Rep. Greg Harris

Filed: 5/26/2014

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1 AMENDMENT TO SENATE BILL 741

2 AMENDMENT NO. ______. Amend Senate Bill 741 by replacing

3 everything after the enacting clause with the following:

4 "Article 1

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

6 adding Article V-F as follows:

7 (305 ILCS 5/Art. V-F heading new)

8 ARTICLE V-F. MEDICARE-MEDICAID ALIGNMENT

9 INITIATIVE (MMAI) NURSING HOME

10 RESIDENTS' MANAGED CARE RIGHTS LAW

11 (305 ILCS 5/5F-1 new)

12 Sec. 5F-1. Short title. This Article may be referred to as

13 the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home

14 Residents' Managed Care Rights Law.

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

2 Sec. 5F-5. Findings. The General Assembly finds that

3 elderly Illinoisans residing in a nursing home have the right

4 to:

5 (1) quality health care regardless of the payer;

6 (2) receive medically necessary care prescribed by

7 their doctors;

8 (3) a simple appeal process when care is denied; and

9 (4) make decisions about their care and where they

10 receive it.

11 (305 ILCS 5/5F-10 new)

12 Sec. 5F-10. Scope. This Article applies to policies and

13 contracts amended, delivered, issued, or renewed on or after

14 the effective date of this amendatory Act of the 98th General

15 Assembly for the nursing home component of the

16 Medicare-Medicaid Alignment Initiative. This Article does not

17 diminish a managed care organization's duties and

18 responsibilities under other federal or State laws or rules

19 adopted under those laws and the 3-way Medicare-Medicaid

20 Alignment Initiative contract.

21 (305 ILCS 5/5F-15 new)

22 Sec. 5F-15. Definitions. As used in this Article:

23 "Appeal" means any of the procedures that deal with the

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1 review of adverse organization determinations on the health

2 care services the enrollee believes he or she is entitled to

3 receive, including delay in providing, arranging for, or

4 approving the health care services, such that a delay would

5 adversely affect the health of the enrollee or on any amounts

6 the enrollee must pay for a service, as defined under 42 CFR

7 422.566(b). These procedures include reconsiderations by the

8 managed care organization and, if necessary, an independent

9 review entity as provided by the Health Carrier External Review

10 Act, hearings before administrative law judges, review by the

11 Medicare Appeals Council, and judicial review.

12 "Demonstration Project" means the nursing home component

13 of the Medicare-Medicaid Alignment Initiative Demonstration

14 Project.

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 with

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1 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 of

6 Insurance, and is authorized to participate in the nursing home

7 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 all

4 branches of medicine under the Medical Practice Act of 1987.

5 "Physician assistant" means an individual properly

6 licensed under the Physician Assistant Practice Act of 1987.

7 "Resident" means an enrollee who is receiving personal or

8 medical care, including, but not limited to, mental health

9 treatment, psychiatric rehabilitation, physical

10 rehabilitation, and assistance with activities of daily

11 living, from a nursing home.

12 "RAI Manual" means the most recent Resident Assessment

13 Instrument Manual, published by the Centers for Medicare and

14 Medicaid Services.

15 "Resident's representative" means a person designated in

16 writing by a resident to be the resident's representative or

17 the resident's guardian, as described by the Nursing Home Care

18 Act.

19 "SNFist" means a medical professional specializing in the

20 care of individuals residing in nursing homes employed by or

21 under contract with a MCO.

22 "Transition period" means a period of time immediately

23 following enrollment into the Demonstration Project or an

24 enrollee's movement from one managed care organization to

25 another managed care organization or one care setting to

26 another care setting.

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1 (305 ILCS 5/5F-20 new)

2 Sec. 5F-20. Network adequacy.

3 (a) Every managed care organization shall allow every

4 nursing home in its service area an opportunity to be a network

5 contracted facility at the plan's standard terms, conditions,

6 and rates. Either party may opt to limit the contract to

7 existing residents only.

8 (b) With the exception of subsection (c) of this Section, a

9 managed care organization shall only terminate or refuse to

10 renew a contract with a nursing home if the nursing home fails

11 to meet quality standards if the following conditions are met:

12 (1) the quality standards are made known to the nursing

13 home;

14 (2) the quality standards can be objectively measured

15 through data;

16 (3) the nursing home is measured on at least a year's

17 worth of performance;

18 (4) a nursing home that the MCO has determined did not

19 meet a quality standard has the opportunity to contest that

20 determination by challenging the accuracy or the

21 measurement of the data through an arbitration process

22 agreed to by contract; and

23 (5) the Department may attempt to mediate a dispute

24 prior to arbitration.

25 (c) A managed care organization may terminate or refuse to

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1 renew a contract with a nursing home for a material breach of

2 the contract, including, but not limited to, failure to grant

3 reasonable and timely access to the MCO's care coordinators,

4 SNFists and other providers, termination from the Medicare or

5 Medicaid program, or revocation of license.

6 (305 ILCS 5/5F-25 new)

7 Sec. 5F-25. Care coordination. Care coordination provided

8 to all enrollees in the Demonstration Project shall conform to

9 the following requirements:

10 (1) care coordination services shall be

11 enrollee-driven and person-centered;

12 (2) all enrollees in the Demonstration Project shall

13 have the right to receive health care services in the care

14 setting of their choice, except as permitted by Part 4 of

15 Article III of the Nursing Home Care Act with respect to

16 involuntary transfers and discharges; and

17 (3) decisions shall be based on the enrollee's best

18 interests.

19 (305 ILCS 5/5F-30 new)

20 Sec. 5F-30. Continuity of care. When a nursing home

21 resident first transitions to a managed care organization from

22 the fee-for-service system or from another managed care

23 organization, the managed care organization shall honor the

24 existing care plan and any necessary changes to that care plan

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1 until the MCO has completed a comprehensive assessment and new

2 care plan, to the extent such services are covered benefits

3 under the contract, which shall be consistent with the

4 requirements of the RAI Manual.

5 When an enrollee of a managed care organization is moving

6 from a community setting to a nursing home, and the MCO is

7 properly notified of the proposed admission by a network

8 nursing home, and the managed care organization fails to

9 participate in developing a care plan within the time frames

10 required by nursing home regulations, the MCO must honor a care

11 plan developed by the nursing home until the MCO has completed

12 a comprehensive assessment and a new care plan to the extent

13 such services are covered benefits under the contract,

14 consistent with the requirements of the RAI Manual.

15 A nursing home shall have the ability to refuse admission

16 of an enrollee for whom care is required that the nursing home

17 determines is outside the scope of its license and healthcare

18 capabilities.

19 (305 ILCS 5/5F-32 new)

20 Sec. 5F-32. Non-emergency prior approval and appeal.

21 (a) MCOs must have a method of receiving prior approval

22 requests 24 hours a day, 7 days a week, 365 days a year for

23 nursing home residents. If a response is not provided within 24

24 hours of the request and the nursing home is required by

25 regulation to provide a service because a physician ordered it,

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1 the MCO must pay for the service if it is a covered service

2 under the MCO's contract in the Demonstration Project, provided

3 that the request is consistent with the policies and procedures

4 of the MCO.

5 In a non-emergency situation, notwithstanding any

6 provisions in State law to the contrary, in the event a

7 resident's physician orders a service, treatment, or test that

8 is not approved by the MCO, the physician and the provider may

9 utilize an expedited appeal to the MCO.

10 If an enrollee or provider requests an expedited appeal

11 pursuant to 42 CFR 438.410, the MCO shall notify the enrollee

12 or provider within 24 hours after the submission of the appeal

13 of all information from the enrollee or provider that the MCO

14 requires to evaluate the appeal. The MCO shall render a

15 decision on an expedited appeal within 24 hours after receipt

16 of the required information.

17 (b) While the appeal is pending or if the ordered service,

18 treatment, or test is denied after appeal, the Department of

19 Public Health may not cite the nursing home for failure to

20 provide the ordered service, treatment, or test. The nursing

21 home shall not be liable or responsible for an injury in any

22 regulatory proceeding for the following:

23 (1) failure to follow the appealed or denied order; or

24 (2) injury to the extent it was caused by the delay or

25 failure to perform the appealed or denied service,

26 treatment, or test.

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1 Provided however, a nursing home shall continue to monitor,

2 document, and ensure the patient's safety. Nothing in this

3 subsection (b) is intended to otherwise change the nursing

4 home's existing obligations under State and federal law to

5 appropriately care for its residents.

6 (305 ILCS 5/5F-35 new)

7 Sec. 5F-35. Reimbursement. The Department shall provide

8 each managed care organization with the quarterly

9 facility-specific RUG-IV nursing component per diem along with

10 any add-ons for enhanced care services, support component per

11 diem, and capital component per diem effective for each nursing

12 home under contract with the managed care organization.

13 (305 ILCS 5/5F-40 new)

14 Sec. 5F-40. Contractual requirements.

15 (a) Every contract shall contain a clause for termination

16 consistent with the Managed Care Reform and Patient Rights Act

17 providing nursing homes the ability to terminate the contract.

18 (b) All changes to the contract by the MCO shall be

19 preceded by 30 days' written notice sent to the nursing home.

20 (305 ILCS 5/5F-45 new)

21 Sec. 5F-45. Prohibition. No managed care organization or

22 contract shall contain any provision, policy, or procedure that

23 limits, restricts, or waives any rights set forth in this

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1 Article or is expressly prohibited by this Article. Any such

2 policy or procedure is void and unenforceable.

3 Section 1-10. The Health Maintenance Organization Act is

4 amended by changing Section 1-2 as follows:

5 (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)

6 Sec. 1-2. Definitions. As used in this Act, unless the

7 context otherwise requires, the following terms shall have the

8 meanings ascribed to them:

9 (1) "Advertisement" means any printed or published

10 material, audiovisual material and descriptive literature of

11 the health care plan used in direct mail, newspapers,

12 magazines, radio scripts, television scripts, billboards and

13 similar displays; and any descriptive literature or sales aids

14 of all kinds disseminated by a representative of the health

15 care plan for presentation to the public including, but not

16 limited to, circulars, leaflets, booklets, depictions,

17 illustrations, form letters and prepared sales presentations.

18 (2) "Director" means the Director of Insurance.

19 (3) "Basic health care services" means emergency care, and

20 inpatient hospital and physician care, outpatient medical

21 services, mental health services and care for alcohol and drug

22 abuse, including any reasonable deductibles and co-payments,

23 all of which are subject to the limitations described in

24 Section 4-20 of this Act and as determined by the Director

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1 pursuant to rule.

2 (4) "Enrollee" means an individual who has been enrolled in

3 a health care plan.

4 (5) "Evidence of coverage" means any certificate,

5 agreement, or contract issued to an enrollee setting out the

6 coverage to which he is entitled in exchange for a per capita

7 prepaid sum.

8 (6) "Group contract" means a contract for health care

9 services which by its terms limits eligibility to members of a

10 specified group.

11 (7) "Health care plan" means any arrangement whereby any

12 organization undertakes to provide or arrange for and pay for

13 or reimburse the cost of basic health care services, excluding

14 any reasonable deductibles and copayments, from providers

15 selected by the Health Maintenance Organization and such

16 arrangement consists of arranging for or the provision of such

17 health care services, as distinguished from mere

18 indemnification against the cost of such services, except as

19 otherwise authorized by Section 2-3 of this Act, on a per

20 capita prepaid basis, through insurance or otherwise. A "health

21 care plan" also includes any arrangement whereby an

22 organization undertakes to provide or arrange for or pay for or

23 reimburse the cost of any health care service for persons who

24 are enrolled under Article V of the Illinois Public Aid Code or

25 under the Children's Health Insurance Program Act through

26 providers selected by the organization and the arrangement

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1 consists of making provision for the delivery of health care

2 services, as distinguished from mere indemnification. A

3 "health care plan" also includes any arrangement pursuant to

4 Section 4-17. Nothing in this definition, however, affects the

5 total medical services available to persons eligible for

6 medical assistance under the Illinois Public Aid Code.

7 (8) "Health care services" means any services included in

8 the furnishing to any individual of medical or dental care, or

9 the hospitalization or incident to the furnishing of such care

10 or hospitalization as well as the furnishing to any person of

11 any and all other services for the purpose of preventing,

12 alleviating, curing or healing human illness or injury.

13 (9) "Health Maintenance Organization" means any

14 organization formed under the laws of this or another state to

15 provide or arrange for one or more health care plans under a

16 system which causes any part of the risk of health care

17 delivery to be borne by the organization or its providers.

18 (10) "Net worth" means admitted assets, as defined in

19 Section 1-3 of this Act, minus liabilities.

20 (11) "Organization" means any insurance company, a

21 nonprofit corporation authorized under the Dental Service Plan

22 Act or the Voluntary Health Services Plans Act, or a

23 corporation organized under the laws of this or another state

24 for the purpose of operating one or more health care plans and

25 doing no business other than that of a Health Maintenance

26 Organization or an insurance company. "Organization" shall

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1 also mean the University of Illinois Hospital as defined in the

2 University of Illinois Hospital Act or a unit of local

3 government health system operating within a county with a

4 population of 3,000,000 or more.

5 (12) "Provider" means any physician, hospital facility,

6 facility licensed under the Nursing Home Care Act, or other

7 person which is licensed or otherwise authorized to furnish

8 health care services and also includes any other entity that

9 arranges for the delivery or furnishing of health care service.

10 (13) "Producer" means a person directly or indirectly

11 associated with a health care plan who engages in solicitation

12 or enrollment.

13 (14) "Per capita prepaid" means a basis of prepayment by

14 which a fixed amount of money is prepaid per individual or any

15 other enrollment unit to the Health Maintenance Organization or

16 for health care services which are provided during a definite

17 time period regardless of the frequency or extent of the

18 services rendered by the Health Maintenance Organization,

19 except for copayments and deductibles and except as provided in

20 subsection (f) of Section 5-3 of this Act.

21 (15) "Subscriber" means a person who has entered into a

22 contractual relationship with the Health Maintenance

23 Organization for the provision of or arrangement of at least

24 basic health care services to the beneficiaries of such

25 contract.

26 (Source: P.A. 97-1148, eff. 1-24-13.)

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1 Section 1-15. The Managed Care Reform and Patient Rights

2 Act is amended by changing Section 10 as follows:

3 (215 ILCS 134/10)

4 Sec. 10. Definitions:

5 "Adverse determination" means a determination by a health

6 care plan under Section 45 or by a utilization review program

7 under Section 85 that a health care service is not medically

8 necessary.

