9 assets of a married couple to be disregarded shall not be less

10 than $3,000.

11 To the extent permitted under federal law, any person

12 found guilty of a second violation of Article VIIIA shall be

13 ineligible for medical assistance under this Article, as

14 provided in Section 8A-8.

15 The eligibility of any person for medical assistance under

16 this Article shall not be affected by the receipt by the person

17 of donations or benefits from fundraisers held for the person

18 in cases of serious illness, as long as neither the person nor

19 members of the person's family have actual control over the

20 donations or benefits or the disbursement of the donations or

21 benefits.

22 Notwithstanding any other provision of this Code, if the

23 United States Supreme Court holds Title II, Subtitle A,

24 Section 2001(a) of Public Law 111-148 to be unconstitutional,

25 or if a holding of Public Law 111-148 makes Medicaid

26 eligibility allowed under Section 2001(a) inoperable, the

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1 State or a unit of local government shall be prohibited from

2 enrolling individuals in the Medical Assistance Program as the

3 result of federal approval of a State Medicaid waiver on or

4 after June 14, 2012 (the effective date of Public Act 97-687),

5 and any individuals enrolled in the Medical Assistance Program

6 pursuant to eligibility permitted as a result of such a State

7 Medicaid waiver shall become immediately ineligible.

8 Notwithstanding any other provision of this Code, if an

9 Act of Congress that becomes a Public Law eliminates Section

10 2001(a) of Public Law 111-148, the State or a unit of local

11 government shall be prohibited from enrolling individuals in

12 the Medical Assistance Program as the result of federal

13 approval of a State Medicaid waiver on or after June 14, 2012

14 (the effective date of Public Act 97-687), and any individuals

15 enrolled in the Medical Assistance Program pursuant to

16 eligibility permitted as a result of such a State Medicaid

17 waiver shall become immediately ineligible.

18 Effective October 1, 2013, the determination of

19 eligibility of persons who qualify under paragraphs 5, 6, 8,

20 15, 17, and 18 of this Section shall comply with the

21 requirements of 42 U.S.C. 1396a(e)(14) and applicable federal

22 regulations.

23 The Department of Healthcare and Family Services, the

24 Department of Human Services, and the Illinois health

25 insurance marketplace shall work cooperatively to assist

26 persons who would otherwise lose health benefits as a result

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1 of changes made under Public Act 98-104 to transition to other

2 health insurance coverage.

3 (Source: P.A. 104-9, eff. 1-1-26.)

4 (305 ILCS 5/5-2.1d)

5 Sec. 5-2.1d. Retroactive eligibility. Subject to federal

6 approval and in accordance with applicable federal law and

7 requirements, an ~~An~~ applicant for medical assistance may be

8 eligible ~~for up to 3 months~~ prior to the date of application if

9 the person would have been eligible for medical assistance at

10 the time he or she received the services if he or she had

11 applied, regardless of whether the individual is alive when

12 the application for medical assistance is made. In determining

13 financial eligibility for medical assistance for retroactive

14 months, the Department shall consider the amount of income and

15 resources and exemptions available to a person as of the first

16 day of each of the backdated months for which eligibility is

17 sought. The Department shall, by rule, establish the duration

18 of retroactive eligibility, which shall at a minimum equal the

19 duration of eligibility for federal matching funds.

20 (Source: P.A. 97-689, eff. 6-14-12.)

21 (305 ILCS 5/11-4) (from Ch. 23, par. 11-4)

22 Sec. 11-4. Applications; assistance in making

23 applications. An initial application for public assistance

24 shall be deemed an application for all such benefits to which

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1 any person may be entitled except to the extent that the

2 applicant expressly declines in writing to apply for

3 particular benefits. A redetermination of eligibility shall

4 occur at least annually or for any other periodic time period

5 established by the Department by rule that is necessary to

6 implement the federal Medicaid provisions contained in Public

7 Law 119-21 and any corresponding federal regulations or

8 requirements issued by the federal Centers for Medicare and

9 Medicaid Services. A redetermination ~~The redetermination is an~~

10 ~~annual redetermination~~ of eligibility is for ~~of~~ current

11 benefits and is not an initial application. The Illinois

12 Department shall provide information in writing about all

13 benefits provided under this Code to any person seeking public

14 assistance. The Illinois Department shall also provide

15 information in writing and orally to all applicants about an

16 election to have financial aid deposited directly in a

17 recipient's savings account or checking account or in any

18 electronic benefits account or accounts as provided in Section

19 11-3.1, to the extent that those elections are actually

20 available, including information on any programs administered

21 by the State Treasurer to facilitate or encourage the

22 distribution of financial aid by direct deposit or electronic

23 benefits transfer. The Illinois Department shall determine the

24 applicant's eligibility for cash assistance, medical

25 assistance and food stamps unless the applicant expressly

26 declines in writing to apply for particular benefits. The

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1 Illinois Department shall adopt policies and procedures to

2 facilitate timely changes between programs that result from

3 changes in categorical eligibility factors.

4 The County departments, local governmental units and the

5 Illinois Department shall assist applicants for public

6 assistance to properly complete their applications. Such

7 assistance shall include, but not be limited to, assistance in

8 securing evidence in support of their eligibility.

9 (Source: P.A. 104-9, eff. 6-16-25.)

10 (305 ILCS 5/11-5.1)

11 Sec. 11-5.1. Eligibility verification. Notwithstanding any

12 other provision of this Code, with respect to applications for

13 medical assistance provided under Article V of this Code,

14 eligibility shall be determined in a manner that ensures

15 program integrity and complies with federal laws and

16 regulations while minimizing unnecessary barriers to

17 enrollment. To this end, as soon as practicable, and unless

18 the Department receives written denial from the federal

19 government, this Section shall be implemented:

20 (a) The Department of Healthcare and Family Services or

21 its designees shall:

22 (1) By no later than July 1, 2011, require

23 verification of, at a minimum, one month's income from all

24 sources required for determining the eligibility of

25 applicants for medical assistance under this Code. Such

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1 verification shall take the form of pay stubs, business or

2 income and expense records for self-employed persons,

3 letters from employers, and any other valid documentation

4 of income including data obtained electronically by the

5 Department or its designees from other sources as

6 described in subsection (b) of this Section. A month's

7 income may be verified by a single pay stub with the

8 monthly income extrapolated from the time period covered

9 by the pay stub.

10 (2) By no later than October 1, 2011, require

11 verification of, at a minimum, one month's income from all

12 sources required for determining the continued eligibility

13 of recipients at their ~~annual~~ review of eligibility for

14 medical assistance under this Code. Information the

15 Department receives prior to the ~~annual~~ review, including

16 information available to the Department as a result of the

17 recipient's application for other non-Medicaid benefits,

18 that is sufficient to make a determination of continued

19 Medicaid eligibility may be reviewed and verified, and

20 subsequent action taken including client notification of

21 continued Medicaid eligibility. The date of client

22 notification establishes the date for subsequent ~~annual~~

23 Medicaid eligibility reviews. Such verification shall take

24 the form of pay stubs, business or income and expense

25 records for self-employed persons, letters from employers,

26 and any other valid documentation of income including data

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1 obtained electronically by the Department or its designees

2 from other sources as described in subsection (b) of this

3 Section. A month's income may be verified by a single pay

4 stub with the monthly income extrapolated from the time

5 period covered by the pay stub. The Department shall send

6 a notice to recipients at least 60 days prior to the end of

7 their period of eligibility that informs them of the

8 requirements for continued eligibility. If a recipient

9 does not fulfill the requirements for continued

10 eligibility by the deadline established in the notice a

11 notice of cancellation shall be issued to the recipient

12 and coverage shall end no later than the last day of the

13 month following the last day of the eligibility period. A

14 recipient's eligibility may be reinstated without

15 requiring a new application if the recipient fulfills the

16 requirements for continued eligibility prior to the end of

17 the third month following the last date of coverage (or

18 longer period if required by federal regulations). Nothing

19 in this Section shall prevent an individual whose coverage

20 has been cancelled from reapplying for health benefits at

21 any time.

22 (3) By no later than July 1, 2011, require

23 verification of Illinois residency.

24 The Department, with federal approval, may choose to adopt

25 continuous financial eligibility for a full 12 months for

26 adults on Medicaid.

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1 (b) The Department shall establish or continue cooperative

2 arrangements with the Social Security Administration, the

3 Illinois Secretary of State, the Department of Human Services,

4 the Department of Revenue, the Department of Employment

5 Security, and any other appropriate entity to gain electronic

6 access, to the extent allowed by law, to information available

7 to those entities that may be appropriate for electronically

8 verifying any factor of eligibility for benefits under the

9 Program. Data relevant to eligibility shall be provided for no

10 other purpose than to verify the eligibility of new applicants

11 or current recipients of health benefits under the Program.

12 Data shall be requested or provided for any new applicant or

13 current recipient only insofar as that individual's

14 circumstances are relevant to that individual's or another

15 individual's eligibility.

16 (c) Within 90 days of the effective date of this

17 amendatory Act of the 96th General Assembly, the Department of

18 Healthcare and Family Services shall send notice to current

19 recipients informing them of the changes regarding their

20 eligibility verification.

21 (d) As soon as practical if the data is reasonably

22 available, but no later than January 1, 2017, the Department

23 shall compile on a monthly basis data on eligibility

24 redeterminations of beneficiaries of medical assistance

25 provided under Article V of this Code. In addition to the other

26 data required under this subsection, the Department shall

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1 compile on a monthly basis data on the percentage of

2 beneficiaries whose eligibility is renewed through ex parte

3 redeterminations as described in subsection (b) of Section

4 5-1.6 of this Code, subject to federal approval of the changes

5 made in subsection (b) of Section 5-1.6 by this amendatory Act

6 of the 102nd General Assembly. This data shall be posted on the

7 Department's website, and data from prior months shall be

8 retained and available on the Department's website. The data

9 compiled and reported shall include the following:

10 (1) The total number of redetermination decisions made

11 in a month and, of that total number, the number of

12 decisions to continue or change benefits and the number of

13 decisions to cancel benefits.

14 (2) A breakdown of enrollee language preference for

15 the total number of redetermination decisions made in a

16 month and, of that total number, a breakdown of enrollee

17 language preference for the number of decisions to

18 continue or change benefits, and a breakdown of enrollee

19 language preference for the number of decisions to cancel

20 benefits. The language breakdown shall include, at a

21 minimum, English, Spanish, and the next 4 most commonly

22 used languages.

23 (3) The percentage of cancellation decisions made in a

24 month due to each of the following:

25 (A) The beneficiary's ineligibility due to excess

26 income.

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1 (B) The beneficiary's ineligibility due to not

2 being an Illinois resident.

3 (C) The beneficiary's ineligibility due to being

4 deceased.

5 (D) The beneficiary's request to cancel benefits.

6 (E) The beneficiary's lack of response after

7 notices mailed to the beneficiary are returned to the

8 Department as undeliverable by the United States

9 Postal Service.

10 (F) The beneficiary's lack of response to a

11 request for additional information when reliable

12 information in the beneficiary's account, or other

13 more current information, is unavailable to the

14 Department to make a decision on whether to continue

15 benefits.

16 (G) Other reasons tracked by the Department for

17 the purpose of ensuring program integrity.

18 (4) If a vendor is utilized to provide services in

19 support of the Department's redetermination decision

20 process, the total number of redetermination decisions

21 made in a month and, of that total number, the number of

22 decisions to continue or change benefits, and the number

23 of decisions to cancel benefits (i) with the involvement

24 of the vendor and (ii) without the involvement of the

25 vendor.

26 (5) Of the total number of benefit cancellations in a

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1 month, the number of beneficiaries who return from

2 cancellation within one month, the number of beneficiaries

3 who return from cancellation within 2 months, and the

4 number of beneficiaries who return from cancellation

5 within 3 months. Of the number of beneficiaries who return

6 from cancellation within 3 months, the percentage of those

7 cancellations due to each of the reasons listed under

8 paragraph (3) of this subsection.

9 (e) The Department shall conduct a complete review of the

10 Medicaid redetermination process in order to identify changes

11 that can increase the use of ex parte redetermination

12 processing. This review shall be completed within 90 days

13 after the effective date of this amendatory Act of the 101st

14 General Assembly. Within 90 days of completion of the review,

15 the Department shall seek written federal approval of policy

16 changes the review recommended and implement once approved.

17 The review shall specifically include, but not be limited to,

18 use of ex parte redeterminations of the following populations:

19 (1) Recipients of developmental disabilities services.

20 (2) Recipients of benefits under the State's Aid to

21 the Aged, Blind, or Disabled program.

22 (3) Recipients of Medicaid long-term care services and

23 supports, including waiver services.

24 (4) All Modified Adjusted Gross Income (MAGI)

25 populations.

26 (5) Populations with no verifiable income.

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1 (6) Self-employed people.

2 The report shall also outline populations and

3 circumstances in which an ex parte redetermination is not a

4 recommended option.

5 (f) The Department shall explore and implement, as

6 practical and technologically possible, roles that

7 stakeholders outside State agencies can play to assist in

8 expediting eligibility determinations and redeterminations

9 within 24 months after the effective date of this amendatory

10 Act of the 101st General Assembly. Such practical roles to be

11 explored to expedite the eligibility determination processes

12 shall include the implementation of hospital presumptive

13 eligibility, as authorized by the Patient Protection and

14 Affordable Care Act.

15 (g) The Department or its designee shall seek federal

16 approval to enhance the reasonable compatibility standard from

17 5% to 10%.

18 (h) Reporting. The Department of Healthcare and Family

19 Services and the Department of Human Services shall publish

20 quarterly reports on their progress in implementing policies

21 and practices pursuant to this Section as modified by this

22 amendatory Act of the 101st General Assembly.

23 (1) The reports shall include, but not be limited to,

24 the following:

25 (A) Medical application processing, including a

26 breakdown of the number of MAGI, non-MAGI, long-term

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1 care, and other medical cases pending for various

2 incremental time frames between 0 to 181 or more days.

3 (B) Medical redeterminations completed, including:

4 (i) a breakdown of the number of households that were

5 redetermined ex parte and those that were not; (ii)

6 the reasons households were not redetermined ex parte;

7 and (iii) the relative percentages of these reasons.

8 (C) A narrative discussion on issues identified in

9 the functioning of the State's Integrated Eligibility

10 System and progress on addressing those issues, as

11 well as progress on implementing strategies to address

12 eligibility backlogs, including expanding ex parte

13 determinations to ensure timely eligibility

14 determinations and renewals.

15 (2) Initial reports shall be issued within 90 days

16 after the effective date of this amendatory Act of the

17 101st General Assembly.

18 (3) All reports shall be published on the Department's

19 website.

20 (i) It is the determination of the General Assembly that

21 the Department must include seniors and persons with

22 disabilities in ex parte renewals. It is the determination of

23 the General Assembly that the Department must use its asset

24 verification system to assist in the determination of whether

25 an individual's coverage can be renewed using the ex parte

26 process. If a State Plan amendment is required, the Department

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1 shall pursue such State Plan amendment by July 1, 2022. Within

2 60 days after receiving federal approval or guidance, the

3 Department of Healthcare and Family Services and the

4 Department of Human Services shall make necessary technical

5 and rule changes to implement these changes to the

6 redetermination process.

7 (Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20;

8 102-1037, eff. 6-2-22.)

9 (305 ILCS 5/11-5.4)

10 Sec. 11-5.4. Expedited long-term care eligibility

11 determination and enrollment.

12 (a) Establishment of the expedited long-term care

13 eligibility determination and enrollment system shall be a

14 joint venture of the Departments of Human Services and

15 Healthcare and Family Services and the Department on Aging.

16 (b) Streamlined application enrollment process; expedited

17 eligibility process. The streamlined application and

18 enrollment process must include, but need not be limited to,

19 the following:

20 (1) On or before July 1, 2019, a streamlined

21 application and enrollment process shall be put in place

22 which must include, but need not be limited to, the

23 following:

24 (A) Minimize the burden on applicants by

25 collecting only the data necessary to determine

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1 eligibility for medical services, long-term care

2 services, and spousal impoverishment offset.

3 (B) Integrate online data sources to simplify the

4 application process by reducing the amount of

5 information needed to be entered and to expedite

6 eligibility verification.

7 (C) Provide online prompts to alert the applicant

8 that information is missing or not complete.

9 (D) Provide training and step-by-step written

10 instructions for caseworkers, applicants, and

11 providers.

12 (2) The State must expedite the eligibility process

13 for applicants meeting specified guidelines, regardless of

14 the age of the application. The guidelines, subject to

15 federal approval, must include, but need not be limited

16 to, the following individually or collectively:

17 (A) Full Medicaid benefits in the community for a

18 specified period of time.

19 (B) No transfer of assets or resources during the

20 federally prescribed look-back period, as specified in

21 federal law.

22 (C) Receives Supplemental Security Income payments

23 or was receiving such payments at the time of

24 admission to a nursing facility.

25 (D) For applicants or recipients with verified

26 income at or below 100% of the federal poverty level

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1 when the declared value of their countable resources

2 is no greater than the allowable amounts pursuant to

3 Section 5-2 of this Code for classes of eligible

4 persons for whom a resource limit applies. Such

5 simplified verification policies shall apply to

6 community cases as well as long-term care cases.

7 (3) Subject to federal approval, the Department of

8 Healthcare and Family Services must implement an ex parte

9 renewal process for Medicaid-eligible individuals residing

10 in long-term care facilities. "Renewal" has the same

11 meaning as "redetermination" in State policies,

12 administrative rule, and federal Medicaid law. The ex

13 parte renewal process must be fully operational on or

14 before January 1, 2019. If an individual has transferred

15 to another long-term care facility, any ~~annual~~ notice

16 concerning redetermination of eligibility must be sent to

17 the long-term care facility where the individual resides

18 as well as to the individual.

19 (4) The Department of Human Services must use the

20 standards and distribution requirements described in this

21 subsection and in Section 11-6 for notification of missing

22 supporting documents and information during all phases of

23 the application process: initial, renewal, and appeal.

24 (c) The Department of Human Services must adopt policies

25 and procedures to improve communication between long-term care

26 benefits central office personnel, applicants and their

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1 representatives, and facilities in which the applicants

2 reside. Such policies and procedures must at a minimum permit

3 applicants and their representatives and the facility in which

4 the applicants reside to speak directly to an individual

5 trained to take telephone inquiries and provide appropriate

6 responses.

7 (d) Effective 30 days after the completion of 3 regionally

8 based trainings, nursing facilities shall submit all

9 applications for medical assistance online via the Application

10 for Benefits Eligibility (ABE) website. This requirement shall

11 extend to scanning and uploading with the online application

12 any required additional forms such as the Long Term Care

13 Facility Notification and the Additional Financial Information

14 for Long Term Care Applicants as well as scanned copies of any

15 supporting documentation. Long-term care facility admission

16 documents must be submitted as required in Section 5-5 of this

17 Code. No local Department of Human Services office shall

18 refuse to accept an electronically filed application. No

19 Department of Human Services office shall request submission

20 of any document in hard copy.

21 (e) Notwithstanding any other provision of this Code, the

22 Department of Human Services and the Department of Healthcare

23 and Family Services' Office of the Inspector General shall,

24 upon request, allow an applicant additional time to submit

25 information and documents needed as part of a review of

26 available resources or resources transferred during the

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1 look-back period. The initial extension shall not exceed 30

2 days. A second extension of 30 days may be granted upon

3 request. Any request for information issued by the State to an

4 applicant shall include the following: an explanation of the

5 information required and the date by which the information

6 must be submitted; a statement that failure to respond in a

7 timely manner can result in denial of the application; a

8 statement that the applicant or the facility in the name of the

9 applicant may seek an extension; and the name and contact

10 information of a caseworker in case of questions. Any such

11 request for information shall also be sent to the facility. In

12 deciding whether to grant an extension, the Department of

13 Human Services or the Department of Healthcare and Family

14 Services' Office of the Inspector General shall take into

15 account what is in the best interest of the applicant. The time

16 limits for processing an application shall be tolled during

17 the period of any extension granted under this subsection.

18 (f) The Department of Human Services and the Department of

19 Healthcare and Family Services must jointly compile data on

20 pending applications, denials, appeals, and redeterminations

21 into a monthly report, which shall be posted on each

22 Department's website for the purposes of monitoring long-term

23 care eligibility processing. The report must specify the

24 number of applications and redeterminations pending long-term

25 care eligibility determination and admission and the number of

26 appeals of denials in the following categories:

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1 (A) Length of time applications, redeterminations, and

2 appeals are pending - 0 to 45 days, 46 days to 90 days, 91

3 days to 180 days, 181 days to 12 months, over 12 months to

4 18 months, over 18 months to 24 months, and over 24 months.

5 (B) Percentage of applications and redeterminations

6 pending in the Department of Human Services' Family

7 Community Resource Centers, in the Department of Human

8 Services' long-term care hubs, with the Department of

9 Healthcare and Family Services' Office of Inspector

10 General, and those applications which are being tolled due

11 to requests for extension of time for additional

12 information.

13 (C) Status of pending applications, denials, appeals,

14 and redeterminations.

15 (g) Beginning on July 1, 2017, the Auditor General shall

16 report every 3 years to the General Assembly on the

17 performance and compliance of the Department of Healthcare and

18 Family Services, the Department of Human Services, and the

19 Department on Aging in meeting the requirements of this

20 Section and the federal requirements concerning eligibility

21 determinations for Medicaid long-term care services and

22 supports, and shall report any issues or deficiencies and make

23 recommendations. The Auditor General shall, at a minimum,

24 review, consider, and evaluate the following:

25 (1) compliance with federal regulations on furnishing

26 services as related to Medicaid long-term care services

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1 and supports as provided under 42 CFR 435.930;

2 (2) compliance with federal regulations on the timely

3 determination of eligibility as provided under 42 CFR

4 435.912;

5 (3) the accuracy and completeness of the report

6 required under paragraph (9) of subsection (e);

7 (4) the efficacy and efficiency of the task-based

8 process used for making eligibility determinations in the

9 centralized offices of the Department of Human Services

10 for long-term care services, including the role of the

11 State's integrated eligibility system, as opposed to the

12 traditional caseworker-specific process from which these

13 central offices have converted; and

14 (5) any issues affecting eligibility determinations

15 related to the Department of Human Services' staff

16 completing Medicaid eligibility determinations instead of

17 the designated single-state Medicaid agency in Illinois,

18 the Department of Healthcare and Family Services.

19 The Auditor General's report shall include any and all

20 other areas or issues which are identified through an annual

21 review. Paragraphs (1) through (5) of this subsection shall

22 not be construed to limit the scope of the annual review and

23 the Auditor General's authority to thoroughly and completely

24 evaluate any and all processes, policies, and procedures

25 concerning compliance with federal and State law requirements

26 on eligibility determinations for Medicaid long-term care

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1 services and supports.

2 (h) The Department of Healthcare and Family Services shall

3 adopt any rules necessary to administer and enforce any

4 provision of this Section. Rulemaking shall not delay the full

5 implementation of this Section.

6 (i) Beginning on June 29, 2018, provisional eligibility

7 for medical assistance under Article V of this Code, in the

8 form of a recipient identification number and any other

9 necessary credentials to permit an applicant to receive

10 covered services under Article V, must be issued to any

11 applicant who has not received a determination on his or her

12 application for Medicaid and Medicaid long-term care services

13 filed simultaneously or, if already Medicaid enrolled,

14 application for Medicaid long-term care services under Article

15 V of this Code within the federally prescribed timeliness

16 requirements for determinations on such applications. The

17 Department of Healthcare and Family Services must maintain the

18 applicant's provisional eligibility status until a

19 determination is made on the individual's application for

20 long-term care services. The Department of Healthcare and

21 Family Services or the managed care organization, if

22 applicable, must reimburse providers for services rendered

23 during an applicant's provisional eligibility period.

24 (1) Claims for services rendered to an applicant with

25 provisional eligibility status must be submitted and

26 processed in the same manner as those submitted on behalf

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1 of beneficiaries determined to qualify for benefits.

2 (2) An applicant with provisional eligibility status

3 must have his or her long-term care benefits paid for

4 under the State's fee-for-service system during the period

5 of provisional eligibility. If an individual otherwise

6 eligible for medical assistance under Article V of this

7 Code is enrolled with a managed care organization for

8 community benefits at the time the individual's

9 provisional eligibility for long-term care services is

10 issued, the managed care organization is only responsible

11 for paying benefits covered under the capitation payment

12 received by the managed care organization for the

13 individual.

14 (3) The Department of Healthcare and Family Services,

15 within 10 business days of issuing provisional eligibility

16 to an applicant, must submit to the Office of the

17 Comptroller for payment a voucher for all retroactive

18 reimbursement due. The Department of Healthcare and Family

19 Services must clearly identify such vouchers as

20 provisional eligibility vouchers.

21 (Source: P.A. 101-101, eff. 1-1-20; 101-209, eff. 8-5-19;

22 101-265, eff. 8-9-19; 101-559, eff. 8-23-19; 102-558, eff.

23 8-20-21.)

24 ARTICLE 225.

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1 Section 225-5. The Illinois Act on the Aging is amended by

2 changing Section 4.02 as follows:

3 (20 ILCS 105/4.02)

4 Sec. 4.02. Community Care Program. The Department shall

5 establish a program of services to prevent unnecessary

6 institutionalization of persons age 60 and older in need of

7 long term care or who are established as persons who suffer

8 from Alzheimer's disease or a related disorder under the

9 Alzheimer's Disease Assistance Act, thereby enabling them to

10 remain in their own homes or in other living arrangements.

11 Such preventive services, which may be coordinated with other

12 programs for the aged, may include, but are not limited to, any

13 or all of the following:

14 (a) (blank);

15 (b) (blank);

16 (c) home care aide services;

17 (d) personal assistant services;

18 (e) adult day services;

19 (f) home-delivered meals;

20 (g) education in self-care;

21 (h) personal care services;

22 (i) adult day health services;

23 (j) habilitation services;

24 (k) respite care;

25 (k-5) community reintegration services;

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1 (k-6) flexible senior services;

2 (k-7) medication management;

3 (k-8) emergency home response;

4 (l) other nonmedical social services that may enable

5 the person to become self-supporting; or

6 (m) (blank).

7 The Department shall establish eligibility standards for

8 such services. In determining the amount and nature of

9 services for which a person may qualify, consideration shall

10 not be given to the value of cash, property, or other assets

11 held in the name of the person's spouse pursuant to a written

12 agreement dividing marital property into equal but separate

13 shares or pursuant to a transfer of the person's interest in a

14 home to his spouse, provided that the spouse's share of the

15 marital property is not made available to the person seeking

16 such services.

17 The Department shall require as a condition of eligibility

18 that all new financially eligible applicants apply for and

19 enroll in medical assistance under Article V of the Illinois

20 Public Aid Code in accordance with rules promulgated by the

21 Department.

22 The Department shall, in conjunction with the Department

23 of Public Aid (now Department of Healthcare and Family

24 Services), seek appropriate amendments under Sections 1915 and

25 1924 of the Social Security Act. The purpose of the amendments

26 shall be to extend eligibility for home and community based

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1 services under Sections 1915 and 1924 of the Social Security

2 Act to persons who transfer to or for the benefit of a spouse

3 those amounts of income and resources allowed under Section

4 1924 of the Social Security Act. Subject to the approval of

5 such amendments, the Department shall extend the provisions of

6 Section 5-4 of the Illinois Public Aid Code to persons who, but

7 for the provision of home or community-based services, would

8 require the level of care provided in an institution, as is

9 provided for in federal law. Those persons no longer found to

10 be eligible for receiving noninstitutional services due to

11 changes in the eligibility criteria shall be given 45 days

12 notice prior to actual termination. Those persons receiving

13 notice of termination may contact the Department and request

14 the determination be appealed at any time during the 45 day

15 notice period. The target population identified for the

16 purposes of this Section are persons age 60 and older with an

17 identified service need. Priority shall be given to those who

18 are at imminent risk of institutionalization. The services

19 shall be provided to eligible persons age 60 and older to the

20 extent that the cost of the services together with the other

21 personal maintenance expenses of the persons are reasonably

22 related to the standards established for care in a group

23 facility appropriate to the person's condition. These

24 noninstitutional services, pilot projects, or experimental

25 facilities may be provided as part of or in addition to those

26 authorized by federal law or those funded and administered by

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1 the Department of Human Services. The Departments of Human

2 Services, Healthcare and Family Services, Public Health,

3 Veterans' Affairs, and Commerce and Economic Opportunity and

4 other appropriate agencies of State, federal, and local

5 governments shall cooperate with the Department on Aging in

6 the establishment and development of the noninstitutional

7 services. The Department shall require an annual audit from

8 all personal assistant and home care aide vendors contracting

9 with the Department under this Section. The annual audit shall

10 assure that each audited vendor's procedures are in compliance

11 with Department's financial reporting guidelines requiring an

12 administrative and employee wage and benefits cost split as

13 defined in administrative rules. The audit is a public record

14 under the Freedom of Information Act. The Department shall

15 execute, relative to the nursing home prescreening project,

16 written inter-agency agreements with the Department of Human

17 Services and the Department of Healthcare and Family Services,

18 to effect the following: (1) intake procedures and common

19 eligibility criteria for those persons who are receiving

20 noninstitutional services; and (2) the establishment and

21 development of noninstitutional services in areas of the State

22 where they are not currently available or are undeveloped. On

23 and after July 1, 1996, all nursing home prescreenings for

24 individuals 60 years of age or older shall be conducted by the

25 Department.

26 As part of the Department on Aging's routine training of

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1 case managers and case manager supervisors, the Department may

2 include information on family futures planning for persons who

3 are age 60 or older and who are caregivers of their adult

4 children with developmental disabilities. The content of the

5 training shall be at the Department's discretion.

6 The Department is authorized to establish a system of

7 recipient copayment for services provided under this Section,

8 such copayment to be based upon the recipient's ability to pay

9 but in no case to exceed the actual cost of the services

10 provided. Additionally, any portion of a person's income which

11 is equal to or less than the federal poverty standard shall not

12 be considered by the Department in determining the copayment.

13 The level of such copayment shall be adjusted whenever

14 necessary to reflect any change in the officially designated

15 federal poverty standard.

16 The Department, or the Department's authorized

17 representative, may recover the amount of moneys expended for

18 services provided to or in behalf of a person under this

19 Section by a claim against the person's estate or against the

20 estate of the person's surviving spouse, but no recovery may

21 be had until after the death of the surviving spouse, if any,

22 and then only at such time when there is no surviving child who

23 is under age 21 or blind or who has a permanent and total

24 disability. This paragraph, however, shall not bar recovery,

25 at the death of the person, of moneys for services provided to

26 the person or in behalf of the person under this Section to

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1 which the person was not entitled; provided that such recovery

2 shall not be enforced against any real estate while it is

3 occupied as a homestead by the surviving spouse or other

4 dependent, if no claims by other creditors have been filed

5 against the estate, or, if such claims have been filed, they

6 remain dormant for failure of prosecution or failure of the

7 claimant to compel administration of the estate for the

8 purpose of payment. This paragraph shall not bar recovery from

9 the estate of a spouse, under Sections 1915 and 1924 of the

10 Social Security Act and Section 5-4 of the Illinois Public Aid

11 Code, who precedes a person receiving services under this

12 Section in death. All moneys for services paid to or in behalf

13 of the person under this Section shall be claimed for recovery

14 from the deceased spouse's estate. "Homestead", as used in

15 this paragraph, means the dwelling house and contiguous real

16 estate occupied by a surviving spouse or relative, as defined

17 by the rules and regulations of the Department of Healthcare

18 and Family Services, regardless of the value of the property.