9 "Clinical peer" means a health care professional who is in

10 the same profession and the same or similar specialty as the

11 health care provider who typically manages the medical

12 condition, procedures, or treatment under review.

13 "Department" means the Department of Insurance.

14 "Emergency medical condition" means a medical condition

15 manifesting itself by acute symptoms of sufficient severity

16 (including, but not limited to, severe pain) such that a

17 prudent layperson, who possesses an average knowledge of health

18 and medicine, could reasonably expect the absence of immediate

19 medical attention to result in:

20 (1) placing the health of the individual (or, with

21 respect to a pregnant woman, the health of the woman or her

22 unborn child) in serious jeopardy;

23 (2) serious impairment to bodily functions; or

24 (3) serious dysfunction of any bodily organ or part.

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1 "Emergency medical screening examination" means a medical

2 screening examination and evaluation by a physician licensed to

3 practice medicine in all its branches, or to the extent

4 permitted by applicable laws, by other appropriately licensed

5 personnel under the supervision of or in collaboration with a

6 physician licensed to practice medicine in all its branches to

7 determine whether the need for emergency services exists.

8 "Emergency services" means, with respect to an enrollee of

9 a health care plan, transportation services, including but not

10 limited to ambulance services, and covered inpatient and

11 outpatient hospital services furnished by a provider qualified

12 to furnish those services that are needed to evaluate or

13 stabilize an emergency medical condition. "Emergency services"

14 does not refer to post-stabilization medical services.

15 "Enrollee" means any person and his or her dependents

16 enrolled in or covered by a health care plan.

17 "Health care plan" means a plan, including, but not limited

18 to, a health maintenance organization, a managed care community

19 network as defined in the Illinois Public Aid Code, or an

20 accountable care entity as defined in the Illinois Public Aid

21 Code that receives capitated payments to cover medical services

22 from the Department of Healthcare and Family Services, that

23 establishes, operates, or maintains a network of health care

24 providers that has entered into an agreement with the plan to

25 provide health care services to enrollees to whom the plan has

26 the ultimate obligation to arrange for the provision of or

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1 payment for services through organizational arrangements for

2 ongoing quality assurance, utilization review programs, or

3 dispute resolution. Nothing in this definition shall be

4 construed to mean that an independent practice association or a

5 physician hospital organization that subcontracts with a

6 health care plan is, for purposes of that subcontract, a health

7 care plan.

8 For purposes of this definition, "health care plan" shall

9 not include the following:

10 (1) indemnity health insurance policies including

11 those using a contracted provider network;

12 (2) health care plans that offer only dental or only

13 vision coverage;

14 (3) preferred provider administrators, as defined in

15 Section 370g(g) of the Illinois Insurance Code;

16 (4) employee or employer self-insured health benefit

17 plans under the federal Employee Retirement Income

18 Security Act of 1974;

19 (5) health care provided pursuant to the Workers'

20 Compensation Act or the Workers' Occupational Diseases

21 Act; and

22 (6) not-for-profit voluntary health services plans

23 with health maintenance organization authority in

24 existence as of January 1, 1999 that are affiliated with a

25 union and that only extend coverage to union members and

26 their dependents.

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1 "Health care professional" means a physician, a registered

2 professional nurse, or other individual appropriately licensed

3 or registered to provide health care services.

4 "Health care provider" means any physician, hospital

5 facility, facility licensed under the Nursing Home Care Act, or

6 other person that is licensed or otherwise authorized to

7 deliver health care services. Nothing in this Act shall be

8 construed to define Independent Practice Associations or

9 Physician-Hospital Organizations as health care providers.

10 "Health care services" means any services included in the

11 furnishing to any individual of medical care, or the

12 hospitalization incident to the furnishing of such care, as

13 well as the furnishing to any person of any and all other

14 services for the purpose of preventing, alleviating, curing, or

15 healing human illness or injury including home health and

16 pharmaceutical services and products.

17 "Medical director" means a physician licensed in any state

18 to practice medicine in all its branches appointed by a health

19 care plan.

20 "Person" means a corporation, association, partnership,

21 limited liability company, sole proprietorship, or any other

22 legal entity.

23 "Physician" means a person licensed under the Medical

24 Practice Act of 1987.

25 "Post-stabilization medical services" means health care

26 services provided to an enrollee that are furnished in a

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1 licensed hospital by a provider that is qualified to furnish

2 such services, and determined to be medically necessary and

3 directly related to the emergency medical condition following

4 stabilization.

5 "Stabilization" means, with respect to an emergency

6 medical condition, to provide such medical treatment of the

7 condition as may be necessary to assure, within reasonable

8 medical probability, that no material deterioration of the

9 condition is likely to result.

10 "Utilization review" means the evaluation of the medical

11 necessity, appropriateness, and efficiency of the use of health

12 care services, procedures, and facilities.

13 "Utilization review program" means a program established

14 by a person to perform utilization review.

15 (Source: P.A. 91-617, eff. 1-1-00.)

16 Article 5

17 Section 5-5. The Illinois Health Facilities Planning Act is

18 amended by changing Sections 3 and 12 as follows:

19 (20 ILCS 3960/3) (from Ch. 111 1/2, par. 1153)

20 (Section scheduled to be repealed on December 31, 2019)

21 Sec. 3. Definitions. As used in this Act:

22 "Health care facilities" means and includes the following

23 facilities, organizations, and related persons:

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1 1. An ambulatory surgical treatment center required to

2 be licensed pursuant to the Ambulatory Surgical Treatment

3 Center Act;

4 2. An institution, place, building, or agency required

5 to be licensed pursuant to the Hospital Licensing Act;

6 3. Skilled and intermediate long term care facilities

7 licensed under the Nursing Home Care Act;

8 3.5. Skilled and intermediate care facilities licensed

9 under the ID/DD Community Care Act;

10 3.7. Facilities licensed under the Specialized Mental

11 Health Rehabilitation Act of 2013;

12 4. Hospitals, nursing homes, ambulatory surgical

13 treatment centers, or kidney disease treatment centers

14 maintained by the State or any department or agency

15 thereof;

16 5. Kidney disease treatment centers, including a

17 free-standing hemodialysis unit required to be licensed

18 under the End Stage Renal Disease Facility Act;

19 6. An institution, place, building, or room used for

20 the performance of outpatient surgical procedures that is

21 leased, owned, or operated by or on behalf of an

22 out-of-state facility;

23 7. An institution, place, building, or room used for

24 provision of a health care category of service, including,

25 but not limited to, cardiac catheterization and open heart

26 surgery; and

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1 8. An institution, place, building, or room used for

2 provision of major medical equipment used in the direct

3 clinical diagnosis or treatment of patients, and whose

4 project cost is in excess of the capital expenditure

5 minimum.

6 This Act shall not apply to the construction of any new

7 facility or the renovation of any existing facility located on

8 any campus facility as defined in Section 5-5.8b of the

9 Illinois Public Aid Code, provided that the campus facility

10 encompasses 30 or more contiguous acres and that the new or

11 renovated facility is intended for use by a licensed

12 residential facility.

13 No federally owned facility shall be subject to the

14 provisions of this Act, nor facilities used solely for healing

15 by prayer or spiritual means.

16 No facility licensed under the Supportive Residences

17 Licensing Act or the Assisted Living and Shared Housing Act

18 shall be subject to the provisions of this Act.

19 No facility established and operating under the

20 Alternative Health Care Delivery Act as a children's respite

21 care center alternative health care model demonstration

22 program or as an Alzheimer's Disease Management Center

23 alternative health care model demonstration program shall be

24 subject to the provisions of this Act.

25 A facility designated as a supportive living facility that

26 is in good standing with the program established under Section

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1 5-5.01a of the Illinois Public Aid Code shall not be subject to

2 the provisions of this Act.

3 This Act does not apply to facilities granted waivers under

4 Section 3-102.2 of the Nursing Home Care Act. However, if a

5 demonstration project under that Act applies for a certificate

6 of need to convert to a nursing facility, it shall meet the

7 licensure and certificate of need requirements in effect as of

8 the date of application.

9 This Act does not apply to a dialysis facility that

10 provides only dialysis training, support, and related services

11 to individuals with end stage renal disease who have elected to

12 receive home dialysis. This Act does not apply to a dialysis

13 unit located in a licensed nursing home that offers or provides

14 dialysis-related services to residents with end stage renal

15 disease who have elected to receive home dialysis within the

16 nursing home. The Board, however, may require these dialysis

17 facilities and licensed nursing homes to report statistical

18 information on a quarterly basis to the Board to be used by the

19 Board to conduct analyses on the need for proposed kidney

20 disease treatment centers.

21 This Act shall not apply to the closure of an entity or a

22 portion of an entity licensed under the Nursing Home Care Act,

23 the Specialized Mental Health Rehabilitation Act of 2013, or

24 the ID/DD Community Care Act, with the exceptions of facilities

25 operated by a county or Illinois Veterans Homes, that elects to

26 convert, in whole or in part, to an assisted living or shared

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1 housing establishment licensed under the Assisted Living and

2 Shared Housing Act and with the exception of a facility

3 licensed under the Specialized Mental Health Rehabilitation

4 Act of 2013 in connection with a proposal to close a facility

5 and re-establish the facility in another location.

6 This Act does not apply to any change of ownership of a

7 healthcare facility that is licensed under the Nursing Home

8 Care Act, the Specialized Mental Health Rehabilitation Act of

9 2013, or the ID/DD Community Care Act, with the exceptions of

10 facilities operated by a county or Illinois Veterans Homes.

11 Changes of ownership of facilities licensed under the Nursing

12 Home Care Act must meet the requirements set forth in Sections

13 3-101 through 3-119 of the Nursing Home Care Act.

14 With the exception of those health care facilities

15 specifically included in this Section, nothing in this Act

16 shall be intended to include facilities operated as a part of

17 the practice of a physician or other licensed health care

18 professional, whether practicing in his individual capacity or

19 within the legal structure of any partnership, medical or

20 professional corporation, or unincorporated medical or

21 professional group. Further, this Act shall not apply to

22 physicians or other licensed health care professional's

23 practices where such practices are carried out in a portion of

24 a health care facility under contract with such health care

25 facility by a physician or by other licensed health care

26 professionals, whether practicing in his individual capacity

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1 or within the legal structure of any partnership, medical or

2 professional corporation, or unincorporated medical or

3 professional groups, unless the entity constructs, modifies,

4 or establishes a health care facility as specifically defined

5 in this Section. This Act shall apply to construction or

6 modification and to establishment by such health care facility

7 of such contracted portion which is subject to facility

8 licensing requirements, irrespective of the party responsible

9 for such action or attendant financial obligation.

10 No permit or exemption is required for a facility licensed

11 under the ID/DD Community Care Act prior to the reduction of

12 the number of beds at a facility. If there is a total reduction

13 of beds at a facility licensed under the ID/DD Community Care

14 Act, this is a discontinuation or closure of the facility.

15 However, if a facility licensed under the ID/DD Community Care

16 Act reduces the number of beds or discontinues the facility,

17 that facility must notify the Board as provided in Section 14.1

18 of this Act.

19 "Person" means any one or more natural persons, legal

20 entities, governmental bodies other than federal, or any

21 combination thereof.

22 "Consumer" means any person other than a person (a) whose

23 major occupation currently involves or whose official capacity

24 within the last 12 months has involved the providing,

25 administering or financing of any type of health care facility,

26 (b) who is engaged in health research or the teaching of

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1 health, (c) who has a material financial interest in any

2 activity which involves the providing, administering or

3 financing of any type of health care facility, or (d) who is or

4 ever has been a member of the immediate family of the person

5 defined by (a), (b), or (c).

6 "State Board" or "Board" means the Health Facilities and

7 Services Review Board.

8 "Construction or modification" means the establishment,

9 erection, building, alteration, reconstruction, modernization,

10 improvement, extension, discontinuation, change of ownership,

11 of or by a health care facility, or the purchase or acquisition

12 by or through a health care facility of equipment or service

13 for diagnostic or therapeutic purposes or for facility

14 administration or operation, or any capital expenditure made by

15 or on behalf of a health care facility which exceeds the

16 capital expenditure minimum; however, any capital expenditure

17 made by or on behalf of a health care facility for (i) the

18 construction or modification of a facility licensed under the

19 Assisted Living and Shared Housing Act or (ii) a conversion

20 project undertaken in accordance with Section 30 of the Older

21 Adult Services Act shall be excluded from any obligations under

22 this Act.

23 "Establish" means the construction of a health care

24 facility or the replacement of an existing facility on another

25 site or the initiation of a category of service.

26 "Major medical equipment" means medical equipment which is

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1 used for the provision of medical and other health services and

2 which costs in excess of the capital expenditure minimum,

3 except that such term does not include medical equipment

4 acquired by or on behalf of a clinical laboratory to provide

5 clinical laboratory services if the clinical laboratory is

6 independent of a physician's office and a hospital and it has

7 been determined under Title XVIII of the Social Security Act to

8 meet the requirements of paragraphs (10) and (11) of Section

9 1861(s) of such Act. In determining whether medical equipment

10 has a value in excess of the capital expenditure minimum, the

11 value of studies, surveys, designs, plans, working drawings,

12 specifications, and other activities essential to the

13 acquisition of such equipment shall be included.

14 "Capital Expenditure" means an expenditure: (A) made by or

15 on behalf of a health care facility (as such a facility is

16 defined in this Act); and (B) which under generally accepted

17 accounting principles is not properly chargeable as an expense

18 of operation and maintenance, or is made to obtain by lease or

19 comparable arrangement any facility or part thereof or any

20 equipment for a facility or part; and which exceeds the capital

21 expenditure minimum.

22 For the purpose of this paragraph, the cost of any studies,

23 surveys, designs, plans, working drawings, specifications, and

24 other activities essential to the acquisition, improvement,

25 expansion, or replacement of any plant or equipment with

26 respect to which an expenditure is made shall be included in

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1 determining if such expenditure exceeds the capital

2 expenditures minimum. Unless otherwise interdependent, or

3 submitted as one project by the applicant, components of

4 construction or modification undertaken by means of a single

5 construction contract or financed through the issuance of a

6 single debt instrument shall not be grouped together as one

7 project. Donations of equipment or facilities to a health care

8 facility which if acquired directly by such facility would be

9 subject to review under this Act shall be considered capital

10 expenditures, and a transfer of equipment or facilities for

11 less than fair market value shall be considered a capital

12 expenditure for purposes of this Act if a transfer of the

13 equipment or facilities at fair market value would be subject

14 to review.

15 "Capital expenditure minimum" means $11,500,000 for

16 projects by hospital applicants, $6,500,000 for applicants for

17 projects related to skilled and intermediate care long-term

18 care facilities licensed under the Nursing Home Care Act, and

19 $3,000,000 for projects by all other applicants, which shall be

20 annually adjusted to reflect the increase in construction costs

21 due to inflation, for major medical equipment and for all other

22 capital expenditures.

23 "Non-clinical service area" means an area (i) for the

24 benefit of the patients, visitors, staff, or employees of a

25 health care facility and (ii) not directly related to the

26 diagnosis, treatment, or rehabilitation of persons receiving

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1 services from the health care facility. "Non-clinical service

2 areas" include, but are not limited to, chapels; gift shops;

3 news stands; computer systems; tunnels, walkways, and

4 elevators; telephone systems; projects to comply with life

5 safety codes; educational facilities; student housing;

6 patient, employee, staff, and visitor dining areas;

7 administration and volunteer offices; modernization of

8 structural components (such as roof replacement and masonry

9 work); boiler repair or replacement; vehicle maintenance and

10 storage facilities; parking facilities; mechanical systems for

11 heating, ventilation, and air conditioning; loading docks; and

12 repair or replacement of carpeting, tile, wall coverings,

13 window coverings or treatments, or furniture. Solely for the

14 purpose of this definition, "non-clinical service area" does

15 not include health and fitness centers.

16 "Areawide" means a major area of the State delineated on a

17 geographic, demographic, and functional basis for health

18 planning and for health service and having within it one or

19 more local areas for health planning and health service. The

20 term "region", as contrasted with the term "subregion", and the

21 word "area" may be used synonymously with the term "areawide".

22 "Local" means a subarea of a delineated major area that on

23 a geographic, demographic, and functional basis may be

24 considered to be part of such major area. The term "subregion"

25 may be used synonymously with the term "local".

26 "Physician" means a person licensed to practice in

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1 accordance with the Medical Practice Act of 1987, as amended.

2 "Licensed health care professional" means a person

3 licensed to practice a health profession under pertinent

4 licensing statutes of the State of Illinois.

5 "Director" means the Director of the Illinois Department of

6 Public Health.

7 "Agency" means the Illinois Department of Public Health.

8 "Alternative health care model" means a facility or program

9 authorized under the Alternative Health Care Delivery Act.

10 "Out-of-state facility" means a person that is both (i)

11 licensed as a hospital or as an ambulatory surgery center under

12 the laws of another state or that qualifies as a hospital or an

13 ambulatory surgery center under regulations adopted pursuant

14 to the Social Security Act and (ii) not licensed under the

15 Ambulatory Surgical Treatment Center Act, the Hospital

16 Licensing Act, or the Nursing Home Care Act. Affiliates of

17 out-of-state facilities shall be considered out-of-state

18 facilities. Affiliates of Illinois licensed health care

19 facilities 100% owned by an Illinois licensed health care

20 facility, its parent, or Illinois physicians licensed to

21 practice medicine in all its branches shall not be considered

22 out-of-state facilities. Nothing in this definition shall be

23 construed to include an office or any part of an office of a

24 physician licensed to practice medicine in all its branches in

25 Illinois that is not required to be licensed under the

26 Ambulatory Surgical Treatment Center Act.

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1 "Change of ownership of a health care facility" means a

2 change in the person who has ownership or control of a health

3 care facility's physical plant and capital assets. A change in

4 ownership is indicated by the following transactions: sale,

5 transfer, acquisition, lease, change of sponsorship, or other

6 means of transferring control.

7 "Related person" means any person that: (i) is at least 50%

8 owned, directly or indirectly, by either the health care

9 facility or a person owning, directly or indirectly, at least

10 50% of the health care facility; or (ii) owns, directly or

11 indirectly, at least 50% of the health care facility.

12 "Charity care" means care provided by a health care

13 facility for which the provider does not expect to receive

14 payment from the patient or a third-party payer.

15 "Freestanding emergency center" means a facility subject

16 to licensure under Section 32.5 of the Emergency Medical

17 Services (EMS) Systems Act.

18 "Category of service" means a grouping by generic class of

19 various types or levels of support functions, equipment, care,

20 or treatment provided to patients or residents, including, but

21 not limited to, classes such as medical-surgical, pediatrics,

22 or cardiac catheterization. A category of service may include

23 subcategories or levels of care that identify a particular

24 degree or type of care within the category of service. Nothing

25 in this definition shall be construed to include the practice

26 of a physician or other licensed health care professional while

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1 functioning in an office providing for the care, diagnosis, or

2 treatment of patients. A category of service that is subject to

3 the Board's jurisdiction must be designated in rules adopted by

4 the Board.

5 (Source: P.A. 97-38, eff. 6-28-11; 97-277, eff. 1-1-12; 97-813,

6 eff. 7-13-12; 97-980, eff. 8-17-12; 98-414, eff. 1-1-14.)

7 (20 ILCS 3960/12) (from Ch. 111 1/2, par. 1162)

8 (Section scheduled to be repealed on December 31, 2019)

9 Sec. 12. Powers and duties of State Board. For purposes of

10 this Act, the State Board shall exercise the following powers

11 and duties:

12 (1) Prescribe rules, regulations, standards, criteria,

13 procedures or reviews which may vary according to the purpose

14 for which a particular review is being conducted or the type of

15 project reviewed and which are required to carry out the

16 provisions and purposes of this Act. Policies and procedures of

17 the State Board shall take into consideration the priorities

18 and needs of medically underserved areas and other health care

19 services identified through the comprehensive health planning

20 process, giving special consideration to the impact of projects

21 on access to safety net services.

22 (2) Adopt procedures for public notice and hearing on all

23 proposed rules, regulations, standards, criteria, and plans

24 required to carry out the provisions of this Act.

25 (3) (Blank).

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1 (4) Develop criteria and standards for health care

2 facilities planning, conduct statewide inventories of health

3 care facilities, maintain an updated inventory on the Board's

4 web site reflecting the most recent bed and service changes and

5 updated need determinations when new census data become

6 available or new need formulae are adopted, and develop health

7 care facility plans which shall be utilized in the review of

8 applications for permit under this Act. Such health facility

9 plans shall be coordinated by the Board with pertinent State

10 Plans. Inventories pursuant to this Section of skilled or

11 intermediate care facilities licensed under the Nursing Home

12 Care Act, skilled or intermediate care facilities licensed

13 under the ID/DD Community Care Act, facilities licensed under

14 the Specialized Mental Health Rehabilitation Act, or nursing

15 homes licensed under the Hospital Licensing Act shall be

16 conducted on an annual basis no later than July 1 of each year

17 and shall include among the information requested a list of all

18 services provided by a facility to its residents and to the

19 community at large and differentiate between active and

20 inactive beds.

21 In developing health care facility plans, the State Board

22 shall consider, but shall not be limited to, the following:

23 (a) The size, composition and growth of the population

24 of the area to be served;

25 (b) The number of existing and planned facilities

26 offering similar programs;

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1 (c) The extent of utilization of existing facilities;

2 (d) The availability of facilities which may serve as

3 alternatives or substitutes;

4 (e) The availability of personnel necessary to the

5 operation of the facility;

6 (f) Multi-institutional planning and the establishment

7 of multi-institutional systems where feasible;

8 (g) The financial and economic feasibility of proposed

9 construction or modification; and

10 (h) In the case of health care facilities established

11 by a religious body or denomination, the needs of the

12 members of such religious body or denomination may be

13 considered to be public need.

14 The health care facility plans which are developed and

15 adopted in accordance with this Section shall form the basis

16 for the plan of the State to deal most effectively with

17 statewide health needs in regard to health care facilities.

18 (5) Coordinate with the Center for Comprehensive Health

19 Planning and other state agencies having responsibilities

20 affecting health care facilities, including those of licensure

21 and cost reporting. Beginning no later than January 1, 2013,

22 the Department of Public Health shall produce a written annual

23 report to the Governor and the General Assembly regarding the

24 development of the Center for Comprehensive Health Planning.

25 The Chairman of the State Board and the State Board

26 Administrator shall also receive a copy of the annual report.

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1 (6) Solicit, accept, hold and administer on behalf of the

2 State any grants or bequests of money, securities or property

3 for use by the State Board or Center for Comprehensive Health

4 Planning in the administration of this Act; and enter into

5 contracts consistent with the appropriations for purposes

6 enumerated in this Act.

7 (7) The State Board shall prescribe procedures for review,

8 standards, and criteria which shall be utilized to make

9 periodic reviews and determinations of the appropriateness of

10 any existing health services being rendered by health care

11 facilities subject to the Act. The State Board shall consider

12 recommendations of the Board in making its determinations.

13 (8) Prescribe, in consultation with the Center for

14 Comprehensive Health Planning, rules, regulations, standards,

15 and criteria for the conduct of an expeditious review of

16 applications for permits for projects of construction or

17 modification of a health care facility, which projects are

18 classified as emergency, substantive, or non-substantive in

19 nature.

20 Six months after June 30, 2009 (the effective date of

21 Public Act 96-31), substantive projects shall include no more

22 than the following:

23 (a) Projects to construct (1) a new or replacement

24 facility located on a new site or (2) a replacement

25 facility located on the same site as the original facility

26 and the cost of the replacement facility exceeds the

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1 capital expenditure minimum, which shall be reviewed by the

2 Board within 120 days;

3 (b) Projects proposing a (1) new service within an

4 existing healthcare facility or (2) discontinuation of a

5 service within an existing healthcare facility, which

6 shall be reviewed by the Board within 60 days; or

7 (c) Projects proposing a change in the bed capacity of

8 a health care facility by an increase in the total number

9 of beds or by a redistribution of beds among various

10 categories of service or by a relocation of beds from one

11 physical facility or site to another by more than 20 beds

12 or more than 10% of total bed capacity, as defined by the

13 State Board, whichever is less, over a 2-year period.

14 The Chairman may approve applications for exemption that

15 meet the criteria set forth in rules or refer them to the full

16 Board. The Chairman may approve any unopposed application that

17 meets all of the review criteria or refer them to the full

18 Board.

19 Such rules shall not abridge the right of the Center for

20 Comprehensive Health Planning to make recommendations on the

21 classification and approval of projects, nor shall such rules

22 prevent the conduct of a public hearing upon the timely request

23 of an interested party. Such reviews shall not exceed 60 days

24 from the date the application is declared to be complete.

25 (9) Prescribe rules, regulations, standards, and criteria

26 pertaining to the granting of permits for construction and

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1 modifications which are emergent in nature and must be

2 undertaken immediately to prevent or correct structural

3 deficiencies or hazardous conditions that may harm or injure

4 persons using the facility, as defined in the rules and

5 regulations of the State Board. This procedure is exempt from

6 public hearing requirements of this Act.

7 (10) Prescribe rules, regulations, standards and criteria

8 for the conduct of an expeditious review, not exceeding 60

9 days, of applications for permits for projects to construct or

10 modify health care facilities which are needed for the care and

11 treatment of persons who have acquired immunodeficiency

12 syndrome (AIDS) or related conditions.

13 (11) Issue written decisions upon request of the applicant

14 or an adversely affected party to the Board. Requests for a

15 written decision shall be made within 15 days after the Board

16 meeting in which a final decision has been made. A "final

17 decision" for purposes of this Act is the decision to approve

18 or deny an application, or take other actions permitted under

19 this Act, at the time and date of the meeting that such action

20 is scheduled by the Board. The staff of the Board shall prepare

21 a written copy of the final decision and the Board shall

22 approve a final copy for inclusion in the formal record. The

23 Board shall consider, for approval, the written draft of the

24 final decision no later than the next scheduled Board meeting.

25 The written decision shall identify the applicable criteria and

26 factors listed in this Act and the Board's regulations that

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1 were taken into consideration by the Board when coming to a

2 final decision. If the Board denies or fails to approve an

3 application for permit or exemption, the Board shall include in

4 the final decision a detailed explanation as to why the

5 application was denied and identify what specific criteria or

6 standards the applicant did not fulfill.

7 (12) Require at least one of its members to participate in

8 any public hearing, after the appointment of a majority of the

9 members to the Board.

10 (13) Provide a mechanism for the public to comment on, and

11 request changes to, draft rules and standards.

12 (14) Implement public information campaigns to regularly

13 inform the general public about the opportunity for public

14 hearings and public hearing procedures.

15 (15) Establish a separate set of rules and guidelines for

16 long-term care that recognizes that nursing homes are a

17 different business line and service model from other regulated

18 facilities. An open and transparent process shall be developed

19 that considers the following: how skilled nursing fits in the

20 continuum of care with other care providers, modernization of

21 nursing homes, establishment of more private rooms,

22 development of alternative services, and current trends in

23 long-term care services. The Chairman of the Board shall

24 appoint a permanent Health Services Review Board Long-term Care

25 Facility Advisory Subcommittee that shall develop and

26 recommend to the Board the rules to be established by the Board

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1 under this paragraph (15). The Subcommittee shall also provide

2 continuous review and commentary on policies and procedures

3 relative to long-term care and the review of related projects.

4 In consultation with other experts from the health field of

5 long-term care, the Board and the Subcommittee shall study new

6 approaches to the current bed need formula and Health Service

7 Area boundaries to encourage flexibility and innovation in

8 design models reflective of the changing long-term care

9 marketplace and consumer preferences. The Subcommittee shall

10 evaluate, and make recommendations to the State Board

11 regarding, the buying, selling, and exchange of beds between

12 long-term care facilities within a specified geographic area or

13 drive time. The Board shall file the proposed related

14 administrative rules for the separate rules and guidelines for

15 long-term care required by this paragraph (15) by no later than

16 September 30, 2011. The Subcommittee shall be provided a

17 reasonable and timely opportunity to review and comment on any

18 review, revision, or updating of the criteria, standards,

19 procedures, and rules used to evaluate project applications as

20 provided under Section 12.3 of this Act.

21 (16) Establish a separate set of rules and guidelines for

22 facilities licensed under the Specialized Mental Health

23 Rehabilitation Act of 2013. An application for the

24 re-establishment of a facility in connection with the

25 relocation of the facility shall not be granted unless the

26 applicant has a contractual relationship with at least one

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1 hospital to provide emergency and inpatient mental health

2 services required by facility consumers, and at least one

3 community mental health agency to provide oversight and

4 assistance to facility consumers while living in the facility,

5 and appropriate services, including case management, to assist

6 them to prepare for discharge and reside stably in the

7 community thereafter. No new facilities licensed under the

8 Specialized Mental Health Rehabilitation Act of 2013 shall be

9 established after the effective date of this amendatory Act of

10 the 98th General Assembly except in connection with the

11 relocation of an existing facility to a new location. An

12 application for a new location shall not be approved unless

13 there are adequate community services accessible to the

14 consumers within a reasonable distance, or by use of public

15 transportation, so as to facilitate the goal of achieving

16 maximum individual self-care and independence. At no time shall

17 the total number of authorized beds under this Act in

18 facilities licensed under the Specialized Mental Health

19 Rehabilitation Act of 2013 exceed the number of authorized beds

20 on the effective date of this amendatory Act of the 98th

21 General Assembly.

22 (Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813,

23 eff. 7-13-12; 97-1045, eff. 8-21-13; 97-1115, eff. 8-27-12;

24 98-414, eff. 1-1-14; 98-463, eff. 8-16-13.)