19 The Department shall increase the effectiveness of the

20 existing Community Care Program by:

21 (1) ensuring that in-home services included in the

22 care plan are available on evenings and weekends;

23 (2) ensuring that care plans contain the services that

24 eligible participants need based on the number of days in

25 a month, not limited to specific blocks of time, as

26 identified by the comprehensive assessment tool selected

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1 by the Department for use statewide, not to exceed the

2 total monthly service cost maximum allowed for each

3 service; the Department shall develop administrative rules

4 to implement this item (2);

5 (3) ensuring that the participants have the right to

6 choose the services contained in their care plan and to

7 direct how those services are provided, based on

8 administrative rules established by the Department;

9 (4)(blank);

10 (5) ensuring that homemakers can provide personal care

11 services that may or may not involve contact with clients,

12 including, but not limited to:

13 (A) bathing;

14 (B) grooming;

15 (C) toileting;

16 (D) nail care;

17 (E) transferring;

18 (F) respiratory services;

19 (G) exercise; or

20 (H) positioning;

21 (6) ensuring that homemaker program vendors are not

22 restricted from hiring homemakers who are family members

23 of clients or recommended by clients; the Department may

24 not, by rule or policy, require homemakers who are family

25 members of clients or recommended by clients to accept

26 assignments in homes other than the client;

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1 (7) ensuring that the State may access maximum federal

2 matching funds by seeking approval for the Centers for

3 Medicare and Medicaid Services for modifications to the

4 State's home and community based services waiver and

5 additional waiver opportunities, including applying for

6 enrollment in the Balance Incentive Payment Program by May

7 1, 2013, in order to maximize federal matching funds; this

8 shall include, but not be limited to, modification that

9 reflects all changes in the Community Care Program

10 services and all increases in the services cost maximum;

11 (8) ensuring that the determination of need tool

12 accurately reflects the service needs of individuals with

13 Alzheimer's disease and related dementia disorders;

14 (9) ensuring that services are authorized accurately

15 and consistently for the Community Care Program (CCP); the

16 Department shall implement a Service Authorization policy

17 directive; the purpose shall be to ensure that eligibility

18 and services are authorized accurately and consistently in

19 the CCP program; the policy directive shall clarify

20 service authorization guidelines to Care Coordination

21 Units and Community Care Program providers no later than

22 May 1, 2013;

23 (10) working in conjunction with Care Coordination

24 Units, the Department of Healthcare and Family Services,

25 the Department of Human Services, Community Care Program

26 providers, and other stakeholders to make improvements to

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1 the Medicaid claiming processes and the Medicaid

2 enrollment procedures or requirements as needed,

3 including, but not limited to, specific policy changes or

4 rules to improve the up-front enrollment of participants

5 in the Medicaid program and specific policy changes or

6 rules to ensure ~~insure~~ more prompt submission of bills to

7 the federal government to secure maximum federal matching

8 dollars as promptly as possible; the Department on Aging

9 shall have at least 3 meetings with stakeholders by

10 January 1, 2014 in order to address these improvements;

11 (11) requiring home care service providers to comply

12 with the rounding of hours worked provisions under the

13 federal Fair Labor Standards Act (FLSA) and as set forth

14 in 29 CFR 785.48(b) by May 1, 2013;

15 (12) implementing any necessary policy changes or

16 promulgating any rules, no later than January 1, 2014, to

17 assist the Department of Healthcare and Family Services in

18 moving as many participants as possible, consistent with

19 federal regulations, into coordinated care plans if a care

20 coordination plan that covers long term care is available

21 in the recipient's area; and

22 (13) (blank).

23 By January 1, 2009 or as soon after the end of the Cash and

24 Counseling Demonstration Project as is practicable, the

25 Department may, based on its evaluation of the demonstration

26 project, promulgate rules concerning personal assistant

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1 services, to include, but need not be limited to,

2 qualifications, employment screening, rights under fair labor

3 standards, training, fiduciary agent, and supervision

4 requirements. All applicants shall be subject to the

5 provisions of the Health Care Worker Background Check Act.

6 The Department shall develop procedures to enhance

7 availability of services on evenings, weekends, and on an

8 emergency basis to meet the respite needs of caregivers.

9 Procedures shall be developed to permit the utilization of

10 services in successive blocks of 24 hours up to the monthly

11 maximum established by the Department. Workers providing these

12 services shall be appropriately trained.

13 No person may perform chore/housekeeping and home care

14 aide services under a program authorized by this Section

15 unless that person has been issued a certificate of

16 pre-service to do so by his or her employing agency.

17 Information gathered to effect such certification shall

18 include (i) the person's name, (ii) the date the person was

19 hired by his or her current employer, and (iii) the training,

20 including dates and levels. Persons engaged in the program

21 authorized by this Section before the effective date of this

22 amendatory Act of 1991 shall be issued a certificate of all

23 pre-service and in-service training from his or her employer

24 upon submitting the necessary information. The employing

25 agency shall be required to retain records of all staff

26 pre-service and in-service training, and shall provide such

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1 records to the Department upon request and upon termination of

2 the employer's contract with the Department. In addition, the

3 employing agency is responsible for the issuance of

4 certifications of in-service training completed to their

5 employees.

6 The Department is required to develop a system to ensure

7 that persons working as home care aides and personal

8 assistants receive increases in their wages when the federal

9 minimum wage is increased by requiring vendors to certify that

10 they are meeting the federal minimum wage statute for home

11 care aides and personal assistants. An employer that cannot

12 ensure that the minimum wage increase is being given to home

13 care aides and personal assistants shall be denied any

14 increase in reimbursement costs.

15 The Community Care Program Advisory Committee is created

16 in the Department on Aging. The Director shall appoint

17 individuals to serve in the Committee, who shall serve at

18 their own expense. Members of the Committee must abide by all

19 applicable ethics laws. The Committee shall advise the

20 Department on issues related to the Department's program of

21 services to prevent unnecessary institutionalization. The

22 Committee shall meet on a bi-monthly basis and shall serve to

23 identify and advise the Department on present and potential

24 issues affecting the service delivery network, the program's

25 clients, and the Department and to recommend solution

26 strategies. Persons appointed to the Committee shall be

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1 appointed on, but not limited to, their own and their agency's

2 experience with the program, geographic representation, and

3 willingness to serve. The Director shall appoint members to

4 the Committee to represent provider, advocacy, policy

5 research, and other constituencies committed to the delivery

6 of high quality home and community-based services to older

7 adults. Representatives shall be appointed to ensure

8 representation from community care providers, including, but

9 not limited to, adult day service providers, homemaker

10 providers, case coordination and case management units,

11 emergency home response providers, statewide trade or labor

12 unions that represent home care aides and direct care staff,

13 area agencies on aging, adults over age 60, membership

14 organizations representing older adults, and other

15 organizational entities, providers of care, or individuals

16 with demonstrated interest and expertise in the field of home

17 and community care as determined by the Director.

18 Nominations may be presented from any agency or State

19 association with interest in the program. The Director, or his

20 or her designee, shall serve as the permanent co-chair of the

21 advisory committee. One other co-chair shall be nominated and

22 approved by the members of the committee on an annual basis.

23 Committee members' terms of appointment shall be for 4 years

24 with one-quarter of the appointees' terms expiring each year.

25 A member shall continue to serve until his or her replacement

26 is named. The Department shall fill vacancies that have a

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1 remaining term of over one year, and this replacement shall

2 occur through the annual replacement of expiring terms. The

3 Director shall designate Department staff to provide technical

4 assistance and staff support to the committee. Department

5 representation shall not constitute membership of the

6 committee. All Committee papers, issues, recommendations,

7 reports, and meeting memoranda are advisory only. The

8 Director, or his or her designee, shall make a written report,

9 as requested by the Committee, regarding issues before the

10 Committee.

11 The Department on Aging and the Department of Human

12 Services shall cooperate in the development and submission of

13 an annual report on programs and services provided under this

14 Section. Such joint report shall be filed with the Governor

15 and the General Assembly on or before March 31 of the following

16 fiscal year.

17 The requirement for reporting to the General Assembly

18 shall be satisfied by filing copies of the report as required

19 by Section 3.1 of the General Assembly Organization Act and

20 filing such additional copies with the State Government Report

21 Distribution Center for the General Assembly as is required

22 under paragraph (t) of Section 7 of the State Library Act.

23 Those persons previously found eligible for receiving

24 noninstitutional services whose services were discontinued

25 under the Emergency Budget Act of Fiscal Year 1992, and who do

26 not meet the eligibility standards in effect on or after July

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1 1, 1992, shall remain ineligible on and after July 1, 1992.

2 Those persons previously not required to cost-share and who

3 were required to cost-share effective March 1, 1992, shall

4 continue to meet cost-share requirements on and after July 1,

5 1992. Beginning July 1, 1992, all clients will be required to

6 meet eligibility, cost-share, and other requirements and will

7 have services discontinued or altered when they fail to meet

8 these requirements.

9 For the purposes of this Section, "flexible senior

10 services" refers to services that require one-time or periodic

11 expenditures, including, but not limited to, respite care,

12 home modification, assistive technology, housing assistance,

13 and transportation.

14 The Department shall implement an electronic service

15 verification based on global positioning systems or other

16 cost-effective technology for the Community Care Program no

17 later than January 1, 2014.

18 The Department shall require, as a condition of

19 eligibility, application for the medical assistance program

20 under Article V of the Illinois Public Aid Code.

21 The Department may authorize Community Care Program

22 services until an applicant is determined eligible for medical

23 assistance under Article V of the Illinois Public Aid Code.

24 The Department shall continue to provide Community Care

25 Program reports as required by statute, which shall include an

26 annual report on Care Coordination Unit performance and

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1 adherence to service guidelines and a 6-month supplemental

2 report.

3 In regard to community care providers, failure to comply

4 with Department on Aging policies shall be cause for

5 disciplinary action, including, but not limited to,

6 disqualification from serving Community Care Program clients.

7 Each provider, upon submission of any bill or invoice to the

8 Department for payment for services rendered, shall include a

9 notarized statement, under penalty of perjury pursuant to

10 Section 1-109 of the Code of Civil Procedure, that the

11 provider has complied with all Department policies.

12 The Director of the Department on Aging shall make

13 information available to the State Board of Elections as may

14 be required by an agreement the State Board of Elections has

15 entered into with a multi-state voter registration list

16 maintenance system.

17 The Department shall pay an enhanced rate of at least

18 $1.77 per unit under the Community Care Program to those

19 in-home service provider agencies that offer health insurance

20 coverage as a benefit to their direct service worker employees

21 pursuant to rules adopted by the Department. The Department

22 shall review the enhanced rate as part of its process to rebase

23 in-home service provider reimbursement rates pursuant to

24 federal waiver requirements. Subject to federal approval,

25 beginning on January 1, 2024, rates for adult day services

26 shall be increased to $16.84 per hour and rates for each way

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1 transportation services for adult day services shall be

2 increased to $12.44 per unit transportation.

3 Subject to federal approval, on and after January 1, 2024,

4 rates for homemaker services shall be increased to $28.07 to

5 sustain a minimum wage of $17 per hour for direct service

6 workers. Rates in subsequent State fiscal years shall be no

7 lower than the rates put into effect upon federal approval.

8 Providers of in-home services shall be required to certify to

9 the Department that they remain in compliance with the

10 mandated wage increase for direct service workers. Fringe

11 benefits, including, but not limited to, paid time off and

12 payment for training, health insurance, travel, or

13 transportation, shall not be reduced in relation to the rate

14 increases described in this paragraph.

15 Subject to and upon federal approval, on and after January

16 1, 2025, rates for homemaker services shall be increased to

17 $29.63 to sustain a minimum wage of $18 per hour for direct

18 service workers. Rates in subsequent State fiscal years shall

19 be no lower than the rates put into effect upon federal

20 approval. Providers of in-home services shall be required to

21 certify to the Department that they remain in compliance with

22 the mandated wage increase for direct service workers. Fringe

23 benefits, including, but not limited to, paid time off and

24 payment for training, health insurance, travel, or

25 transportation, shall not be reduced in relation to the rate

26 increases described in this paragraph.

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1 Subject to and upon federal approval, on and after January

2 1, 2026, rates for homemaker services shall be increased to

3 $30.80 to sustain a minimum wage of $18.75 per hour for direct

4 service workers. Rates in subsequent State fiscal years shall

5 be no lower than the rates put into effect upon federal

6 approval. Providers of in-home services shall be required to

7 certify to the Department that they remain in compliance with

8 the mandated wage increase for direct service workers. Fringe

9 benefits, including, but not limited to, paid time off and

10 payment for training, health insurance, travel, or

11 transportation, shall not be reduced in relation to the rate

12 increases described in this paragraph.

13 The General Assembly finds it necessary to authorize an

14 aggressive Medicaid enrollment initiative designed to maximize

15 federal Medicaid funding for the Community Care Program which

16 produces significant savings for the State of Illinois. The

17 Department on Aging shall establish and implement a Community

18 Care Program Medicaid Initiative. Under the Initiative, the

19 Department on Aging shall, at a minimum: (i) provide an

20 enhanced rate to adequately compensate care coordination units

21 to enroll eligible Community Care Program clients into

22 Medicaid; (ii) use recommendations from a stakeholder

23 committee on how best to implement the Initiative; and (iii)

24 establish requirements for State agencies to make enrollment

25 in the State's Medical Assistance program easier for seniors.

26 The Community Care Program Medicaid Enrollment Oversight

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1 Subcommittee is created as a subcommittee of the Older Adult

2 Services Advisory Committee established in Section 35 of the

3 Older Adult Services Act to make recommendations on how best

4 to increase the number of medical assistance recipients who

5 are enrolled in the Community Care Program. The Subcommittee

6 shall consist of all of the following persons who must be

7 appointed within 30 days after June 4, 2018 (the effective

8 date of Public Act 100-587):

9 (1) The Director of Aging, or his or her designee, who

10 shall serve as the chairperson of the Subcommittee.

11 (2) One representative of the Department of Healthcare

12 and Family Services, appointed by the Director of

13 Healthcare and Family Services.

14 (3) One representative of the Department of Human

15 Services, appointed by the Secretary of Human Services.

16 (4) One individual representing a care coordination

17 unit, appointed by the Director of Aging.

18 (5) One individual from a non-governmental statewide

19 organization that advocates for seniors, appointed by the

20 Director of Aging.

21 (6) One individual representing Area Agencies on

22 Aging, appointed by the Director of Aging.

23 (7) One individual from a statewide association

24 dedicated to Alzheimer's care, support, and research,

25 appointed by the Director of Aging.

26 (8) One individual from an organization that employs

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1 persons who provide services under the Community Care

2 Program, appointed by the Director of Aging.

3 (9) One member of a trade or labor union representing

4 persons who provide services under the Community Care

5 Program, appointed by the Director of Aging.

6 (10) One member of the Senate, who shall serve as

7 co-chairperson, appointed by the President of the Senate.

8 (11) One member of the Senate, who shall serve as

9 co-chairperson, appointed by the Minority Leader of the

10 Senate.

11 (12) One member of the House of Representatives, who

12 shall serve as co-chairperson, appointed by the Speaker of

13 the House of Representatives.

14 (13) One member of the House of Representatives, who

15 shall serve as co-chairperson, appointed by the Minority

16 Leader of the House of Representatives.

17 (14) One individual appointed by a labor organization

18 representing frontline employees at the Department of

19 Human Services.

20 The Subcommittee shall provide oversight to the Community

21 Care Program Medicaid Initiative and shall meet quarterly. At

22 each Subcommittee meeting the Department on Aging shall

23 provide the following data sets to the Subcommittee: (A) the

24 number of Illinois residents, categorized by planning and

25 service area, who are receiving services under the Community

26 Care Program and are enrolled in the State's Medical

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1 Assistance Program; (B) the number of Illinois residents,

2 categorized by planning and service area, who are receiving

3 services under the Community Care Program, but are not

4 enrolled in the State's Medical Assistance Program; and (C)

5 the number of Illinois residents, categorized by planning and

6 service area, who are receiving services under the Community

7 Care Program and are eligible for benefits under the State's

8 Medical Assistance Program, but are not enrolled in the

9 State's Medical Assistance Program. In addition to this data,

10 the Department on Aging shall provide the Subcommittee with

11 plans on how the Department on Aging will reduce the number of

12 Illinois residents who are not enrolled in the State's Medical

13 Assistance Program but who are eligible for medical assistance

14 benefits. The Department on Aging shall enroll in the State's

15 Medical Assistance Program those Illinois residents who

16 receive services under the Community Care Program and are

17 eligible for medical assistance benefits but are not enrolled

18 in the State's Medicaid Assistance Program. The data provided

19 to the Subcommittee shall be made available to the public via

20 the Department on Aging's website.

21 The Department on Aging, with the involvement of the

22 Subcommittee, shall collaborate with the Department of Human

23 Services and the Department of Healthcare and Family Services

24 on how best to achieve the responsibilities of the Community

25 Care Program Medicaid Initiative.

26 The Department on Aging, the Department of Human Services,

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1 and the Department of Healthcare and Family Services shall

2 coordinate and implement a streamlined process for seniors to

3 access benefits under the State's Medical Assistance Program.

4 The Subcommittee shall collaborate with the Department of

5 Human Services on the adoption of a uniform application

6 submission process. The Department of Human Services and any

7 other State agency involved with processing the medical

8 assistance application of any person enrolled in the Community

9 Care Program shall include the appropriate care coordination

10 unit in all communications related to the determination or

11 status of the application.

12 The Community Care Program Medicaid Initiative shall

13 provide targeted funding to care coordination units to help

14 seniors complete their applications for medical assistance

15 benefits. On and after July 1, 2019, care coordination units

16 shall receive no less than $200 per completed application,

17 which rate may be included in a bundled rate for initial intake

18 services when Medicaid application assistance is provided in

19 conjunction with the initial intake process for new program

20 participants.

21 The Community Care Program Medicaid Initiative shall cease

22 operation 5 years after June 4, 2018 (the effective date of

23 Public Act 100-587), after which the Subcommittee shall

24 dissolve.

25 Effective July 1, 2023 through June 30, 2026, subject to

26 federal approval, the Department on Aging shall reimburse Care

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1 Coordination Units at the following rates for case management

2 services: $252.40 for each initial assessment; $366.40 for

3 each initial assessment with translation; $229.68 for each

4 redetermination assessment; $313.68 for each redetermination

5 assessment with translation; $200.00 for each completed

6 application for medical assistance benefits; $132.26 for each

7 face-to-face, choices-for-care screening; $168.26 for each

8 face-to-face, choices-for-care screening with translation;

9 $124.56 for each 6-month, face-to-face visit; $132.00 for each

10 MCO participant eligibility determination; and $157.00 for

11 each MCO participant eligibility determination with

12 translation.

13 Effective July 1, 2026, subject to federal approval, the

14 Department on Aging shall reimburse Care Coordination Units at

15 the following rates for case management services: $252.40 for

16 each initial assessment; $366.40 for each initial assessment

17 with translation; $229.68 for each redetermination assessment;

18 $313.68 for each redetermination assessment with translation;

19 $200.00 for each completed application for medical assistance

20 benefits; $132.26 for each face-to-face, choices-for-care

21 screening; $168.26 for each face-to-face, choices-for-care

22 screening with translation; $124.56 for each 6-month,

23 face-to-face visit; $172 for each managed care participant

24 eligibility determination; $197.00 for each managed care

25 participant eligibility determination with translation; and

26 $90 for each administration of a participant transfer from

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1 non-managed care CCP to managed care CCP or from managed care

2 CCP to non-managed care CCP.

3 (Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section

4 45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.

5 1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;

6 103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.

7 1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)

8 ARTICLE 230.

9 Section 230-5. The Specialized Mental Health

10 Rehabilitation Act of 2013 is amended by changing Sections

11 5-107 and 5-113 and by adding Section 5-114 as follows:

12 (210 ILCS 49/5-107)

13 Sec. 5-107. Quality of life enhancement. Beginning on July

14 1, 2019, for improving the quality of life and the quality of

15 care, an additional payment shall be awarded to a facility for

16 their single occupancy rooms. This payment shall be in

17 addition to the rate for recovery and rehabilitation. The

18 additional rate for single room occupancy shall be no less

19 than $10 per day, per single room occupancy. The Department of

20 Healthcare and Family Services shall adjust payment to

21 Medicaid managed care entities to cover these costs. Beginning

22 July 1, 2022, for improving the quality of life and the quality

23 of care, a payment of no less than $5 per day, per single room

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1 occupancy shall be added to the existing $10 additional per

2 day, per single room occupancy rate for a total of at least $15

3 per day, per single room occupancy. For improving the quality

4 of life and the quality of care, on January 1, 2024, a payment

5 of no less than $10.50 per day, per single room occupancy shall

6 be added to the existing $15 additional per day, per single

7 room occupancy rate for a total of at least $25.50 per day, per

8 single room occupancy. For improving the quality of life and

9 the quality of care, beginning on January 1, 2025, a payment of

10 no less than $10 per day, per single room occupancy shall be

11 added to the existing $25.50 additional per day, per single

12 room occupancy rate for a total of at least $35.50 per day, per

13 single room occupancy. For improving the quality of life and

14 the quality of care, beginning on July 1, 2026, a payment of no

15 less than $8 per day, per single room occupancy shall be added

16 to the existing $35.50 additional per day, per single room

17 occupancy rate for a total of at least $43.50 per day, per

18 single room occupancy. Beginning July 1, 2022, for improving

19 the quality of life and the quality of care, an additional

20 payment shall be awarded to a facility for its dual-occupancy

21 rooms. This payment shall be in addition to the rate for

22 recovery and rehabilitation. The additional rate for

23 dual-occupancy rooms shall be no less than $10 per day, per

24 Medicaid-occupied bed, in each dual-occupancy room. Beginning

25 January 1, 2024, for improving the quality of life and the

26 quality of care, a payment of no less than $4.50 per day, per

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1 dual-occupancy room shall be added to the existing $10

2 additional per day, per dual-occupancy room rate for a total

3 of at least $14.50, per Medicaid-occupied bed, in each

4 dual-occupancy room. Beginning January 1, 2025, for improving

5 the quality of life and the quality of care, a payment of no

6 less than $8.75 per day, per dual-occupancy room shall be

7 added to the existing $14.50 additional per day, per

8 dual-occupancy room rate for a total of at least $23.25, per

9 Medicaid-occupied bed, in each dual-occupancy room. The

10 Department of Healthcare and Family Services shall adjust

11 payment to Medicaid managed care entities to cover these

12 costs. Beginning July 1, 2026, for improving the quality of

13 life and the quality of care, a payment of no less than $2.50

14 per day, per dual-occupancy room shall be added to the

15 existing $23.25 additional per day, per dual-occupancy room

16 rate for a total of at least $25.75, per Medicaid-occupied

17 bed, in each dual-occupancy room. The Department of Healthcare

18 and Family Services shall adjust payment to Medicaid managed

19 care entities to cover these costs. As used in this Section,

20 "dual-occupancy room" means a room that contains 2 resident

21 beds.

22 (Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24;

23 103-593, eff. 6-7-24.)

24 (210 ILCS 49/5-113)

25 Sec. 5-113. Specialized mental health rehabilitation

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1 facility; one payment. Notwithstanding any other provision of

2 this Act to the contrary, beginning January 1, 2025, there

3 shall be a separate per diem ~~add-on~~ paid solely and

4 exclusively to facilities licensed under this Act that are

5 licensed for only single occupancy rooms and have reduced

6 their licensed capacity. No facility licensed under this Act

7 shall be eligible for these payments if the facility contains

8 any rooms that house more than a single occupant and has ~~have~~

9 failed to reduce the facility's ~~facilities'~~ licensed capacity.

10 The payment shall be a per diem ~~add-on~~ payment. For

11 facilities with less than 100 licensed beds, the ~~add-on~~

12 payment shall result in a rate not less than $240 per day. For

13 facilities with 100 licensed beds to 130 licensed beds, the

14 ~~add-on~~ payment shall result in a rate not less than $230 per

15 day. For facilities with more than 130 licensed beds, the

16 ~~add-on~~ payment shall result in a rate of not less than $220 per

17 day. All ~~add-on~~ rates shall be based upon the new licensed

18 capacity.

19 ~~Any additional payments in effect after January 1, 2025~~

20 ~~under Section 5-107 shall be paid in addition to the amounts~~

21 ~~listed in this Section.~~ Facilities receiving payments under

22 this Section shall receive payment as prescribed under Section

23 5-101.

24 Beginning July 1, 2026, for facilities with less than 100

25 licensed beds, the payment shall result in a rate not less than

26 $247.50 per day. Beginning July 1, 2026, for facilities with

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1 100 licensed beds to 130 licensed beds, the payment shall

2 result in a rate not less than $237.50 per day. For facilities

3 with more than 130 beds, the payment shall result in a rate of

4 no less than $225 per day.

5 (Source: P.A. 103-593, eff. 6-7-24.)

6 (210 ILCS 49/5-114 new)

7 Sec. 5-114. Forensic add-on payment. Notwithstanding any

8 other provisions to the contrary, any facility that provides

9 services to a resident found not guilty by reason of insanity

10 and is thereby deemed unable to stand trial shall receive an

11 additional payment of $15 per bed, per day for any resident

12 found not guilty by reason of insanity and is thereby deemed

13 unable to stand trial.

14 ARTICLE 235.

15 Section 235-5. The Department of Human Services Act is

16 amended by adding Section 10-13 as follows:

17 (20 ILCS 1305/10-13 new)

18 Sec. 10-13. Pilot programs with local government entities,

19 nonprofits, or privately funded programs. The Department of

20 Human Services may, subject to appropriation, establish pilot

21 programs with local government entities, nonprofits, or

22 privately funded programs seeking to provide financial or

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1 other support to residents of Illinois through current or

2 future benefit distribution methods utilized by the Department

3 of Human Services.

4 ARTICLE 240.

5 Section 240-5. The Illinois Public Aid Code is amended by

6 adding Section 5-54 as follows:

7 (305 ILCS 5/5-54 new)

8 Sec. 5-54. Coverage for proteomic blood tests.

9 (a) The medical assistance program shall provide coverage

10 and reimbursement for a prescribed proteomic blood test, with

11 clinical trial proof of improved infant outcomes published in

12 peer-reviewed journals, that identifies and quantifies the

13 risk of preterm birth for an individual pregnancy.

14 (b) The medical assistance program shall provide coverage

15 and reimbursement for remote patient management services,

16 including telecare management and remote physiologic

17 monitoring, that address maternity and postpartum care access

18 challenges for individualized care delivery by licensed

19 providers. Only remote patient management services with

20 evidence of improved patient care shall be covered and

21 reimbursed under this subsection.

22 ARTICLE 245.

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1 Section 245-5. The Illinois Public Aid Code is amended by

2 adding Section 5-30.19 as follows:

3 (305 ILCS 5/5-30.19 new)

4 Sec. 5-30.19. MCO behavioral health post-payment reviews.

5 (a) In this Section:

6 "Extrapolated" shall be used as "extrapolation" is used in

7 89 Ill. Adm. Code 140.30(b) or any successor rule.

8 "Managed care organization" or "MCO" has the meaning given

9 to that term in Section 5-30.1 of this Code.

10 "Post-payment review" means an examination that occurs

11 after payment is made by an MCO for a selected claim to

12 determine whether the initial determination for payment was

13 appropriate.

14 "Provider" means a community mental health center,

15 behavioral health clinic, certified community behavioral

16 health clinic, or substance use treatment and recovery center

17 that is enrolled in the medical assistance program and

18 contracted with or reimbursed by an MCO.

19 (b) Beginning July 1, 2027, when conducting post-payment

20 reviews of providers, MCOs must establish guidelines that

21 follow the Department's guidance. The Department's guidance

22 shall mandate that MCOs:

23 (1) Clearly define the documentation and the response

24 time frames ensuring that all requests are directly tied

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1 to the review objectives. Documentation and response time

2 frames do not apply to methods necessary for fraud, waste,

3 and abuse post-payment reviews, including, but not limited

4 to, unscheduled or unannounced site visits and database

5 checks.

6 (2) Identify regulatory, statutory, or contractual

7 authority and standards for conducting the post-payment

8 review.

9 (3) Clearly define evaluation criteria and provide

10 documentation checklists.

11 (4) Establish a process to dispute MCO record requests

12 not made in conformance with this Section.

13 (5) Establish a process and clarify the instances that

14 allow for entry and exit communications with providers to

15 clearly convey the review scope, expectations, preliminary

16 findings, compliance status, and next steps, ensuring

17 consistent messaging throughout the review process.

18 (6) Establish qualifications of reviewers with

19 relevant knowledge, experience, and training.

20 (7) Provide the data on how the provider varies

21 significantly from other providers in the same provider

22 type, service specialty, jurisdiction, or locality, if the

23 basis for selection of a provider for review is

24 comparative data except where fraud, waste, and abuse

25 processes and procedures prevent disclosure.

26 (8) Clearly outline communication protocols, including

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1 advance written notice, delivered electronically, by MCOs

2 to providers of documentation requests with an allowance

3 for reasonable response times and except for instances

4 where fraud, waste, and abuse processes and procedures

5 prevent advance notice, including, but not limited to,

6 unscheduled or unannounced site visits.

7 (9) Upon completion of the review, issue a formal

8 written notice of compliance or closure to the provider.

9 The final review findings shall include clear references

10 to applicable regulatory or contractual citations, an

11 explanation of the rationale for each finding, guidance on

12 required next steps or corrective actions, and information

13 regarding the process and timelines for appealing the

14 findings.

15 (10) Use the least burdensome and lowest-cost method

16 of record submission, including secure electronic methods,

17 when available. The date on which documentation is

18 received in the electronic communication shall be the

19 official date of receipt. All communication protocols

20 shall be compliant with privacy and security laws.

21 (11) Issue findings and related written communications

22 in a clear, consistent, and non-contradictory manner to

23 prevent confusion or conflicting conclusions.

24 (12) Disclose the methodology supporting any

25 extrapolated finding.

26 (c) The MCO shall post the guidelines and any updates on

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1 its publicly available website.

2 (d) Providers must not be subject to any adverse action,

3 payment delay, sanctions, or contract termination solely for

4 exercising the right to dispute a records request in

5 accordance with this Section, except for matters involving

6 allegations of fraud, waste, or abuse.

7 (e) Nothing in this Section shall be construed to conflict

8 with State or federal program integrity law, regulations,

9 guidance, processes, or procedures.

10 ARTICLE 250.

11 Section 250-5. The Illinois Public Aid Code is amended by

12 adding Section 5-70 as follows:

13 (305 ILCS 5/5-70 new)

14 Sec. 5-70. Virtual intensive outpatient program services.

15 For dates of service on and after January 1, 2027, subject to

16 any necessary federal approval, the medical assistance program

17 shall provide coverage for virtual intensive outpatient

18 program services when clinically appropriate, delivered in

19 line with generally accepted standards of care, and only at

20 the request of or with the consent of the patient. The

21 Department shall establish provider qualifications for

22 intensive outpatient program services offering a virtual

23 service delivery option. The Department may establish

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1 utilization controls and any appropriate guidelines for

2 coverage of the virtual intensive outpatient program to

3 protect the well-being of persons eligible and enrolled in the

4 medical assistance program. The Department may adopt rules

5 necessary to implement this Section.

6 ARTICLE 255.

7 Section 255-5. The Illinois Public Aid Code is amended by

8 changing Section 5-5.01a as follows:

9 (305 ILCS 5/5-5.01a)

10 Sec. 5-5.01a. Supportive living facilities program.

11 (a) The Department shall establish and provide oversight

12 for a program of supportive living facilities that seek to

13 promote resident independence, dignity, respect, and

14 well-being in the most cost-effective manner.

15 A supportive living facility is (i) a free-standing

16 facility or (ii) a distinct physical and operational entity

17 within a mixed-use building that meets the criteria

18 established in subsection (d). A supportive living facility

19 integrates housing with health, personal care, and supportive

20 services and is a designated setting that offers residents

21 their own separate, private, and distinct living units.

22 Sites for the operation of the program shall be selected

23 by the Department based upon criteria that may include the

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1 need for services in a geographic area, the availability of

2 funding, and the site's ability to meet the standards.

3 (b) Beginning July 1, 2014, subject to federal approval,

4 the Medicaid rates for supportive living facilities shall be

5 equal to the supportive living facility Medicaid rate

6 effective on June 30, 2014 increased by 8.85%. Once the

7 assessment imposed at Article V-G of this Code is determined

8 to be a permissible tax under Title XIX of the Social Security

9 Act, the Department shall increase the Medicaid rates for

10 supportive living facilities effective on July 1, 2014 by

11 9.09%. The Department shall apply this increase retroactively

12 to coincide with the imposition of the assessment in Article

13 V-G of this Code in accordance with the approval for federal

14 financial participation by the Centers for Medicare and

15 Medicaid Services.

16 The Medicaid rates for supportive living facilities

17 effective on July 1, 2017 must be equal to the rates in effect

18 for supportive living facilities on June 30, 2017 increased by

19 2.8%.

20 The Medicaid rates for supportive living facilities

21 effective on July 1, 2018 must be equal to the rates in effect

22 for supportive living facilities on June 30, 2018.

23 Subject to federal approval, the Medicaid rates for

24 supportive living services on and after July 1, 2019 must be at

25 least 54.3% of the average total nursing facility services per

26 diem for the geographic areas defined by the Department while

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1 maintaining the rate differential for dementia care and must

2 be updated whenever the total nursing facility service per

3 diems are updated. Beginning July 1, 2022, upon the

4 implementation of the Patient Driven Payment Model, Medicaid

5 rates for supportive living services must be at least 54.3% of

6 the average total nursing services per diem rate for the

7 geographic areas. For purposes of this provision, the average

8 total nursing services per diem rate shall include all add-ons

9 for nursing facilities for the geographic area provided for in

10 Section 5-5.2. The rate differential for dementia care must be

11 maintained in these rates and the rates shall be updated

12 whenever nursing facility per diem rates are updated.

13 Subject to federal approval, beginning January 1, 2024,

14 the dementia care rate for supportive living services must be

15 no less than the non-dementia care supportive living services

16 rate multiplied by 1.5.

17 (b-5) Subject to federal approval, beginning January 1,

18 2025, Medicaid rates for supportive living services must be at

19 least 54.75% of the average total nursing facility per diem

20 rate for the geographic areas defined by the Department and

21 shall include all add-ons for nursing facilities for the

22 geographic area provided for in Section 5-5.2.

23 (c) The Department may adopt rules to implement this

24 Section. Rules that establish or modify the services,

25 standards, and conditions for participation in the program

26 shall be adopted by the Department in consultation with the

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1 Department on Aging, the Department of Rehabilitation

2 Services, and the Department of Mental Health and

3 Developmental Disabilities (or their successor agencies).

4 (d) Subject to federal approval by the Centers for

5 Medicare and Medicaid Services, the Department shall accept

6 for consideration of certification under the program any

7 application for a site or building where distinct parts of the

8 site or building are designated for purposes other than the

9 provision of supportive living services, but only if:

10 (1) those distinct parts of the site or building are

11 not designated for the purpose of providing assisted

12 living services as required under the Assisted Living and

13 Shared Housing Act;

14 (2) those distinct parts of the site or building are

15 completely separate from the part of the building used for

16 the provision of supportive living program services,

17 including separate entrances;

18 (3) those distinct parts of the site or building do

19 not share any common spaces with the part of the building

20 used for the provision of supportive living program

21 services; and

22 (4) those distinct parts of the site or building do

23 not share staffing with the part of the building used for

24 the provision of supportive living program services.

25 (e) Facilities or distinct parts of facilities which are

26 selected as supportive living facilities and are in good

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1 standing with the Department's rules are exempt from the

2 provisions of the Nursing Home Care Act and the Illinois

3 Health Facilities Planning Act.

4 (f) Section 9817 of the American Rescue Plan Act of 2021

5 (Public Law 117-2) authorizes a 10% enhanced federal medical

6 assistance percentage for supportive living services for a

7 12-month period from April 1, 2021 through March 31, 2022.

8 Subject to federal approval, including the approval of any

9 necessary waiver amendments or other federally required

10 documents or assurances, for a 12-month period the Department

11 must pay a supplemental $26 per diem rate to all supportive

12 living facilities with the additional federal financial

13 participation funds that result from the enhanced federal

14 medical assistance percentage from April 1, 2021 through March

15 31, 2022. The Department may issue parameters around how the

16 supplemental payment should be spent, including quality

17 improvement activities. The Department may alter the form,

18 methods, or timeframes concerning the supplemental per diem

19 rate to comply with any subsequent changes to federal law,

20 changes made by guidance issued by the federal Centers for

21 Medicare and Medicaid Services, or other changes necessary to

22 receive the enhanced federal medical assistance percentage.

23 (g) All applications for the expansion of supportive

24 living dementia care settings involving sites not approved by

25 the Department by January 1, 2024 may allow new elderly

26 non-dementia units in addition to new dementia care units. The

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1 Department may approve such applications only if the

2 application has: (1) no more than one non-dementia care unit

3 for each dementia care unit and (2) the site is not located

4 within 4 miles of an existing supportive living program site

5 in Cook County (including the City of Chicago), not located

6 within 12 miles of an existing supportive living program site

7 in Alexander, Bond, Boone, Calhoun, Champaign, Clinton,

8 DeKalb, DuPage, Fulton, Grundy, Henry, Jackson, Jersey,

9 Johnson, Kane, Kankakee, Kendall, Lake, Macon, Macoupin,

10 Madison, Marshall, McHenry, McLean, Menard, Mercer, Monroe,

11 Peoria, Piatt, Rock Island, Sangamon, Stark, St. Clair,

12 Tazewell, Vermilion, Will, Williamson, Winnebago, or Woodford

13 counties, or not located within 25 miles of an existing

14 supportive living program site in any other county.

15 (g-5) Subject to federal approval, beginning January 1,

16 2027, any individual age 44 to 64 who is diagnosed as having

17 Alzheimer's disease or a related dementia and is determined to

18 be a person with a disability by the Social Security

19 Administration shall be eligible for services in a supportive

20 living dementia care setting if the individual meets all other

21 eligibility requirements to receive services in a supportive

22 living dementia care setting under 89 Ill. Adm. Code 146

23 Subpart B and E. The Department shall apply for any federal

24 waiver necessary to implement this subsection.

25 (h) Beginning January 1, 2025, subject to federal

26 approval, for a person who is a resident of a supportive living

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1 facility under this Section, the monthly personal needs

2 allowance shall be $120 per month.

3 (i) As stated in the supportive living program home and

4 community-based service waiver approved by the federal Centers

5 for Medicare and Medicaid Services, and beginning July 1,

6 2025, the Department must maintain the rate add-on implemented

7 on January 1, 2023 for the provision of 2 meals per day at no

8 less than $6.15 per day.

9 (j) Subject to federal approval, the Department shall

10 allow a certified medication aide to administer medication in

11 a supportive living facility. For purposes of this subsection,

12 "certified medication aide" means a person who has met the

13 qualifications for certification under Section 79 of the

14 Assisted Living and Shared Housing Act and assists with

15 medication administration while under the supervision of a

16 registered professional nurse as authorized by Section 50-75

17 of the Nurse Practice Act. The Department may adopt rules to

18 implement this subsection.

19 (Source: P.A. 103-102, Article 20, Section 20-5, eff. 1-1-24;

20 103-102, Article 100, Section 100-5, eff. 1-1-24; 103-593,

21 Article 15, Section 15-5, eff. 6-7-24; 103-593, Article 100,

22 Section 100-5, eff. 6-7-24; 103-593, Article 165, Section

23 165-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-886, eff.

24 8-9-24; 104-9, eff. 6-16-25; 104-417, eff. 8-15-25; revised

25 9-12-25.)

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1 ARTICLE 257.

2 Section 257-3. The Department of Public Health Powers and

3 Duties Law is amended by adding Section 2310-716 as follows:

4 (20 ILCS 2310/2310-716 new)

5 Sec. 2310-716. Report on patient access and care. With a

6 health care landscape shifting dramatically from inpatient,

7 volume-drive care to more outpatient, community-faced care and

8 further exacerbated by HR1 changes that disinvests billions of

9 dollars from the health care system and increase uninsured

10 populations, the Department of Public Health, in partnership

11 with relevant State agencies and with the advice of

12 stakeholders and experts in the field, shall develop a

13 comprehensive report that identifies how the resources of the

14 State and other health care payers may be optimized to protect

15 communities' and patients' access and care and to improve

16 Illinois' population health outcomes.

17 The Department may engage a third-party experienced and

18 expert research entity to develop this report. The report

19 shall include analysis, findings, and recommendations to

20 reform and strengthen the health care system in Illinois. The

21 report will have emphasis on the needs and vulnerabilities

22 experienced by individuals living in communities with limited

23 access to critical health care services.

24 The report will include epidemiological analyses and

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1 recommendations on policy and resource strategies to protect

2 and improve population health outcomes and health care access

3 including but not limited to:

4 (1) Patient experience that includes social needs

5 integration, reduced administrative burden, and enhanced

6 digital tools.

7 (2) Care model transformation that emphasizes

8 continuous, community-based care built to address health

9 access gaps and needs.

10 (3) Workforce resilience and optimization that

11 highlights partnership and care-delivery opportunities

12 across institutions.

13 (4) System agility to absorb and recover from

14 unforeseen public health crises and other external

15 factors.

16 The Department shall have access to all the necessary data

17 from State agencies as well as health care facilities as

18 required to inform on these recommendations, within the bounds

19 of relevance to their mission. Health care facilities will

20 hereby be directed to provide the necessary data to the

21 Department.

22 The Department shall issue recommendations to the General

23 Assembly and the Governor no later than January 31, 2027,

24 including proposed statutory or administrative changes

25 necessary to strengthen health care access, quality, and

26 effectiveness.

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1 (20 ILCS 2310/2310-715 rep.)

2 Section 257-5. The Department of Public Health Powers and

3 Duties Law of the Civil Administrative Code of Illinois is

4 amended by repealing Section 2310-715.

5 Section 257-10. The Illinois Public Aid Code is amended by

6 changing Sections 5A-2, 5A-7, 5A-8, and 12-4.25 as follows:

7 (305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2)

8 Sec. 5A-2. Assessment.

9 (a)(1) Subject to Sections 5A-3 and 5A-10, for State

10 fiscal years 2009 through 2018, or as long as continued under

11 Section 5A-16, an annual assessment on inpatient services is

12 imposed on each hospital provider in an amount equal to

13 $218.38 multiplied by the difference of the hospital's

14 occupied bed days less the hospital's Medicare bed days,

15 provided, however, that the amount of $218.38 shall be

16 increased by a uniform percentage to generate an amount equal

17 to 75% of the State share of the payments authorized under

18 Section 5A-12.5, with such increase only taking effect upon

19 the date that a State share for such payments is required under

20 federal law. For the period of April through June 2015, the

21 amount of $218.38 used to calculate the assessment under this

22 paragraph shall, by emergency rule under subsection (s) of

23 Section 5-45 of the Illinois Administrative Procedure Act, be

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1 increased by a uniform percentage to generate $20,250,000 in

2 the aggregate for that period from all hospitals subject to

3 the annual assessment under this paragraph.

4 (2) In addition to any other assessments imposed under

5 this Article, effective July 1, 2016 and semi-annually

6 thereafter through June 2018, or as provided in Section 5A-16,

7 in addition to any federally required State share as

8 authorized under paragraph (1), the amount of $218.38 shall be

9 increased by a uniform percentage to generate an amount equal

10 to 75% of the ACA Assessment Adjustment, as defined in

11 subsection (b-6) of this Section.

12 For State fiscal years 2009 through 2018, or as provided

13 in Section 5A-16, a hospital's occupied bed days and Medicare

14 bed days shall be determined using the most recent data

15 available from each hospital's 2005 Medicare cost report as

16 contained in the Healthcare Cost Report Information System

17 file, for the quarter ending on December 31, 2006, without

18 regard to any subsequent adjustments or changes to such data.

19 If a hospital's 2005 Medicare cost report is not contained in

20 the Healthcare Cost Report Information System, then the

21 Illinois Department may obtain the hospital provider's

22 occupied bed days and Medicare bed days from any source

23 available, including, but not limited to, records maintained

24 by the hospital provider, which may be inspected at all times

25 during business hours of the day by the Illinois Department or

26 its duly authorized agents and employees.

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1 (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State

2 fiscal years 2019 and 2020, an annual assessment on inpatient

3 services is imposed on each hospital provider in an amount

4 equal to $197.19 multiplied by the difference of the

5 hospital's occupied bed days less the hospital's Medicare bed

6 days. For State fiscal years 2019 and 2020, a hospital's

7 occupied bed days and Medicare bed days shall be determined

8 using the most recent data available from each hospital's 2015

9 Medicare cost report as contained in the Healthcare Cost

10 Report Information System file, for the quarter ending on

11 March 31, 2017, without regard to any subsequent adjustments

12 or changes to such data. If a hospital's 2015 Medicare cost

13 report is not contained in the Healthcare Cost Report

14 Information System, then the Illinois Department may obtain

15 the hospital provider's occupied bed days and Medicare bed

16 days from any source available, including, but not limited to,

17 records maintained by the hospital provider, which may be

18 inspected at all times during business hours of the day by the

19 Illinois Department or its duly authorized agents and

20 employees. Notwithstanding any other provision in this

21 Article, for a hospital provider that did not have a 2015

22 Medicare cost report, but paid an assessment in State fiscal

23 year 2018 on the basis of hypothetical data, that assessment

24 amount shall be used for State fiscal years 2019 and 2020.

25 (4) Subject to Sections 5A-3 and 5A-10 and to subsection

26 (b-8), for the period of July 1, 2020 through December 31, 2020

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1 and calendar years 2021 through 2024, an annual assessment on

2 inpatient services is imposed on each hospital provider in an

3 amount equal to $221.50 multiplied by the difference of the

4 hospital's occupied bed days less the hospital's Medicare bed

5 days, provided however: for the period of July 1, 2020 through

6 December 31, 2020, (i) the assessment shall be equal to 50% of

7 the annual amount; and (ii) the amount of $221.50 shall be

8 retroactively adjusted by a uniform percentage to generate an

9 amount equal to 50% of the Assessment Adjustment, as defined

10 in subsection (b-7). For the period of July 1, 2020 through

11 December 31, 2020 and calendar years 2021 through 2024, a

12 hospital's occupied bed days and Medicare bed days shall be

13 determined using the most recent data available from each

14 hospital's 2015 Medicare cost report as contained in the

15 Healthcare Cost Report Information System file, for the

16 quarter ending on March 31, 2017, without regard to any

17 subsequent adjustments or changes to such data. If a

18 hospital's 2015 Medicare cost report is not contained in the

19 Healthcare Cost Report Information System, then the Illinois

20 Department may obtain the hospital provider's occupied bed

21 days and Medicare bed days from any source available,

22 including, but not limited to, records maintained by the

23 hospital provider, which may be inspected at all times during

24 business hours of the day by the Illinois Department or its

25 duly authorized agents and employees. Should the change in the

26 assessment methodology for fiscal years 2021 through December

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1 31, 2022 not be approved on or before June 30, 2020, the

2 assessment and payments under this Article in effect for

3 fiscal year 2020 shall remain in place until the new

4 assessment is approved. If the assessment methodology for July

5 1, 2020 through December 31, 2022, is approved on or after July

6 1, 2020, it shall be retroactive to July 1, 2020, subject to

7 federal approval and provided that the payments authorized

8 under Section 5A-12.7 have the same effective date as the new

9 assessment methodology. In giving retroactive effect to the

10 assessment approved after June 30, 2020, credit toward the new

11 assessment shall be given for any payments of the previous

12 assessment for periods after June 30, 2020. Notwithstanding

13 any other provision of this Article, for a hospital provider

14 that did not have a 2015 Medicare cost report, but paid an

15 assessment in State Fiscal Year 2020 on the basis of

16 hypothetical data, the data that was the basis for the 2020

17 assessment shall be used to calculate the assessment under

18 this paragraph until December 31, 2023. Beginning July 1, 2022

19 and through December 31, 2024, a safety-net hospital that had

20 a change of ownership in calendar year 2021, and whose

21 inpatient utilization had decreased by 90% from the prior year

22 and prior to the change of ownership, may be eligible to pay a

23 tax based on hypothetical data based on a determination of

24 financial distress by the Department. Subject to federal

25 approval, the Department may, by January 1, 2024, develop a

26 hypothetical tax for a specialty cancer hospital which had a

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1 structural change of ownership during calendar year 2022 from

2 a for-profit entity to a non-profit entity, and which has

3 experienced a decline of 60% or greater in inpatient days of

4 care as compared to the prior owners 2015 Medicare cost

5 report. This change of ownership may make the hospital

6 eligible for a hypothetical tax under the new hospital

7 provision of the assessment defined in this Section. This new

8 hypothetical tax may be applicable from January 1, 2024

9 through December 31, 2026.

10 (5) Subject to Sections 5A-3 and 5A-10, beginning January

11 1, 2025, an annual assessment on inpatient services is imposed

12 on each hospital provider in an amount equal to $362, or any

13 reduction thereof in accordance with this subsection,

14 multiplied by the difference of the hospital's occupied bed

15 days less the hospital's Medicare bed days; however, the rate

16 shall be $221.50 until the Department receives federal

17 approval and implements the reimbursement rates in subsection

18 (r) of Section 5A-12.7. The Department may bill for the

19 difference between the assessment rate of $362, or any

20 reduction thereof in accordance with this subsection, and

21 $221.50 no earlier than 17 calendar days after implementing

22 the reimbursement rates in subsection (r) of Section 5A-12.7.

23 (A) Upon receiving federal approval for the

24 reimbursement rates in subsection (r) of Section 5A-12.7,

25 the Department shall bill the hospital for the incremental

26 difference in total tax due resulting from the increase

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1 provided in this subsection for the number of months from

2 January 1, 2025 through the date of federal approval. The

3 amount shall be due and payable no later than December 31,

4 2025 and no earlier than 17 calendar days after

5 implementing the reimbursement rates in subsection (r) of

6 Section 5A-12.7. The Department shall bill hospitals in

7 the same proportional rate as the Department has

8 implemented the inpatient reimbursement rates in

9 subsection (r) of Section 5A-12.7.

10 (B) Beginning January 1, 2025, a hospital's occupied

11 bed days and Medicare bed days shall be determined using

12 the most recent data available from each hospital's 2015

13 Medicare cost report as contained in the Healthcare Cost

14 Report Information System file, for the quarter ending on

15 March 31, 2017, without regard to any subsequent

16 adjustments or changes to such data. If a hospital's 2015

17 Medicare cost report is not contained in the Healthcare

18 Cost Report Information System, then the Department may

19 obtain the hospital provider's occupied bed days and

20 Medicare bed days from any source available, including,

21 but not limited to, records maintained by the hospital

22 provider, which may be inspected at all times during

23 business hours of the day by the Department or its duly

24 authorized agents and employees. If the reimbursement

25 rates in subsection (r) of Section 5A-12.7 require

26 reduction to comply with federal spending limits, then the

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1 tax rate of $362 shall be reduced, in accordance with

2 subsection (s) of Section 5A-12.7, by the same percentage

3 reduction to payments required to comply with federal

4 spending limits.

5 (6) For calendar year 2026, and for each year thereafter

6 in which a tax is imposed under this Section, the Department

7 may seek to obtain a waiver from the federal Centers for

8 Medicare and Medicaid Services of the uniformity requirements

9 in place for the tax imposed under this Section, provided that

10 such waiver request does not risk the assessment imposed or

11 payments authorized under this Section from continuing. Such

12 uniformity requirements shall only be waived for

13 not-for-profit hospitals operating as a freestanding cancer

14 hospital that have contracted to provide services to members

15 served by at least 50% of the managed care organizations

16 contracted with the Department. Such tax rates imposed on a

17 hospital shall be no more than 50% and no less than 25% of the

18 tax imposed on all other hospitals in this State unless

19 different rates are necessary to meet federal statistical

20 tests necessary for continued federal financial participation.

21 Upon federal approval of such a waiver, other tax rates

22 imposed under this Article shall be adjusted to ensure budget

23 neutrality.

24 (b) (Blank).

25 (b-5)(1) Subject to Sections 5A-3 and 5A-10, for the

26 portion of State fiscal year 2012, beginning June 10, 2012

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1 through June 30, 2012, and for State fiscal years 2013 through

2 2018, or as provided in Section 5A-16, an annual assessment on

3 outpatient services is imposed on each hospital provider in an

4 amount equal to .008766 multiplied by the hospital's

5 outpatient gross revenue, provided, however, that the amount

6 of .008766 shall be increased by a uniform percentage to

7 generate an amount equal to 25% of the State share of the

8 payments authorized under Section 5A-12.5, with such increase

9 only taking effect upon the date that a State share for such

10 payments is required under federal law. For the period

11 beginning June 10, 2012 through June 30, 2012, the annual

12 assessment on outpatient services shall be prorated by

13 multiplying the assessment amount by a fraction, the numerator

14 of which is 21 days and the denominator of which is 365 days.

15 For the period of April through June 2015, the amount of

16 .008766 used to calculate the assessment under this paragraph

17 shall, by emergency rule under subsection (s) of Section 5-45

18 of the Illinois Administrative Procedure Act, be increased by

19 a uniform percentage to generate $6,750,000 in the aggregate

20 for that period from all hospitals subject to the annual

21 assessment under this paragraph.

22 (2) In addition to any other assessments imposed under

23 this Article, effective July 1, 2016 and semi-annually

24 thereafter through June 2018, in addition to any federally

25 required State share as authorized under paragraph (1), the

26 amount of .008766 shall be increased by a uniform percentage

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1 to generate an amount equal to 25% of the ACA Assessment

2 Adjustment, as defined in subsection (b-6) of this Section.

3 For the portion of State fiscal year 2012, beginning June

4 10, 2012 through June 30, 2012, and State fiscal years 2013

5 through 2018, or as provided in Section 5A-16, a hospital's

6 outpatient gross revenue shall be determined using the most

7 recent data available from each hospital's 2009 Medicare cost

8 report as contained in the Healthcare Cost Report Information

9 System file, for the quarter ending on June 30, 2011, without

10 regard to any subsequent adjustments or changes to such data.

11 If a hospital's 2009 Medicare cost report is not contained in

12 the Healthcare Cost Report Information System, then the

13 Department may obtain the hospital provider's outpatient gross

14 revenue from any source available, including, but not limited

15 to, records maintained by the hospital provider, which may be

16 inspected at all times during business hours of the day by the

17 Department or its duly authorized agents and employees.

18 (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State

19 fiscal years 2019 and 2020, an annual assessment on outpatient

20 services is imposed on each hospital provider in an amount

21 equal to .01358 multiplied by the hospital's outpatient gross

22 revenue. For State fiscal years 2019 and 2020, a hospital's

23 outpatient gross revenue shall be determined using the most

24 recent data available from each hospital's 2015 Medicare cost

25 report as contained in the Healthcare Cost Report Information

26 System file, for the quarter ending on March 31, 2017, without

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1 regard to any subsequent adjustments or changes to such data.

2 If a hospital's 2015 Medicare cost report is not contained in

3 the Healthcare Cost Report Information System, then the

4 Department may obtain the hospital provider's outpatient gross

5 revenue from any source available, including, but not limited

6 to, records maintained by the hospital provider, which may be

7 inspected at all times during business hours of the day by the

8 Department or its duly authorized agents and employees.

9 Notwithstanding any other provision in this Article, for a

10 hospital provider that did not have a 2015 Medicare cost

11 report, but paid an assessment in State fiscal year 2018 on the

12 basis of hypothetical data, that assessment amount shall be

13 used for State fiscal years 2019 and 2020.

14 (4) Subject to Sections 5A-3 and 5A-10 and to subsection

15 (b-8), for the period of July 1, 2020 through December 31, 2020

16 and calendar years 2021 through 2024, an annual assessment on

17 outpatient services is imposed on each hospital provider in an

18 amount equal to .01525 multiplied by the hospital's outpatient

19 gross revenue, provided however: (i) for the period of July 1,

20 2020 through December 31, 2020, the assessment shall be equal

21 to 50% of the annual amount; and (ii) the amount of .01525

22 shall be retroactively adjusted by a uniform percentage to

23 generate an amount equal to 50% of the Assessment Adjustment,

24 as defined in subsection (b-7). For the period of July 1, 2020

25 through December 31, 2020 and calendar years 2021 through

26 2024, a hospital's outpatient gross revenue shall be

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1 determined using the most recent data available from each

2 hospital's 2015 Medicare cost report as contained in the

3 Healthcare Cost Report Information System file, for the

4 quarter ending on March 31, 2017, without regard to any

5 subsequent adjustments or changes to such data. If a

6 hospital's 2015 Medicare cost report is not contained in the

7 Healthcare Cost Report Information System, then the Illinois

8 Department may obtain the hospital provider's outpatient

9 revenue data from any source available, including, but not

10 limited to, records maintained by the hospital provider, which

11 may be inspected at all times during business hours of the day

12 by the Illinois Department or its duly authorized agents and

13 employees. Should the change in the assessment methodology

14 above for fiscal years 2021 through calendar year 2022 not be

15 approved prior to July 1, 2020, the assessment and payments

16 under this Article in effect for fiscal year 2020 shall remain

17 in place until the new assessment is approved. If the change in

18 the assessment methodology above for July 1, 2020 through

19 December 31, 2022, is approved after June 30, 2020, it shall

20 have a retroactive effective date of July 1, 2020, subject to

21 federal approval and provided that the payments authorized

22 under Section 12A-7 have the same effective date as the new

23 assessment methodology. In giving retroactive effect to the

24 assessment approved after June 30, 2020, credit toward the new

25 assessment shall be given for any payments of the previous

26 assessment for periods after June 30, 2020. Notwithstanding

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1 any other provision of this Article, for a hospital provider

2 that did not have a 2015 Medicare cost report, but paid an

3 assessment in State Fiscal Year 2020 on the basis of

4 hypothetical data, the data that was the basis for the 2020

5 assessment shall be used to calculate the assessment under

6 this paragraph until December 31, 2023. Beginning July 1, 2022

7 and through December 31, 2024, a safety-net hospital that had

8 a change of ownership in calendar year 2021, and whose

9 inpatient utilization had decreased by 90% from the prior year

10 and prior to the change of ownership, may be eligible to pay a

11 tax based on hypothetical data based on a determination of

12 financial distress by the Department.

13 (5) Subject to Sections 5A-3 and 5A-10, beginning January

14 1, 2025, an annual assessment on outpatient services is

15 imposed on each hospital provider in an amount equal to

16 .03273, or any reduction thereof in accordance with this

17 subsection, multiplied by the hospital's outpatient gross

18 revenue; however the rate shall remain .01525, until the

19 Department receives federal approval and implements the

20 reimbursement rates of payment in subsection (r) of Section

21 5A-12.7. The Department may bill for the difference between

22 the assessment multiplier of .03273 and .01525 no earlier than

23 17 calendar days after the first payment based on the

24 reimbursement rates in subsection (r) of Section 5A-12.7.

25 (A) Upon receiving federal approval for the

26 reimbursement rates in subsection (r) of Section 5A-12.7,

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1 the Department shall bill the hospital for the incremental

2 difference in total tax due resulting from the increase

3 provided in this subsection for the number of months from

4 January 1, 2025 through the date of federal approval. The

5 amount shall be due and payable no later than December 31,

6 2025 and no earlier than 17 calendar days after

7 implementing the reimbursement rates in subsection (r) of

8 Section 5A-12.7. The Department shall bill hospitals in

9 the same proportional rate as the Department has

10 implemented the outpatient reimbursement rates in

11 subsection (r) of Section 5A-12.7.

12 (B) Beginning January 1, 2025, a hospital's outpatient

13 gross revenue shall be determined using the most recent

14 data available from each hospital's 2015 Medicare cost

15 report as contained in the Healthcare Cost Report

16 Information System file, for the quarter ending on March

17 31, 2017, without regard to any subsequent adjustments or

18 changes to such data. If a hospital's 2015 Medicare cost

19 report is not contained in the Healthcare Cost Report

20 Information System, then the Department may obtain the

21 hospital provider's outpatient revenue data from any

22 source available, including, but not limited to, records

23 maintained by the hospital provider, which may be

24 inspected at all times during business hours of the day by

25 the Department or its duly authorized agents and

26 employees. If the reimbursement rates in subsection (r) of

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1 Section 5A-12.7 require reduction to comply with federal

2 spending limits, then the tax rate of .03273 shall be

3 reduced, in accordance with subsection (s) of Section

4 5A-12.7, by the same percentage reduction to payments

5 required to comply with federal spending limits.

6 (6) For calendar year 2026, and for each year thereafter

7 in which a tax is imposed under this Section, the Department

8 may seek to obtain a waiver from the federal Centers for

9 Medicare and Medicaid Services of the uniformity requirements

10 in place for the tax imposed under this Section, provided that

11 such waiver request does not risk the assessment imposed or

12 payments authorized under this Section from continuing. Such

13 uniformity requirements shall only be waived for

14 not-for-profit hospitals operating as a freestanding cancer

15 hospital that have contracted to provide services to members

16 served by at least 50% of the managed care organizations

17 contracted with the Department. Such tax rates imposed on a

18 hospital shall be no more than 50% and no less than 25% of the

19 tax imposed on all other hospitals in this State unless

20 different rates are necessary to meet federal statistical

21 tests necessary for continued federal financial participation.

22 Upon federal approval of such a waiver, other tax rates

23 imposed under this Article shall be adjusted to ensure budget

24 neutrality.

25 (b-6)(1) As used in this Section, "ACA Assessment

26 Adjustment" means:

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1 (A) For the period of July 1, 2016 through December

2 31, 2016, the product of .19125 multiplied by the sum of

3 the fee-for-service payments to hospitals as authorized

4 under Section 5A-12.5 and the adjustments authorized under

5 subsection (t) of Section 5A-12.2 to managed care

6 organizations for hospital services due and payable in the

7 month of April 2016 multiplied by 6.

8 (B) For the period of January 1, 2017 through June 30,

9 2017, the product of .19125 multiplied by the sum of the

10 fee-for-service payments to hospitals as authorized under

11 Section 5A-12.5 and the adjustments authorized under

12 subsection (t) of Section 5A-12.2 to managed care

13 organizations for hospital services due and payable in the

14 month of October 2016 multiplied by 6, except that the

15 amount calculated under this subparagraph (B) shall be

16 adjusted, either positively or negatively, to account for

17 the difference between the actual payments issued under

18 Section 5A-12.5 for the period beginning July 1, 2016

19 through December 31, 2016 and the estimated payments due

20 and payable in the month of April 2016 multiplied by 6 as

21 described in subparagraph (A).

22 (C) For the period of July 1, 2017 through December

23 31, 2017, the product of .19125 multiplied by the sum of

24 the fee-for-service payments to hospitals as authorized

25 under Section 5A-12.5 and the adjustments authorized under

26 subsection (t) of Section 5A-12.2 to managed care

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1 organizations for hospital services due and payable in the

2 month of April 2017 multiplied by 6, except that the

3 amount calculated under this subparagraph (C) shall be

4 adjusted, either positively or negatively, to account for

5 the difference between the actual payments issued under

6 Section 5A-12.5 for the period beginning January 1, 2017

7 through June 30, 2017 and the estimated payments due and

8 payable in the month of October 2016 multiplied by 6 as

9 described in subparagraph (B).

10 (D) For the period of January 1, 2018 through June 30,

11 2018, the product of .19125 multiplied by the sum of the

12 fee-for-service payments to hospitals as authorized under

13 Section 5A-12.5 and the adjustments authorized under

14 subsection (t) of Section 5A-12.2 to managed care

15 organizations for hospital services due and payable in the

16 month of October 2017 multiplied by 6, except that:

17 (i) the amount calculated under this subparagraph

18 (D) shall be adjusted, either positively or

19 negatively, to account for the difference between the

20 actual payments issued under Section 5A-12.5 for the

21 period of July 1, 2017 through December 31, 2017 and

22 the estimated payments due and payable in the month of

23 April 2017 multiplied by 6 as described in

24 subparagraph (C); and

25 (ii) the amount calculated under this subparagraph

26 (D) shall be adjusted to include the product of .19125

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1 multiplied by the sum of the fee-for-service payments,

2 if any, estimated to be paid to hospitals under

3 subsection (b) of Section 5A-12.5.

4 (2) The Department shall complete and apply a final

5 reconciliation of the ACA Assessment Adjustment prior to June

6 30, 2018 to account for:

7 (A) any differences between the actual payments issued

8 or scheduled to be issued prior to June 30, 2018 as

9 authorized in Section 5A-12.5 for the period of January 1,

10 2018 through June 30, 2018 and the estimated payments due

11 and payable in the month of October 2017 multiplied by 6 as

12 described in subparagraph (D); and

13 (B) any difference between the estimated

14 fee-for-service payments under subsection (b) of Section

15 5A-12.5 and the amount of such payments that are actually

16 scheduled to be paid.

17 The Department shall notify hospitals of any additional

18 amounts owed or reduction credits to be applied to the June

19 2018 ACA Assessment Adjustment. This is to be considered the

20 final reconciliation for the ACA Assessment Adjustment.

21 (3) Notwithstanding any other provision of this Section,

22 if for any reason the scheduled payments under subsection (b)

23 of Section 5A-12.5 are not issued in full by the final day of

24 the period authorized under subsection (b) of Section 5A-12.5,

25 funds collected from each hospital pursuant to subparagraph

26 (D) of paragraph (1) and pursuant to paragraph (2),

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1 attributable to the scheduled payments authorized under

2 subsection (b) of Section 5A-12.5 that are not issued in full

3 by the final day of the period attributable to each payment

4 authorized under subsection (b) of Section 5A-12.5, shall be

5 refunded.