25 Section 5-10. The Illinois Public Aid Code is amended by

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1 changing Sections 5-5.12 and 5-30 and by adding Section 5-30.1

2 as follows:

3 (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)

4 Sec. 5-5.12. Pharmacy payments.

5 (a) Every request submitted by a pharmacy for reimbursement

6 under this Article for prescription drugs provided to a

7 recipient of aid under this Article shall include the name of

8 the prescriber or an acceptable identification number as

9 established by the Department.

10 (b) Pharmacies providing prescription drugs under this

11 Article shall be reimbursed at a rate which shall include a

12 professional dispensing fee as determined by the Illinois

13 Department, plus the current acquisition cost of the

14 prescription drug dispensed. The Illinois Department shall

15 update its information on the acquisition costs of all

16 prescription drugs no less frequently than every 30 days.

17 However, the Illinois Department may set the rate of

18 reimbursement for the acquisition cost, by rule, at a

19 percentage of the current average wholesale acquisition cost.

20 (c) (Blank).

21 (d) The Department shall review utilization of narcotic

22 medications in the medical assistance program and impose

23 utilization controls that protect against abuse.

24 (e) When making determinations as to which drugs shall be

25 on a prior approval list, the Department shall include as part

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1 of the analysis for this determination, the degree to which a

2 drug may affect individuals in different ways based on factors

3 including the gender of the person taking the medication.

4 (f) The Department shall cooperate with the Department of

5 Public Health and the Department of Human Services Division of

6 Mental Health in identifying psychotropic medications that,

7 when given in a particular form, manner, duration, or frequency

8 (including "as needed") in a dosage, or in conjunction with

9 other psychotropic medications to a nursing home resident or to

10 a resident of a facility licensed under the ID/DD Community

11 Care Act, may constitute a chemical restraint or an

12 "unnecessary drug" as defined by the Nursing Home Care Act or

13 Titles XVIII and XIX of the Social Security Act and the

14 implementing rules and regulations. The Department shall

15 require prior approval for any such medication prescribed for a

16 nursing home resident or to a resident of a facility licensed

17 under the ID/DD Community Care Act, that appears to be a

18 chemical restraint or an unnecessary drug. The Department shall

19 consult with the Department of Human Services Division of

20 Mental Health in developing a protocol and criteria for

21 deciding whether to grant such prior approval.

22 (g) The Department may by rule provide for reimbursement of

23 the dispensing of a 90-day supply of a generic or brand name,

24 non-narcotic maintenance medication in circumstances where it

25 is cost effective.

26 (g-5) On and after July 1, 2012, the Department may require

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1 the dispensing of drugs to nursing home residents be in a 7-day

2 supply or other amount less than a 31-day supply. The

3 Department shall pay only one dispensing fee per 31-day supply.

4 (h) Effective July 1, 2011, the Department shall

5 discontinue coverage of select over-the-counter drugs,

6 including analgesics and cough and cold and allergy

7 medications.

8 (h-5) On and after July 1, 2012, the Department shall

9 impose utilization controls, including, but not limited to,

10 prior approval on specialty drugs, oncolytic drugs, drugs for

11 the treatment of HIV or AIDS, immunosuppressant drugs, and

12 biological products in order to maximize savings on these

13 drugs. The Department may adjust payment methodologies for

14 non-pharmacy billed drugs in order to incentivize the selection

15 of lower-cost drugs. For drugs for the treatment of AIDS, the

16 Department shall take into consideration the potential for

17 non-adherence by certain populations, and shall develop

18 protocols with organizations or providers primarily serving

19 those with HIV/AIDS, as long as such measures intend to

20 maintain cost neutrality with other utilization management

21 controls such as prior approval. For hemophilia, the Department

22 shall develop a program of utilization review and control which

23 may include, in the discretion of the Department, prior

24 approvals. The Department may impose special standards on

25 providers that dispense blood factors which shall include, in

26 the discretion of the Department, staff training and education;

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1 patient outreach and education; case management; in-home

2 patient assessments; assay management; maintenance of stock;

3 emergency dispensing timeframes; data collection and

4 reporting; dispensing of supplies related to blood factor

5 infusions; cold chain management and packaging practices; care

6 coordination; product recalls; and emergency clinical

7 consultation. The Department may require patients to receive a

8 comprehensive examination annually at an appropriate provider

9 in order to be eligible to continue to receive blood factor.

10 (i) On and after July 1, 2012, the Department shall reduce

11 any rate of reimbursement for services or other payments or

12 alter any methodologies authorized by this Code to reduce any

13 rate of reimbursement for services or other payments in

14 accordance with Section 5-5e.

15 (j) On and after July 1, 2012, the Department shall impose

16 limitations on prescription drugs such that the Department

17 shall not provide reimbursement for more than 4 prescriptions,

18 including 3 brand name prescriptions, for distinct drugs in a

19 30-day period, unless prior approval is received for all

20 prescriptions in excess of the 4-prescription limit. Drugs in

21 the following therapeutic classes shall not be subject to prior

22 approval as a result of the 4-prescription limit:

23 immunosuppressant drugs, oncolytic drugs, ~~and~~ anti-retroviral

24 drugs, and, on or after July 1, 2014, antipsychotic drugs. On

25 or after July 1, 2014, the Department may exempt children with

26 complex medical needs enrolled in a care coordination entity

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1 contracted with the Department to solely coordinate care for

2 such children, if the Department determines that the entity has

3 a comprehensive drug reconciliation program.

4 (k) No medication therapy management program implemented

5 by the Department shall be contrary to the provisions of the

6 Pharmacy Practice Act.

7 (l) Any provider enrolled with the Department that bills

8 the Department for outpatient drugs and is eligible to enroll

9 in the federal Drug Pricing Program under Section 340B of the

10 federal Public Health Services Act shall enroll in that

11 program. No entity participating in the federal Drug Pricing

12 Program under Section 340B of the federal Public Health

13 Services Act may exclude Medicaid from their participation in

14 that program, although the Department may exclude entities

15 defined in Section 1905(l)(2)(B) of the Social Security Act

16 from this requirement.

17 (Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333,

18 eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12;

19 97-813, eff. 7-13-12; 98-463, eff. 8-16-13.)

20 (305 ILCS 5/5-30)

21 Sec. 5-30. Care coordination.

22 (a) At least 50% of recipients eligible for comprehensive

23 medical benefits in all medical assistance programs or other

24 health benefit programs administered by the Department,

25 including the Children's Health Insurance Program Act and the

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1 Covering ALL KIDS Health Insurance Act, shall be enrolled in a

2 care coordination program by no later than January 1, 2015. For

3 purposes of this Section, "coordinated care" or "care

4 coordination" means delivery systems where recipients will

5 receive their care from providers who participate under

6 contract in integrated delivery systems that are responsible

7 for providing or arranging the majority of care, including

8 primary care physician services, referrals from primary care

9 physicians, diagnostic and treatment services, behavioral

10 health services, in-patient and outpatient hospital services,

11 dental services, and rehabilitation and long-term care

12 services. The Department shall designate or contract for such

13 integrated delivery systems (i) to ensure enrollees have a

14 choice of systems and of primary care providers within such

15 systems; (ii) to ensure that enrollees receive quality care in

16 a culturally and linguistically appropriate manner; and (iii)

17 to ensure that coordinated care programs meet the diverse needs

18 of enrollees with developmental, mental health, physical, and

19 age-related disabilities.

20 (b) Payment for such coordinated care shall be based on

21 arrangements where the State pays for performance related to

22 health care outcomes, the use of evidence-based practices, the

23 use of primary care delivered through comprehensive medical

24 homes, the use of electronic medical records, and the

25 appropriate exchange of health information electronically made

26 either on a capitated basis in which a fixed monthly premium

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1 per recipient is paid and full financial risk is assumed for

2 the delivery of services, or through other risk-based payment

3 arrangements.

4 (c) To qualify for compliance with this Section, the 50%

5 goal shall be achieved by enrolling medical assistance

6 enrollees from each medical assistance enrollment category,

7 including parents, children, seniors, and people with

8 disabilities to the extent that current State Medicaid payment

9 laws would not limit federal matching funds for recipients in

10 care coordination programs. In addition, services must be more

11 comprehensively defined and more risk shall be assumed than in

12 the Department's primary care case management program as of the

13 effective date of this amendatory Act of the 96th General

14 Assembly.

15 (d) The Department shall report to the General Assembly in

16 a separate part of its annual medical assistance program

17 report, beginning April, 2012 until April, 2016, on the

18 progress and implementation of the care coordination program

19 initiatives established by the provisions of this amendatory

20 Act of the 96th General Assembly. The Department shall include

21 in its April 2011 report a full analysis of federal laws or

22 regulations regarding upper payment limitations to providers

23 and the necessary revisions or adjustments in rate

24 methodologies and payments to providers under this Code that

25 would be necessary to implement coordinated care with full

26 financial risk by a party other than the Department.

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1 (e) Integrated Care Program for individuals with chronic

2 mental health conditions.

3 (1) The Integrated Care Program shall encompass

4 services administered to recipients of medical assistance

5 under this Article to prevent exacerbations and

6 complications using cost-effective, evidence-based

7 practice guidelines and mental health management

8 strategies.

9 (2) The Department may utilize and expand upon existing

10 contractual arrangements with integrated care plans under

11 the Integrated Care Program for providing the coordinated

12 care provisions of this Section.

13 (3) Payment for such coordinated care shall be based on

14 arrangements where the State pays for performance related

15 to mental health outcomes on a capitated basis in which a

16 fixed monthly premium per recipient is paid and full

17 financial risk is assumed for the delivery of services, or

18 through other risk-based payment arrangements such as

19 provider-based care coordination.

20 (4) The Department shall examine whether chronic

21 mental health management programs and services for

22 recipients with specific chronic mental health conditions

23 do any or all of the following:

24 (A) Improve the patient's overall mental health in

25 a more expeditious and cost-effective manner.

26 (B) Lower costs in other aspects of the medical

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1 assistance program, such as hospital admissions,

2 emergency room visits, or more frequent and

3 inappropriate psychotropic drug use.

4 (5) The Department shall work with the facilities and

5 any integrated care plan participating in the program to

6 identify and correct barriers to the successful

7 implementation of this subsection (e) prior to and during

8 the implementation to best facilitate the goals and

9 objectives of this subsection (e).

10 (f) A hospital that is located in a county of the State in

11 which the Department mandates some or all of the beneficiaries

12 of the Medical Assistance Program residing in the county to

13 enroll in a Care Coordination Program, as set forth in Section

14 5-30 of this Code, shall not be eligible for any non-claims

15 based payments not mandated by Article V-A of this Code for

16 which it would otherwise be qualified to receive, unless the

17 hospital is a Coordinated Care Participating Hospital no later

18 than 60 days after the effective date of this amendatory Act of

19 the 97th General Assembly or 60 days after the first mandatory

20 enrollment of a beneficiary in a Coordinated Care program. For

21 purposes of this subsection, "Coordinated Care Participating

22 Hospital" means a hospital that meets one of the following

23 criteria:

24 (1) The hospital has entered into a contract to provide

25 hospital services with one or more MCOs to enrollees of the

26 care coordination program.

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1 (2) The hospital has not been offered a contract by a

2 care coordination plan that the Department has determined

3 to be a good faith offer and that pays at least as much as

4 the Department would pay, on a fee-for-service basis, not

5 including disproportionate share hospital adjustment

6 payments or any other supplemental adjustment or add-on

7 payment to the base fee-for-service rate, except to the

8 extent such adjustments or add-on payments are

9 incorporated into the development of the applicable MCO

10 capitated rates.

11 As used in this subsection (f), "MCO" means any entity

12 which contracts with the Department to provide services where

13 payment for medical services is made on a capitated basis.

14 (g) No later than August 1, 2013, the Department shall

15 issue a purchase of care solicitation for Accountable Care

16 Entities (ACE) to serve any children and parents or caretaker

17 relatives of children eligible for medical assistance under

18 this Article. An ACE may be a single corporate structure or a

19 network of providers organized through contractual

20 relationships with a single corporate entity. The solicitation

21 shall require that:

22 (1) An ACE operating in Cook County be capable of

23 serving at least 40,000 eligible individuals in that

24 county; an ACE operating in Lake, Kane, DuPage, or Will

25 Counties be capable of serving at least 20,000 eligible

26 individuals in those counties and an ACE operating in other

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1 regions of the State be capable of serving at least 10,000

2 eligible individuals in the region in which it operates.

3 During initial periods of mandatory enrollment, the

4 Department shall require its enrollment services

5 contractor to use a default assignment algorithm that

6 ensures if possible an ACE reaches the minimum enrollment

7 levels set forth in this paragraph.

8 (2) An ACE must include at a minimum the following

9 types of providers: primary care, specialty care,

10 hospitals, and behavioral healthcare.

11 (3) An ACE shall have a governance structure that

12 includes the major components of the health care delivery

13 system, including one representative from each of the

14 groups listed in paragraph (2).

15 (4) An ACE must be an integrated delivery system,

16 including a network able to provide the full range of

17 services needed by Medicaid beneficiaries and system

18 capacity to securely pass clinical information across

19 participating entities and to aggregate and analyze that

20 data in order to coordinate care.

21 (5) An ACE must be capable of providing both care

22 coordination and complex case management, as necessary, to

23 beneficiaries. To be responsive to the solicitation, a

24 potential ACE must outline its care coordination and

25 complex case management model and plan to reduce the cost

26 of care.

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1 (6) In the first 18 months of operation, unless the ACE

2 selects a shorter period, an ACE shall be paid care

3 coordination fees on a per member per month basis that are

4 projected to be cost neutral to the State during the term

5 of their payment and, subject to federal approval, be

6 eligible to share in additional savings generated by their

7 care coordination.