6 (4) The increases authorized under paragraph (2) of

7 subsection (a) and paragraph (2) of subsection (b-5) shall be

8 limited to the federally required State share of the total

9 payments authorized under Section 5A-12.5 if the sum of such

10 payments yields an annualized amount equal to or less than

11 $450,000,000, or if the adjustments authorized under

12 subsection (t) of Section 5A-12.2 are found not to be

13 actuarially sound; however, this limitation shall not apply to

14 the fee-for-service payments described in subsection (b) of

15 Section 5A-12.5.

16 (b-7)(1) As used in this Section, "Assessment Adjustment"

17 means:

18 (A) For the period of July 1, 2020 through December

19 31, 2020, the product of .3853 multiplied by the total of

20 the actual payments made under subsections (c) through (k)

21 of Section 5A-12.7 attributable to the period, less the

22 total of the assessment imposed under subsections (a) and

23 (b-5) of this Section for the period.

24 (B) For each calendar quarter beginning January 1,

25 2021 through December 31, 2022, the product of .3853

26 multiplied by the total of the actual payments made under

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1 subsections (c) through (k) of Section 5A-12.7

2 attributable to the period, less the total of the

3 assessment imposed under subsections (a) and (b-5) of this

4 Section for the period.

5 (C) Beginning on January 1, 2023, and each subsequent

6 July 1 and January 1, the product of .3853 multiplied by

7 the total of the actual payments made under subsections

8 (c) through (j) and subsection (r) of Section 5A-12.7

9 attributable to the 6-month period immediately preceding

10 the period to which the adjustment applies, less the total

11 of the assessment imposed under subsections (a) and (b-5)

12 of this Section for the 6-month period immediately

13 preceding the period to which the adjustment applies.

14 (D) For the 6-month tax adjustment period beginning

15 July 1, 2026, the Assessment Adjustment defined in

16 subparagraph (C) of this paragraph (1) shall be half of

17 the amount calculated under subparagraph (C) of this

18 paragraph (1).

19 (2) The Department shall calculate and notify each

20 hospital of the total Assessment Adjustment and any additional

21 assessment owed by the hospital or refund owed to the hospital

22 on either a semi-annual or annual basis. Such notice shall be

23 issued at least 30 days prior to any period in which the

24 assessment will be adjusted. Any additional assessment owed by

25 the hospital or refund owed to the hospital shall be uniformly

26 applied to the assessment owed by the hospital in monthly

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1 installments for the subsequent semi-annual period or calendar

2 year. If no assessment is owed in the subsequent year, any

3 amount owed by the hospital or refund due to the hospital,

4 shall be paid in a lump sum. If the calculation that is

5 computed under this Section could result in a decrease in the

6 Department's federal financial participation percentage for

7 payments authorized under Section 5A-12.7, then the Department

8 shall instead apply a uniform percentage reduction to the

9 payment rates outlined in subsection (r) of Section 5A-12.7

10 for all classes as defined in subsections (g) and (h) of

11 Section 5A-12.7 by an amount no more than necessary to

12 maximize federal reimbursement.

13 (3) The Department shall publish all details of the

14 Assessment Adjustment calculation performed each year on its

15 website within 30 days of completing the calculation, and also

16 submit the details of the Assessment Adjustment calculation as

17 part of the Department's annual report to the General

18 Assembly.

19 (b-8) Notwithstanding any other provision of this Article,

20 the Department shall reduce the assessments imposed on each

21 hospital under subsections (a) and (b-5) by the uniform

22 percentage necessary to reduce the total assessment imposed on

23 all hospitals by an aggregate amount of $240,000,000, with

24 such reduction being applied by June 30, 2022. The assessment

25 reduction required for each hospital under this subsection

26 shall be forever waived, forgiven, and released by the

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1 Department.

2 (c) (Blank).

3 (d) Notwithstanding any of the other provisions of this

4 Section, the Department is authorized to adopt rules to reduce

5 the rate of any annual assessment imposed under this Section,

6 as authorized by Section 5-46.2 of the Illinois Administrative

7 Procedure Act.

8 (e) Notwithstanding any other provision of this Section,

9 any plan providing for an assessment on a hospital provider as

10 a permissible tax under Title XIX of the federal Social

11 Security Act and Medicaid-eligible payments to hospital

12 providers from the revenues derived from that assessment shall

13 be reviewed by the Illinois Department of Healthcare and

14 Family Services, as the Single State Medicaid Agency required

15 by federal law, to determine whether those assessments and

16 hospital provider payments meet federal Medicaid standards. If

17 the Department determines that the elements of the plan may

18 meet federal Medicaid standards and a related State Medicaid

19 Plan Amendment is prepared in a manner and form suitable for

20 submission, that State Plan Amendment shall be submitted in a

21 timely manner for review by the Centers for Medicare and

22 Medicaid Services of the United States Department of Health

23 and Human Services and subject to approval by the Centers for

24 Medicare and Medicaid Services of the United States Department

25 of Health and Human Services. No such plan shall become

26 effective without approval by the Illinois General Assembly by

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1 the enactment into law of related legislation. Notwithstanding

2 any other provision of this Section, the Department is

3 authorized to adopt rules to reduce the rate of any annual

4 assessment imposed under this Section. Any such rules may be

5 adopted by the Department under Section 5-50 of the Illinois

6 Administrative Procedure Act.

7 (f) To provide for the expeditious and timely

8 implementation of the changes made to this Section by Public

9 Act 104-7 ~~this amendatory Act of the 104th General Assembly~~,

10 the Department may adopt emergency rules as authorized by

11 Section 5-45 of the Illinois Administrative Procedure Act. The

12 adoption of emergency rules is deemed to be necessary for the

13 public interest, safety, and welfare.

14 (Source: P.A. 103-102, eff. 1-1-24; 104-7, eff. 6-16-25;

15 104-9, eff. 6-16-25; revised 8-5-25.)

16 (305 ILCS 5/5A-7) (from Ch. 23, par. 5A-7)

17 Sec. 5A-7. Administration; enforcement provisions.

18 (a) The Illinois Department shall establish and maintain a

19 listing of all hospital providers appearing in the licensing

20 records of the Illinois Department of Public Health, which

21 shall show each provider's name and principal place of

22 business and the name and address of each hospital operated,

23 conducted, or maintained by the provider in this State. The

24 listing shall also include the monthly assessment amounts owed

25 for each hospital and any unpaid assessment liability greater

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1 than 90 days delinquent. The Illinois Department shall

2 administer and enforce this Article and collect the

3 assessments and penalty assessments imposed under this Article

4 using procedures employed in its administration of this Code

5 generally. The Illinois Department, its Director, and every

6 hospital provider subject to assessment under this Article

7 shall have the following powers, duties, and rights:

8 (1) The Illinois Department may initiate either

9 administrative or judicial proceedings, or both, to

10 enforce provisions of this Article. Administrative

11 enforcement proceedings initiated hereunder shall be

12 governed by the Illinois Department's administrative

13 rules. Judicial enforcement proceedings initiated

14 hereunder shall be governed by the rules of procedure

15 applicable in the courts of this State.

16 (2) (Blank).

17 (3) Any unpaid assessment under this Article shall

18 become a lien upon the assets of the hospital upon which it

19 was assessed. If any hospital provider, outside the usual

20 course of its business, sells or transfers the major part

21 of any one or more of (A) the real property and

22 improvements, (B) the machinery and equipment, or (C) the

23 furniture or fixtures, of any hospital that is subject to

24 the provisions of this Article, the seller or transferor

25 shall pay the Illinois Department the amount of any

26 assessment, assessment penalty, and interest (if any) due

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1 from it under this Article up to the date of the sale or

2 transfer. The Illinois Department may, in its discretion,

3 foreclose on such a lien, but shall do so in a manner that

4 is consistent with Section 5e of the Retailers' Occupation

5 Tax Act. If the seller or transferor fails to pay any

6 assessment, assessment penalty, and interest (if any) due,

7 the purchaser or transferee of such asset shall be liable

8 for the amount of the assessment, penalties, and interest

9 (if any) up to the amount of the reasonable value of the

10 property acquired by the purchaser or transferee. The

11 purchaser or transferee shall continue to be liable until

12 the purchaser or transferee pays the full amount of the

13 assessment, penalties, and interest (if any) up to the

14 amount of the reasonable value of the property acquired by

15 the purchaser or transferee or until the purchaser or

16 transferee receives from the Illinois Department a

17 certificate showing that such assessment, penalty, and

18 interest have been paid or a certificate from the Illinois

19 Department showing that no assessment, penalty, or

20 interest is due from the seller or transferor under this

21 Article.

22 (4) Payments under this Article are not subject to the

23 Illinois Prompt Payment Act. Credits or refunds shall not

24 bear interest.

25 (b) In addition to any other remedy provided for and

26 without sending a notice of assessment liability, the Illinois

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1 Department shall collect an unpaid assessment by withholding,

2 as payment of the assessment, reimbursements or other amounts

3 otherwise payable by the Illinois Department to the hospital

4 provider, including, but not limited to, payment amounts

5 otherwise payable from a managed care organization performing

6 duties under contract with the Illinois Department. To the

7 extent not prohibited by federal or State law, the Department

8 may collect an unpaid assessment by offsetting or recouping,

9 as payment of the assessment obligation, amounts otherwise

10 payable by any State agency to the hospital provider,

11 including, but not limited to, State grants and grant

12 appropriations.

13 (1) The requirements of this subsection may be waived

14 in instances when a disaster proclamation has been

15 declared by the Governor. In such circumstances, a

16 hospital must demonstrate temporary financial distress and

17 establish an agreement with the Illinois Department

18 specifying when repayment in full of all taxes owed will

19 occur.

20 (2) The requirements of this subsection may be waived

21 by the Illinois Department in instances when a hospital

22 has entered into and remains in compliance with a

23 repayment plan or a tax deferral plan. A repayment plan or

24 tax deferral plan must be entered into no later than 30

25 days after notice of an unpaid assessment payment.

26 Beginning July 1, 2026, the Illinois Department shall not

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1 enter into any new tax deferral plan with a hospital. A

2 hospital may enter into a repayment plan with the

3 Department that includes terms for repayment of the total

4 amount owed over 72 months or less, repaid in equal

5 payment increments. Payments shall begin within 30 days of

6 the signed agreement date. Hospitals with existing

7 repayment agreements that were negotiated and remain in

8 effect prior to June 1, 2026 may either adhere to the terms

9 of their existing agreements or, alternatively, seek to

10 amend the existing agreement's repayment period to 72

11 months or less from the date the new agreement is entered

12 into. Renegotiated repayment plans shall include equal

13 payment increments for the total amount owed over the

14 period of the renegotiated agreement. Such renegotiated

15 repayment agreements may only include amendments to (a)

16 the length of the repayment period and (b) the payment

17 increments, provided that the total amount to be repaid

18 does not change from what remained unpaid under the

19 original repayment agreement and any additional amounts

20 owed. An existing repayment or tax deferral agreement

21 cannot be amended more than once unless otherwise agreed

22 upon by the Department. ~~No repayment plan may exceed a~~

23 ~~period of 36 months. No tax deferral plan may exceed a~~

24 ~~period of 6 months, and repayment after the end of a tax~~

25 ~~deferral plan shall not exceed 36 months.~~ Failure to

26 remain in compliance with a repayment plan or tax deferral

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1 plan shall cause immediate termination of such plan unless

2 there is prior written consent from the Illinois

3 Department for a period of non-compliance.

4 (3) Beginning September 1, 2025, the Illinois

5 Department shall immediately collect all overdue unpaid

6 assessments and penalties through the collection methods

7 authorized under this Section, unless a repayment plan or

8 tax deferral plan has already been agreed to ~~by September~~

9 ~~1, 2025~~.

10 (4) For any unpaid assessments and penalties that are

11 overdue as of the effective date of this amendatory Act of

12 the 104th General Assembly ~~of House Bill 2771 of the 104th~~

13 ~~General Assembly~~, upon receipt of payment the Department

14 may, at its discretion, transfer funds from the Hospital

15 Provider Fund to the Healthcare Provider Relief Fund,

16 provided that, at the time of each transfer, there are no

17 outstanding assessment-related payments owed to hospitals

18 that cannot be paid from resources remaining in the

19 Hospital Provider Fund after the transfer.

20 (c) To provide for the expeditious and timely

21 implementation of the changes made to this Section by this

22 amendatory Act of the 104th General Assembly, the Department

23 may adopt emergency rules as authorized by Section 5-45 of the

24 Illinois Administrative Procedure Act. The adoption of

25 emergency rules is deemed to be necessary for the public

26 interest, safety, and welfare.

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1 (Source: P.A. 104-2, eff. 6-16-25; 104-7, eff. 6-16-25.)

2 (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)

3 Sec. 12-4.25. Medical assistance program; vendor

4 participation.

5 (A) The Illinois Department may deny, suspend, or

6 terminate the eligibility of any person, firm, corporation,

7 association, agency, institution or other legal entity to

8 participate as a vendor of goods or services to recipients

9 under the medical assistance program under Article V, or may

10 exclude any such person or entity from participation as such a

11 vendor, and may deny, suspend, or recover payments, if after

12 reasonable notice and opportunity for a hearing the Illinois

13 Department finds:

14 (a) Such vendor is not complying with the Department's

15 policy or rules and regulations, or with the terms and

16 conditions prescribed by the Illinois Department in its

17 vendor agreement, which document shall be developed by the

18 Department as a result of negotiations with each vendor

19 category, including physicians, hospitals, long term care

20 facilities, pharmacists, optometrists, podiatric

21 physicians, and dentists setting forth the terms and

22 conditions applicable to the participation of each vendor

23 group in the program; or

24 (b) Such vendor has failed to keep or make available

25 for inspection, audit or copying, after receiving a

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1 written request from the Illinois Department, such records

2 regarding payments claimed for providing services. This

3 section does not require vendors to make available patient

4 records of patients for whom services are not reimbursed

5 under this Code; or

6 (c) Such vendor has failed to furnish any information

7 requested by the Department regarding payments for

8 providing goods or services; or

9 (d) Such vendor has knowingly made, or caused to be

10 made, any false statement or representation of a material

11 fact in connection with the administration of the medical

12 assistance program; or

13 (e) Such vendor has furnished goods or services to a

14 recipient which are (1) in excess of need, (2) harmful, or

15 (3) of grossly inferior quality, all of such

16 determinations to be based upon competent medical judgment

17 and evaluations; or

18 (f) The vendor; a person with management

19 responsibility for a vendor; an officer or person owning,

20 either directly or indirectly, 5% or more of the shares of

21 stock or other evidences of ownership in a corporate

22 vendor; an owner of a sole proprietorship which is a

23 vendor; or a partner in a partnership which is a vendor,

24 either:

25 (1) was previously terminated, suspended, or

26 excluded from participation in the Illinois medical

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1 assistance program, or was terminated, suspended, or

2 excluded from participation in another state or

3 federal medical assistance or health care program; or

4 (2) was a person with management responsibility

5 for a vendor previously terminated, suspended, or

6 excluded from participation in the Illinois medical

7 assistance program, or terminated, suspended, or

8 excluded from participation in another state or

9 federal medical assistance or health care program

10 during the time of conduct which was the basis for that

11 vendor's termination, suspension, or exclusion; or

12 (3) was an officer, or person owning, either

13 directly or indirectly, 5% or more of the shares of

14 stock or other evidences of ownership in a corporate

15 or limited liability company vendor previously

16 terminated, suspended, or excluded from participation

17 in the Illinois medical assistance program, or

18 terminated, suspended, or excluded from participation

19 in a state or federal medical assistance or health

20 care program during the time of conduct which was the

21 basis for that vendor's termination, suspension, or

22 exclusion; or

23 (4) was an owner of a sole proprietorship or

24 partner of a partnership previously terminated,

25 suspended, or excluded from participation in the

26 Illinois medical assistance program, or terminated,

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1 suspended, or excluded from participation in a state

2 or federal medical assistance or health care program

3 during the time of conduct which was the basis for that

4 vendor's termination, suspension, or exclusion; or

5 (f-1) Such vendor has a delinquent debt owed to the

6 Illinois Department; or

7 (g) The vendor; a person with management

8 responsibility for a vendor; an officer or person owning,

9 either directly or indirectly, 5% or more of the shares of

10 stock or other evidences of ownership in a corporate or

11 limited liability company vendor; an owner of a sole

12 proprietorship which is a vendor; or a partner in a

13 partnership which is a vendor, either:

14 (1) has engaged in practices prohibited by

15 applicable federal or State law or regulation; or

16 (2) was a person with management responsibility

17 for a vendor at the time that such vendor engaged in

18 practices prohibited by applicable federal or State

19 law or regulation; or

20 (3) was an officer, or person owning, either

21 directly or indirectly, 5% or more of the shares of

22 stock or other evidences of ownership in a vendor at

23 the time such vendor engaged in practices prohibited

24 by applicable federal or State law or regulation; or

25 (4) was an owner of a sole proprietorship or

26 partner of a partnership which was a vendor at the time

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1 such vendor engaged in practices prohibited by

2 applicable federal or State law or regulation; or

3 (h) The direct or indirect ownership of the vendor

4 (including the ownership of a vendor that is a sole

5 proprietorship, a partner's interest in a vendor that is a

6 partnership, or ownership of 5% or more of the shares of

7 stock or other evidences of ownership in a corporate

8 vendor) has been transferred by an individual who is

9 terminated, suspended, or excluded or barred from

10 participating as a vendor to the individual's spouse,

11 child, brother, sister, parent, grandparent, grandchild,

12 uncle, aunt, niece, nephew, cousin, or relative by

13 marriage.

14 (A-5) The Illinois Department may deny, suspend, or

15 terminate the eligibility of any person, firm, corporation,

16 association, agency, institution, or other legal entity to

17 participate as a vendor of goods or services to recipients

18 under the medical assistance program under Article V, or may

19 exclude any such person or entity from participation as such a

20 vendor, if, after reasonable notice and opportunity for a

21 hearing, the Illinois Department finds that the vendor; a

22 person with management responsibility for a vendor; an officer

23 or person owning, either directly or indirectly, 5% or more of

24 the shares of stock or other evidences of ownership in a

25 corporate vendor; an owner of a sole proprietorship that is a

26 vendor; or a partner in a partnership that is a vendor has been

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1 convicted of an offense based on fraud or willful

2 misrepresentation related to any of the following:

3 (1) The medical assistance program under Article V of

4 this Code.

5 (2) A medical assistance or health care program in

6 another state.

7 (3) The Medicare program under Title XVIII of the

8 Social Security Act.

9 (4) The provision of health care services.

10 (5) A violation of this Code, as provided in Article

11 VIIIA, or another state or federal medical assistance

12 program or health care program.

13 (A-10) The Illinois Department may deny, suspend, or

14 terminate the eligibility of any person, firm, corporation,

15 association, agency, institution, or other legal entity to

16 participate as a vendor of goods or services to recipients

17 under the medical assistance program under Article V, or may

18 exclude any such person or entity from participation as such a

19 vendor, if, after reasonable notice and opportunity for a

20 hearing, the Illinois Department finds that (i) the vendor,

21 (ii) a person with management responsibility for a vendor,

22 (iii) an officer or person owning, either directly or

23 indirectly, 5% or more of the shares of stock or other

24 evidences of ownership in a corporate vendor, (iv) an owner of

25 a sole proprietorship that is a vendor, or (v) a partner in a

26 partnership that is a vendor has been convicted of an offense

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1 related to any of the following:

2 (1) Murder.

3 (2) A Class X felony under the Criminal Code of 1961 or

4 the Criminal Code of 2012.

5 (3) Sexual misconduct that may subject recipients to

6 an undue risk of harm.

7 (4) A criminal offense that may subject recipients to

8 an undue risk of harm.

9 (5) A crime of fraud or dishonesty.

10 (6) A crime involving a controlled substance.

11 (7) A misdemeanor relating to fraud, theft,

12 embezzlement, breach of fiduciary responsibility, or other

13 financial misconduct related to a health care program.

14 (A-15) The Illinois Department may deny the eligibility of

15 any person, firm, corporation, association, agency,

16 institution, or other legal entity to participate as a vendor

17 of goods or services to recipients under the medical

18 assistance program under Article V if, after reasonable notice

19 and opportunity for a hearing, the Illinois Department finds:

20 (1) The applicant or any person with management

21 responsibility for the applicant; an officer or member of

22 the board of directors of an applicant; an entity owning

23 (directly or indirectly) 5% or more of the shares of stock

24 or other evidences of ownership in a corporate vendor

25 applicant; an owner of a sole proprietorship applicant; a

26 partner in a partnership applicant; or a technical or

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1 other advisor to an applicant has a debt owed to the

2 Illinois Department, and no payment arrangements

3 acceptable to the Illinois Department have been made by

4 the applicant.

5 (2) The applicant or any person with management

6 responsibility for the applicant; an officer or member of

7 the board of directors of an applicant; an entity owning

8 (directly or indirectly) 5% or more of the shares of stock

9 or other evidences of ownership in a corporate vendor

10 applicant; an owner of a sole proprietorship applicant; a

11 partner in a partnership vendor applicant; or a technical

12 or other advisor to an applicant was (i) a person with

13 management responsibility, (ii) an officer or member of

14 the board of directors of an applicant, (iii) an entity

15 owning (directly or indirectly) 5% or more of the shares

16 of stock or other evidences of ownership in a corporate

17 vendor, (iv) an owner of a sole proprietorship, (v) a

18 partner in a partnership vendor, (vi) a technical or other

19 advisor to a vendor, during a period of time where the

20 conduct of that vendor resulted in a debt owed to the

21 Illinois Department, and no payment arrangements

22 acceptable to the Illinois Department have been made by

23 that vendor.

24 (3) There is a credible allegation of the use,

25 transfer, or lease of assets of any kind to an applicant

26 from a current or prior vendor who has a debt owed to the

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1 Illinois Department, no payment arrangements acceptable to

2 the Illinois Department have been made by that vendor or

3 the vendor's alternate payee, and the applicant knows or

4 should have known of such debt.

5 (4) There is a credible allegation of a transfer of

6 management responsibilities, or direct or indirect

7 ownership, to an applicant from a current or prior vendor

8 who has a debt owed to the Illinois Department, and no

9 payment arrangements acceptable to the Illinois Department

10 have been made by that vendor or the vendor's alternate

11 payee, and the applicant knows or should have known of

12 such debt.

13 (5) There is a credible allegation of the use,

14 transfer, or lease of assets of any kind to an applicant

15 who is a spouse, child, brother, sister, parent,

16 grandparent, grandchild, uncle, aunt, niece, relative by

17 marriage, nephew, cousin, or relative of a current or

18 prior vendor who has a debt owed to the Illinois

19 Department and no payment arrangements acceptable to the

20 Illinois Department have been made.

21 (6) There is a credible allegation that the

22 applicant's previous affiliations with a provider of

23 medical services that has an uncollected debt, a provider

24 that has been or is subject to a payment suspension under a

25 federal health care program, or a provider that has been

26 previously excluded from participation in the medical

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1 assistance program, poses a risk of fraud, waste, or abuse

2 to the Illinois Department.

3 As used in this subsection, "credible allegation" is

4 defined to include an allegation from any source, including,

5 but not limited to, fraud hotline complaints, claims data

6 mining, patterns identified through provider audits, civil

7 actions filed under the Illinois False Claims Act, and law

8 enforcement investigations. An allegation is considered to be

9 credible when it has indicia of reliability.

10 (B) The Illinois Department shall deny, suspend or

11 terminate the eligibility of any person, firm, corporation,

12 association, agency, institution or other legal entity to

13 participate as a vendor of goods or services to recipients

14 under the medical assistance program under Article V, or may

15 exclude any such person or entity from participation as such a

16 vendor:

17 (1) immediately, if such vendor is not properly

18 licensed, certified, or authorized;

19 (2) within 30 days of the date when such vendor's

20 professional license, certification or other authorization

21 has been refused renewal, restricted, revoked, suspended,

22 or otherwise terminated; or

23 (3) if such vendor has been convicted of a violation

24 of this Code, as provided in Article VIIIA.

25 (C) Upon termination, suspension, or exclusion of a vendor

26 of goods or services from participation in the medical

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1 assistance program authorized by this Article, a person with

2 management responsibility for such vendor during the time of

3 any conduct which served as the basis for that vendor's

4 termination, suspension, or exclusion is barred from

5 participation in the medical assistance program.

6 Upon termination, suspension, or exclusion of a corporate

7 vendor, the officers and persons owning, directly or

8 indirectly, 5% or more of the shares of stock or other

9 evidences of ownership in the vendor during the time of any

10 conduct which served as the basis for that vendor's

11 termination, suspension, or exclusion are barred from

12 participation in the medical assistance program. A person who

13 owns, directly or indirectly, 5% or more of the shares of stock

14 or other evidences of ownership in a terminated, suspended, or

15 excluded vendor may not transfer his or her ownership interest

16 in that vendor to his or her spouse, child, brother, sister,

17 parent, grandparent, grandchild, uncle, aunt, niece, nephew,

18 cousin, or relative by marriage.

19 Upon termination, suspension, or exclusion of a sole

20 proprietorship or partnership, the owner or partners during

21 the time of any conduct which served as the basis for that

22 vendor's termination, suspension, or exclusion are barred from

23 participation in the medical assistance program. The owner of

24 a terminated, suspended, or excluded vendor that is a sole

25 proprietorship, and a partner in a terminated, suspended, or

26 excluded vendor that is a partnership, may not transfer his or

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1 her ownership or partnership interest in that vendor to his or

2 her spouse, child, brother, sister, parent, grandparent,

3 grandchild, uncle, aunt, niece, nephew, cousin, or relative by

4 marriage.

5 A person who owns, directly or indirectly, 5% or more of

6 the shares of stock or other evidences of ownership in a

7 corporate or limited liability company vendor who owes a debt

8 to the Department, if that vendor has not made payment

9 arrangements acceptable to the Department, shall not transfer

10 his or her ownership interest in that vendor, or vendor assets

11 of any kind, to his or her spouse, child, brother, sister,

12 parent, grandparent, grandchild, uncle, aunt, niece, nephew,

13 cousin, or relative by marriage.

14 Rules adopted by the Illinois Department to implement

15 these provisions shall specifically include a definition of

16 the term "management responsibility" as used in this Section.

17 Such definition shall include, but not be limited to, typical

18 job titles, and duties and descriptions which will be

19 considered as within the definition of individuals with

20 management responsibility for a provider.

21 A vendor or a prior vendor who has been terminated,

22 excluded, or suspended from the medical assistance program, or

23 from another state or federal medical assistance or health

24 care program, and any individual currently or previously

25 barred from the medical assistance program, or from another

26 state or federal medical assistance or health care program, as

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1 a result of being an officer or a person owning, directly or

2 indirectly, 5% or more of the shares of stock or other

3 evidences of ownership in a corporate or limited liability

4 company vendor during the time of any conduct which served as

5 the basis for that vendor's termination, suspension, or

6 exclusion, may be required to post a surety bond as part of a

7 condition of enrollment or participation in the medical

8 assistance program. The Illinois Department shall establish,

9 by rule, the criteria and requirements for determining when a

10 surety bond must be posted and the value of the bond.

11 A vendor or a prior vendor who has a debt owed to the

12 Illinois Department and any individual currently or previously

13 barred from the medical assistance program, or from another

14 state or federal medical assistance or health care program, as

15 a result of being an officer or a person owning, directly or

16 indirectly, 5% or more of the shares of stock or other

17 evidences of ownership in that corporate or limited liability

18 company vendor during the time of any conduct which served as

19 the basis for the debt, may be required to post a surety bond

20 as part of a condition of enrollment or participation in the

21 medical assistance program. The Illinois Department shall

22 establish, by rule, the criteria and requirements for

23 determining when a surety bond must be posted and the value of

24 the bond.

25 (D) If a vendor has been suspended from the medical

26 assistance program under Article V of the Code, the Director

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1 may require that such vendor correct any deficiencies which

2 served as the basis for the suspension. The Director shall

3 specify in the suspension order a specific period of time,

4 which shall not exceed one year from the date of the order,

5 during which a suspended vendor shall not be eligible to

6 participate. At the conclusion of the period of suspension the

7 Director shall reinstate such vendor, unless he finds that

8 such vendor has not corrected deficiencies upon which the

9 suspension was based.

10 If a vendor has been terminated, suspended, or excluded

11 from the medical assistance program under Article V, such

12 vendor shall be barred from participation for at least one

13 year, except that if a vendor has been terminated, suspended,

14 or excluded based on a conviction of a violation of Article

15 VIIIA or a conviction of a felony based on fraud or a willful

16 misrepresentation related to (i) the medical assistance

17 program under Article V, (ii) a federal or another state's

18 medical assistance or health care program, or (iii) the

19 provision of health care services, then the vendor shall be

20 barred from participation for 5 years or for the length of the

21 vendor's sentence for that conviction, whichever is longer. At

22 the end of one year a vendor who has been terminated,

23 suspended, or excluded may apply for reinstatement to the

24 program. Upon proper application to be reinstated such vendor

25 may be deemed eligible by the Director providing that such

26 vendor meets the requirements for eligibility under this Code.

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1 If such vendor is deemed not eligible for reinstatement, he

2 shall be barred from again applying for reinstatement for one

3 year from the date his application for reinstatement is

4 denied.

5 A vendor whose termination, suspension, or exclusion from

6 participation in the Illinois medical assistance program under

7 Article V was based solely on an action by a governmental

8 entity other than the Illinois Department may, upon

9 reinstatement by that governmental entity or upon reversal of

10 the termination, suspension, or exclusion, apply for

11 rescission of the termination, suspension, or exclusion from

12 participation in the Illinois medical assistance program. Upon

13 proper application for rescission, the vendor may be deemed

14 eligible by the Director if the vendor meets the requirements

15 for eligibility under this Code.

16 If a vendor has been terminated, suspended, or excluded

17 and reinstated to the medical assistance program under Article

18 V and the vendor is terminated, suspended, or excluded a

19 second or subsequent time from the medical assistance program,

20 the vendor shall be barred from participation for at least 2

21 years, except that if a vendor has been terminated, suspended,

22 or excluded a second time based on a conviction of a violation

23 of Article VIIIA or a conviction of a felony based on fraud or

24 a willful misrepresentation related to (i) the medical

25 assistance program under Article V, (ii) a federal or another

26 state's medical assistance or health care program, or (iii)

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1 the provision of health care services, then the vendor shall

2 be barred from participation for life. At the end of 2 years, a

3 vendor who has been terminated, suspended, or excluded may

4 apply for reinstatement to the program. Upon application to be

5 reinstated, the vendor may be deemed eligible if the vendor

6 meets the requirements for eligibility under this Code. If the

7 vendor is deemed not eligible for reinstatement, the vendor

8 shall be barred from again applying for reinstatement for 2

9 years from the date the vendor's application for reinstatement

10 is denied.

11 (E) The Illinois Department may recover money improperly

12 or erroneously paid, or overpayments, either by setoff,

13 crediting against future billings or by requiring direct

14 repayment to the Illinois Department. The Illinois Department

15 may suspend or deny payment, in whole or in part, if such

16 payment would be improper or erroneous or would otherwise

17 result in overpayment.

18 (1) Payments may be suspended, denied, or recovered

19 from a vendor or alternate payee: (i) for services

20 rendered in violation of the Illinois Department's

21 provider notices, statutes, rules, and regulations; (ii)

22 for services rendered in violation of the terms and

23 conditions prescribed by the Illinois Department in its

24 vendor agreement; (iii) for any vendor who fails to grant

25 the Office of Inspector General timely access to full and

26 complete records, including, but not limited to, records

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1 relating to recipients under the medical assistance

2 program for the most recent 6 years, in accordance with

3 Section 140.28 of Title 89 of the Illinois Administrative

4 Code, and other information for the purpose of audits,

5 investigations, or other program integrity functions,

6 after reasonable written request by the Inspector General;

7 this subsection (E) does not require vendors to make

8 available the medical records of patients for whom

9 services are not reimbursed under this Code or to provide

10 access to medical records more than 6 years old; (iv) when

11 the vendor has knowingly made, or caused to be made, any

12 false statement or representation of a material fact in

13 connection with the administration of the medical

14 assistance program; or (v) when the vendor previously

15 rendered services while terminated, suspended, or excluded

16 from participation in the medical assistance program or

17 while terminated or excluded from participation in another

18 state or federal medical assistance or health care

19 program.

20 (2) Notwithstanding any other provision of law, if a

21 vendor has the same taxpayer identification number

22 (assigned under Section 6109 of the Internal Revenue Code

23 of 1986) as is assigned to a vendor with past-due

24 financial obligations to the Illinois Department, the

25 Illinois Department may make any necessary adjustments to

26 payments to that vendor in order to satisfy any past-due

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1 obligations, regardless of whether the vendor is assigned

2 a different billing number under the medical assistance

3 program.

4 (E-5) Civil monetary penalties.