8 (7) In months 19 through 36 of operation, unless the

9 ACE selects a shorter period, an ACE shall be paid on a

10 pre-paid capitation basis for all medical assistance

11 covered services, under contract terms similar to Managed

12 Care Organizations (MCO), with the Department sharing the

13 risk through either stop-loss insurance for extremely high

14 cost individuals or corridors of shared risk based on the

15 overall cost of the total enrollment in the ACE. The ACE

16 shall be responsible for claims processing, encounter data

17 submission, utilization control, and quality assurance.

18 (8) In the fourth and subsequent years of operation, an

19 ACE shall convert to a Managed Care Community Network

20 (MCCN), as defined in this Article, or Health Maintenance

21 Organization pursuant to the Illinois Insurance Code,

22 accepting full-risk capitation payments.

23 The Department shall allow potential ACE entities 5 months

24 from the date of the posting of the solicitation to submit

25 proposals. After the solicitation is released, in addition to

26 the MCO rate development data available on the Department's

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1 website, subject to federal and State confidentiality and

2 privacy laws and regulations, the Department shall provide 2

3 years of de-identified summary service data on the targeted

4 population, split between children and adults, showing the

5 historical type and volume of services received and the cost of

6 those services to those potential bidders that sign a data use

7 agreement. The Department may add up to 2 non-state government

8 employees with expertise in creating integrated delivery

9 systems to its review team for the purchase of care

10 solicitation described in this subsection. Any such

11 individuals must sign a no-conflict disclosure and

12 confidentiality agreement and agree to act in accordance with

13 all applicable State laws.

14 During the first 2 years of an ACE's operation, the

15 Department shall provide claims data to the ACE on its

16 enrollees on a periodic basis no less frequently than monthly.

17 Nothing in this subsection shall be construed to limit the

18 Department's mandate to enroll 50% of its beneficiaries into

19 care coordination systems by January 1, 2015, using all

20 available care coordination delivery systems, including Care

21 Coordination Entities (CCE), MCCNs, or MCOs, nor be construed

22 to affect the current CCEs, MCCNs, and MCOs selected to serve

23 seniors and persons with disabilities prior to that date.

24 Nothing in this subsection precludes the Department from

25 considering future proposals for new ACEs or expansion of

26 existing ACEs at the discretion of the Department.

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1 (h) Department contracts with MCOs and other entities

2 reimbursed by risk based capitation shall have a minimum

3 medical loss ratio of 85%, ~~shall require the MCO or other~~

4 ~~entity to pay claims within 30 days of receiving a bill that~~

5 ~~contains all the essential information needed to adjudicate the~~

6 ~~bill, and shall require the entity to pay a penalty that is at~~

7 ~~least equal to the penalty imposed under the Illinois Insurance~~

8 ~~Code for any claims not paid within this time period~~ shall

9 require the entity to establish an appeals and grievances

10 process for consumers and providers, and shall require the

11 entity to provide a quality assurance and utilization review

12 program. Entities contracted with the Department to coordinate

13 healthcare regardless of risk shall be measured utilizing the

14 same quality metrics. The quality metrics may be population

15 specific. Any contracted entity serving at least 5,000 seniors

16 or people with disabilities or 15,000 individuals in other

17 populations covered by the Medical Assistance Program that has

18 been receiving full-risk capitation for a year shall be

19 accredited by a national accreditation organization authorized

20 by the Department within 2 years after the date it is eligible

21 to become accredited. The requirements of this subsection shall

22 apply to contracts with MCOs entered into or renewed or

23 extended after June 1, 2013.

24 (h-5) The Department shall monitor and enforce compliance

25 by MCOs with agreements they have entered into with providers

26 on issues that include, but are not limited to, timeliness of

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1 payment, payment rates, and processes for obtaining prior

2 approval. The Department may impose sanctions on MCOs for

3 violating provisions of those agreements that include, but are

4 not limited to, financial penalties, suspension of enrollment

5 of new enrollees, and termination of the MCO's contract with

6 the Department. As used in this subsection (h-5), "MCO" has the

7 meaning ascribed to that term in Section 5-30.1 of this Code.

8 (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)

9 (305 ILCS 5/5-30.1 new)

10 Sec. 5-30.1. Managed care protections.

11 (a) As used in this Section:

12 "Managed care organization" or "MCO" means any entity which

13 contracts with the Department to provide services where payment

14 for medical services is made on a capitated basis.

15 "Emergency services" include:

16 (1) emergency services, as defined by Section 10 of the

17 Managed Care Reform and Patient Rights Act;

18 (2) emergency medical screening examinations, as

19 defined by Section 10 of the Managed Care Reform and

20 Patient Rights Act;

21 (3) post-stabilization medical services, as defined by

22 Section 10 of the Managed Care Reform and Patient Rights

23 Act; and

24 (4) emergency medical conditions, as defined by

25 Section 10 of the Managed Care Reform and Patient Rights

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1 Act.

2 (b) As provided by Section 5-16.12, managed care

3 organizations are subject to the provisions of the Managed Care

4 Reform and Patient Rights Act.

5 (c) An MCO shall pay any provider of emergency services

6 that does not have in effect a contract with the contracted

7 Medicaid MCO. The default rate of reimbursement shall be the

8 rate paid under Illinois Medicaid fee-for-service program

9 methodology, including all policy adjusters, including but not

10 limited to Medicaid High Volume Adjustments, Medicaid

11 Percentage Adjustments, Outpatient High Volume Adjustments,

12 and all outlier add-on adjustments to the extent such

13 adjustments are incorporated in the development of the

14 applicable MCO capitated rates.

15 (d) An MCO shall pay for all post-stabilization services as

16 a covered service in any of the following situations:

17 (1) the MCO authorized such services;

18 (2) such services were administered to maintain the

19 enrollee's stabilized condition within one hour after a

20 request to the MCO for authorization of further

21 post-stabilization services;

22 (3) the MCO did not respond to a request to authorize

23 such services within one hour;

24 (4) the MCO could not be contacted; or

25 (5) the MCO and the treating provider, if the treating

26 provider is a non-affiliated provider, could not reach an

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1 agreement concerning the enrollee's care and an affiliated

2 provider was unavailable for a consultation, in which case

3 the MCO must pay for such services rendered by the treating

4 non-affiliated provider until an affiliated provider was

5 reached and either concurred with the treating

6 non-affiliated provider's plan of care or assumed

7 responsibility for the enrollee's care. Such payment shall

8 be made at the default rate of reimbursement paid under

9 Illinois Medicaid fee-for-service program methodology,

10 including all policy adjusters, including but not limited

11 to Medicaid High Volume Adjustments, Medicaid Percentage

12 Adjustments, Outpatient High Volume Adjustments and all

13 outlier add-on adjustments to the extent that such

14 adjustments are incorporated in the development of the

15 applicable MCO capitated rates.

16 (e) The following requirements apply to MCOs in determining

17 payment for all emergency services:

18 (1) MCOs shall not impose any requirements for prior

19 approval of emergency services.

20 (2) The MCO shall cover emergency services provided to

21 enrollees who are temporarily away from their residence and

22 outside the contracting area to the extent that the

23 enrollees would be entitled to the emergency services if

24 they still were within the contracting area.

25 (3) The MCO shall have no obligation to cover medical

26 services provided on an emergency basis that are not

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1 covered services under the contract.

2 (4) The MCO shall not condition coverage for emergency

3 services on the treating provider notifying the MCO of the

4 enrollee's screening and treatment within 10 days after

5 presentation for emergency services.

6 (5) The determination of the attending emergency

7 physician, or the provider actually treating the enrollee,

8 of whether an enrollee is sufficiently stabilized for

9 discharge or transfer to another facility, shall be binding

10 on the MCO. The MCO shall cover emergency services for all

11 enrollees whether the emergency services are provided by an

12 affiliated or non-affiliated provider.

13 (6) The MCO's financial responsibility for

14 post-stabilization care services it has not pre-approved

15 ends when:

16 (A) a plan physician with privileges at the

17 treating hospital assumes responsibility for the

18 enrollee's care;

19 (B) a plan physician assumes responsibility for

20 the enrollee's care through transfer;

21 (C) a contracting entity representative and the

22 treating physician reach an agreement concerning the

23 enrollee's care; or

24 (D) the enrollee is discharged.

25 (f) Network adequacy.

26 (1) The Department shall:

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1 (A) ensure that an adequate provider network is in

2 place, taking into consideration health professional

3 shortage areas and medically underserved areas;

4 (B) publicly release an explanation of its process

5 for analyzing network adequacy;

6 (C) periodically ensure that an MCO continues to

7 have an adequate network in place; and

8 (D) require MCOs to maintain an updated and public

9 list of network providers.

10 (g) Timely payment of claims.

11 (1) The MCO shall pay a claim within 30 days of

12 receiving a claim that contains all the essential

13 information needed to adjudicate the claim.

14 (2) The MCO shall notify the billing party of its

15 inability to adjudicate a claim within 30 days of receiving

16 that claim.

17 (3) The MCO shall pay a penalty that is at least equal

18 to the penalty imposed under the Illinois Insurance Code

19 for any claims not timely paid.

20 (4) The Department may establish a process for MCOs to

21 expedite payments to providers based on criteria

22 established by the Department.

23 (h) The Department shall not expand mandatory MCO

24 enrollment into new counties beyond those counties already

25 designated by the Department as of June 1, 2014 for the

26 individuals whose eligibility for medical assistance is not the

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1 seniors or people with disabilities population until the

2 Department provides an opportunity for accountable care

3 entities and MCOs to participate in such newly designated

4 counties.

5 (i) The requirements of this Section apply to contracts

6 with accountable care entities and MCOs entered into, amended,

7 or renewed after the effective date of this amendatory Act of

8 the 98th General Assembly.

9 Article 10

10 Section 10-5. The Specialized Mental Health Rehabilitation

11 Act of 2013 is amended by changing Sections 1-101.5, 1-101.6,

12 1-102, 4-108, and 5-101 and by adding Section 4-108.5 as

13 follows:

14 (210 ILCS 49/1-101.5)

15 Sec. 1-101.5. Prior law.

16 (a) This Act provides for licensure of long term care

17 facilities that are federally designated as institutions for

18 the mentally diseased on the effective date of this Act and

19 specialize in providing services to individuals with a serious

20 mental illness. On and after the effective date of this Act,

21 these facilities shall be governed by this Act instead of the

22 Nursing Home Care Act.

23 (b) All consent decrees that apply to facilities federally

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1 designated as institutions for the mentally diseased shall

2 continue to apply to facilities licensed under this Act.

3 (c) A facility licensed under this Act may voluntarily

4 close, and the facility may reopen in an underserved region of

5 the State, if the facility receives a certificate of need from

6 the Health Facilities and Services Review Board. At no time

7 shall the total number of licensed beds under this Act exceed

8 the total number of licensed beds existing on July 22, 2013

9 (the effective date of Public Act 98-104).

10 (Source: P.A. 98-104, eff. 7-22-13.)

11 (210 ILCS 49/1-101.6)

12 Sec. 1-101.6. Mental health system planning. The General

13 Assembly finds the services contained in this Act are necessary

14 for the effective delivery of mental health services for the

15 citizens of the State of Illinois. The General Assembly also

16 finds that the mental health system in the State requires

17 further review to develop additional needed services. To ensure

18 the adequacy of community-based services and to offer choice to

19 all individuals with serious mental illness who choose to live

20 in the community, and for whom the community is the appropriate

21 setting, but are at risk of institutional care, the Governor

22 shall convene a working group to develop the process and

23 procedure for identifying needed services in the different

24 geographic regions of the State. The Governor shall include the

25 Division of Mental Health of the Department of Human Services,

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1 the Department of Healthcare and Family Services, the

2 Department of Public Health, community mental health

3 providers, statewide associations of mental health providers,

4 mental health advocacy groups, and any other entity as deemed

5 appropriate for participation in the working group. The

6 Department of Human Services shall provide staff and support to

7 this working group.

8 Before September 1, 2014, the State shall develop and

9 implement a service authorization system available 24 hours a

10 day, 7 days a week for approval of services in the following 3

11 levels of care under this Act: crisis stabilization; recovery

12 and rehabilitation supports; and transitional living units.

13 (Source: P.A. 98-104, eff. 7-22-13.)

14 (210 ILCS 49/1-102)

15 Sec. 1-102. Definitions. For the purposes of this Act,

16 unless the context otherwise requires:

17 "Abuse" means any physical or mental injury or sexual

18 assault inflicted on a consumer other than by accidental means

19 in a facility.

20 "Accreditation" means any of the following:

21 (1) the Joint Commission;

22 (2) the Commission on Accreditation of Rehabilitation

23 Facilities;

24 (3) the Healthcare Facilities Accreditation Program;

25 or

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1 (4) any other national standards of care as approved by

2 the Department.

3 "Applicant" means any person making application for a

4 license or a provisional license under this Act.

5 "Consumer" means a person, 18 years of age or older,

6 admitted to a mental health rehabilitation facility for

7 evaluation, observation, diagnosis, treatment, stabilization,

8 recovery, and rehabilitation.

9 "Consumer" does not mean any of the following:

10 (i) an individual requiring a locked setting;

11 (ii) an individual requiring psychiatric

12 hospitalization because of an acute psychiatric crisis;

13 (iii) an individual under 18 years of age;

14 (iv) an individual who is actively suicidal or violent

15 toward others;

16 (v) an individual who has been found unfit to stand

17 trial;

18 (vi) an individual who has been found not guilty by

19 reason of insanity based on committing a violent act, such

20 as sexual assault, assault with a deadly weapon, arson, or

21 murder;

22 (vii) an individual subject to temporary detention and

23 examination under Section 3-607 of the Mental Health and

24 Developmental Disabilities Code;

25 (viii) an individual deemed clinically appropriate for

26 inpatient admission in a State psychiatric hospital; and

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1 (ix) an individual transferred by the Department of

2 Corrections pursuant to Section 3-8-5 of the Unified Code

3 of Corrections.

4 "Consumer record" means a record that organizes all

5 information on the care, treatment, and rehabilitation

6 services rendered to a consumer in a specialized mental health

7 rehabilitation facility.

8 "Controlled drugs" means those drugs covered under the

9 federal Comprehensive Drug Abuse Prevention Control Act of

10 1970, as amended, or the Illinois Controlled Substances Act.

11 "Department" means the Department of Public Health.

12 "Discharge" means the full release of any consumer from a

13 facility.

14 "Drug administration" means the act in which a single dose

15 of a prescribed drug or biological is given to a consumer. The

16 complete act of administration entails removing an individual

17 dose from a container, verifying the dose with the prescriber's

18 orders, giving the individual dose to the consumer, and

19 promptly recording the time and dose given.