5 (1) As used in this subsection (E-5):

6 (a) "Knowingly" means that a person, with respect

7 to information: (i) has actual knowledge of the

8 information; (ii) acts in deliberate ignorance of the

9 truth or falsity of the information; or (iii) acts in

10 reckless disregard of the truth or falsity of the

11 information. No proof of specific intent to defraud is

12 required.

13 (b) "Overpayment" means any funds that a person

14 receives or retains from the medical assistance

15 program to which the person, after applicable

16 reconciliation, is not entitled under this Code.

17 (c) "Remuneration" means the offer or transfer of

18 items or services for free or for other than fair

19 market value by a person; however, remuneration does

20 not include items or services of a nominal value of no

21 more than $10 per item or service, or $50 in the

22 aggregate on an annual basis, or any other offer or

23 transfer of items or services as determined by the

24 Department.

25 (d) "Should know" means that a person, with

26 respect to information: (i) acts in deliberate

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1 ignorance of the truth or falsity of the information;

2 or (ii) acts in reckless disregard of the truth or

3 falsity of the information. No proof of specific

4 intent to defraud is required.

5 (2) Any person (including a vendor, provider,

6 organization, agency, or other entity, or an alternate

7 payee thereof, but excluding a recipient) who:

8 (a) knowingly presents or causes to be presented

9 to an officer, employee, or agent of the State, a claim

10 that the Department determines:

11 (i) is for a medical or other item or service

12 that the person knows or should know was not

13 provided as claimed, including any person who

14 engages in a pattern or practice of presenting or

15 causing to be presented a claim for an item or

16 service that is based on a code that the person

17 knows or should know will result in a greater

18 payment to the person than the code the person

19 knows or should know is applicable to the item or

20 service actually provided;

21 (ii) is for a medical or other item or service

22 and the person knows or should know that the claim

23 is false or fraudulent;

24 (iii) is presented for a vendor physician's

25 service, or an item or service incident to a

26 vendor physician's service, by a person who knows

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1 or should know that the individual who furnished,

2 or supervised the furnishing of, the service:

3 (AA) was not licensed as a physician;

4 (BB) was licensed as a physician but such

5 license had been obtained through a

6 misrepresentation of material fact (including

7 cheating on an examination required for

8 licensing); or

9 (CC) represented to the patient at the

10 time the service was furnished that the

11 physician was certified in a medical specialty

12 by a medical specialty board, when the

13 individual was not so certified;

14 (iv) is for a medical or other item or service

15 furnished during a period in which the person was

16 excluded from the medical assistance program or a

17 federal or state health care program under which

18 the claim was made pursuant to applicable law; or

19 (v) is for a pattern of medical or other items

20 or services that a person knows or should know are

21 not medically necessary;

22 (b) knowingly presents or causes to be presented

23 to any person a request for payment which is in

24 violation of the conditions for receipt of vendor

25 payments under the medical assistance program under

26 Section 11-13 of this Code;

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1 (c) knowingly gives or causes to be given to any

2 person, with respect to medical assistance program

3 coverage of inpatient hospital services, information

4 that he or she knows or should know is false or

5 misleading, and that could reasonably be expected to

6 influence the decision when to discharge such person

7 or other individual from the hospital;

8 (d) in the case of a person who is not an

9 organization, agency, or other entity, is excluded

10 from participating in the medical assistance program

11 or a federal or state health care program and who, at

12 the time of a violation of this subsection (E-5):

13 (i) retains a direct or indirect ownership or

14 control interest in an entity that is

15 participating in the medical assistance program or

16 a federal or state health care program, and who

17 knows or should know of the action constituting

18 the basis for the exclusion; or

19 (ii) is an officer or managing employee of

20 such an entity;

21 (e) offers or transfers remuneration to any

22 individual eligible for benefits under the medical

23 assistance program that such person knows or should

24 know is likely to influence such individual to order

25 or receive from a particular vendor, provider,

26 practitioner, or supplier any item or service for

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1 which payment may be made, in whole or in part, under

2 the medical assistance program;

3 (f) arranges or contracts (by employment or

4 otherwise) with an individual or entity that the

5 person knows or should know is excluded from

6 participation in the medical assistance program or a

7 federal or state health care program, for the

8 provision of items or services for which payment may

9 be made under such a program;

10 (g) commits an act described in subsection (b) or

11 (c) of Section 8A-3;

12 (h) knowingly makes, uses, or causes to be made or

13 used, a false record or statement material to a false

14 or fraudulent claim for payment for items and services

15 furnished under the medical assistance program;

16 (i) fails to grant timely access, upon reasonable

17 request (as defined by the Department by rule), to the

18 Inspector General, for the purpose of audits,

19 investigations, evaluations, or other statutory

20 functions of the Inspector General of the Department;

21 (j) orders or prescribes a medical or other item

22 or service during a period in which the person was

23 excluded from the medical assistance program or a

24 federal or state health care program, in the case

25 where the person knows or should know that a claim for

26 such medical or other item or service will be made

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1 under such a program;

2 (k) knowingly makes or causes to be made any false

3 statement, omission, or misrepresentation of a

4 material fact in any application, bid, or contract to

5 participate or enroll as a vendor or provider of

6 services or a supplier under the medical assistance

7 program;

8 (l) knows of an overpayment and does not report

9 and return the overpayment to the Department in

10 accordance with paragraph (6);

11 shall be subject, in addition to any other penalties that

12 may be prescribed by law, to a civil money penalty of not

13 more than $10,000 for each item or service (or, in cases

14 under subparagraph (c), $15,000 for each individual with

15 respect to whom false or misleading information was given;

16 in cases under subparagraph (d), $10,000 for each day the

17 prohibited relationship occurs; in cases under

18 subparagraph (g), $50,000 for each such act; in cases

19 under subparagraph (h), $50,000 for each false record or

20 statement; in cases under subparagraph (i), $15,000 for

21 each day of the failure described in such subparagraph; or

22 in cases under subparagraph (k), $50,000 for each false

23 statement, omission, or misrepresentation of a material

24 fact). In addition, such a person shall be subject to an

25 assessment of not more than 3 times the amount claimed for

26 each such item or service in lieu of damages sustained by

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1 the State because of such claim (or, in cases under

2 subparagraph (g), damages of not more than 3 times the

3 total amount of remuneration offered, paid, solicited, or

4 received, without regard to whether a portion of such

5 remuneration was offered, paid, solicited, or received for

6 a lawful purpose; or in cases under subparagraph (k), an

7 assessment of not more than 3 times the total amount

8 claimed for each item or service for which payment was

9 made based upon the application, bid, or contract

10 containing the false statement, omission, or

11 misrepresentation of a material fact).

12 (3) In addition, the Director or his or her designee

13 may make a determination in the same proceeding to

14 exclude, terminate, suspend, or bar the person from

15 participation in the medical assistance program.

16 (4) The Illinois Department may seek the civil

17 monetary penalties and exclusion, termination, suspension,

18 or barment identified in this subsection (E-5). Prior to

19 the imposition of any penalties or sanctions, the affected

20 person shall be afforded an opportunity for a hearing

21 after reasonable notice. The Department shall establish

22 hearing procedures by rule.

23 (5) Any final order, decision, or other determination

24 made, issued, or executed by the Director under the

25 provisions of this subsection (E-5), whereby a person is

26 aggrieved, shall be subject to review in accordance with

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1 the provisions of the Administrative Review Law, and the

2 rules adopted pursuant thereto, which shall apply to and

3 govern all proceedings for the judicial review of final

4 administrative decisions of the Director.

5 (6)(a) If a person has received an overpayment, the

6 person shall:

7 (i) report and return the overpayment to the

8 Department at the correct address; and

9 (ii) notify the Department in writing of the

10 reason for the overpayment.

11 (b) An overpayment must be reported and returned under

12 subparagraph (a) by the later of:

13 (i) the date which is 60 days after the date on

14 which the overpayment was identified; or

15 (ii) the date any corresponding cost report is

16 due, if applicable.

17 (E-10) A vendor who disputes an overpayment identified as

18 part of a Department audit shall utilize the Department's

19 self-referral disclosure protocol as set forth under this Code

20 to identify, investigate, and return to the Department any

21 undisputed audit overpayment amount. Unless the disputed

22 overpayment amount is subject to a fraud payment suspension,

23 or involves a termination sanction, the Department shall defer

24 the recovery of the disputed overpayment amount up to one year

25 after the date of the Department's final audit determination,

26 or earlier, or as required by State or federal law. If the

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1 administrative hearing extends beyond one year, and such delay

2 was not caused by the request of the vendor, then the

3 Department shall not recover the disputed overpayment amount

4 until the date of the final administrative decision. If a

5 final administrative decision establishes that the disputed

6 overpayment amount is owed to the Department, then the amount

7 shall be immediately due to the Department. The Department

8 shall be entitled to recover interest from the vendor on the

9 overpayment amount from the date of the overpayment through

10 the date the vendor returns the overpayment to the Department

11 at a rate not to exceed the Wall Street Journal Prime Rate, as

12 published from time to time, but not to exceed 5%. Any interest

13 billed by the Department shall be due immediately upon receipt

14 of the Department's billing statement.

15 (F) The Illinois Department may withhold payments to any

16 vendor or alternate payee prior to or during the pendency of

17 any audit or proceeding under this Section, and through the

18 pendency of any administrative appeal or administrative review

19 by any court proceeding. The Illinois Department shall state

20 by rule with as much specificity as practicable the conditions

21 under which payments will not be withheld under this Section.

22 Payments may be denied for bills submitted with service dates

23 occurring during the pendency of a proceeding, after a final

24 decision has been rendered, or after the conclusion of any

25 administrative appeal, where the final administrative decision

26 is to terminate, exclude, or suspend eligibility to

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1 participate in the medical assistance program. The Illinois

2 Department shall state by rule with as much specificity as

3 practicable the conditions under which payments will not be

4 denied for such bills. The Illinois Department shall state by

5 rule a process and criteria by which a vendor or alternate

6 payee may request full or partial release of payments withheld

7 under this subsection. The Department must complete a

8 proceeding under this Section in a timely manner.

9 Notwithstanding recovery allowed under subsection (E) or

10 this subsection (F), the Illinois Department may withhold

11 payments to any vendor or alternate payee who is not properly

12 licensed, certified, or in compliance with State or federal

13 agency regulations. Payments may be denied for bills submitted

14 with service dates occurring during the period of time that a

15 vendor is not properly licensed, certified, or in compliance

16 with State or federal regulations. Facilities licensed under

17 the Nursing Home Care Act shall have payments denied or

18 withheld pursuant to subsection (I) of this Section.

19 (F-5) The Illinois Department may temporarily withhold

20 payments to a vendor or alternate payee if any of the following

21 individuals have been indicted or otherwise charged under a

22 law of the United States or this or any other state with an

23 offense that is based on alleged fraud or willful

24 misrepresentation on the part of the individual related to (i)

25 the medical assistance program under Article V of this Code,

26 (ii) a federal or another state's medical assistance or health

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1 care program, or (iii) the provision of health care services:

2 (1) If the vendor or alternate payee is a corporation:

3 an officer of the corporation or an individual who owns,

4 either directly or indirectly, 5% or more of the shares of

5 stock or other evidence of ownership of the corporation.

6 (2) If the vendor is a sole proprietorship: the owner

7 of the sole proprietorship.

8 (3) If the vendor or alternate payee is a partnership:

9 a partner in the partnership.

10 (4) If the vendor or alternate payee is any other

11 business entity authorized by law to transact business in

12 this State: an officer of the entity or an individual who

13 owns, either directly or indirectly, 5% or more of the

14 evidences of ownership of the entity.

15 If the Illinois Department withholds payments to a vendor

16 or alternate payee under this subsection, the Department shall

17 not release those payments to the vendor or alternate payee

18 while any criminal proceeding related to the indictment or

19 charge is pending unless the Department determines that there

20 is good cause to release the payments before completion of the

21 proceeding. If the indictment or charge results in the

22 individual's conviction, the Illinois Department shall retain

23 all withheld payments, which shall be considered forfeited to

24 the Department. If the indictment or charge does not result in

25 the individual's conviction, the Illinois Department shall

26 release to the vendor or alternate payee all withheld

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1 payments.

2 (F-10) If the Illinois Department establishes that the

3 vendor or alternate payee owes a debt to the Illinois

4 Department, and the vendor or alternate payee subsequently

5 fails to pay or make satisfactory payment arrangements with

6 the Illinois Department for the debt owed, the Illinois

7 Department may seek all remedies available under the law of

8 this State to recover the debt, including, but not limited to,

9 wage garnishment or the filing of claims or liens against the

10 vendor or alternate payee.

11 (F-15) Enforcement of judgment.

12 (1) Any fine, recovery amount, other sanction, or

13 costs imposed, or part of any fine, recovery amount, other

14 sanction, or cost imposed, remaining unpaid after the

15 exhaustion of or the failure to exhaust judicial review

16 procedures under the Illinois Administrative Review Law is

17 a debt due and owing the State and may be collected using

18 all remedies available under the law.

19 (2) After expiration of the period in which judicial

20 review under the Illinois Administrative Review Law may be

21 sought for a final administrative decision, unless stayed

22 by a court of competent jurisdiction, the findings,

23 decision, and order of the Director may be enforced in the

24 same manner as a judgment entered by a court of competent

25 jurisdiction.

26 (3) In any case in which any person or entity has

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1 failed to comply with a judgment ordering or imposing any

2 fine or other sanction, any expenses incurred by the

3 Illinois Department to enforce the judgment, including,

4 but not limited to, attorney's fees, court costs, and

5 costs related to property demolition or foreclosure, after

6 they are fixed by a court of competent jurisdiction or the

7 Director, shall be a debt due and owing the State and may

8 be collected in accordance with applicable law. Prior to

9 any expenses being fixed by a final administrative

10 decision pursuant to this subsection (F-15), the Illinois

11 Department shall provide notice to the individual or

12 entity that states that the individual or entity shall

13 appear at a hearing before the administrative hearing

14 officer to determine whether the individual or entity has

15 failed to comply with the judgment. The notice shall set

16 the date for such a hearing, which shall not be less than 7

17 days from the date that notice is served. If notice is

18 served by mail, the 7-day period shall begin to run on the

19 date that the notice was deposited in the mail.

20 (4) Upon being recorded in the manner required by

21 Article XII of the Code of Civil Procedure or by the

22 Uniform Commercial Code, a lien shall be imposed on the

23 real estate or personal estate, or both, of the individual

24 or entity in the amount of any debt due and owing the State

25 under this Section. The lien may be enforced in the same

26 manner as a judgment of a court of competent jurisdiction.

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1 A lien shall attach to all property and assets of such

2 person, firm, corporation, association, agency,

3 institution, or other legal entity until the judgment is

4 satisfied.

5 (5) The Director may set aside any judgment entered by

6 default and set a new hearing date upon a petition filed at

7 any time (i) if the petitioner's failure to appear at the

8 hearing was for good cause, or (ii) if the petitioner

9 established that the Department did not provide proper

10 service of process. If any judgment is set aside pursuant

11 to this paragraph (5), the hearing officer shall have

12 authority to enter an order extinguishing any lien which

13 has been recorded for any debt due and owing the Illinois

14 Department as a result of the vacated default judgment.

15 (G) The provisions of the Administrative Review Law, as

16 now or hereafter amended, and the rules adopted pursuant

17 thereto, shall apply to and govern all proceedings for the

18 judicial review of final administrative decisions of the

19 Illinois Department under this Section. The term

20 "administrative decision" is defined as in Section 3-101 of

21 the Code of Civil Procedure.

22 (G-5) Vendors who pose a risk of fraud, waste, abuse, or

23 harm.

24 (1) Notwithstanding any other provision in this

25 Section, the Department may terminate, suspend, or exclude

26 vendors who pose a risk of fraud, waste, abuse, or harm

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1 from participation in the medical assistance program prior

2 to an evidentiary hearing but after reasonable notice and

3 opportunity to respond as established by the Department by

4 rule.

5 (2) Vendors who pose a risk of fraud, waste, abuse, or

6 harm shall submit to a fingerprint-based criminal

7 background check on current and future information

8 available in the State system and current information

9 available through the Federal Bureau of Investigation's

10 system by submitting all necessary fees and information in

11 the form and manner prescribed by the Illinois State

12 Police. The following individuals shall be subject to the

13 check:

14 (A) In the case of a vendor that is a corporation,

15 every shareholder who owns, directly or indirectly, 5%

16 or more of the outstanding shares of the corporation.

17 (B) In the case of a vendor that is a partnership,

18 every partner.

19 (C) In the case of a vendor that is a sole

20 proprietorship, the sole proprietor.

21 (D) Each officer or manager of the vendor.

22 Each such vendor shall be responsible for payment of

23 the cost of the criminal background check.

24 (3) Vendors who pose a risk of fraud, waste, abuse, or

25 harm may be required to post a surety bond. The Department

26 shall establish, by rule, the criteria and requirements

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1 for determining when a surety bond must be posted and the

2 value of the bond.

3 (4) The Department, or its agents, may refuse to

4 accept requests for authorization from specific vendors

5 who pose a risk of fraud, waste, abuse, or harm, including

6 prior-approval and post-approval requests, if:

7 (A) the Department has initiated a notice of

8 termination, suspension, or exclusion of the vendor

9 from participation in the medical assistance program;

10 or

11 (B) the Department has issued notification of its

12 withholding of payments pursuant to subsection (F-5)

13 of this Section; or

14 (C) the Department has issued a notification of

15 its withholding of payments due to reliable evidence

16 of fraud or willful misrepresentation pending

17 investigation.

18 (5) As used in this subsection, the following terms

19 are defined as follows:

20 (A) "Fraud" means an intentional deception or

21 misrepresentation made by a person with the knowledge

22 that the deception could result in some unauthorized

23 benefit to himself or herself or some other person. It

24 includes any act that constitutes fraud under

25 applicable federal or State law.

26 (B) "Abuse" means provider practices that are

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1 inconsistent with sound fiscal, business, or medical

2 practices and that result in an unnecessary cost to

3 the medical assistance program or in reimbursement for

4 services that are not medically necessary or that fail

5 to meet professionally recognized standards for health

6 care. It also includes recipient practices that result

7 in unnecessary cost to the medical assistance program.

8 Abuse does not include diagnostic or therapeutic

9 measures conducted primarily as a safeguard against

10 possible vendor liability.

11 (C) "Waste" means the unintentional misuse of

12 medical assistance resources, resulting in unnecessary

13 cost to the medical assistance program. Waste does not

14 include diagnostic or therapeutic measures conducted

15 primarily as a safeguard against possible vendor

16 liability.

17 (D) "Harm" means physical, mental, or monetary

18 damage to recipients or to the medical assistance

19 program.

20 (G-6) The Illinois Department, upon making a determination

21 based upon information in the possession of the Illinois

22 Department that continuation of participation in the medical

23 assistance program by a vendor would constitute an immediate

24 danger to the public, may immediately suspend such vendor's

25 participation in the medical assistance program without a

26 hearing. In instances in which the Illinois Department

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1 immediately suspends the medical assistance program

2 participation of a vendor under this Section, a hearing upon

3 the vendor's participation must be convened by the Illinois

4 Department within 15 days after such suspension and completed

5 without appreciable delay. Such hearing shall be held to

6 determine whether to recommend to the Director that the

7 vendor's medical assistance program participation be denied,

8 terminated, suspended, placed on provisional status, or

9 reinstated. In the hearing, any evidence relevant to the

10 vendor constituting an immediate danger to the public may be

11 introduced against such vendor; provided, however, that the

12 vendor, or his or her counsel, shall have the opportunity to

13 discredit, impeach, and submit evidence rebutting such

14 evidence.

15 (H) Nothing contained in this Code shall in any way limit

16 or otherwise impair the authority or power of any State agency

17 responsible for licensing of vendors.

18 (I) Based on a finding of noncompliance on the part of a

19 nursing home with any requirement for certification under

20 Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.

21 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois

22 Department may impose one or more of the following remedies

23 after notice to the facility:

24 (1) Termination of the provider agreement.

25 (2) Temporary management.

26 (3) Denial of payment for new admissions.

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1 (4) Civil money penalties.

2 (5) Closure of the facility in emergency situations or

3 transfer of residents, or both.

4 (6) State monitoring.

5 (7) Denial of all payments when the U.S. Department of

6 Health and Human Services has imposed this sanction.

7 The Illinois Department shall by rule establish criteria

8 governing continued payments to a nursing facility subsequent

9 to termination of the facility's provider agreement if, in the

10 sole discretion of the Illinois Department, circumstances

11 affecting the health, safety, and welfare of the facility's

12 residents require those continued payments. The Illinois

13 Department may condition those continued payments on the

14 appointment of temporary management, sale of the facility to

15 new owners or operators, or other arrangements that the

16 Illinois Department determines best serve the needs of the

17 facility's residents.

18 Except in the case of a facility that has a right to a

19 hearing on the finding of noncompliance before an agency of

20 the federal government, a facility may request a hearing

21 before a State agency on any finding of noncompliance within

22 60 days after the notice of the intent to impose a remedy.

23 Except in the case of civil money penalties, a request for a

24 hearing shall not delay imposition of the penalty. The choice

25 of remedies is not appealable at a hearing. The level of

26 noncompliance may be challenged only in the case of a civil

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1 money penalty. The Illinois Department shall provide by rule

2 for the State agency that will conduct the evidentiary

3 hearings.

4 The Illinois Department may collect interest on unpaid

5 civil money penalties.

6 The Illinois Department may adopt all rules necessary to

7 implement this subsection (I).

8 (J) The Illinois Department, by rule, may permit

9 individual practitioners to designate that Department payments

10 that may be due the practitioner be made to an alternate payee

11 or alternate payees.

12 (a) Such alternate payee or alternate payees shall be

13 required to register as an alternate payee in the Medical

14 Assistance Program with the Illinois Department.

15 (b) If a practitioner designates an alternate payee,

16 the alternate payee and practitioner shall be jointly and

17 severally liable to the Department for payments made to

18 the alternate payee. Pursuant to subsection (E) of this

19 Section, any Department action to suspend or deny payment

20 or recover money or overpayments from an alternate payee

21 shall be subject to an administrative hearing.

22 (c) Registration as an alternate payee or alternate

23 payees in the Illinois Medical Assistance Program shall be

24 conditional. At any time, the Illinois Department may deny

25 or cancel any alternate payee's registration in the

26 Illinois Medical Assistance Program without cause. Any

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1 such denial or cancellation is not subject to an

2 administrative hearing.

3 (d) The Illinois Department may seek a revocation of

4 any alternate payee, and all owners, officers, and

5 individuals with management responsibility for such

6 alternate payee shall be permanently prohibited from

7 participating as an owner, an officer, or an individual

8 with management responsibility with an alternate payee in

9 the Illinois Medical Assistance Program, if after

10 reasonable notice and opportunity for a hearing the

11 Illinois Department finds that:

12 (1) the alternate payee is not complying with the

13 Department's policy or rules and regulations, or with

14 the terms and conditions prescribed by the Illinois

15 Department in its alternate payee registration

16 agreement; or

17 (2) the alternate payee has failed to keep or make

18 available for inspection, audit, or copying, after

19 receiving a written request from the Illinois

20 Department, such records regarding payments claimed as

21 an alternate payee; or

22 (3) the alternate payee has failed to furnish any

23 information requested by the Illinois Department

24 regarding payments claimed as an alternate payee; or

25 (4) the alternate payee has knowingly made, or

26 caused to be made, any false statement or

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1 representation of a material fact in connection with

2 the administration of the Illinois Medical Assistance

3 Program; or

4 (5) the alternate payee, a person with management

5 responsibility for an alternate payee, an officer or

6 person owning, either directly or indirectly, 5% or

7 more of the shares of stock or other evidences of

8 ownership in a corporate alternate payee, or a partner

9 in a partnership which is an alternate payee:

10 (a) was previously terminated, suspended, or

11 excluded from participation as a vendor in the

12 Illinois Medical Assistance Program, or was

13 previously revoked as an alternate payee in the

14 Illinois Medical Assistance Program, or was

15 terminated, suspended, or excluded from

16 participation as a vendor in a medical assistance

17 program in another state that is of the same kind

18 as the program of medical assistance provided

19 under Article V of this Code; or

20 (b) was a person with management

21 responsibility for a vendor previously terminated,

22 suspended, or excluded from participation as a

23 vendor in the Illinois Medical Assistance Program,

24 or was previously revoked as an alternate payee in

25 the Illinois Medical Assistance Program, or was

26 terminated, suspended, or excluded from

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1 participation as a vendor in a medical assistance

2 program in another state that is of the same kind

3 as the program of medical assistance provided

4 under Article V of this Code, during the time of

5 conduct which was the basis for that vendor's

6 termination, suspension, or exclusion or alternate

7 payee's revocation; or

8 (c) was an officer, or person owning, either

9 directly or indirectly, 5% or more of the shares

10 of stock or other evidences of ownership in a

11 corporate vendor previously terminated, suspended,

12 or excluded from participation as a vendor in the

13 Illinois Medical Assistance Program, or was

14 previously revoked as an alternate payee in the

15 Illinois Medical Assistance Program, or was

16 terminated, suspended, or excluded from

17 participation as a vendor in a medical assistance

18 program in another state that is of the same kind

19 as the program of medical assistance provided

20 under Article V of this Code, during the time of

21 conduct which was the basis for that vendor's

22 termination, suspension, or exclusion; or

23 (d) was an owner of a sole proprietorship or

24 partner in a partnership previously terminated,

25 suspended, or excluded from participation as a

26 vendor in the Illinois Medical Assistance Program,

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1 or was previously revoked as an alternate payee in

2 the Illinois Medical Assistance Program, or was

3 terminated, suspended, or excluded from

4 participation as a vendor in a medical assistance

5 program in another state that is of the same kind

6 as the program of medical assistance provided

7 under Article V of this Code, during the time of

8 conduct which was the basis for that vendor's

9 termination, suspension, or exclusion or alternate

10 payee's revocation; or

11 (6) the alternate payee, a person with management

12 responsibility for an alternate payee, an officer or

13 person owning, either directly or indirectly, 5% or

14 more of the shares of stock or other evidences of

15 ownership in a corporate alternate payee, or a partner

16 in a partnership which is an alternate payee:

17 (a) has engaged in conduct prohibited by

18 applicable federal or State law or regulation

19 relating to the Illinois Medical Assistance

20 Program; or

21 (b) was a person with management

22 responsibility for a vendor or alternate payee at

23 the time that the vendor or alternate payee

24 engaged in practices prohibited by applicable

25 federal or State law or regulation relating to the

26 Illinois Medical Assistance Program; or

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1 (c) was an officer, or person owning, either

2 directly or indirectly, 5% or more of the shares

3 of stock or other evidences of ownership in a

4 vendor or alternate payee at the time such vendor

5 or alternate payee engaged in practices prohibited

6 by applicable federal or State law or regulation

7 relating to the Illinois Medical Assistance

8 Program; or

9 (d) was an owner of a sole proprietorship or

10 partner in a partnership which was a vendor or

11 alternate payee at the time such vendor or

12 alternate payee engaged in practices prohibited by

13 applicable federal or State law or regulation

14 relating to the Illinois Medical Assistance

15 Program; or

16 (7) the direct or indirect ownership of the vendor

17 or alternate payee (including the ownership of a

18 vendor or alternate payee that is a partner's interest

19 in a vendor or alternate payee, or ownership of 5% or

20 more of the shares of stock or other evidences of

21 ownership in a corporate vendor or alternate payee)

22 has been transferred by an individual who is

23 terminated, suspended, or excluded or barred from

24 participating as a vendor or is prohibited or revoked

25 as an alternate payee to the individual's spouse,

26 child, brother, sister, parent, grandparent,

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1 grandchild, uncle, aunt, niece, nephew, cousin, or

2 relative by marriage.

3 (K) The Illinois Department of Healthcare and Family

4 Services may withhold payments, in whole or in part, to a

5 provider or alternate payee where there is credible evidence,

6 received from State or federal law enforcement or federal

7 oversight agencies or from the results of a preliminary

8 Department audit, that the circumstances giving rise to the

9 need for a withholding of payments may involve fraud or

10 willful misrepresentation under the Illinois Medical

11 Assistance program. The Department shall by rule define what

12 constitutes "credible" evidence for purposes of this

13 subsection. The Department may withhold payments without first

14 notifying the provider or alternate payee of its intention to

15 withhold such payments. A provider or alternate payee may

16 request a reconsideration of payment withholding, and the

17 Department must grant such a request. The Department shall

18 state by rule a process and criteria by which a provider or

19 alternate payee may request full or partial release of

20 payments withheld under this subsection. This request may be

21 made at any time after the Department first withholds such

22 payments.

23 (a) The Illinois Department must send notice of its

24 withholding of program payments within 5 days of taking

25 such action. The notice must set forth the general

26 allegations as to the nature of the withholding action,

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1 but need not disclose any specific information concerning

2 its ongoing investigation. The notice must do all of the

3 following:

4 (1) State that payments are being withheld in

5 accordance with this subsection.

6 (2) State that the withholding is for a temporary

7 period, as stated in paragraph (b) of this subsection,

8 and cite the circumstances under which withholding

9 will be terminated.

10 (3) Specify, when appropriate, which type or types

11 of Medicaid claims withholding is effective.

12 (4) Inform the provider or alternate payee of the

13 right to submit written evidence for reconsideration

14 of the withholding by the Illinois Department.

15 (5) Inform the provider or alternate payee that a

16 written request may be made to the Illinois Department

17 for full or partial release of withheld payments and

18 that such requests may be made at any time after the

19 Department first withholds such payments.

20 (b) All withholding-of-payment actions under this

21 subsection shall be temporary and shall not continue after

22 any of the following:

23 (1) The Illinois Department or the prosecuting

24 authorities determine that there is insufficient

25 evidence of fraud or willful misrepresentation by the

26 provider or alternate payee.

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1 (2) Legal proceedings related to the provider's or

2 alternate payee's alleged fraud, willful

3 misrepresentation, violations of this Act, or

4 violations of the Illinois Department's administrative

5 rules are completed.

6 (3) The withholding of payments for a period of 3

7 years.

8 (c) The Illinois Department may adopt all rules

9 necessary to implement this subsection (K).

10 (K-5) The Illinois Department may withhold payments, in

11 whole or in part, to a provider or alternate payee upon

12 initiation of an audit, quality of care review, investigation

13 when there is a credible allegation of fraud, or the provider

14 or alternate payee demonstrating a clear failure to cooperate

15 with the Illinois Department such that the circumstances give

16 rise to the need for a withholding of payments. As used in this

17 subsection, "credible allegation" is defined to include an

18 allegation from any source, including, but not limited to,

19 fraud hotline complaints, claims data mining, patterns

20 identified through provider audits, civil actions filed under

21 the Illinois False Claims Act, and law enforcement

22 investigations. An allegation is considered to be credible

23 when it has indicia of reliability. The Illinois Department

24 may withhold payments without first notifying the provider or

25 alternate payee of its intention to withhold such payments. A

26 provider or alternate payee may request a hearing or a

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1 reconsideration of payment withholding, and the Illinois

2 Department must grant such a request. The Illinois Department

3 shall state by rule a process and criteria by which a provider

4 or alternate payee may request a hearing or a reconsideration

5 for the full or partial release of payments withheld under

6 this subsection. This request may be made at any time after the

7 Illinois Department first withholds such payments.

8 (a) The Illinois Department must send notice of its

9 withholding of program payments within 5 days of taking

10 such action. The notice must set forth the general

11 allegations as to the nature of the withholding action but

12 need not disclose any specific information concerning its

13 ongoing investigation. The notice must do all of the

14 following:

15 (1) State that payments are being withheld in

16 accordance with this subsection.

17 (2) State that the withholding is for a temporary

18 period, as stated in paragraph (b) of this subsection,

19 and cite the circumstances under which withholding

20 will be terminated.

21 (3) Specify, when appropriate, which type or types

22 of claims are withheld.

23 (4) Inform the provider or alternate payee of the

24 right to request a hearing or a reconsideration of the

25 withholding by the Illinois Department, including the

26 ability to submit written evidence.

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1 (5) Inform the provider or alternate payee that a

2 written request may be made to the Illinois Department

3 for a hearing or a reconsideration for the full or

4 partial release of withheld payments and that such

5 requests may be made at any time after the Illinois

6 Department first withholds such payments.

7 (b) All withholding of payment actions under this

8 subsection shall be temporary and shall not continue after

9 any of the following:

10 (1) The Illinois Department determines that there

11 is insufficient evidence of fraud, or the provider or

12 alternate payee demonstrates clear cooperation with

13 the Illinois Department, as determined by the Illinois

14 Department, such that the circumstances do not give

15 rise to the need for withholding of payments; or

16 (2) The withholding of payments has lasted for a

17 period in excess of 3 years.