20 "Drug dispensing" means the act entailing the following of

21 a prescription order for a drug or biological and proper

22 selection, measuring, packaging, labeling, and issuance of the

23 drug or biological to a consumer.

24 "Emergency" means a situation, physical condition, or one

25 or more practices, methods, or operations which present

26 imminent danger of death or serious physical or mental harm to

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1 consumers of a facility.

2 "Facility" means a specialized mental health

3 rehabilitation facility that provides at least one of the

4 following services: (1) triage center; (2) crisis

5 stabilization; (3) recovery and rehabilitation supports; or

6 (4) transitional living units for 3 or more persons. The

7 facility shall provide a 24-hour program that provides

8 intensive support and recovery services designed to assist

9 persons, 18 years or older, with mental disorders to develop

10 the skills to become self-sufficient and capable of increasing

11 levels of independent functioning. It includes facilities that

12 meet the following criteria:

13 (1) 100% of the consumer population of the facility has

14 a diagnosis of serious mental illness;

15 (2) no more than 15% of the consumer population of the

16 facility is 65 years of age or older;

17 (3) none of the consumers are non-ambulatory;

18 (4) none of the consumers have a primary diagnosis of

19 moderate, severe, or profound intellectual disability; and

20 (5) the facility must have been licensed under the

21 Specialized Mental Health Rehabilitation Act or the

22 Nursing Home Care Act immediately preceding the effective

23 date of this Act and qualifies as a institute for mental

24 disease under the federal definition of the term.

25 "Facility" does not include the following:

26 (1) a home, institution, or place operated by the

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1 federal government or agency thereof, or by the State of

2 Illinois;

3 (2) a hospital, sanitarium, or other institution whose

4 principal activity or business is the diagnosis, care, and

5 treatment of human illness through the maintenance and

6 operation as organized facilities therefor which is

7 required to be licensed under the Hospital Licensing Act;

8 (3) a facility for child care as defined in the Child

9 Care Act of 1969;

10 (4) a community living facility as defined in the

11 Community Living Facilities Licensing Act;

12 (5) a nursing home or sanatorium operated solely by and

13 for persons who rely exclusively upon treatment by

14 spiritual means through prayer, in accordance with the

15 creed or tenets of any well-recognized church or religious

16 denomination; however, such nursing home or sanatorium

17 shall comply with all local laws and rules relating to

18 sanitation and safety;

19 (6) a facility licensed by the Department of Human

20 Services as a community-integrated living arrangement as

21 defined in the Community-Integrated Living Arrangements

22 Licensure and Certification Act;

23 (7) a supportive residence licensed under the

24 Supportive Residences Licensing Act;

25 (8) a supportive living facility in good standing with

26 the program established under Section 5-5.01a of the

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1 Illinois Public Aid Code, except only for purposes of the

2 employment of persons in accordance with Section 3-206.01

3 of the Nursing Home Care Act;

4 (9) an assisted living or shared housing establishment

5 licensed under the Assisted Living and Shared Housing Act,

6 except only for purposes of the employment of persons in

7 accordance with Section 3-206.01 of the Nursing Home Care

8 Act;

9 (10) an Alzheimer's disease management center

10 alternative health care model licensed under the

11 Alternative Health Care Delivery Act;

12 (11) a home, institution, or other place operated by or

13 under the authority of the Illinois Department of Veterans'

14 Affairs;

15 (12) a facility licensed under the ID/DD Community Care

16 Act; or

17 (13) a facility licensed under the Nursing Home Care

18 Act after the effective date of this Act.

19 "Executive director" means a person who is charged with the

20 general administration and supervision of a facility licensed

21 under this Act.

22 "Guardian" means a person appointed as a guardian of the

23 person or guardian of the estate, or both, of a consumer under

24 the Probate Act of 1975.

25 "Identified offender" means a person who meets any of the

26 following criteria:

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1 (1) Has been convicted of, found guilty of, adjudicated

2 delinquent for, found not guilty by reason of insanity for,

3 or found unfit to stand trial for, any felony offense

4 listed in Section 25 of the Health Care Worker Background

5 Check Act, except for the following:

6 (i) a felony offense described in Section 10-5 of

7 the Nurse Practice Act;

8 (ii) a felony offense described in Section 4, 5, 6,

9 8, or 17.02 of the Illinois Credit Card and Debit Card

10 Act;

11 (iii) a felony offense described in Section 5, 5.1,

12 5.2, 7, or 9 of the Cannabis Control Act;

13 (iv) a felony offense described in Section 401,

14 401.1, 404, 405, 405.1, 407, or 407.1 of the Illinois

15 Controlled Substances Act; and

16 (v) a felony offense described in the

17 Methamphetamine Control and Community Protection Act.

18 (2) Has been convicted of, adjudicated delinquent for,

19 found not guilty by reason of insanity for, or found unfit

20 to stand trial for, any sex offense as defined in

21 subsection (c) of Section 10 of the Sex Offender Management

22 Board Act.

23 "Transitional living units" are residential units within a

24 facility that have the purpose of assisting the consumer in

25 developing and reinforcing the necessary skills to live

26 independently outside of the facility. The duration of stay in

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1 such a setting shall not exceed 120 days for each consumer.

2 Nothing in this definition shall be construed to be a

3 prerequisite for transitioning out of a facility.

4 "Licensee" means the person, persons, firm, partnership,

5 association, organization, company, corporation, or business

6 trust to which a license has been issued.

7 "Misappropriation of a consumer's property" means the

8 deliberate misplacement, exploitation, or wrongful temporary

9 or permanent use of a consumer's belongings or money without

10 the consent of a consumer or his or her guardian.

11 "Neglect" means a facility's failure to provide, or willful

12 withholding of, adequate medical care, mental health

13 treatment, psychiatric rehabilitation, personal care, or

14 assistance that is necessary to avoid physical harm and mental

15 anguish of a consumer.

16 "Personal care" means assistance with meals, dressing,

17 movement, bathing, or other personal needs, maintenance, or

18 general supervision and oversight of the physical and mental

19 well-being of an individual who is incapable of maintaining a

20 private, independent residence or who is incapable of managing

21 his or her person, whether or not a guardian has been appointed

22 for such individual. "Personal care" shall not be construed to

23 confine or otherwise constrain a facility's pursuit to develop

24 the skills and abilities of a consumer to become

25 self-sufficient and capable of increasing levels of

26 independent functioning.

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1 "Recovery and rehabilitation supports" means a program

2 that facilitates a consumer's longer-term symptom management

3 and stabilization while preparing the consumer for

4 transitional living units by improving living skills and

5 community socialization. The duration of stay in such a setting

6 shall be established by the Department by rule.

7 "Restraint" means:

8 (i) a physical restraint that is any manual method or

9 physical or mechanical device, material, or equipment

10 attached or adjacent to a consumer's body that the consumer

11 cannot remove easily and restricts freedom of movement or

12 normal access to one's body; devices used for positioning,

13 including, but not limited to, bed rails, gait belts, and

14 cushions, shall not be considered to be restraints for

15 purposes of this Section; or

16 (ii) a chemical restraint that is any drug used for

17 discipline or convenience and not required to treat medical

18 symptoms; the Department shall, by rule, designate certain

19 devices as restraints, including at least all those devices

20 that have been determined to be restraints by the United

21 States Department of Health and Human Services in

22 interpretive guidelines issued for the purposes of

23 administering Titles XVIII and XIX of the federal Social

24 Security Act. For the purposes of this Act, restraint shall

25 be administered only after utilizing a coercive free

26 environment and culture.

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1 "Self-administration of medication" means consumers shall

2 be responsible for the control, management, and use of their

3 own medication.

4 "Crisis stabilization" means a secure and separate unit

5 that provides short-term behavioral, emotional, or psychiatric

6 crisis stabilization as an alternative to hospitalization or

7 re-hospitalization for consumers from residential or community

8 placement. The duration of stay in such a setting shall not

9 exceed 21 days for each consumer.

10 "Therapeutic separation" means the removal of a consumer

11 from the milieu to a room or area which is designed to aid in

12 the emotional or psychiatric stabilization of that consumer.

13 "Triage center" means a non-residential 23-hour center

14 that serves as an alternative to emergency room care,

15 hospitalization, or re-hospitalization for consumers in need

16 of short-term crisis stabilization. Consumers may access a

17 triage center from a number of referral sources, including

18 family, emergency rooms, hospitals, community behavioral

19 health providers, federally qualified health providers, or

20 schools, including colleges or universities. A triage center

21 may be located in a building separate from the licensed

22 location of a facility, but shall not be more than 1,000 feet

23 from the licensed location of the facility and must meet all of

24 the facility standards applicable to the licensed location. If

25 the triage center does operate in a separate building, safety

26 personnel shall be provided, on site, 24 hours per day and the

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1 triage center shall meet all other staffing requirements

2 without counting any staff employed in the main facility

3 building.

4 (Source: P.A. 98-104, eff. 7-22-13.)

5 (210 ILCS 49/4-108)

6 Sec. 4-108. Surveys and inspections. The Department shall

7 conduct surveys of licensed facilities and their certified

8 programs and services. The Department shall review the records

9 or premises, or both, as it deems appropriate for the purpose

10 of determining compliance with this Act and the rules

11 promulgated under this Act. The Department shall have access to

12 and may reproduce or photocopy any books, records, and other

13 documents maintained by the facility to the extent necessary to

14 carry out this Act and the rules promulgated under this Act.

15 The Department shall not divulge or disclose the contents of a

16 record under this Section as otherwise prohibited by this Act.

17 Any holder of a license or applicant for a license shall be

18 deemed to have given consent to any authorized officer,

19 employee, or agent of the Department to enter and inspect the

20 facility in accordance with this Article. Refusal to permit

21 such entry or inspection shall constitute grounds for denial,

22 suspension, or revocation of a license under this Act.

23 (1) The Department shall conduct surveys to determine

24 compliance and may conduct surveys to investigate

25 complaints.

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1 (2) Determination of compliance with the service

2 requirements shall be based on a survey centered on

3 individuals that sample services being provided.

4 (3) Determination of compliance with the general

5 administrative requirements shall be based on a review of

6 facility records and observation of individuals and staff.

7 (4) The Department shall conduct surveys of licensed

8 facilities and their certified programs and services to

9 determine the extent to which these facilities provide high

10 quality interventions, especially evidence-based

11 practices, appropriate to the assessed clinical needs of

12 individuals in the various levels of care.

13 (Source: P.A. 98-104, eff. 7-22-13.)

14 (210 ILCS 49/4-108.5 new)

15 Sec. 4-108.5. Provisional licensure period; surveys.

16 During the provisional licensure period, the Department shall

17 conduct surveys to determine compliance with timetables and

18 benchmarks with a facility's provisional licensure application

19 plan of operation. Timetables and benchmarks shall be

20 established in rule and shall include, but not be limited to,

21 the following: (1) training of new and existing staff; (2)

22 establishment of a data collection and reporting program for

23 the facility's Quality Assessment and Performance Improvement

24 Program; and (3) compliance with building environment

25 standards beyond compliance with Chapter 33 of the National

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1 Fire Protection Association (NFPA) 101 Life Safety Code.

2 During the provisional licensure period, the Department

3 shall conduct State licensure surveys as well as a conformance

4 standard review to determine compliance with timetables and

5 benchmarks associated with the accreditation process.

6 Timetables and benchmarks shall be met in accordance with the

7 preferred accrediting organization conformance standards and

8 recommendations and shall include, but not be limited to,

9 conducting a comprehensive facility self-evaluation in

10 accordance with an established national accreditation program.

11 The facility shall submit all data reporting and outcomes

12 required by accrediting organization to the Department of

13 Public Health for review to determine progress towards

14 accreditation. Accreditation status shall supplement but not

15 replace the State's licensure surveys of facilities licensed

16 under this Act and their certified programs and services to

17 determine the extent to which these facilities provide high

18 quality interventions, especially evidence-based practices,

19 appropriate to the assessed clinical needs of individuals in

20 the 4 certified levels of care.

21 Except for incidents involving the potential for harm,

22 serious harm, death, or substantial facility failure to address

23 a serious systemic issue within 60 days, findings of the

24 facility's root cause analysis of problems and the facility's

25 Quality Assessment and Performance Improvement program in

26 accordance with item (22) of Section 4-104 shall not be used as

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1 a basis for non-compliance.

2 The Department shall have the authority to hire licensed

3 practitioners of the healing arts and qualified mental health

4 professionals to consult with and participate in survey and

5 inspection activities.

6 (210 ILCS 49/5-101)

7 Sec. 5-101. Managed care entity, coordinated care entity,

8 and accountable care entity payments. For facilities licensed

9 by the Department of Public Health under this Act, the payment

10 for services provided shall be determined by negotiation with

11 managed care entities, coordinated care entities, or

12 accountable care entities. However, for 3 years after the

13 effective date of this Act, in no event shall the reimbursement

14 rate paid to facilities licensed under this Act be less than

15 the rate in effect on June 30, 2013 less $7.07 times the number

16 of occupied bed days, as that term is defined in Article V-B of

17 the Illinois Public Aid Code, for each facility previously

18 licensed under the Nursing Home Care Act on June 30, 2013; or

19 the rate in effect on June 30, 2013 for each facility licensed

20 under the Specialized Mental Health Rehabilitation Act on June

21 30, 2013. Any adjustment in the support component or the

22 capital component for facilities licensed by the Department of

23 Public Health under the Nursing Home Care Act shall apply

24 equally to facilities licensed by the Department of Public

25 Health under this Act for the duration of the provisional

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1 licensure period as defined in Section 4-105 of this Act.

2 The Department of Healthcare and Family Services shall

3 publish a reimbursement rate for triage, crisis stabilization,

4 and transitional living services by December 1, 2014.

5 (Source: P.A. 98-104, eff. 7-22-13.)

6 Article 15

7 Section 15-5. The Illinois Public Aid Code is amended by

8 changing Sections 5A-8 and 5A-12.2 as follows:

9 (305 ILCS 5/5A-8) (from Ch. 23, par. 5A-8)

10 Sec. 5A-8. Hospital Provider Fund.

11 (a) There is created in the State Treasury the Hospital

12 Provider Fund. Interest earned by the Fund shall be credited to

13 the Fund. The Fund shall not be used to replace any moneys

14 appropriated to the Medicaid program by the General Assembly.