18 (c) The Illinois Department may adopt all rules

19 necessary to implement this subsection (K-5).

20 (L) The Illinois Department shall establish a protocol to

21 enable health care providers to disclose an actual or

22 potential violation of this Section pursuant to a

23 self-referral disclosure protocol, referred to in this

24 subsection as "the protocol". The protocol shall include

25 direction for health care providers on a specific person,

26 official, or office to whom such disclosures shall be made.

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1 The Illinois Department shall post information on the protocol

2 on the Illinois Department's public website. The Illinois

3 Department may adopt rules necessary to implement this

4 subsection (L). In addition to other factors that the Illinois

5 Department finds appropriate, the Illinois Department may

6 consider a health care provider's timely use or failure to use

7 the protocol in considering the provider's failure to comply

8 with this Code.

9 (M) Notwithstanding any other provision of this Code, the

10 Illinois Department, at its discretion, may exempt an entity

11 licensed under the Nursing Home Care Act, the ID/DD Community

12 Care Act, or the MC/DD Act from the provisions of subsections

13 (A-15), (B), and (C) of this Section if the licensed entity is

14 in receivership.

15 (N) Enforcement of advance payment agreements. To the

16 extent not prohibited by federal or State law, and

17 notwithstanding any other provision of this Code, if a

18 provider fails to comply with the terms of an advance payment

19 agreement, the Department is authorized to collect any unpaid

20 advance balance through one or more of the following methods:

21 (1) Direct withholding of Department reimbursements.

22 The Department may withhold reimbursement or other amounts

23 otherwise payable by the Department to the provider,

24 including, but not limited to, fee-for-service claims

25 payments, supplemental payments, and any other amounts the

26 Department is obligated to pay the provider under the

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1 medical assistance program, and apply such withheld

2 amounts as repayment of the unpaid advance.

3 (2) Managed care organizations remittance. If a

4 provider participates in a managed care program

5 administered by the Department, the Department may direct

6 the managed care organization to remit to the Department

7 amounts otherwise payable by the managed care organization

8 to the provider, and apply such remitted amounts as

9 repayment of the unpaid advance.

10 (3) Interagency recoupment. The Department may recoup

11 amounts otherwise payable by any State agency to the

12 provider, including, but not limited to, State grants and

13 grant appropriations, and apply such amounts as repayment

14 of the unpaid advance.

15 (4) Other collection methods. The Department may

16 pursue any other collection remedy available at law.

17 The Department shall adopt rules establishing procedures

18 for collection under this subsection (N). For purposes of this

19 subsection (N), "provider" includes, but is not limited to, a

20 long-term care facility as defined under the Nursing Home Care

21 Act and a hospital provider as defined under Article V-A of

22 this Code.

23 (Source: P.A. 102-538, eff. 8-20-21.)

24 ARTICLE 260.

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1 Section 260-5. The Illinois Administrative Procedure Act

2 is amended by adding Section 5-45.73 as follows:

3 (5 ILCS 100/5-45.73 new)

4 Sec. 5-45.73. Emergency rulemaking; Nursing home staffing

5 ratios. To provide for the expeditious and timely

6 implementation of the changes made by this amendatory Act of

7 the 104th General Assembly to Section 3-202.05 of the Nursing

8 Home Care Act, emergency rules implementing the changes made

9 by this amendatory Act of the 104th General Assembly to

10 Section 3-202.05 of the Nursing Home Care Act may be adopted in

11 accordance with Section 5-45 by the Department of Public

12 Health. The adoption of emergency rules authorized by Section

13 5-45 and this Section is deemed to be necessary for the public

14 interest, safety, and welfare.

15 This Section is repealed one year after the effective date

16 of this amendatory Act of the 104th General Assembly.

17 Section 260-10. The Nursing Home Care Act is amended by

18 changing Sections 3-130 and 3-202.05 as follows:

19 (210 ILCS 45/3-130 new)

20 Sec. 3-130. Annual training for facility staff. A facility

21 must provide its staff with annual training based on the most

22 recurrent citations as specified by the Department. The annual

23 training requirements will be defined by the Department

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1 annually based on the most frequent and recurrent findings or

2 citations during surveys or complaint investigations. The

3 facility must provide proof or documentation of the annual

4 training performed for the recurrent violations. Failure to

5 provide such proof or documentation may result in

6 administrative fines and penalties under this Act. The

7 Department may adopt any rules necessary to implement this

8 Section.

9 The provisions of this Section are declarative of existing

10 law.

11 (210 ILCS 45/3-202.05)

12 Sec. 3-202.05. Staffing ratios effective July 1, 2010 and

13 thereafter.

14 (a) For the purpose of computing staff to resident ratios,

15 direct care staff shall include:

16 (1) registered nurses;

17 (2) licensed practical nurses;

18 (3) certified nurse assistants;

19 (4) psychiatric services rehabilitation aides;

20 (5) rehabilitation and therapy aides;

21 (6) psychiatric services rehabilitation coordinators;

22 (7) assistant directors of nursing;

23 (8) 50% of the Director of Nurses' time; and

24 (9) 30% of the Social Services Directors' time.

25 The Department shall, by rule, allow certain facilities

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1 subject to 77 Ill. Adm. Code 300.4000 and following (Subpart

2 S) to utilize specialized clinical staff, as defined in rules,

3 to count towards the staffing ratios.

4 Within 120 days of June 14, 2012 (the effective date of

5 Public Act 97-689), the Department shall promulgate rules

6 specific to the staffing requirements for facilities federally

7 defined as Institutions for Mental Disease. These rules shall

8 recognize the unique nature of individuals with chronic mental

9 health conditions, shall include minimum requirements for

10 specialized clinical staff, including clinical social workers,

11 psychiatrists, psychologists, and direct care staff set forth

12 in paragraphs (4) through (6) and any other specialized staff

13 which may be utilized and deemed necessary to count toward

14 staffing ratios.

15 Within 120 days of June 14, 2012 (the effective date of

16 Public Act 97-689), the Department shall promulgate rules

17 specific to the staffing requirements for facilities licensed

18 under the Specialized Mental Health Rehabilitation Act of

19 2013. These rules shall recognize the unique nature of

20 individuals with chronic mental health conditions, shall

21 include minimum requirements for specialized clinical staff,

22 including clinical social workers, psychiatrists,

23 psychologists, and direct care staff set forth in paragraphs

24 (4) through (6) and any other specialized staff which may be

25 utilized and deemed necessary to count toward staffing ratios.

26 (a-5) The Centers for Medicare and Medicaid Services'

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1 payroll-based journal job title codes, which correspond to the

2 staff used for the staffing ratios in subsection (a), are as

3 follows:

4 (1) Registered Nurse Director of Nursing, job title

5 code 5.

6 (2) Registered Nurse with Administrative Duties, job

7 title code 6.

8 (3) Registered Nurse, job title code 7.

9 (4) Licensed Practical/Vocational Nurse with

10 Administrative Duties, job title code 8.

11 (5) Licensed Practical/Vocational Nurse, job title

12 code 9.

13 (6) Certified Nurse Aide, job title code 10.

14 (7) Nurse Aide in Training, job title code 11.

15 (8) Medication Aide/Technician, job title code 12.

16 (9) Nurse Practitioner, job title code 13.

17 (10) Clinical Nurse Specialist, job title code 14.

18 (11) Occupational Therapist, job title code 18.

19 (12) Occupational Therapy Assistant, job title code

20 19.

21 (13) Occupational Therapy Aide, job title code 20.

22 (14) Physical Therapist, job title code 21.

23 (15) Physical Therapy Assistant, job title code 22.

24 (16) Physical Therapy Assistant, job title code 23.

25 (17) Respiratory Therapist, job title code 24.

26 (18) Respiratory Therapy Technician, job title code

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1 25.

2 (19) Speech/Language Pathologist, job title code 26.

3 (20) Qualified Activities Professional, job title code

4 28.

5 (21) Other Activities Staff, job title code 29.

6 (22) Qualified Social Worker, job title code 30.

7 (23) Other Social Worker, job title code 31.

8 (24) Mental Health Service Worker, job title code 34.

9 For all job title codes in this subsection, 100% of the

10 hours worked by the staff must be counted toward the

11 staff-to-resident ratio, except job code title 5, which is

12 limited to 50%, and job title codes 28, 30, and 31, which are

13 limited to 30%.

14 (b) (Blank).

15 (b-5) For purposes of the minimum staffing ratios in this

16 Section, all residents shall be classified as requiring either

17 skilled care or intermediate care.

18 As used in this subsection:

19 "Intermediate care" means basic nursing care and other

20 restorative services under periodic medical direction.

21 "Skilled care" means skilled nursing care, continuous

22 skilled nursing observations, restorative nursing, and other

23 services under professional direction with frequent medical

24 supervision.

25 (c) Facilities shall notify the Department within 60 days

26 after July 29, 2010 (the effective date of Public Act

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1 96-1372), in a form and manner prescribed by the Department,

2 of the staffing ratios in effect on July 29, 2010 (the

3 effective date of Public Act 96-1372) for both intermediate

4 and skilled care and the number of residents receiving each

5 level of care.

6 (d)(1) (Blank).

7 (2) (Blank).

8 (3) (Blank).

9 (4) (Blank).

10 (5) Effective January 1, 2014, the minimum staffing ratios

11 shall be increased to 3.8 hours of nursing and personal care

12 each day for a resident needing skilled care and 2.5 hours of

13 nursing and personal care each day for a resident needing

14 intermediate care.

15 (e) Ninety days after June 14, 2012 (the effective date of

16 Public Act 97-689), a minimum of 25% of nursing and personal

17 care time shall be provided by licensed nurses, with at least

18 10% of nursing and personal care time provided by registered

19 nurses. These minimum requirements shall remain in effect

20 until an acuity based registered nurse requirement is

21 promulgated by rule concurrent with the adoption of the

22 Resource Utilization Group classification-based payment

23 methodology, as provided in Section 5-5.2 of the Illinois

24 Public Aid Code. Registered nurses and licensed practical

25 nurses employed by a facility in excess of these requirements

26 may be used to satisfy the remaining 75% of the nursing and

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1 personal care time requirements. Notwithstanding this

2 subsection, no staffing requirement in statute in effect on

3 June 14, 2012 (the effective date of Public Act 97-689) shall

4 be reduced on account of this subsection.

5 (f) The Department shall propose rules that are necessary

6 to implement the provisions of this Section, consistent with

7 the changes made by this amendatory Act of the 104th General

8 Assembly, within 60 days after the effective date of this

9 amendatory Act of the 104th General Assembly. ~~submit proposed~~

10 ~~rules for adoption by January 1, 2020 establishing a system~~

11 ~~for determining compliance with minimum staffing set forth in~~

12 ~~this Section and the requirements of 77 Ill. Adm. Code~~

13 ~~300.1230 adjusted for any waivers granted under Section~~

14 ~~3-303.1.~~ Compliance with minimum staffing as required by this

15 Section shall be determined on a quarterly basis. The

16 Department shall determine compliance by comparing the number

17 of hours provided per resident per day using the Centers for

18 Medicare and Medicaid Services' payroll-based journal and the

19 facility's daily census, broken down by intermediate and

20 skilled care as self-reported by the facility to the

21 Department on a quarterly basis. As used in this subsection,

22 "quarterly basis" means the Centers for Medicare and Medicaid

23 Services' quarterly reporting periods for the federal fiscal

24 year. The Department shall use the quarterly payroll-based

25 journal and the self-reported census to calculate the number

26 of hours provided per resident per day and compare this ratio

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1 to the minimum staffing standards required under this Section,

2 as impacted by any waivers granted under Section 3-303.1.

3 Discrepancies between job titles contained in this Section and

4 the payroll-based journal shall be addressed by rule. The

5 manner in which the Department requests payroll-based journal

6 information to be submitted shall align with the federal

7 Centers for Medicare and Medicaid Services' requirements that

8 allow providers to submit the quarterly data in an aggregate

9 manner.

10 (g) Monetary penalties for non-compliance. The Department

11 shall propose rules that are necessary to implement the

12 provisions of this Section, consistent with the changes made

13 by this amendatory Act of the 104th General Assembly, within

14 60 days after the effective date of this amendatory Act of the

15 104th General Assembly. ~~submit proposed rules for adoption by~~

16 ~~January 1, 2020 establishing monetary penalties for facilities~~

17 ~~not in compliance with minimum staffing standards under this~~

18 ~~Section.~~ Facilities shall be required to comply with the

19 provisions of this subsection beginning January 1, 2025. No

20 monetary penalty may be issued for noncompliance prior to the

21 revised implementation date, which shall be January 1, 2025.

22 If a facility is found to be noncompliant prior to the revised

23 implementation date, the Department shall provide a written

24 notice identifying the staffing deficiencies and require the

25 facility to provide a sufficiently detailed correction plan

26 that describes proposed and completed actions the facility

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1 will take or has taken, including hiring actions, to address

2 the facility's failure to meet the statutory minimum staffing

3 levels. Monetary penalties shall be imposed ~~beginning no later~~

4 ~~than July 1, 2025,~~ based on data for the quarter beginning July

5 1, 2026 through September 30, 2026 ~~January 1, 2025 through~~

6 ~~March 31, 2025~~ and quarterly thereafter. Monetary penalties

7 shall be assessed on a quarterly basis and established based

8 on a formula that calculates on a daily basis the cost of wages

9 and benefits for the missing staffing hours. All notices of

10 noncompliance shall include the computations used to determine

11 noncompliance and establishing the variance between minimum

12 staffing ratios and the Department's computations. The penalty

13 for the first offense shall be 125% of the cost of wages and

14 benefits for the missing staffing hours. The penalty shall

15 increase to 150% of the cost of wages and benefits for the

16 missing staffing hours for the second offense and 200% the

17 cost of wages and benefits for the missing staffing hours for

18 the third and all subsequent offenses. The penalty shall be

19 imposed regardless of whether the facility has committed other

20 violations of this Act during the same period that the

21 staffing offense occurred. The penalty may not be waived,

22 except where there is no more than a 10% deviation from the

23 staffing requirements, in which case the facility shall not

24 receive a violation or penalty. The Department shall:

25 (1) when calculating whether there is no more than a

26 10% deviation from the staffing requirements, determine

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1 the deviation based only on days of the quarter where a

2 facility failed to meet the minimum staffing requirements;

3 and

4 (2) only assess penalties against categories of

5 payroll-based journal job titles that deviate from the

6 staffing requirements by more than 10%. Categories include

7 registered nurses, licensed practical nurses, and other

8 payroll-based journal job titles, as determined by the

9 required staffing levels in subsection (e) of this Section

10 and as listed in subsections (a) and (a-5) of this

11 Section. Penalties shall not be assessed against

12 categories of payroll-based journal job titles that have

13 no more than a 10% deviation from staffing requirements.

14 The Department is granted discretion to waive the

15 violation and penalty when unforeseen circumstances have

16 occurred that resulted in call-offs of scheduled staff. This

17 provision shall be applied no more than 6 times per quarter.

18 Nothing in this Section diminishes a facility's right to

19 appeal the imposition of a monetary penalty. No facility may

20 appeal a notice of noncompliance issued during the revised

21 implementation period. The changes made to this subsection by

22 this amendatory Act of the 104th General Assembly in regard to

23 nursing home staffing fines shall apply to ~~the July 1, 2025~~

24 fines based on data for the quarter beginning July 1, 2026

25 through September 30, 2026, ~~January 1, 2025 through March 31,~~

26 ~~2025~~ and quarterly thereafter.

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1 (Source: P.A. 104-9, eff. 6-16-25.)

2 Section 260-15. The Illinois Public Aid Code is amended by

3 changing Sections 5-5.2 and 12-4.25 as follows:

4 (305 ILCS 5/5-5.2)

5 Sec. 5-5.2. Payment.

6 (a) All nursing facilities that are grouped pursuant to

7 Section 5-5.1 of this Act shall receive the same rate of

8 payment for similar services.

9 (b) It shall be a matter of State policy that the Illinois

10 Department shall utilize a uniform billing cycle throughout

11 the State for the long-term care providers.

12 (c) (Blank).

13 (c-1) Notwithstanding any other provisions of this Code,

14 the methodologies for reimbursement of nursing services as

15 provided under this Article shall no longer be applicable for

16 bills payable for nursing services rendered on or after a new

17 reimbursement system based on the Patient Driven Payment Model

18 (PDPM) has been fully operationalized, which shall take effect

19 for services provided on or after the implementation of the

20 PDPM reimbursement system begins. For the purposes of Public

21 Act 102-1035, the implementation date of the PDPM

22 reimbursement system and all related provisions shall be July

23 1, 2022 if the following conditions are met: (i) the Centers

24 for Medicare and Medicaid Services has approved corresponding

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1 changes in the reimbursement system and bed assessment; and

2 (ii) the Department has filed rules to implement these changes

3 no later than June 1, 2022. Failure of the Department to file

4 rules to implement the changes provided in Public Act 102-1035

5 no later than June 1, 2022 shall result in the implementation

6 date being delayed to October 1, 2022.

7 (d) The new nursing services reimbursement methodology

8 utilizing the Patient Driven Payment Model, which shall be

9 referred to as the PDPM reimbursement system, taking effect

10 July 1, 2022, upon federal approval by the Centers for

11 Medicare and Medicaid Services, shall be based on the

12 following:

13 (1) The methodology shall be resident-centered,

14 facility-specific, cost-based, and based on guidance from

15 the Centers for Medicare and Medicaid Services.

16 (2) Costs shall be annually rebased and case mix index

17 quarterly updated. The nursing services methodology will

18 be assigned to the Medicaid enrolled residents on record

19 as of 30 days prior to the beginning of the rate period in

20 the Department's Medicaid Management Information System

21 (MMIS) as present on the last day of the second quarter

22 preceding the rate period based upon the Assessment

23 Reference Date of the Minimum Data Set (MDS).

24 (3) Regional wage adjustors based on the Health

25 Service Areas (HSA) groupings and adjusters in effect on

26 April 30, 2012 shall be included, except no adjuster shall

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1 be lower than 1.06.

2 (4) PDPM nursing case mix indices in effect on March

3 1, 2022 shall be assigned to each resident class at no less

4 than 0.7858 of the Centers for Medicare and Medicaid

5 Services PDPM unadjusted case mix values, in effect on

6 March 1, 2022.

7 (5) The pool of funds available for distribution by

8 case mix and the base facility rate shall be determined

9 using the formula contained in subsection (d-1).

10 (6) The Department shall establish a variable per diem

11 staffing add-on in accordance with the most recent

12 available federal staffing report, currently the Payroll

13 Based Journal, for the same period of time, and if

14 applicable adjusted for acuity using the same quarter's

15 MDS. The Department shall rely on Payroll Based Journals

16 provided to the Department of Public Health to make a

17 determination of non-submission. If the Department is

18 notified by a facility of missing or inaccurate Payroll

19 Based Journal data or an incorrect calculation of

20 staffing, the Department must make a correction as soon as

21 the error is verified for the applicable quarter.

22 Beginning October 1, 2024, the staffing percentage

23 used in the calculation of the per diem staffing add-on

24 shall be its PDPM STRIVE Staffing Ratio which equals: its

25 Reported Total Nurse Staffing Hours Per Resident Per Day

26 as published in the most recent federal staffing report

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1 (the Provider Information File), divided by the facility's

2 PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE

3 Staffing Target is equal to .82 times the facility's

4 Illinois Adjusted Facility Case-Mix Hours Per Resident Per

5 Day. A facility's Illinois Adjusted Facility Case Mix

6 Hours Per Resident Per Day is equal to its Case-Mix Total

7 Nurse Staffing Hours Per Resident Per Day (as published in

8 the most recent federal Provider Information file) times

9 3.662 (which reflects the national resident days-weighted

10 mean Reported Total Nurse Staffing Hours Per Resident Per

11 Day as calculated using the January 2024 federal Provider

12 Information Files), divided by the national resident

13 days-weighted mean Reported Total Nurse Staffing Hours Per

14 Resident Per Day calculated using the most recent State US

15 Averages file.

16 Beginning January 1, 2025, the staffing percentage

17 used in the calculation of the per diem staffing add-on

18 shall be its PDPM STRIVE Staffing Ratio which equals: its

19 Reported Total Nurse Staffing Hours Per Resident Per Day

20 as published in the most recent federal staffing report

21 (the Provider Information File), divided by the facility's

22 PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE

23 Staffing Target is equal to .7122 times the facility's

24 Illinois Adjusted Facility Case-Mix Hours Per Resident Per

25 Day. A facility's Illinois Adjusted Facility Case Mix

26 Hours Per Resident Per Day is equal to its Case-Mix Total

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1 Nurse Staffing Hours Per Resident Per Day (as published in

2 the most recent federal staffing report Provider

3 Information file) times 3.79 (which is the Reported Total

4 Nurse Staffing Hours Per Resident Per Day for the Nation

5 as reported the January 2024 State US Averages file),

6 divided by the Reported Total Nurse Staffing Hours Per

7 Resident Per Day for the Nation as reported in the most

8 recent State US Averages file.

9 (6.5) Beginning July 1, 2024, the paid per diem

10 staffing add-on shall be the paid per diem staffing add-on

11 in effect April 1, 2024. For dates beginning October 1,

12 2024 and through September 30, 2025, the denominator for

13 the staffing percentage shall be the lesser of the

14 facility's PDPM STRIVE Staffing Target and:

15 (A) For the quarter beginning October 1, 2024, the

16 sum of 20% of the facility's PDPM STRIVE Staffing

17 Target and 80% of the facility's Case-Mix Total Nurse

18 Staffing Hours Per Resident Per Day (as published in

19 the January 2024 federal staffing report).

20 (B) For the quarter beginning January 1, 2025, the

21 sum of 40% of the facility's PDPM STRIVE Staffing

22 Target and 60% of the facility's Case-Mix Total Nurse

23 Staffing Hours Per Resident Per Day (as published in

24 the January 2024 federal staffing report).

25 (C) For the quarter beginning March 1, 2025, the

26 sum of 60% of the facility's PDPM STRIVE Staffing

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1 Target and 40% of the facility's Case-Mix Total Nurse

2 Staffing Hours Per Resident Per Day (as published in

3 the January 2024 federal staffing report).

4 (D) For the quarter beginning July 1, 2025, the

5 sum of 80% of the facility's PDPM STRIVE Staffing

6 Target and 20% of the facility's Case-Mix Total Nurse

7 Staffing Hours Per Resident Per Day (as published in

8 the January 2024 federal staffing report).

9 Facilities with at least 70% of the staffing

10 indicated by the STRIVE study shall be paid a per diem

11 add-on of $9, increasing by equivalent steps for each

12 whole percentage point until the facilities reach a per

13 diem of $16.52. Facilities with at least 80% of the

14 staffing indicated by the STRIVE study shall be paid a per

15 diem add-on of $16.52, increasing by equivalent steps for

16 each whole percentage point until the facilities reach a

17 per diem add-on of $25.77. Facilities with at least 92% of

18 the staffing indicated by the STRIVE study shall be paid a

19 per diem add-on of $25.77, increasing by equivalent steps

20 for each whole percentage point until the facilities reach

21 a per diem add-on of $30.98. Facilities with at least 100%

22 of the staffing indicated by the STRIVE study shall be

23 paid a per diem add-on of $30.98, increasing by equivalent

24 steps for each whole percentage point until the facilities

25 reach a per diem add-on of $36.44. Facilities with at

26 least 110% of the staffing indicated by the STRIVE study

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1 shall be paid a per diem add-on of $36.44, increasing by

2 equivalent steps for each whole percentage point until the

3 facilities reach a per diem add-on of $38.68. Facilities

4 with at least 125% or higher of the staffing indicated by

5 the STRIVE study shall be paid a per diem add-on of $38.68.

6 No nursing facility's variable staffing per diem add-on

7 shall be reduced by more than 5% in 2 consecutive

8 quarters. For the quarters beginning July 1, 2022 and

9 October 1, 2022, no facility's variable per diem staffing

10 add-on shall be calculated at a rate lower than 85% of the

11 staffing indicated by the STRIVE study. No facility below

12 70% of the staffing indicated by the STRIVE study shall

13 receive a variable per diem staffing add-on after December

14 31, 2022.

15 Beginning January 1, 2027, a $2.25 rate increase shall

16 be added to each STRIVE staffing per diem add-on under

17 subparagraph (D) of this paragraph (6.5) for facilities

18 with at least 80% of the staffing indicated by the STRIVE

19 study.

20 (7) For dates of services beginning July 1, 2022, the

21 PDPM nursing component per diem for each nursing facility

22 shall be the product of the facility's (i) statewide PDPM

23 nursing base per diem rate, $92.25, adjusted for the

24 facility average PDPM case mix index calculated quarterly

25 and (ii) the regional wage adjuster, and then add the

26 Medicaid access adjustment as defined in (e-3) of this

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1 Section. Transition rates for services provided between

2 July 1, 2022 and October 1, 2023 shall be the greater of

3 the PDPM nursing component per diem or:

4 (A) for the quarter beginning July 1, 2022, the

5 RUG-IV nursing component per diem;

6 (B) for the quarter beginning October 1, 2022, the

7 sum of the RUG-IV nursing component per diem

8 multiplied by 0.80 and the PDPM nursing component per

9 diem multiplied by 0.20;

10 (C) for the quarter beginning January 1, 2023, the

11 sum of the RUG-IV nursing component per diem

12 multiplied by 0.60 and the PDPM nursing component per

13 diem multiplied by 0.40;

14 (D) for the quarter beginning April 1, 2023, the

15 sum of the RUG-IV nursing component per diem

16 multiplied by 0.40 and the PDPM nursing component per

17 diem multiplied by 0.60;

18 (E) for the quarter beginning July 1, 2023, the

19 sum of the RUG-IV nursing component per diem

20 multiplied by 0.20 and the PDPM nursing component per

21 diem multiplied by 0.80; or

22 (F) for the quarter beginning October 1, 2023 and

23 each subsequent quarter, the transition rate shall end

24 and a nursing facility shall be paid 100% of the PDPM

25 nursing component per diem.

26 (d-1) Calculation of base year Statewide RUG-IV nursing

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1 base per diem rate.

2 (1) Base rate spending pool shall be:

3 (A) The base year resident days which are

4 calculated by multiplying the number of Medicaid

5 residents in each nursing home as indicated in the MDS

6 data defined in paragraph (4) by 365.

7 (B) Each facility's nursing component per diem in

8 effect on July 1, 2012 shall be multiplied by

9 subsection (A).

10 (C) Thirteen million is added to the product of

11 subparagraph (A) and subparagraph (B) to adjust for

12 the exclusion of nursing homes defined in paragraph

13 (5).

14 (2) For each nursing home with Medicaid residents as

15 indicated by the MDS data defined in paragraph (4),

16 weighted days adjusted for case mix and regional wage

17 adjustment shall be calculated. For each home this

18 calculation is the product of:

19 (A) Base year resident days as calculated in

20 subparagraph (A) of paragraph (1).

21 (B) The nursing home's regional wage adjustor

22 based on the Health Service Areas (HSA) groupings and

23 adjustors in effect on April 30, 2012.

24 (C) Facility weighted case mix which is the number

25 of Medicaid residents as indicated by the MDS data

26 defined in paragraph (4) multiplied by the associated

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1 case weight for the RUG-IV 48 grouper model using

2 standard RUG-IV procedures for index maximization.

3 (D) The sum of the products calculated for each

4 nursing home in subparagraphs (A) through (C) above

5 shall be the base year case mix, rate adjusted

6 weighted days.

7 (3) The Statewide RUG-IV nursing base per diem rate:

8 (A) on January 1, 2014 shall be the quotient of the

9 paragraph (1) divided by the sum calculated under

10 subparagraph (D) of paragraph (2);

11 (B) on and after July 1, 2014 and until July 1,

12 2022, shall be the amount calculated under

13 subparagraph (A) of this paragraph (3) plus $1.76; and

14 (C) beginning July 1, 2022 and thereafter, $7

15 shall be added to the amount calculated under

16 subparagraph (B) of this paragraph (3) of this

17 Section.

18 (4) Minimum Data Set (MDS) comprehensive assessments

19 for Medicaid residents on the last day of the quarter used

20 to establish the base rate.

21 (5) Nursing facilities designated as of July 1, 2012

22 by the Department as "Institutions for Mental Disease"

23 shall be excluded from all calculations under this

24 subsection. The data from these facilities shall not be

25 used in the computations described in paragraphs (1)

26 through (4) above to establish the base rate.

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1 (e) Beginning July 1, 2014, the Department shall allocate

2 funding in the amount up to $10,000,000 for per diem add-ons to

3 the RUGS methodology for dates of service on and after July 1,

4 2014:

5 (1) $0.63 for each resident who scores in I4200

6 Alzheimer's Disease or I4800 non-Alzheimer's Dementia.

7 (2) $2.67 for each resident who scores either a "1" or

8 "2" in any items S1200A through S1200I and also scores in

9 RUG groups PA1, PA2, BA1, or BA2.

10 (e-1) (Blank).

11 (e-2) For dates of services beginning January 1, 2014 and

12 ending September 30, 2023, the RUG-IV nursing component per

13 diem for a nursing home shall be the product of the statewide

14 RUG-IV nursing base per diem rate, the facility average case

15 mix index, and the regional wage adjustor. For dates of

16 service beginning July 1, 2022 and ending September 30, 2023,

17 the Medicaid access adjustment described in subsection (e-3)

18 shall be added to the product.

19 (e-3) A Medicaid Access Adjustment of $4 adjusted for the

20 facility average PDPM case mix index calculated quarterly

21 shall be added to the statewide PDPM nursing per diem for all

22 facilities with annual Medicaid bed days of at least 70% of all

23 occupied bed days adjusted quarterly. For each new calendar

24 year and for the 6-month period beginning July 1, 2022, the

25 percentage of a facility's occupied bed days comprised of

26 Medicaid bed days shall be determined by the Department

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1 quarterly. For dates of service beginning January 1, 2023, the

2 Medicaid Access Adjustment shall be increased to $4.75. This

3 subsection shall be inoperative on and after December 31, 2029

4 ~~January 1, 2028~~.

5 (e-3.5) For dates of service beginning January 1, 2027,

6 the Medicaid Access Adjustment shall be increased by $5.55 to

7 $10.30 per diem for those facilities with at least 70% of the

8 staffing indicated by the STRIVE study as described in

9 subparagraph (D) of paragraph (6.5) of subsection (d). A

10 facility shall be eligible for Medicaid Access Adjustment

11 described in this subsection (e-3.5) only if the facility

12 demonstrates compliance with the training requirements for

13 staff outlined in Section 3-130 of the Nursing Home Care Act.

14 This subsection (e-3.5) shall be inoperative on and after

15 December 31, 2029.

16 (e-3.6) For dates of service beginning January 1, 2027,

17 facilities located outside of Rate Areas 6, 7, and 8 that have

18 Medicaid bed days of at least 65% of all occupied bed days

19 adjusted quarterly shall qualify for the Medicaid Access

20 Adjustment described in subsections (e-3) and (e-3.5).

21 Facilities located inside Rate Areas 6, 7, and 8 shall have

22 their threshold remain at 70% for all qualifying facilities

23 described in subsections (e-3) and (e-3.5). This subsection

24 (e-3.6) shall be inoperative on and after December 31, 2029.

25 (e-4) Subject to federal approval, on and after January 1,

26 2024, the Department shall increase the rate add-on at

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1 paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335

2 for ventilator services from $208 per day to $481 per day.

3 Payment is subject to the criteria and requirements under 89

4 Ill. Adm. Code 147.335.

5 (f) (Blank).

6 (g) Notwithstanding any other provision of this Code, on

7 and after July 1, 2012, for facilities not designated by the

8 Department of Healthcare and Family Services as "Institutions

9 for Mental Disease", rates effective May 1, 2011 shall be

10 adjusted as follows:

11 (1) (Blank);

12 (2) (Blank);

13 (3) Facility rates for the capital and support

14 components shall be reduced by 1.7%.

15 (h) Notwithstanding any other provision of this Code, on

16 and after July 1, 2012, nursing facilities designated by the

17 Department of Healthcare and Family Services as "Institutions

18 for Mental Disease" and "Institutions for Mental Disease" that

19 are facilities licensed under the Specialized Mental Health

20 Rehabilitation Act of 2013 shall have the nursing,

21 socio-developmental, capital, and support components of their

22 reimbursement rate effective May 1, 2011 reduced in total by

23 2.7%.