15 (b) The Fund is created for the purpose of receiving moneys

16 in accordance with Section 5A-6 and disbursing moneys only for

17 the following purposes, notwithstanding any other provision of

18 law:

19 (1) For making payments to hospitals as required under

20 this Code, under the Children's Health Insurance Program

21 Act, under the Covering ALL KIDS Health Insurance Act, and

22 under the Long Term Acute Care Hospital Quality Improvement

23 Transfer Program Act.

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1 (2) For the reimbursement of moneys collected by the

2 Illinois Department from hospitals or hospital providers

3 through error or mistake in performing the activities

4 authorized under this Code.

5 (3) For payment of administrative expenses incurred by

6 the Illinois Department or its agent in performing

7 activities under this Code, under the Children's Health

8 Insurance Program Act, under the Covering ALL KIDS Health

9 Insurance Act, and under the Long Term Acute Care Hospital

10 Quality Improvement Transfer Program Act.

11 (4) For payments of any amounts which are reimbursable

12 to the federal government for payments from this Fund which

13 are required to be paid by State warrant.

14 (5) For making transfers, as those transfers are

15 authorized in the proceedings authorizing debt under the

16 Short Term Borrowing Act, but transfers made under this

17 paragraph (5) shall not exceed the principal amount of debt

18 issued in anticipation of the receipt by the State of

19 moneys to be deposited into the Fund.

20 (6) For making transfers to any other fund in the State

21 treasury, but transfers made under this paragraph (6) shall

22 not exceed the amount transferred previously from that

23 other fund into the Hospital Provider Fund plus any

24 interest that would have been earned by that fund on the

25 monies that had been transferred.

26 (6.5) For making transfers to the Healthcare Provider

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1 Relief Fund, except that transfers made under this

2 paragraph (6.5) shall not exceed $60,000,000 in the

3 aggregate.

4 (7) For making transfers not exceeding the following

5 amounts, related to ~~in~~ State fiscal years 2013 through 2018

6 ~~and 2014~~, to the following designated funds:

7 Health and Human Services Medicaid Trust

8 Fund..............................$20,000,000

9 Long-Term Care Provider Fund..........$30,000,000

10 General Revenue Fund.................$80,000,000.

11 Transfers under this paragraph shall be made within 7 days

12 after the payments have been received pursuant to the

13 schedule of payments provided in subsection (a) of Section

14 5A-4.

15 (7.1) (Blank). ~~For making transfers not exceeding the~~

16 ~~following amounts, in State fiscal year 2015, to the~~

17 ~~following designated funds:~~

18 ~~Health and Human Services Medicaid Trust~~

19 ~~Fund..............................$10,000,000~~

20 ~~Long-Term Care Provider Fund..........$15,000,000~~

21 ~~General Revenue Fund.................$40,000,000.~~

22 ~~Transfers under this paragraph shall be made within 7 days~~

23 ~~after the payments have been received pursuant to the~~

24 ~~schedule of payments provided in subsection (a) of Section~~

25 ~~5A-4.~~

26 (7.5) (Blank).

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1 (7.8) (Blank).

2 (7.9) (Blank).

3 (7.10) For State fiscal year ~~years 2013 and~~ 2014, for

4 making transfers of the moneys resulting from the

5 assessment under subsection (b-5) of Section 5A-2 and

6 received from hospital providers under Section 5A-4 and

7 transferred into the Hospital Provider Fund under Section

8 5A-6 to the designated funds not exceeding the following

9 amounts in that State fiscal year:

10 Health Care Provider Relief Fund.....$100,000,000

11 ~~$50,000,000~~

12 Transfers under this paragraph shall be made within 7

13 days after the payments have been received pursuant to the

14 schedule of payments provided in subsection (a) of Section

15 5A-4.

16 The additional amount of transfers in this paragraph

17 (7.10), authorized by this amendatory Act of the 98th

18 General Assembly, shall be made within 10 State business

19 days after the effective date of this amendatory Act of the

20 98th General Assembly. That authority shall remain in

21 effect even if this amendatory Act of the 98th General

22 Assembly does not become law until State fiscal year 2015.

23 (7.10a) For State fiscal years 2015 through 2018, for

24 making transfers of the moneys resulting from the

25 assessment under subsection (b-5) of Section 5A-2 and

26 received from hospital providers under Section 5A-4 and

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1 transferred into the Hospital Provider Fund under Section

2 5A-6 to the designated funds not exceeding the following

3 amounts related to each State fiscal year:

4 Health Care Provider Relief

5 Fund .....................................$50,000,000

6 Transfers under this paragraph shall be made within 7

7 days after the payments have been received pursuant to the

8 schedule of payments provided in subsection (a) of Section

9 5A-4.

10 (7.11) (Blank). ~~For State fiscal year 2015, for making~~

11 ~~transfers of the moneys resulting from the assessment under~~

12 ~~subsection (b-5) of Section 5A-2 and received from hospital~~

13 ~~providers under Section 5A-4 and transferred into the~~

14 ~~Hospital Provider Fund under Section 5A-6 to the designated~~

15 ~~funds not exceeding the following amounts in that State~~

16 ~~fiscal year:~~

17 ~~Health Care Provider Relief Fund......$25,000,000~~

18 ~~Transfers under this paragraph shall be made within 7~~

19 ~~days after the payments have been received pursuant to the~~

20 ~~schedule of payments provided in subsection (a) of Section~~

21 ~~5A-4.~~

22 (7.12) For State fiscal year 2013, for increasing by

23 21/365ths the transfer of the moneys resulting from the

24 assessment under subsection (b-5) of Section 5A-2 and

25 received from hospital providers under Section 5A-4 for the

26 portion of State fiscal year 2012 beginning June 10, 2012

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1 through June 30, 2012 and transferred into the Hospital

2 Provider Fund under Section 5A-6 to the designated funds

3 not exceeding the following amounts in that State fiscal

4 year:

5 Health Care Provider Relief Fund......$2,870,000

6 Since the federal Centers for Medicare and Medicaid

7 Services approval of the assessment authorized under

8 subsection (b-5) of Section 5A-2, received from hospital

9 providers under Section 5A-4 and the payment methodologies

10 to hospitals required under Section 5A-12.4 was not

11 received by the Department until State fiscal year 2014 and

12 since the Department made retroactive payments during

13 State fiscal year 2014 related to the referenced period of

14 June 2012, the transfer authority granted in this paragraph

15 (7.12) is extended through the date that is 10 State

16 business days after the effective date of this amendatory

17 Act of the 98th General Assembly.

18 (8) For making refunds to hospital providers pursuant

19 to Section 5A-10.

20 (9) For making payment to capitated managed care

21 organizations as described in subsections (s) and (t) of

22 Section 5A-12.2 of this Code.

23 Disbursements from the Fund, other than transfers

24 authorized under paragraphs (5) and (6) of this subsection,

25 shall be by warrants drawn by the State Comptroller upon

26 receipt of vouchers duly executed and certified by the Illinois

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1 Department.

2 (c) The Fund shall consist of the following:

3 (1) All moneys collected or received by the Illinois

4 Department from the hospital provider assessment imposed

5 by this Article.

6 (2) All federal matching funds received by the Illinois

7 Department as a result of expenditures made by the Illinois

8 Department that are attributable to moneys deposited in the

9 Fund.

10 (3) Any interest or penalty levied in conjunction with

11 the administration of this Article.

12 (3.5) As applicable, proceeds from surety bond

13 payments payable to the Department as referenced in

14 subsection (s) of Section 5A-12.2 of this Code

15 (4) Moneys transferred from another fund in the State

16 treasury.

17 (5) All other moneys received for the Fund from any

18 other source, including interest earned thereon.

19 (d) (Blank).

20 (Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12;

21 98-104, eff. 7-22-13; 98-463, eff. 8-16-13; revised 10-21-13.)

22 (305 ILCS 5/5A-12.2)

23 (Section scheduled to be repealed on January 1, 2015)

24 Sec. 5A-12.2. Hospital access payments on or after July 1,

25 2008.

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1 (a) To preserve and improve access to hospital services,

2 for hospital services rendered on or after July 1, 2008, the

3 Illinois Department shall, except for hospitals described in

4 subsection (b) of Section 5A-3, make payments to hospitals as

5 set forth in this Section. These payments shall be paid in 12

6 equal installments on or before the seventh State business day

7 of each month, except that no payment shall be due within 100

8 days after the later of the date of notification of federal

9 approval of the payment methodologies required under this

10 Section or any waiver required under 42 CFR 433.68, at which

11 time the sum of amounts required under this Section prior to

12 the date of notification is due and payable. Payments under

13 this Section are not due and payable, however, until (i) the

14 methodologies described in this Section are approved by the

15 federal government in an appropriate State Plan amendment and

16 (ii) the assessment imposed under this Article is determined to

17 be a permissible tax under Title XIX of the Social Security

18 Act.

19 (a-5) The Illinois Department may, when practicable,

20 accelerate the schedule upon which payments authorized under

21 this Section are made.

22 (b) Across-the-board inpatient adjustment.

23 (1) In addition to rates paid for inpatient hospital

24 services, the Department shall pay to each Illinois general

25 acute care hospital an amount equal to 40% of the total

26 base inpatient payments paid to the hospital for services

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1 provided in State fiscal year 2005.

2 (2) In addition to rates paid for inpatient hospital

3 services, the Department shall pay to each freestanding

4 Illinois specialty care hospital as defined in 89 Ill. Adm.

5 Code 149.50(c)(1), (2), or (4) an amount equal to 60% of

6 the total base inpatient payments paid to the hospital for

7 services provided in State fiscal year 2005.

8 (3) In addition to rates paid for inpatient hospital

9 services, the Department shall pay to each freestanding

10 Illinois rehabilitation or psychiatric hospital an amount

11 equal to $1,000 per Medicaid inpatient day multiplied by

12 the increase in the hospital's Medicaid inpatient

13 utilization ratio (determined using the positive

14 percentage change from the rate year 2005 Medicaid

15 inpatient utilization ratio to the rate year 2007 Medicaid

16 inpatient utilization ratio, as calculated by the

17 Department for the disproportionate share determination).

18 (4) In addition to rates paid for inpatient hospital

19 services, the Department shall pay to each Illinois

20 children's hospital an amount equal to 20% of the total

21 base inpatient payments paid to the hospital for services

22 provided in State fiscal year 2005 and an additional amount

23 equal to 20% of the base inpatient payments paid to the

24 hospital for psychiatric services provided in State fiscal

25 year 2005.

26 (5) In addition to rates paid for inpatient hospital

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1 services, the Department shall pay to each Illinois

2 hospital eligible for a pediatric inpatient adjustment

3 payment under 89 Ill. Adm. Code 148.298, as in effect for

4 State fiscal year 2007, a supplemental pediatric inpatient

5 adjustment payment equal to:

6 (i) For freestanding children's hospitals as

7 defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5

8 multiplied by the hospital's pediatric inpatient

9 adjustment payment required under 89 Ill. Adm. Code

10 148.298, as in effect for State fiscal year 2008.

11 (ii) For hospitals other than freestanding

12 children's hospitals as defined in 89 Ill. Adm. Code

13 149.50(c)(3)(B), 1.0 multiplied by the hospital's

14 pediatric inpatient adjustment payment required under

15 89 Ill. Adm. Code 148.298, as in effect for State

16 fiscal year 2008.

17 (c) Outpatient adjustment.

18 (1) In addition to the rates paid for outpatient

19 hospital services, the Department shall pay each Illinois

20 hospital an amount equal to 2.2 multiplied by the

21 hospital's ambulatory procedure listing payments for

22 categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code

23 148.140(b), for State fiscal year 2005.

24 (2) In addition to the rates paid for outpatient

25 hospital services, the Department shall pay each Illinois

26 freestanding psychiatric hospital an amount equal to 3.25

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1 multiplied by the hospital's ambulatory procedure listing

2 payments for category 5b, as defined in 89 Ill. Adm. Code

3 148.140(b)(1)(E), for State fiscal year 2005.

4 (d) Medicaid high volume adjustment. In addition to rates

5 paid for inpatient hospital services, the Department shall pay

6 to each Illinois general acute care hospital that provided more

7 than 20,500 Medicaid inpatient days of care in State fiscal

8 year 2005 amounts as follows:

9 (1) For hospitals with a case mix index equal to or

10 greater than the 85th percentile of hospital case mix

11 indices, $350 for each Medicaid inpatient day of care

12 provided during that period; and

13 (2) For hospitals with a case mix index less than the

14 85th percentile of hospital case mix indices, $100 for each

15 Medicaid inpatient day of care provided during that period.

16 (e) Capital adjustment. In addition to rates paid for

17 inpatient hospital services, the Department shall pay an

18 additional payment to each Illinois general acute care hospital

19 that has a Medicaid inpatient utilization rate of at least 10%

20 (as calculated by the Department for the rate year 2007

21 disproportionate share determination) amounts as follows:

22 (1) For each Illinois general acute care hospital that

23 has a Medicaid inpatient utilization rate of at least 10%

24 and less than 36.94% and whose capital cost is less than

25 the 60th percentile of the capital costs of all Illinois

26 hospitals, the amount of such payment shall equal the

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1 hospital's Medicaid inpatient days multiplied by the

2 difference between the capital costs at the 60th percentile

3 of the capital costs of all Illinois hospitals and the

4 hospital's capital costs.

5 (2) For each Illinois general acute care hospital that

6 has a Medicaid inpatient utilization rate of at least

7 36.94% and whose capital cost is less than the 75th

8 percentile of the capital costs of all Illinois hospitals,

9 the amount of such payment shall equal the hospital's

10 Medicaid inpatient days multiplied by the difference

11 between the capital costs at the 75th percentile of the

12 capital costs of all Illinois hospitals and the hospital's

13 capital costs.

14 (f) Obstetrical care adjustment.

15 (1) In addition to rates paid for inpatient hospital

16 services, the Department shall pay $1,500 for each Medicaid

17 obstetrical day of care provided in State fiscal year 2005

18 by each Illinois rural hospital that had a Medicaid

19 obstetrical percentage (Medicaid obstetrical days divided

20 by Medicaid inpatient days) greater than 15% for State

21 fiscal year 2005.

22 (2) In addition to rates paid for inpatient hospital

23 services, the Department shall pay $1,350 for each Medicaid

24 obstetrical day of care provided in State fiscal year 2005

25 by each Illinois general acute care hospital that was

26 designated a level III perinatal center as of December 31,

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1 2006, and that had a case mix index equal to or greater

2 than the 45th percentile of the case mix indices for all

3 level III perinatal centers.