24 (i) On and after July 1, 2014, the reimbursement rates for

25 the support component of the nursing facility rate for

26 facilities licensed under the Nursing Home Care Act as skilled

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1 or intermediate care facilities shall be the rate in effect on

2 June 30, 2014 increased by 8.17%.

3 (i-1) Subject to federal approval, on and after January 1,

4 2024, the reimbursement rates for the support component of the

5 nursing facility rate for facilities licensed under the

6 Nursing Home Care Act as skilled or intermediate care

7 facilities shall be the rate in effect on June 30, 2023

8 increased by 12%.

9 (j) Notwithstanding any other provision of law, subject to

10 federal approval, effective July 1, 2019, sufficient funds

11 shall be allocated for changes to rates for facilities

12 licensed under the Nursing Home Care Act as skilled nursing

13 facilities or intermediate care facilities for dates of

14 services on and after July 1, 2019: (i) to establish, through

15 June 30, 2022 a per diem add-on to the direct care per diem

16 rate not to exceed $70,000,000 annually in the aggregate

17 taking into account federal matching funds for the purpose of

18 addressing the facility's unique staffing needs, adjusted

19 quarterly and distributed by a weighted formula based on

20 Medicaid bed days on the last day of the second quarter

21 preceding the quarter for which the rate is being adjusted.

22 Beginning July 1, 2022, the annual $70,000,000 described in

23 the preceding sentence shall be dedicated to the variable per

24 diem add-on for staffing under paragraph (6) of subsection

25 (d); and (ii) in an amount not to exceed $170,000,000 annually

26 in the aggregate taking into account federal matching funds to

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1 permit the support component of the nursing facility rate to

2 be updated as follows:

3 (1) 80%, or $136,000,000, of the funds shall be used

4 to update each facility's rate in effect on June 30, 2019

5 using the most recent cost reports on file, which have had

6 a limited review conducted by the Department of Healthcare

7 and Family Services and will not hold up enacting the rate

8 increase, with the Department of Healthcare and Family

9 Services.

10 (2) After completing the calculation in paragraph (1),

11 any facility whose rate is less than the rate in effect on

12 June 30, 2019 shall have its rate restored to the rate in

13 effect on June 30, 2019 from the 20% of the funds set

14 aside.

15 (3) The remainder of the 20%, or $34,000,000, shall be

16 used to increase each facility's rate by an equal

17 percentage.

18 (k) During the first quarter of State Fiscal Year 2020,

19 the Department of Healthcare of Family Services must convene a

20 technical advisory group consisting of members of all trade

21 associations representing Illinois skilled nursing providers

22 to discuss changes necessary with federal implementation of

23 Medicare's Patient-Driven Payment Model. Implementation of

24 Medicare's Patient-Driven Payment Model shall, by September 1,

25 2020, end the collection of the MDS data that is necessary to

26 maintain the current RUG-IV Medicaid payment methodology. The

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1 technical advisory group must consider a revised reimbursement

2 methodology that takes into account transparency,

3 accountability, actual staffing as reported under the

4 federally required Payroll Based Journal system, changes to

5 the minimum wage, adequacy in coverage of the cost of care, and

6 a quality component that rewards quality improvements.

7 (l) The Department shall establish per diem add-on

8 payments to improve the quality of care delivered by

9 facilities, including:

10 (1) Incentive payments determined by facility

11 performance on specified quality measures in an initial

12 amount of $70,000,000. Nothing in this subsection shall be

13 construed to limit the quality of care payments in the

14 aggregate statewide to $70,000,000, and, if quality of

15 care has improved across nursing facilities, the

16 Department shall adjust those add-on payments accordingly.

17 The quality payment methodology described in this

18 subsection must be used for at least State Fiscal Year

19 2023. Beginning with the quarter starting July 1, 2023,

20 the Department may add, remove, or change quality metrics

21 and make associated changes to the quality payment

22 methodology as outlined in subparagraph (E). Facilities

23 designated by the Centers for Medicare and Medicaid

24 Services as a special focus facility or a hospital-based

25 nursing home do not qualify for quality payments.

26 (A) Each quality pool must be distributed by

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1 assigning a quality weighted score for each nursing

2 home which is calculated by multiplying the nursing

3 home's quality base period Medicaid days by the

4 nursing home's star rating weight in that period.

5 (B) Star rating weights are assigned based on the

6 nursing home's star rating for the LTS quality star

7 rating. As used in this subparagraph, "LTS quality

8 star rating" means the long-term stay quality rating

9 for each nursing facility, as assigned by the Centers

10 for Medicare and Medicaid Services under the Five-Star

11 Quality Rating System. The rating is a number ranging

12 from 0 (lowest) to 5 (highest).

13 (i) Zero-star or one-star rating has a weight

14 of 0.

15 (ii) Two-star rating has a weight of 0.75.

16 (iii) Three-star rating has a weight of 1.5.

17 (iv) Four-star rating has a weight of 2.5.

18 (v) Five-star rating has a weight of 3.5.

19 (C) Each nursing home's quality weight score is

20 divided by the sum of all quality weight scores for

21 qualifying nursing homes to determine the proportion

22 of the quality pool to be paid to the nursing home.

23 (D) The quality pool is no less than $70,000,000

24 annually or $17,500,000 per quarter. The Department

25 shall publish on its website the estimated payments

26 and the associated weights for each facility 45 days

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1 prior to when the initial payments for the quarter are

2 to be paid. The Department shall assign each facility

3 the most recent and applicable quarter's STAR value

4 unless the facility notifies the Department within 15

5 days of an issue and the facility provides reasonable

6 evidence demonstrating its timely compliance with

7 federal data submission requirements for the quarter

8 of record. If such evidence cannot be provided to the

9 Department, the STAR rating assigned to the facility

10 shall be reduced by one from the prior quarter.

11 (E) The Department shall review quality metrics

12 used for payment of the quality pool and make

13 recommendations for any associated changes to the

14 methodology for distributing quality pool payments in

15 consultation with associations representing long-term

16 care providers, consumer advocates, organizations

17 representing workers of long-term care facilities, and

18 payors. The Department may establish, by rule, changes

19 to the methodology for distributing quality pool

20 payments.

21 (F) The Department shall disburse quality pool

22 payments from the Long-Term Care Provider Fund on a

23 monthly basis in amounts proportional to the total

24 quality pool payment determined for the quarter.

25 (G) The Department shall publish any changes in

26 the methodology for distributing quality pool payments

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1 prior to the beginning of the measurement period or

2 quality base period for any metric added to the

3 distribution's methodology.

4 (2) Payments based on CNA tenure, promotion, and CNA

5 training for the purpose of increasing CNA compensation.

6 It is the intent of this subsection that payments made in

7 accordance with this paragraph be directly incorporated

8 into increased compensation for CNAs. As used in this

9 paragraph, "CNA" means a certified nursing assistant as

10 that term is described in Section 3-206 of the Nursing

11 Home Care Act, Section 3-206 of the ID/DD Community Care

12 Act, and Section 3-206 of the MC/DD Act. The Department

13 shall establish, by rule, payments to nursing facilities

14 equal to Medicaid's share of the tenure wage increments

15 specified in this paragraph for all reported CNA employee

16 hours compensated according to a posted schedule

17 consisting of increments at least as large as those

18 specified in this paragraph. The increments are as

19 follows: an additional $1.50 per hour for CNAs with at

20 least one and less than 2 years' experience plus another

21 $1 per hour for each additional year of experience up to a

22 maximum of $6.50 for CNAs with at least 6 years of

23 experience. For purposes of this paragraph, Medicaid's

24 share shall be the ratio determined by paid Medicaid bed

25 days divided by total bed days for the applicable time

26 period used in the calculation. In addition, and additive

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1 to any tenure increments paid as specified in this

2 paragraph, the Department shall establish, by rule,

3 payments supporting Medicaid's share of the

4 promotion-based wage increments for CNA employee hours

5 compensated for that promotion with at least a $1.50

6 hourly increase. Medicaid's share shall be established as

7 it is for the tenure increments described in this

8 paragraph. Qualifying promotions shall be defined by the

9 Department in rules for an expected 10-15% subset of CNAs

10 assigned intermediate, specialized, or added roles such as

11 CNA trainers, CNA scheduling "captains", and CNA

12 specialists for resident conditions like dementia or

13 memory care or behavioral health.

14 (m) The Department shall work with nursing facility

15 industry representatives to design policies and procedures to

16 permit facilities to address the integrity of data from

17 federal reporting sites used by the Department in setting

18 facility rates.

19 (Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;

20 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,

21 Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,

22 Section 50-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff.

23 7-1-24; 103-1075, eff. 3-21-25.)

24 (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)

25 Sec. 12-4.25. Medical assistance program; vendor

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1 participation.

2 (A) The Illinois Department may deny, suspend, or

3 terminate the eligibility of any person, firm, corporation,

4 association, agency, institution or other legal entity to

5 participate as a vendor of goods or services to recipients

6 under the medical assistance program under Article V, or may

7 exclude any such person or entity from participation as such a

8 vendor, and may deny, suspend, or recover payments, if after

9 reasonable notice and opportunity for a hearing the Illinois

10 Department finds:

11 (a) Such vendor is not complying with the Department's

12 policy or rules and regulations, or with the terms and

13 conditions prescribed by the Illinois Department in its

14 vendor agreement, which document shall be developed by the

15 Department as a result of negotiations with each vendor

16 category, including physicians, hospitals, long term care

17 facilities, pharmacists, optometrists, podiatric

18 physicians, and dentists setting forth the terms and

19 conditions applicable to the participation of each vendor

20 group in the program; or

21 (b) Such vendor has failed to keep or make available

22 for inspection, audit or copying, after receiving a

23 written request from the Illinois Department, such records

24 regarding payments claimed for providing services. This

25 section does not require vendors to make available patient

26 records of patients for whom services are not reimbursed

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1 under this Code; or

2 (c) Such vendor has failed to furnish any information

3 requested by the Department regarding payments for

4 providing goods or services; or

5 (d) Such vendor has knowingly made, or caused to be

6 made, any false statement or representation of a material

7 fact in connection with the administration of the medical

8 assistance program; or

9 (e) Such vendor has furnished goods or services to a

10 recipient which are (1) in excess of need, (2) harmful, or

11 (3) of grossly inferior quality, all of such

12 determinations to be based upon competent medical judgment

13 and evaluations; or

14 (f) The vendor; a person with management

15 responsibility for a vendor; an officer or person owning,

16 either directly or indirectly, 5% or more of the shares of

17 stock or other evidences of ownership in a corporate

18 vendor; an owner of a sole proprietorship which is a

19 vendor; or a partner in a partnership which is a vendor,

20 either:

21 (1) was previously terminated, suspended, or

22 excluded from participation in the Illinois medical

23 assistance program, or was terminated, suspended, or

24 excluded from participation in another state or

25 federal medical assistance or health care program; or

26 (2) was a person with management responsibility

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1 for a vendor previously terminated, suspended, or

2 excluded from participation in the Illinois medical

3 assistance program, or terminated, suspended, or

4 excluded from participation in another state or

5 federal medical assistance or health care program

6 during the time of conduct which was the basis for that

7 vendor's termination, suspension, or exclusion; or

8 (3) was an officer, or person owning, either

9 directly or indirectly, 5% or more of the shares of

10 stock or other evidences of ownership in a corporate

11 or limited liability company vendor previously

12 terminated, suspended, or excluded from participation

13 in the Illinois medical assistance program, or

14 terminated, suspended, or excluded from participation

15 in a state or federal medical assistance or health

16 care program during the time of conduct which was the

17 basis for that vendor's termination, suspension, or

18 exclusion; or

19 (4) was an owner of a sole proprietorship or

20 partner of a partnership previously terminated,

21 suspended, or excluded from participation in the

22 Illinois medical assistance program, or terminated,

23 suspended, or excluded from participation in a state

24 or federal medical assistance or health care program

25 during the time of conduct which was the basis for that

26 vendor's termination, suspension, or exclusion; or

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1 (f-1) Such vendor has a delinquent debt owed to the

2 Illinois Department; or

3 (g) The vendor; a person with management

4 responsibility for a vendor; an officer or person owning,

5 either directly or indirectly, 5% or more of the shares of

6 stock or other evidences of ownership in a corporate or

7 limited liability company vendor; an owner of a sole

8 proprietorship which is a vendor; or a partner in a

9 partnership which is a vendor, either:

10 (1) has engaged in practices prohibited by

11 applicable federal or State law or regulation; or

12 (2) was a person with management responsibility

13 for a vendor at the time that such vendor engaged in

14 practices prohibited by applicable federal or State

15 law or regulation; or

16 (3) was an officer, or person owning, either

17 directly or indirectly, 5% or more of the shares of

18 stock or other evidences of ownership in a vendor at

19 the time such vendor engaged in practices prohibited

20 by applicable federal or State law or regulation; or

21 (4) was an owner of a sole proprietorship or

22 partner of a partnership which was a vendor at the time

23 such vendor engaged in practices prohibited by

24 applicable federal or State law or regulation; or

25 (h) The direct or indirect ownership of the vendor

26 (including the ownership of a vendor that is a sole

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1 proprietorship, a partner's interest in a vendor that is a

2 partnership, or ownership of 5% or more of the shares of

3 stock or other evidences of ownership in a corporate

4 vendor) has been transferred by an individual who is

5 terminated, suspended, or excluded or barred from

6 participating as a vendor to the individual's spouse,

7 child, brother, sister, parent, grandparent, grandchild,

8 uncle, aunt, niece, nephew, cousin, or relative by

9 marriage.

10 (A-5) The Illinois Department may deny, suspend, or

11 terminate the eligibility of any person, firm, corporation,

12 association, agency, institution, or other legal entity to

13 participate as a vendor of goods or services to recipients

14 under the medical assistance program under Article V, or may

15 exclude any such person or entity from participation as such a

16 vendor, if, after reasonable notice and opportunity for a

17 hearing, the Illinois Department finds that the vendor; a

18 person with management responsibility for a vendor; an officer

19 or person owning, either directly or indirectly, 5% or more of

20 the shares of stock or other evidences of ownership in a

21 corporate vendor; an owner of a sole proprietorship that is a

22 vendor; or a partner in a partnership that is a vendor has been

23 convicted of an offense based on fraud or willful

24 misrepresentation related to any of the following:

25 (1) The medical assistance program under Article V of

26 this Code.

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1 (2) A medical assistance or health care program in

2 another state.

3 (3) The Medicare program under Title XVIII of the

4 Social Security Act.

5 (4) The provision of health care services.

6 (5) A violation of this Code, as provided in Article

7 VIIIA, or another state or federal medical assistance

8 program or health care program.

9 (A-10) The Illinois Department may deny, suspend, or

10 terminate the eligibility of any person, firm, corporation,

11 association, agency, institution, or other legal entity to

12 participate as a vendor of goods or services to recipients

13 under the medical assistance program under Article V, or may

14 exclude any such person or entity from participation as such a

15 vendor, if, after reasonable notice and opportunity for a

16 hearing, the Illinois Department finds that (i) the vendor,

17 (ii) a person with management responsibility for a vendor,

18 (iii) an officer or person owning, either directly or

19 indirectly, 5% or more of the shares of stock or other

20 evidences of ownership in a corporate vendor, (iv) an owner of

21 a sole proprietorship that is a vendor, or (v) a partner in a

22 partnership that is a vendor has been convicted of an offense

23 related to any of the following:

24 (1) Murder.

25 (2) A Class X felony under the Criminal Code of 1961 or

26 the Criminal Code of 2012.

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1 (3) Sexual misconduct that may subject recipients to

2 an undue risk of harm.

3 (4) A criminal offense that may subject recipients to

4 an undue risk of harm.

5 (5) A crime of fraud or dishonesty.

6 (6) A crime involving a controlled substance.

7 (7) A misdemeanor relating to fraud, theft,

8 embezzlement, breach of fiduciary responsibility, or other

9 financial misconduct related to a health care program.

10 (A-15) The Illinois Department may deny the eligibility of

11 any person, firm, corporation, association, agency,

12 institution, or other legal entity to participate as a vendor

13 of goods or services to recipients under the medical

14 assistance program under Article V if, after reasonable notice

15 and opportunity for a hearing, the Illinois Department finds:

16 (1) The applicant or any person with management

17 responsibility for the applicant; an officer or member of

18 the board of directors of an applicant; an entity owning

19 (directly or indirectly) 5% or more of the shares of stock

20 or other evidences of ownership in a corporate vendor

21 applicant; an owner of a sole proprietorship applicant; a

22 partner in a partnership applicant; or a technical or

23 other advisor to an applicant has a debt owed to the

24 Illinois Department, and no payment arrangements

25 acceptable to the Illinois Department have been made by

26 the applicant.

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1 (2) The applicant or any person with management

2 responsibility for the applicant; an officer or member of

3 the board of directors of an applicant; an entity owning

4 (directly or indirectly) 5% or more of the shares of stock

5 or other evidences of ownership in a corporate vendor

6 applicant; an owner of a sole proprietorship applicant; a

7 partner in a partnership vendor applicant; or a technical

8 or other advisor to an applicant was (i) a person with

9 management responsibility, (ii) an officer or member of

10 the board of directors of an applicant, (iii) an entity

11 owning (directly or indirectly) 5% or more of the shares

12 of stock or other evidences of ownership in a corporate

13 vendor, (iv) an owner of a sole proprietorship, (v) a

14 partner in a partnership vendor, (vi) a technical or other

15 advisor to a vendor, during a period of time where the

16 conduct of that vendor resulted in a debt owed to the

17 Illinois Department, and no payment arrangements

18 acceptable to the Illinois Department have been made by

19 that vendor.

20 (3) There is a credible allegation of the use,

21 transfer, or lease of assets of any kind to an applicant

22 from a current or prior vendor who has a debt owed to the

23 Illinois Department, no payment arrangements acceptable to

24 the Illinois Department have been made by that vendor or

25 the vendor's alternate payee, and the applicant knows or

26 should have known of such debt.

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1 (4) There is a credible allegation of a transfer of

2 management responsibilities, or direct or indirect

3 ownership, to an applicant from a current or prior vendor

4 who has a debt owed to the Illinois Department, and no

5 payment arrangements acceptable to the Illinois Department

6 have been made by that vendor or the vendor's alternate

7 payee, and the applicant knows or should have known of

8 such debt.

9 (5) There is a credible allegation of the use,

10 transfer, or lease of assets of any kind to an applicant

11 who is a spouse, child, brother, sister, parent,

12 grandparent, grandchild, uncle, aunt, niece, relative by

13 marriage, nephew, cousin, or relative of a current or

14 prior vendor who has a debt owed to the Illinois

15 Department and no payment arrangements acceptable to the

16 Illinois Department have been made.

17 (6) There is a credible allegation that the

18 applicant's previous affiliations with a provider of

19 medical services that has an uncollected debt, a provider

20 that has been or is subject to a payment suspension under a

21 federal health care program, or a provider that has been

22 previously excluded from participation in the medical

23 assistance program, poses a risk of fraud, waste, or abuse

24 to the Illinois Department.

25 As used in this subsection, "credible allegation" is

26 defined to include an allegation from any source, including,

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1 but not limited to, fraud hotline complaints, claims data

2 mining, patterns identified through provider audits, civil

3 actions filed under the Illinois False Claims Act, and law

4 enforcement investigations. An allegation is considered to be

5 credible when it has indicia of reliability.

6 (B) The Illinois Department shall deny, suspend or

7 terminate the eligibility of any person, firm, corporation,

8 association, agency, institution or other legal entity to

9 participate as a vendor of goods or services to recipients

10 under the medical assistance program under Article V, or may

11 exclude any such person or entity from participation as such a

12 vendor:

13 (1) immediately, if such vendor is not properly

14 licensed, certified, or authorized;

15 (2) within 30 days of the date when such vendor's

16 professional license, certification or other authorization

17 has been refused renewal, restricted, revoked, suspended,

18 or otherwise terminated; or

19 (3) if such vendor has been convicted of a violation

20 of this Code, as provided in Article VIIIA.

21 (C) Upon termination, suspension, or exclusion of a vendor

22 of goods or services from participation in the medical

23 assistance program authorized by this Article, a person with

24 management responsibility for such vendor during the time of

25 any conduct which served as the basis for that vendor's

26 termination, suspension, or exclusion is barred from

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1 participation in the medical assistance program.

2 Upon termination, suspension, or exclusion of a corporate

3 vendor, the officers and persons owning, directly or

4 indirectly, 5% or more of the shares of stock or other

5 evidences of ownership in the vendor during the time of any

6 conduct which served as the basis for that vendor's

7 termination, suspension, or exclusion are barred from

8 participation in the medical assistance program. A person who

9 owns, directly or indirectly, 5% or more of the shares of stock

10 or other evidences of ownership in a terminated, suspended, or

11 excluded vendor may not transfer his or her ownership interest

12 in that vendor to his or her spouse, child, brother, sister,

13 parent, grandparent, grandchild, uncle, aunt, niece, nephew,

14 cousin, or relative by marriage.

15 Upon termination, suspension, or exclusion of a sole

16 proprietorship or partnership, the owner or partners during

17 the time of any conduct which served as the basis for that

18 vendor's termination, suspension, or exclusion are barred from

19 participation in the medical assistance program. The owner of

20 a terminated, suspended, or excluded vendor that is a sole

21 proprietorship, and a partner in a terminated, suspended, or

22 excluded vendor that is a partnership, may not transfer his or

23 her ownership or partnership interest in that vendor to his or

24 her spouse, child, brother, sister, parent, grandparent,

25 grandchild, uncle, aunt, niece, nephew, cousin, or relative by

26 marriage.

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1 A person who owns, directly or indirectly, 5% or more of

2 the shares of stock or other evidences of ownership in a

3 corporate or limited liability company vendor who owes a debt

4 to the Department, if that vendor has not made payment

5 arrangements acceptable to the Department, shall not transfer

6 his or her ownership interest in that vendor, or vendor assets

7 of any kind, to his or her spouse, child, brother, sister,

8 parent, grandparent, grandchild, uncle, aunt, niece, nephew,

9 cousin, or relative by marriage.

10 Rules adopted by the Illinois Department to implement

11 these provisions shall specifically include a definition of

12 the term "management responsibility" as used in this Section.

13 Such definition shall include, but not be limited to, typical

14 job titles, and duties and descriptions which will be

15 considered as within the definition of individuals with

16 management responsibility for a provider.

17 A vendor or a prior vendor who has been terminated,

18 excluded, or suspended from the medical assistance program, or

19 from another state or federal medical assistance or health

20 care program, and any individual currently or previously

21 barred from the medical assistance program, or from another

22 state or federal medical assistance or health care program, as

23 a result of being an officer or a person owning, directly or

24 indirectly, 5% or more of the shares of stock or other

25 evidences of ownership in a corporate or limited liability

26 company vendor during the time of any conduct which served as

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1 the basis for that vendor's termination, suspension, or

2 exclusion, may be required to post a surety bond as part of a

3 condition of enrollment or participation in the medical

4 assistance program. The Illinois Department shall establish,

5 by rule, the criteria and requirements for determining when a

6 surety bond must be posted and the value of the bond.

7 A vendor or a prior vendor who has a debt owed to the

8 Illinois Department and any individual currently or previously

9 barred from the medical assistance program, or from another

10 state or federal medical assistance or health care program, as

11 a result of being an officer or a person owning, directly or

12 indirectly, 5% or more of the shares of stock or other

13 evidences of ownership in that corporate or limited liability

14 company vendor during the time of any conduct which served as

15 the basis for the debt, may be required to post a surety bond

16 as part of a condition of enrollment or participation in the

17 medical assistance program. The Illinois Department shall

18 establish, by rule, the criteria and requirements for

19 determining when a surety bond must be posted and the value of

20 the bond.

21 (D) If a vendor has been suspended from the medical

22 assistance program under Article V of the Code, the Director

23 may require that such vendor correct any deficiencies which

24 served as the basis for the suspension. The Director shall

25 specify in the suspension order a specific period of time,

26 which shall not exceed one year from the date of the order,

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1 during which a suspended vendor shall not be eligible to

2 participate. At the conclusion of the period of suspension the

3 Director shall reinstate such vendor, unless he finds that

4 such vendor has not corrected deficiencies upon which the

5 suspension was based.

6 If a vendor has been terminated, suspended, or excluded

7 from the medical assistance program under Article V, such

8 vendor shall be barred from participation for at least one

9 year, except that if a vendor has been terminated, suspended,

10 or excluded based on a conviction of a violation of Article

11 VIIIA or a conviction of a felony based on fraud or a willful

12 misrepresentation related to (i) the medical assistance

13 program under Article V, (ii) a federal or another state's

14 medical assistance or health care program, or (iii) the

15 provision of health care services, then the vendor shall be

16 barred from participation for 5 years or for the length of the

17 vendor's sentence for that conviction, whichever is longer. At

18 the end of one year a vendor who has been terminated,

19 suspended, or excluded may apply for reinstatement to the

20 program. Upon proper application to be reinstated such vendor

21 may be deemed eligible by the Director providing that such

22 vendor meets the requirements for eligibility under this Code.

23 If such vendor is deemed not eligible for reinstatement, he

24 shall be barred from again applying for reinstatement for one

25 year from the date his application for reinstatement is

26 denied.

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1 A vendor whose termination, suspension, or exclusion from

2 participation in the Illinois medical assistance program under

3 Article V was based solely on an action by a governmental

4 entity other than the Illinois Department may, upon

5 reinstatement by that governmental entity or upon reversal of

6 the termination, suspension, or exclusion, apply for

7 rescission of the termination, suspension, or exclusion from

8 participation in the Illinois medical assistance program. Upon

9 proper application for rescission, the vendor may be deemed

10 eligible by the Director if the vendor meets the requirements

11 for eligibility under this Code.

12 If a vendor has been terminated, suspended, or excluded

13 and reinstated to the medical assistance program under Article

14 V and the vendor is terminated, suspended, or excluded a

15 second or subsequent time from the medical assistance program,

16 the vendor shall be barred from participation for at least 2

17 years, except that if a vendor has been terminated, suspended,

18 or excluded a second time based on a conviction of a violation

19 of Article VIIIA or a conviction of a felony based on fraud or

20 a willful misrepresentation related to (i) the medical

21 assistance program under Article V, (ii) a federal or another

22 state's medical assistance or health care program, or (iii)

23 the provision of health care services, then the vendor shall

24 be barred from participation for life. At the end of 2 years, a

25 vendor who has been terminated, suspended, or excluded may

26 apply for reinstatement to the program. Upon application to be

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1 reinstated, the vendor may be deemed eligible if the vendor

2 meets the requirements for eligibility under this Code. If the

3 vendor is deemed not eligible for reinstatement, the vendor

4 shall be barred from again applying for reinstatement for 2

5 years from the date the vendor's application for reinstatement

6 is denied.

7 (E) The Illinois Department may recover money improperly

8 or erroneously paid, or overpayments, either by setoff,

9 crediting against future billings or by requiring direct

10 repayment to the Illinois Department. The Illinois Department

11 may suspend or deny payment, in whole or in part, if such

12 payment would be improper or erroneous or would otherwise

13 result in overpayment.

14 (1) Payments may be suspended, denied, or recovered

15 from a vendor or alternate payee: (i) for services

16 rendered in violation of the Illinois Department's

17 provider notices, statutes, rules, and regulations; (ii)

18 for services rendered in violation of the terms and

19 conditions prescribed by the Illinois Department in its

20 vendor agreement; (iii) for any vendor who fails to grant

21 the Office of Inspector General timely access to full and

22 complete records, including, but not limited to, records

23 relating to recipients under the medical assistance

24 program for the most recent 6 years, in accordance with

25 Section 140.28 of Title 89 of the Illinois Administrative

26 Code, and other information for the purpose of audits,

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1 investigations, or other program integrity functions,

2 after reasonable written request by the Inspector General;

3 this subsection (E) does not require vendors to make

4 available the medical records of patients for whom

5 services are not reimbursed under this Code or to provide

6 access to medical records more than 6 years old; (iv) when

7 the vendor has knowingly made, or caused to be made, any

8 false statement or representation of a material fact in

9 connection with the administration of the medical

10 assistance program; or (v) when the vendor previously

11 rendered services while terminated, suspended, or excluded

12 from participation in the medical assistance program or

13 while terminated or excluded from participation in another

14 state or federal medical assistance or health care

15 program.

16 (2) Notwithstanding any other provision of law, if a

17 vendor has the same taxpayer identification number

18 (assigned under Section 6109 of the Internal Revenue Code

19 of 1986) as is assigned to a vendor with past-due

20 financial obligations to the Illinois Department, the

21 Illinois Department may make any necessary adjustments to

22 payments to that vendor in order to satisfy any past-due

23 obligations, regardless of whether the vendor is assigned

24 a different billing number under the medical assistance

25 program.

26 (E-5) Civil monetary penalties.

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1 (1) As used in this subsection (E-5):

2 (a) "Knowingly" means that a person, with respect

3 to information: (i) has actual knowledge of the

4 information; (ii) acts in deliberate ignorance of the

5 truth or falsity of the information; or (iii) acts in

6 reckless disregard of the truth or falsity of the

7 information. No proof of specific intent to defraud is

8 required.

9 (b) "Overpayment" means any funds that a person

10 receives or retains from the medical assistance

11 program to which the person, after applicable

12 reconciliation, is not entitled under this Code.

13 (c) "Remuneration" means the offer or transfer of

14 items or services for free or for other than fair

15 market value by a person; however, remuneration does

16 not include items or services of a nominal value of no

17 more than $10 per item or service, or $50 in the

18 aggregate on an annual basis, or any other offer or

19 transfer of items or services as determined by the

20 Department.

21 (d) "Should know" means that a person, with

22 respect to information: (i) acts in deliberate

23 ignorance of the truth or falsity of the information;

24 or (ii) acts in reckless disregard of the truth or

25 falsity of the information. No proof of specific

26 intent to defraud is required.

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1 (2) Any person (including a vendor, provider,

2 organization, agency, or other entity, or an alternate

3 payee thereof, but excluding a recipient) who:

4 (a) knowingly presents or causes to be presented

5 to an officer, employee, or agent of the State, a claim

6 that the Department determines:

7 (i) is for a medical or other item or service

8 that the person knows or should know was not

9 provided as claimed, including any person who

10 engages in a pattern or practice of presenting or

11 causing to be presented a claim for an item or

12 service that is based on a code that the person

13 knows or should know will result in a greater

14 payment to the person than the code the person

15 knows or should know is applicable to the item or

16 service actually provided;

17 (ii) is for a medical or other item or service

18 and the person knows or should know that the claim

19 is false or fraudulent;

20 (iii) is presented for a vendor physician's

21 service, or an item or service incident to a

22 vendor physician's service, by a person who knows

23 or should know that the individual who furnished,

24 or supervised the furnishing of, the service:

25 (AA) was not licensed as a physician;

26 (BB) was licensed as a physician but such

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1 license had been obtained through a

2 misrepresentation of material fact (including

3 cheating on an examination required for

4 licensing); or

5 (CC) represented to the patient at the

6 time the service was furnished that the

7 physician was certified in a medical specialty

8 by a medical specialty board, when the

9 individual was not so certified;

10 (iv) is for a medical or other item or service

11 furnished during a period in which the person was

12 excluded from the medical assistance program or a

13 federal or state health care program under which

14 the claim was made pursuant to applicable law; or

15 (v) is for a pattern of medical or other items

16 or services that a person knows or should know are

17 not medically necessary;

18 (b) knowingly presents or causes to be presented

19 to any person a request for payment which is in

20 violation of the conditions for receipt of vendor

21 payments under the medical assistance program under

22 Section 11-13 of this Code;

23 (c) knowingly gives or causes to be given to any

24 person, with respect to medical assistance program

25 coverage of inpatient hospital services, information

26 that he or she knows or should know is false or

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1 misleading, and that could reasonably be expected to

2 influence the decision when to discharge such person

3 or other individual from the hospital;

4 (d) in the case of a person who is not an

5 organization, agency, or other entity, is excluded

6 from participating in the medical assistance program

7 or a federal or state health care program and who, at

8 the time of a violation of this subsection (E-5):

9 (i) retains a direct or indirect ownership or

10 control interest in an entity that is

11 participating in the medical assistance program or

12 a federal or state health care program, and who

13 knows or should know of the action constituting

14 the basis for the exclusion; or

15 (ii) is an officer or managing employee of

16 such an entity;

17 (e) offers or transfers remuneration to any

18 individual eligible for benefits under the medical

19 assistance program that such person knows or should

20 know is likely to influence such individual to order

21 or receive from a particular vendor, provider,

22 practitioner, or supplier any item or service for

23 which payment may be made, in whole or in part, under

24 the medical assistance program;

25 (f) arranges or contracts (by employment or

26 otherwise) with an individual or entity that the

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1 person knows or should know is excluded from

2 participation in the medical assistance program or a

3 federal or state health care program, for the

4 provision of items or services for which payment may

5 be made under such a program;

6 (g) commits an act described in subsection (b) or

7 (c) of Section 8A-3;

8 (h) knowingly makes, uses, or causes to be made or

9 used, a false record or statement material to a false

10 or fraudulent claim for payment for items and services

11 furnished under the medical assistance program;

12 (i) fails to grant timely access, upon reasonable

13 request (as defined by the Department by rule), to the

14 Inspector General, for the purpose of audits,

15 investigations, evaluations, or other statutory

16 functions of the Inspector General of the Department;

17 (j) orders or prescribes a medical or other item

18 or service during a period in which the person was

19 excluded from the medical assistance program or a

20 federal or state health care program, in the case

21 where the person knows or should know that a claim for

22 such medical or other item or service will be made

23 under such a program;

24 (k) knowingly makes or causes to be made any false

25 statement, omission, or misrepresentation of a

26 material fact in any application, bid, or contract to

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1 participate or enroll as a vendor or provider of

2 services or a supplier under the medical assistance

3 program;

4 (l) knows of an overpayment and does not report

5 and return the overpayment to the Department in

6 accordance with paragraph (6);

7 shall be subject, in addition to any other penalties that

8 may be prescribed by law, to a civil money penalty of not

9 more than $10,000 for each item or service (or, in cases

10 under subparagraph (c), $15,000 for each individual with

11 respect to whom false or misleading information was given;

12 in cases under subparagraph (d), $10,000 for each day the

13 prohibited relationship occurs; in cases under

14 subparagraph (g), $50,000 for each such act; in cases

15 under subparagraph (h), $50,000 for each false record or

16 statement; in cases under subparagraph (i), $15,000 for

17 each day of the failure described in such subparagraph; or

18 in cases under subparagraph (k), $50,000 for each false

19 statement, omission, or misrepresentation of a material

20 fact). In addition, such a person shall be subject to an

21 assessment of not more than 3 times the amount claimed for

22 each such item or service in lieu of damages sustained by

23 the State because of such claim (or, in cases under

24 subparagraph (g), damages of not more than 3 times the

25 total amount of remuneration offered, paid, solicited, or

26 received, without regard to whether a portion of such

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1 remuneration was offered, paid, solicited, or received for

2 a lawful purpose; or in cases under subparagraph (k), an

3 assessment of not more than 3 times the total amount

4 claimed for each item or service for which payment was

5 made based upon the application, bid, or contract

6 containing the false statement, omission, or

7 misrepresentation of a material fact).

8 (3) In addition, the Director or his or her designee

9 may make a determination in the same proceeding to

10 exclude, terminate, suspend, or bar the person from

11 participation in the medical assistance program.

12 (4) The Illinois Department may seek the civil

13 monetary penalties and exclusion, termination, suspension,

14 or barment identified in this subsection (E-5). Prior to

15 the imposition of any penalties or sanctions, the affected

16 person shall be afforded an opportunity for a hearing

17 after reasonable notice. The Department shall establish

18 hearing procedures by rule.

19 (5) Any final order, decision, or other determination

20 made, issued, or executed by the Director under the

21 provisions of this subsection (E-5), whereby a person is

22 aggrieved, shall be subject to review in accordance with

23 the provisions of the Administrative Review Law, and the

24 rules adopted pursuant thereto, which shall apply to and

25 govern all proceedings for the judicial review of final

26 administrative decisions of the Director.

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1 (6)(a) If a person has received an overpayment, the

2 person shall:

3 (i) report and return the overpayment to the

4 Department at the correct address; and

5 (ii) notify the Department in writing of the

6 reason for the overpayment.

7 (b) An overpayment must be reported and returned under

8 subparagraph (a) by the later of:

9 (i) the date which is 60 days after the date on

10 which the overpayment was identified; or

11 (ii) the date any corresponding cost report is

12 due, if applicable.

13 (E-10) A vendor who disputes an overpayment identified as

14 part of a Department audit shall utilize the Department's

15 self-referral disclosure protocol as set forth under this Code

16 to identify, investigate, and return to the Department any

17 undisputed audit overpayment amount. Unless the disputed

18 overpayment amount is subject to a fraud payment suspension,

19 or involves a termination sanction, the Department shall defer

20 the recovery of the disputed overpayment amount up to one year

21 after the date of the Department's final audit determination,

22 or earlier, or as required by State or federal law. If the

23 administrative hearing extends beyond one year, and such delay

24 was not caused by the request of the vendor, then the

25 Department shall not recover the disputed overpayment amount

26 until the date of the final administrative decision. If a

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1 final administrative decision establishes that the disputed

2 overpayment amount is owed to the Department, then the amount

3 shall be immediately due to the Department. The Department

4 shall be entitled to recover interest from the vendor on the

5 overpayment amount from the date of the overpayment through

6 the date the vendor returns the overpayment to the Department

7 at a rate not to exceed the Wall Street Journal Prime Rate, as

8 published from time to time, but not to exceed 5%. Any interest

9 billed by the Department shall be due immediately upon receipt

10 of the Department's billing statement.

11 (F) The Illinois Department may withhold payments to any

12 vendor or alternate payee prior to or during the pendency of

13 any audit or proceeding under this Section, and through the

14 pendency of any administrative appeal or administrative review

15 by any court proceeding. The Illinois Department shall state

16 by rule with as much specificity as practicable the conditions

17 under which payments will not be withheld under this Section.

18 Payments may be denied for bills submitted with service dates

19 occurring during the pendency of a proceeding, after a final

20 decision has been rendered, or after the conclusion of any

21 administrative appeal, where the final administrative decision

22 is to terminate, exclude, or suspend eligibility to

23 participate in the medical assistance program. The Illinois

24 Department shall state by rule with as much specificity as

25 practicable the conditions under which payments will not be

26 denied for such bills. The Illinois Department shall state by

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1 rule a process and criteria by which a vendor or alternate

2 payee may request full or partial release of payments withheld

3 under this subsection. The Department must complete a

4 proceeding under this Section in a timely manner.

5 Notwithstanding recovery allowed under subsection (E) or

6 this subsection (F), the Illinois Department may withhold

7 payments to any vendor or alternate payee who is not properly

8 licensed, certified, or in compliance with State or federal

9 agency regulations. Payments may be denied for bills submitted

10 with service dates occurring during the period of time that a

11 vendor is not properly licensed, certified, or in compliance

12 with State or federal regulations. Facilities licensed under

13 the Nursing Home Care Act shall have payments denied or

14 withheld pursuant to subsection (I) of this Section.

15 (F-5) The Illinois Department may temporarily withhold

16 payments to a vendor or alternate payee if any of the following

17 individuals have been indicted or otherwise charged under a

18 law of the United States or this or any other state with an

19 offense that is based on alleged fraud or willful

20 misrepresentation on the part of the individual related to (i)

21 the medical assistance program under Article V of this Code,

22 (ii) a federal or another state's medical assistance or health

23 care program, or (iii) the provision of health care services:

24 (1) If the vendor or alternate payee is a corporation:

25 an officer of the corporation or an individual who owns,

26 either directly or indirectly, 5% or more of the shares of

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1 stock or other evidence of ownership of the corporation.

2 (2) If the vendor is a sole proprietorship: the owner

3 of the sole proprietorship.

4 (3) If the vendor or alternate payee is a partnership:

5 a partner in the partnership.

6 (4) If the vendor or alternate payee is any other

7 business entity authorized by law to transact business in

8 this State: an officer of the entity or an individual who

9 owns, either directly or indirectly, 5% or more of the

10 evidences of ownership of the entity.

11 If the Illinois Department withholds payments to a vendor

12 or alternate payee under this subsection, the Department shall

13 not release those payments to the vendor or alternate payee

14 while any criminal proceeding related to the indictment or

15 charge is pending unless the Department determines that there

16 is good cause to release the payments before completion of the

17 proceeding. If the indictment or charge results in the

18 individual's conviction, the Illinois Department shall retain

19 all withheld payments, which shall be considered forfeited to

20 the Department. If the indictment or charge does not result in

21 the individual's conviction, the Illinois Department shall

22 release to the vendor or alternate payee all withheld

23 payments.

24 (F-10) If the Illinois Department establishes that the

25 vendor or alternate payee owes a debt to the Illinois

26 Department, and the vendor or alternate payee subsequently

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1 fails to pay or make satisfactory payment arrangements with

2 the Illinois Department for the debt owed, the Illinois

3 Department may seek all remedies available under the law of

4 this State to recover the debt, including, but not limited to,

5 wage garnishment or the filing of claims or liens against the

6 vendor or alternate payee.

7 (F-15) Enforcement of judgment.

8 (1) Any fine, recovery amount, other sanction, or

9 costs imposed, or part of any fine, recovery amount, other

10 sanction, or cost imposed, remaining unpaid after the

11 exhaustion of or the failure to exhaust judicial review

12 procedures under the Illinois Administrative Review Law is

13 a debt due and owing the State and may be collected using

14 all remedies available under the law.

15 (2) After expiration of the period in which judicial

16 review under the Illinois Administrative Review Law may be

17 sought for a final administrative decision, unless stayed

18 by a court of competent jurisdiction, the findings,

19 decision, and order of the Director may be enforced in the

20 same manner as a judgment entered by a court of competent

21 jurisdiction.

22 (3) In any case in which any person or entity has

23 failed to comply with a judgment ordering or imposing any

24 fine or other sanction, any expenses incurred by the

25 Illinois Department to enforce the judgment, including,

26 but not limited to, attorney's fees, court costs, and

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1 costs related to property demolition or foreclosure, after

2 they are fixed by a court of competent jurisdiction or the

3 Director, shall be a debt due and owing the State and may

4 be collected in accordance with applicable law. Prior to

5 any expenses being fixed by a final administrative

6 decision pursuant to this subsection (F-15), the Illinois

7 Department shall provide notice to the individual or

8 entity that states that the individual or entity shall

9 appear at a hearing before the administrative hearing

10 officer to determine whether the individual or entity has

11 failed to comply with the judgment. The notice shall set

12 the date for such a hearing, which shall not be less than 7

13 days from the date that notice is served. If notice is

14 served by mail, the 7-day period shall begin to run on the

15 date that the notice was deposited in the mail.

16 (4) Upon being recorded in the manner required by

17 Article XII of the Code of Civil Procedure or by the

18 Uniform Commercial Code, a lien shall be imposed on the

19 real estate or personal estate, or both, of the individual

20 or entity in the amount of any debt due and owing the State

21 under this Section. The lien may be enforced in the same

22 manner as a judgment of a court of competent jurisdiction.

23 A lien shall attach to all property and assets of such

24 person, firm, corporation, association, agency,

25 institution, or other legal entity until the judgment is

26 satisfied.

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1 (5) The Director may set aside any judgment entered by

2 default and set a new hearing date upon a petition filed at

3 any time (i) if the petitioner's failure to appear at the

4 hearing was for good cause, or (ii) if the petitioner

5 established that the Department did not provide proper

6 service of process. If any judgment is set aside pursuant

7 to this paragraph (5), the hearing officer shall have

8 authority to enter an order extinguishing any lien which

9 has been recorded for any debt due and owing the Illinois

10 Department as a result of the vacated default judgment.

11 (G) The provisions of the Administrative Review Law, as

12 now or hereafter amended, and the rules adopted pursuant

13 thereto, shall apply to and govern all proceedings for the

14 judicial review of final administrative decisions of the

15 Illinois Department under this Section. The term

16 "administrative decision" is defined as in Section 3-101 of

17 the Code of Civil Procedure.

18 (G-5) Vendors who pose a risk of fraud, waste, abuse, or

19 harm.

20 (1) Notwithstanding any other provision in this

21 Section, the Department may terminate, suspend, or exclude

22 vendors who pose a risk of fraud, waste, abuse, or harm

23 from participation in the medical assistance program prior

24 to an evidentiary hearing but after reasonable notice and

25 opportunity to respond as established by the Department by

26 rule.

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1 (2) Vendors who pose a risk of fraud, waste, abuse, or

2 harm shall submit to a fingerprint-based criminal

3 background check on current and future information

4 available in the State system and current information

5 available through the Federal Bureau of Investigation's

6 system by submitting all necessary fees and information in

7 the form and manner prescribed by the Illinois State

8 Police. The following individuals shall be subject to the

9 check:

10 (A) In the case of a vendor that is a corporation,

11 every shareholder who owns, directly or indirectly, 5%

12 or more of the outstanding shares of the corporation.

13 (B) In the case of a vendor that is a partnership,

14 every partner.

15 (C) In the case of a vendor that is a sole

16 proprietorship, the sole proprietor.

17 (D) Each officer or manager of the vendor.

18 Each such vendor shall be responsible for payment of

19 the cost of the criminal background check.

20 (3) Vendors who pose a risk of fraud, waste, abuse, or

21 harm may be required to post a surety bond. The Department

22 shall establish, by rule, the criteria and requirements

23 for determining when a surety bond must be posted and the

24 value of the bond.

25 (4) The Department, or its agents, may refuse to

26 accept requests for authorization from specific vendors

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1 who pose a risk of fraud, waste, abuse, or harm, including

2 prior-approval and post-approval requests, if:

3 (A) the Department has initiated a notice of

4 termination, suspension, or exclusion of the vendor

5 from participation in the medical assistance program;

6 or

7 (B) the Department has issued notification of its

8 withholding of payments pursuant to subsection (F-5)

9 of this Section; or

10 (C) the Department has issued a notification of

11 its withholding of payments due to reliable evidence

12 of fraud or willful misrepresentation pending

13 investigation.

14 (5) As used in this subsection, the following terms

15 are defined as follows:

16 (A) "Fraud" means an intentional deception or

17 misrepresentation made by a person with the knowledge

18 that the deception could result in some unauthorized

19 benefit to himself or herself or some other person. It

20 includes any act that constitutes fraud under

21 applicable federal or State law.

22 (B) "Abuse" means provider practices that are

23 inconsistent with sound fiscal, business, or medical

24 practices and that result in an unnecessary cost to

25 the medical assistance program or in reimbursement for

26 services that are not medically necessary or that fail

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1 to meet professionally recognized standards for health

2 care. It also includes recipient practices that result

3 in unnecessary cost to the medical assistance program.

4 Abuse does not include diagnostic or therapeutic

5 measures conducted primarily as a safeguard against

6 possible vendor liability.

7 (C) "Waste" means the unintentional misuse of

8 medical assistance resources, resulting in unnecessary

9 cost to the medical assistance program. Waste does not

10 include diagnostic or therapeutic measures conducted

11 primarily as a safeguard against possible vendor

12 liability.

13 (D) "Harm" means physical, mental, or monetary

14 damage to recipients or to the medical assistance

15 program.

16 (G-6) The Illinois Department, upon making a determination

17 based upon information in the possession of the Illinois

18 Department that continuation of participation in the medical

19 assistance program by a vendor would constitute an immediate

20 danger to the public, may immediately suspend such vendor's

21 participation in the medical assistance program without a

22 hearing. In instances in which the Illinois Department

23 immediately suspends the medical assistance program

24 participation of a vendor under this Section, a hearing upon

25 the vendor's participation must be convened by the Illinois

26 Department within 15 days after such suspension and completed

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1 without appreciable delay. Such hearing shall be held to

2 determine whether to recommend to the Director that the

3 vendor's medical assistance program participation be denied,

4 terminated, suspended, placed on provisional status, or

5 reinstated. In the hearing, any evidence relevant to the

6 vendor constituting an immediate danger to the public may be

7 introduced against such vendor; provided, however, that the

8 vendor, or his or her counsel, shall have the opportunity to

9 discredit, impeach, and submit evidence rebutting such

10 evidence.

11 (H) Nothing contained in this Code shall in any way limit

12 or otherwise impair the authority or power of any State agency

13 responsible for licensing of vendors.

14 (I) Based on a finding of noncompliance on the part of a

15 nursing home with any requirement for certification under

16 Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.

17 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois

18 Department may impose one or more of the following remedies

19 after notice to the facility:

20 (1) Termination of the provider agreement.

21 (2) Temporary management.

22 (3) Denial of payment for new admissions.

23 (4) Civil money penalties.

24 (5) Closure of the facility in emergency situations or

25 transfer of residents, or both.

26 (6) State monitoring.

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1 (7) Denial of all payments when the U.S. Department of

2 Health and Human Services has imposed this sanction.

3 The Illinois Department shall by rule establish criteria

4 governing continued payments to a nursing facility subsequent

5 to termination of the facility's provider agreement if, in the

6 sole discretion of the Illinois Department, circumstances

7 affecting the health, safety, and welfare of the facility's

8 residents require those continued payments. The Illinois

9 Department may condition those continued payments on the

10 appointment of temporary management, sale of the facility to

11 new owners or operators, or other arrangements that the

12 Illinois Department determines best serve the needs of the

13 facility's residents.

14 Except in the case of a facility that has a right to a

15 hearing on the finding of noncompliance before an agency of

16 the federal government, a facility may request a hearing

17 before a State agency on any finding of noncompliance within

18 60 days after the notice of the intent to impose a remedy.

19 Except in the case of civil money penalties, a request for a

20 hearing shall not delay imposition of the penalty. The choice

21 of remedies is not appealable at a hearing. The level of

22 noncompliance may be challenged only in the case of a civil

23 money penalty. The Illinois Department shall provide by rule

24 for the State agency that will conduct the evidentiary

25 hearings.

26 The Illinois Department may collect interest on unpaid

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1 civil money penalties.

2 The Illinois Department may adopt all rules necessary to

3 implement this subsection (I).

4 (J) The Illinois Department, by rule, may permit

5 individual practitioners to designate that Department payments

6 that may be due the practitioner be made to an alternate payee

7 or alternate payees.

8 (a) Such alternate payee or alternate payees shall be

9 required to register as an alternate payee in the Medical

10 Assistance Program with the Illinois Department.

11 (b) If a practitioner designates an alternate payee,

12 the alternate payee and practitioner shall be jointly and

13 severally liable to the Department for payments made to

14 the alternate payee. Pursuant to subsection (E) of this

15 Section, any Department action to suspend or deny payment

16 or recover money or overpayments from an alternate payee

17 shall be subject to an administrative hearing.

18 (c) Registration as an alternate payee or alternate

19 payees in the Illinois Medical Assistance Program shall be

20 conditional. At any time, the Illinois Department may deny

21 or cancel any alternate payee's registration in the

22 Illinois Medical Assistance Program without cause. Any

23 such denial or cancellation is not subject to an

24 administrative hearing.

25 (d) The Illinois Department may seek a revocation of

26 any alternate payee, and all owners, officers, and

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1 individuals with management responsibility for such

2 alternate payee shall be permanently prohibited from

3 participating as an owner, an officer, or an individual

4 with management responsibility with an alternate payee in

5 the Illinois Medical Assistance Program, if after

6 reasonable notice and opportunity for a hearing the

7 Illinois Department finds that:

8 (1) the alternate payee is not complying with the

9 Department's policy or rules and regulations, or with

10 the terms and conditions prescribed by the Illinois

11 Department in its alternate payee registration

12 agreement; or

13 (2) the alternate payee has failed to keep or make

14 available for inspection, audit, or copying, after

15 receiving a written request from the Illinois

16 Department, such records regarding payments claimed as

17 an alternate payee; or

18 (3) the alternate payee has failed to furnish any

19 information requested by the Illinois Department

20 regarding payments claimed as an alternate payee; or

21 (4) the alternate payee has knowingly made, or

22 caused to be made, any false statement or

23 representation of a material fact in connection with

24 the administration of the Illinois Medical Assistance

25 Program; or

26 (5) the alternate payee, a person with management

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1 responsibility for an alternate payee, an officer or

2 person owning, either directly or indirectly, 5% or

3 more of the shares of stock or other evidences of

4 ownership in a corporate alternate payee, or a partner

5 in a partnership which is an alternate payee:

6 (a) was previously terminated, suspended, or

7 excluded from participation as a vendor in the

8 Illinois Medical Assistance Program, or was

9 previously revoked as an alternate payee in the

10 Illinois Medical Assistance Program, or was

11 terminated, suspended, or excluded from

12 participation as a vendor in a medical assistance

13 program in another state that is of the same kind

14 as the program of medical assistance provided

15 under Article V of this Code; or

16 (b) was a person with management

17 responsibility for a vendor previously terminated,

18 suspended, or excluded from participation as a

19 vendor in the Illinois Medical Assistance Program,

20 or was previously revoked as an alternate payee in

21 the Illinois Medical Assistance Program, or was

22 terminated, suspended, or excluded from

23 participation as a vendor in a medical assistance

24 program in another state that is of the same kind

25 as the program of medical assistance provided

26 under Article V of this Code, during the time of

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1 conduct which was the basis for that vendor's

2 termination, suspension, or exclusion or alternate

3 payee's revocation; or

4 (c) was an officer, or person owning, either

5 directly or indirectly, 5% or more of the shares

6 of stock or other evidences of ownership in a

7 corporate vendor previously terminated, suspended,

8 or excluded from participation as a vendor in the

9 Illinois Medical Assistance Program, or was

10 previously revoked as an alternate payee in the

11 Illinois Medical Assistance Program, or was

12 terminated, suspended, or excluded from

13 participation as a vendor in a medical assistance

14 program in another state that is of the same kind

15 as the program of medical assistance provided

16 under Article V of this Code, during the time of

17 conduct which was the basis for that vendor's

18 termination, suspension, or exclusion; or

19 (d) was an owner of a sole proprietorship or

20 partner in a partnership previously terminated,

21 suspended, or excluded from participation as a

22 vendor in the Illinois Medical Assistance Program,

23 or was previously revoked as an alternate payee in

24 the Illinois Medical Assistance Program, or was

25 terminated, suspended, or excluded from

26 participation as a vendor in a medical assistance

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1 program in another state that is of the same kind

2 as the program of medical assistance provided

3 under Article V of this Code, during the time of

4 conduct which was the basis for that vendor's

5 termination, suspension, or exclusion or alternate

6 payee's revocation; or

7 (6) the alternate payee, a person with management

8 responsibility for an alternate payee, an officer or

9 person owning, either directly or indirectly, 5% or

10 more of the shares of stock or other evidences of

11 ownership in a corporate alternate payee, or a partner

12 in a partnership which is an alternate payee:

13 (a) has engaged in conduct prohibited by

14 applicable federal or State law or regulation

15 relating to the Illinois Medical Assistance

16 Program; or

17 (b) was a person with management

18 responsibility for a vendor or alternate payee at

19 the time that the vendor or alternate payee

20 engaged in practices prohibited by applicable

21 federal or State law or regulation relating to the

22 Illinois Medical Assistance Program; or

23 (c) was an officer, or person owning, either

24 directly or indirectly, 5% or more of the shares

25 of stock or other evidences of ownership in a

26 vendor or alternate payee at the time such vendor

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1 or alternate payee engaged in practices prohibited

2 by applicable federal or State law or regulation

3 relating to the Illinois Medical Assistance

4 Program; or

5 (d) was an owner of a sole proprietorship or

6 partner in a partnership which was a vendor or

7 alternate payee at the time such vendor or

8 alternate payee engaged in practices prohibited by

9 applicable federal or State law or regulation

10 relating to the Illinois Medical Assistance

11 Program; or

12 (7) the direct or indirect ownership of the vendor

13 or alternate payee (including the ownership of a

14 vendor or alternate payee that is a partner's interest

15 in a vendor or alternate payee, or ownership of 5% or

16 more of the shares of stock or other evidences of

17 ownership in a corporate vendor or alternate payee)

18 has been transferred by an individual who is

19 terminated, suspended, or excluded or barred from

20 participating as a vendor or is prohibited or revoked

21 as an alternate payee to the individual's spouse,

22 child, brother, sister, parent, grandparent,

23 grandchild, uncle, aunt, niece, nephew, cousin, or

24 relative by marriage.

25 (K) The Illinois Department of Healthcare and Family

26 Services may withhold payments, in whole or in part, to a

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1 provider or alternate payee where there is credible evidence,

2 received from State or federal law enforcement or federal

3 oversight agencies or from the results of a preliminary

4 Department audit, that the circumstances giving rise to the

5 need for a withholding of payments may involve fraud or

6 willful misrepresentation under the Illinois Medical

7 Assistance program. The Department shall by rule define what

8 constitutes "credible" evidence for purposes of this

9 subsection. The Department may withhold payments without first

10 notifying the provider or alternate payee of its intention to

11 withhold such payments. A provider or alternate payee may

12 request a reconsideration of payment withholding, and the

13 Department must grant such a request. The Department shall

14 state by rule a process and criteria by which a provider or

15 alternate payee may request full or partial release of

16 payments withheld under this subsection. This request may be

17 made at any time after the Department first withholds such

18 payments.

19 (a) The Illinois Department must send notice of its

20 withholding of program payments within 5 days of taking

21 such action. The notice must set forth the general

22 allegations as to the nature of the withholding action,

23 but need not disclose any specific information concerning

24 its ongoing investigation. The notice must do all of the

25 following:

26 (1) State that payments are being withheld in

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1 accordance with this subsection.

2 (2) State that the withholding is for a temporary

3 period, as stated in paragraph (b) of this subsection,

4 and cite the circumstances under which withholding

5 will be terminated.

6 (3) Specify, when appropriate, which type or types

7 of Medicaid claims withholding is effective.

8 (4) Inform the provider or alternate payee of the

9 right to submit written evidence for reconsideration

10 of the withholding by the Illinois Department.

11 (5) Inform the provider or alternate payee that a

12 written request may be made to the Illinois Department

13 for full or partial release of withheld payments and

14 that such requests may be made at any time after the

15 Department first withholds such payments.

16 (b) All withholding-of-payment actions under this

17 subsection shall be temporary and shall not continue after

18 any of the following:

19 (1) The Illinois Department or the prosecuting

20 authorities determine that there is insufficient

21 evidence of fraud or willful misrepresentation by the

22 provider or alternate payee.

23 (2) Legal proceedings related to the provider's or

24 alternate payee's alleged fraud, willful

25 misrepresentation, violations of this Act, or

26 violations of the Illinois Department's administrative

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1 rules are completed.

2 (3) The withholding of payments for a period of 3

3 years.

4 (c) The Illinois Department may adopt all rules

5 necessary to implement this subsection (K).

6 (K-5) The Illinois Department may withhold payments, in

7 whole or in part, to a provider or alternate payee upon

8 initiation of an audit, quality of care review, investigation

9 when there is a credible allegation of fraud, or the provider

10 or alternate payee demonstrating a clear failure to cooperate

11 with the Illinois Department such that the circumstances give

12 rise to the need for a withholding of payments. As used in this

13 subsection, "credible allegation" is defined to include an

14 allegation from any source, including, but not limited to,

15 fraud hotline complaints, claims data mining, patterns

16 identified through provider audits, civil actions filed under

17 the Illinois False Claims Act, and law enforcement

18 investigations. An allegation is considered to be credible

19 when it has indicia of reliability. The Illinois Department

20 may withhold payments without first notifying the provider or

21 alternate payee of its intention to withhold such payments. A

22 provider or alternate payee may request a hearing or a

23 reconsideration of payment withholding, and the Illinois

24 Department must grant such a request. The Illinois Department

25 shall state by rule a process and criteria by which a provider

26 or alternate payee may request a hearing or a reconsideration

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1 for the full or partial release of payments withheld under

2 this subsection. This request may be made at any time after the

3 Illinois Department first withholds such payments.

4 (a) The Illinois Department must send notice of its

5 withholding of program payments within 5 days of taking

6 such action. The notice must set forth the general

7 allegations as to the nature of the withholding action but

8 need not disclose any specific information concerning its

9 ongoing investigation. The notice must do all of the

10 following:

11 (1) State that payments are being withheld in

12 accordance with this subsection.

13 (2) State that the withholding is for a temporary

14 period, as stated in paragraph (b) of this subsection,

15 and cite the circumstances under which withholding

16 will be terminated.

17 (3) Specify, when appropriate, which type or types

18 of claims are withheld.

19 (4) Inform the provider or alternate payee of the

20 right to request a hearing or a reconsideration of the

21 withholding by the Illinois Department, including the

22 ability to submit written evidence.

23 (5) Inform the provider or alternate payee that a

24 written request may be made to the Illinois Department

25 for a hearing or a reconsideration for the full or

26 partial release of withheld payments and that such

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1 requests may be made at any time after the Illinois

2 Department first withholds such payments.

3 (b) All withholding of payment actions under this

4 subsection shall be temporary and shall not continue after

5 any of the following:

6 (1) The Illinois Department determines that there

7 is insufficient evidence of fraud, or the provider or

8 alternate payee demonstrates clear cooperation with

9 the Illinois Department, as determined by the Illinois

10 Department, such that the circumstances do not give

11 rise to the need for withholding of payments; or

12 (2) The withholding of payments has lasted for a

13 period in excess of 3 years.

14 (c) The Illinois Department may adopt all rules

15 necessary to implement this subsection (K-5).

16 (L) The Illinois Department shall establish a protocol to

17 enable health care providers to disclose an actual or

18 potential violation of this Section pursuant to a

19 self-referral disclosure protocol, referred to in this

20 subsection as "the protocol". The protocol shall include

21 direction for health care providers on a specific person,

22 official, or office to whom such disclosures shall be made.

23 The Illinois Department shall post information on the protocol

24 on the Illinois Department's public website. The Illinois

25 Department may adopt rules necessary to implement this

26 subsection (L). In addition to other factors that the Illinois

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1 Department finds appropriate, the Illinois Department may

2 consider a health care provider's timely use or failure to use

3 the protocol in considering the provider's failure to comply

4 with this Code.

5 (M) Notwithstanding any other provision of this Code, the

6 Illinois Department, at its discretion, may exempt an entity

7 licensed under the Nursing Home Care Act, the ID/DD Community

8 Care Act, or the MC/DD Act from the provisions of subsections

9 (A-15), (B), and (C) of this Section if the licensed entity is

10 in receivership.

11 (O) Enforcement of advance payment agreements. To the

12 extent not prohibited by federal or State law, and

13 notwithstanding any other provision of this Code, if a

14 provider fails to comply with the terms of an advance payment

15 agreement, the Department is authorized to collect any unpaid

16 advance balance through one or more of the following methods:

17 (1) Direct withholding of Department reimbursements.

18 The Department may withhold reimbursement or other amounts

19 otherwise payable by the Department to the provider,

20 including, but not limited to, fee-for-service claims

21 payments, supplemental payments, and any other amounts the

22 Department is obligated to pay the provider under the

23 medical assistance program, and apply such withheld

24 amounts as repayment of the unpaid advance.

25 (2) Managed care organizations remittance. If a

26 provider participates in a managed care program

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1 administered by the Department, the Department may direct

2 the managed care organization to remit to the Department

3 amounts otherwise payable by the managed care organization

4 to the provider, and apply such remitted amounts as

5 repayment of the unpaid advance.

6 The requirements of this subsection may be waived by the

7 Department in instances when a nursing home provider has

8 entered into and remains in compliance with a renegotiated

9 advance payment agreement. A renegotiated advance payment

10 agreement must be entered into no later than 60 days after the

11 effective date of this amendatory Act of the 104th General

12 Assembly.

13 A nursing home must enter into a renegotiated advance

14 payment agreement with the Department that includes terms for

15 repayment of the total amount owed for all outstanding amounts

16 over a 12-month period, repaid in equal payment increments.

17 Payments shall begin within 30 days of the signed agreement

18 date.

19 Failure to remain in compliance with a renegotiated

20 advance payment agreement shall cause immediate termination of

21 such an agreement unless there is prior written consent from

22 the Department for a period of non-compliance.

23 Beginning September 1, 2026, the Department shall

24 immediately collect all overdue unpaid advance debts through

25 the collection methods authorized under this Section, unless a

26 renegotiated advance payment agreement has already been agreed

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LRB104 18483 KTG 38682 a

1 to.

2 (Source: P.A. 102-538, eff. 8-20-21.)

3 ARTICLE 800.

4 Section 800-95. No acceleration or delay. Where this Act

5 makes changes in a statute that is represented in this Act by

6 text that is not yet or no longer in effect (for example, a

7 Section represented by multiple versions), the use of that

8 text does not accelerate or delay the taking effect of (i) the

9 changes made by this Act or (ii) provisions derived from any

10 other Public Act.

11 ARTICLE 999.

12 Section 999-99. Effective date. This Act takes effect upon

13 becoming law, except that Section 257-10 of Article 257 and

14 Articles 2, 10, 15, and 225 take effect July 1, 2026, and

15 Article 6 takes effect January 1, 2027, and Article 65 takes

16 effect July 1, 2027.".