4 (3) In addition to rates paid for inpatient hospital

5 services, the Department shall pay $900 for each Medicaid

6 obstetrical day of care provided in State fiscal year 2005

7 by each Illinois general acute care hospital that was

8 designated a level II or II+ perinatal center as of

9 December 31, 2006, and that had a case mix index equal to

10 or greater than the 35th percentile of the case mix indices

11 for all level II and II+ perinatal centers.

12 (g) Trauma adjustment.

13 (1) In addition to rates paid for inpatient hospital

14 services, the Department shall pay each Illinois general

15 acute care hospital designated as a trauma center as of

16 July 1, 2007, a payment equal to 3.75 multiplied by the

17 hospital's State fiscal year 2005 Medicaid capital

18 payments.

19 (2) In addition to rates paid for inpatient hospital

20 services, the Department shall pay $400 for each Medicaid

21 acute inpatient day of care provided in State fiscal year

22 2005 by each Illinois general acute care hospital that was

23 designated a level II trauma center, as defined in 89 Ill.

24 Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1,

25 2007.

26 (3) In addition to rates paid for inpatient hospital

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1 services, the Department shall pay $235 for each Illinois

2 Medicaid acute inpatient day of care provided in State

3 fiscal year 2005 by each level I pediatric trauma center

4 located outside of Illinois that had more than 8,000

5 Illinois Medicaid inpatient days in State fiscal year 2005.

6 (h) Supplemental tertiary care adjustment. In addition to

7 rates paid for inpatient services, the Department shall pay to

8 each Illinois hospital eligible for tertiary care adjustment

9 payments under 89 Ill. Adm. Code 148.296, as in effect for

10 State fiscal year 2007, a supplemental tertiary care adjustment

11 payment equal to the tertiary care adjustment payment required

12 under 89 Ill. Adm. Code 148.296, as in effect for State fiscal

13 year 2007.

14 (i) Crossover adjustment. In addition to rates paid for

15 inpatient services, the Department shall pay each Illinois

16 general acute care hospital that had a ratio of crossover days

17 to total inpatient days for medical assistance programs

18 administered by the Department (utilizing information from

19 2005 paid claims) greater than 50%, and a case mix index

20 greater than the 65th percentile of case mix indices for all

21 Illinois hospitals, a rate of $1,125 for each Medicaid

22 inpatient day including crossover days.

23 (j) Magnet hospital adjustment. In addition to rates paid

24 for inpatient hospital services, the Department shall pay to

25 each Illinois general acute care hospital and each Illinois

26 freestanding children's hospital that, as of February 1, 2008,

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1 was recognized as a Magnet hospital by the American Nurses

2 Credentialing Center and that had a case mix index greater than

3 the 75th percentile of case mix indices for all Illinois

4 hospitals amounts as follows:

5 (1) For hospitals located in a county whose eligibility

6 growth factor is greater than the mean, $450 multiplied by

7 the eligibility growth factor for the county in which the

8 hospital is located for each Medicaid inpatient day of care

9 provided by the hospital during State fiscal year 2005.

10 (2) For hospitals located in a county whose eligibility

11 growth factor is less than or equal to the mean, $225

12 multiplied by the eligibility growth factor for the county

13 in which the hospital is located for each Medicaid

14 inpatient day of care provided by the hospital during State

15 fiscal year 2005.

16 For purposes of this subsection, "eligibility growth

17 factor" means the percentage by which the number of Medicaid

18 recipients in the county increased from State fiscal year 1998

19 to State fiscal year 2005.

20 (k) For purposes of this Section, a hospital that is

21 enrolled to provide Medicaid services during State fiscal year

22 2005 shall have its utilization and associated reimbursements

23 annualized prior to the payment calculations being performed

24 under this Section.

25 (l) For purposes of this Section, the terms "Medicaid

26 days", "ambulatory procedure listing services", and

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1 "ambulatory procedure listing payments" do not include any

2 days, charges, or services for which Medicare or a managed care

3 organization reimbursed on a capitated basis was liable for

4 payment, except where explicitly stated otherwise in this

5 Section.

6 (m) For purposes of this Section, in determining the

7 percentile ranking of an Illinois hospital's case mix index or

8 capital costs, hospitals described in subsection (b) of Section

9 5A-3 shall be excluded from the ranking.

10 (n) Definitions. Unless the context requires otherwise or

11 unless provided otherwise in this Section, the terms used in

12 this Section for qualifying criteria and payment calculations

13 shall have the same meanings as those terms have been given in

14 the Illinois Department's administrative rules as in effect on

15 March 1, 2008. Other terms shall be defined by the Illinois

16 Department by rule.

17 As used in this Section, unless the context requires

18 otherwise:

19 "Base inpatient payments" means, for a given hospital, the

20 sum of base payments for inpatient services made on a per diem

21 or per admission (DRG) basis, excluding those portions of per

22 admission payments that are classified as capital payments.

23 Disproportionate share hospital adjustment payments, Medicaid

24 Percentage Adjustments, Medicaid High Volume Adjustments, and

25 outlier payments, as defined by rule by the Department as of

26 January 1, 2008, are not base payments.

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1 "Capital costs" means, for a given hospital, the total

2 capital costs determined using the most recent 2005 Medicare

3 cost report as contained in the Healthcare Cost Report

4 Information System file, for the quarter ending on December 31,

5 2006, divided by the total inpatient days from the same cost

6 report to calculate a capital cost per day. The resulting

7 capital cost per day is inflated to the midpoint of State

8 fiscal year 2009 utilizing the national hospital market price

9 proxies (DRI) hospital cost index. If a hospital's 2005

10 Medicare cost report is not contained in the Healthcare Cost

11 Report Information System, the Department may obtain the data

12 necessary to compute the hospital's capital costs from any

13 source available, including, but not limited to, records

14 maintained by the hospital provider, which may be inspected at

15 all times during business hours of the day by the Illinois

16 Department or its duly authorized agents and employees.

17 "Case mix index" means, for a given hospital, the sum of

18 the DRG relative weighting factors in effect on January 1,

19 2005, for all general acute care admissions for State fiscal

20 year 2005, excluding Medicare crossover admissions and

21 transplant admissions reimbursed under 89 Ill. Adm. Code

22 148.82, divided by the total number of general acute care

23 admissions for State fiscal year 2005, excluding Medicare

24 crossover admissions and transplant admissions reimbursed

25 under 89 Ill. Adm. Code 148.82.

26 "Medicaid inpatient day" means, for a given hospital, the

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1 sum of days of inpatient hospital days provided to recipients

2 of medical assistance under Title XIX of the federal Social

3 Security Act, excluding days for individuals eligible for

4 Medicare under Title XVIII of that Act (Medicaid/Medicare

5 crossover days), as tabulated from the Department's paid claims

6 data for admissions occurring during State fiscal year 2005

7 that was adjudicated by the Department through March 23, 2007.

8 "Medicaid obstetrical day" means, for a given hospital, the

9 sum of days of inpatient hospital days grouped by the

10 Department to DRGs of 370 through 375 provided to recipients of

11 medical assistance under Title XIX of the federal Social

12 Security Act, excluding days for individuals eligible for

13 Medicare under Title XVIII of that Act (Medicaid/Medicare

14 crossover days), as tabulated from the Department's paid claims

15 data for admissions occurring during State fiscal year 2005

16 that was adjudicated by the Department through March 23, 2007.

17 "Outpatient ambulatory procedure listing payments" means,

18 for a given hospital, the sum of payments for ambulatory

19 procedure listing services, as described in 89 Ill. Adm. Code

20 148.140(b), provided to recipients of medical assistance under

21 Title XIX of the federal Social Security Act, excluding

22 payments for individuals eligible for Medicare under Title

23 XVIII of the Act (Medicaid/Medicare crossover days), as

24 tabulated from the Department's paid claims data for services

25 occurring in State fiscal year 2005 that were adjudicated by

26 the Department through March 23, 2007.

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1 (o) The Department may adjust payments made under this

2 Section 5A-12.2 to comply with federal law or regulations

3 regarding hospital-specific payment limitations on

4 government-owned or government-operated hospitals.

5 (p) Notwithstanding any of the other provisions of this

6 Section, the Department is authorized to adopt rules that

7 change the hospital access improvement payments specified in

8 this Section, but only to the extent necessary to conform to

9 any federally approved amendment to the Title XIX State plan.

10 Any such rules shall be adopted by the Department as authorized

11 by Section 5-50 of the Illinois Administrative Procedure Act.

12 Notwithstanding any other provision of law, any changes

13 implemented as a result of this subsection (p) shall be given

14 retroactive effect so that they shall be deemed to have taken

15 effect as of the effective date of this Section.

16 (q) (Blank).

17 (r) On and after July 1, 2012, the Department shall reduce

18 any rate of reimbursement for services or other payments or

19 alter any methodologies authorized by this Code to reduce any

20 rate of reimbursement for services or other payments in

21 accordance with Section 5-5e.

22 (s) On or after July 1, 2014, but no later than October 1,

23 2014, and no less than annually thereafter, the Department may

24 increase capitation payments to capitated managed care

25 organizations (MCOs) to equal the aggregate reduction of

26 payments made in this Section and in Section 5A-12.4 by a

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1 uniform percentage on a regional basis to preserve access to

2 hospital services for recipients under the Illinois Medical

3 Assistance Program. The aggregate amount of all increased

4 capitation payments to all MCOs for a fiscal year shall be the

5 amount needed to avoid reduction in payments authorized under

6 Section 5A-15. Payments to MCOs under this Section shall be

7 consistent with actuarial certification and shall be published

8 by the Department each year. Each MCO shall only expend the

9 increased capitation payments it receives under this Section to

10 support the availability of hospital services and to ensure

11 access to hospital services, with such expenditures being made

12 within 15 calendar days from when the MCO receives the

13 increased capitation payment. The Department shall make

14 available, on a monthly basis, a report of the capitation

15 payments that are made to each MCO pursuant to this subsection,

16 including the number of enrollees for which such payment is

17 made, the per enrollee amount of the payment, and any

18 adjustments that have been made. Payments made under this

19 subsection shall be guaranteed by a surety bond obtained by the

20 MCO in an amount established by the Department to approximate

21 one month's liability of payments authorized under this

22 subsection. The Department may advance the payments guaranteed

23 by the surety bond. Payments to MCOs that would be paid

24 consistent with actuarial certification and enrollment in the

25 absence of the increased capitation payments under this Section

26 shall not be reduced as a consequence of payments made under

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1 this subsection.

2 As used in this subsection, "MCO" means an entity which

3 contracts with the Department to provide services where payment

4 for medical services is made on a capitated basis.

5 (t) On or after July 1, 2014, the Department may increase

6 capitation payments to capitated managed care organizations

7 (MCOs) to equal the aggregate reduction of payments made in

8 Section 5A-12.5 to preserve access to hospital services for

9 recipients under the Illinois Medical Assistance Program.

10 Payments to MCOs under this Section shall be consistent with

11 actuarial certification and shall be published by the

12 Department each year. Each MCO shall only expend the increased

13 capitation payments it receives under this Section to support

14 the availability of hospital services and to ensure access to

15 hospital services, with such expenditures being made within 15

16 calendar days from when the MCO receives the increased

17 capitation payment. The Department may advance the payments to

18 hospitals under this subsection, in the event the MCO fails to

19 make such payments. The Department shall make available, on a

20 monthly basis, a report of the capitation payments that are

21 made to each MCO pursuant to this subsection, including the

22 number of enrollees for which such payment is made, the per

23 enrollee amount of the payment, and any adjustments that have

24 been made. Payments to MCOs that would be paid consistent with

25 actuarial certification and enrollment in the absence of the

26 increased capitation payments under this subsection shall not

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1 be reduced as a consequence of payments made under this

2 subsection.

3 As used in this subsection, "MCO" means an entity which

4 contracts with the Department to provide services where payment

5 for medical services is made on a capitated basis.

6 (Source: P.A. 96-821, eff. 11-20-09; 97-689, eff. 6-14-12.)

7 Article 20

8 Section 20-5. The Illinois Administrative Procedure Act is

9 amended by changing Section 5-45 as follows:

10 (5 ILCS 100/5-45) (from Ch. 127, par. 1005-45)

11 Sec. 5-45. Emergency rulemaking.

12 (a) "Emergency" means the existence of any situation that

13 any agency finds reasonably constitutes a threat to the public

14 interest, safety, or welfare.

15 (b) If any agency finds that an emergency exists that

16 requires adoption of a rule upon fewer days than is required by

17 Section 5-40 and states in writing its reasons for that

18 finding, the agency may adopt an emergency rule without prior

19 notice or hearing upon filing a notice of emergency rulemaking

20 with the Secretary of State under Section 5-70. The notice

21 shall include the text of the emergency rule and shall be

22 published in the Illinois Register. Consent orders or other

23 court orders adopting settlements negotiated by an agency may

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1 be adopted under this Section. Subject to applicable

2 constitutional or statutory provisions, an emergency rule

3 becomes effective immediately upon filing under Section 5-65 or

4 at a stated date less than 10 days thereafter. The agency's

5 finding and a statement of the specific reasons for the finding

6 shall be filed with the rule. The agency shall take reasonable

7 and appropriate measures to make emergency rules known to the

8 persons who may be affected by them.

9 (c) An emergency rule may be effective for a period of not

10 longer than 150 days, but the agency's authority to adopt an

11 identical rule under Section 5-40 is not precluded. No

12 emergency rule may be adopted more than once in any 24 month

13 period, except that this limitation on the number of emergency

14 rules that may be adopted in a 24 month period does not apply

15 to (i) emergency rules that make additions to and deletions

16 from the Drug Manual under Section 5-5.16 of the Illinois

17 Public Aid Code or the generic drug formulary under Section

18 3.14 of the Illinois Food, Drug and Cosmetic Act, (ii)

19 emergency rules adopted by the Pollution Control Board before

20 July 1, 1997 to implement portions of the Livestock Management

21 Facilities Act, (iii) emergency rules adopted by the Illinois

22 Department of Public Health under subsections (a) through (i)

23 of Section 2 of the Department of Public Health Act when

24 necessary to protect the public's health, (iv) emergency rules

25 adopted pursuant to subsection (n) of this Section, (v)

26 emergency rules adopted pursuant to subsection (o) of this

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1 Section, or (vi) emergency rules adopted pursuant to subsection

2 (c-5) of this Section. Two or more emergency rules having

3 substantially the same purpose and effect shall be deemed to be

4 a single rule for purposes of this Section.

5 (c-5) To facilitate the maintenance of the program of group

6 health benefits provided to annuitants, survivors, and retired

7 employees under the State Employees Group Insurance Act of

8 1971, rules to alter the contributions to be paid by the State,

9 annuitants, survivors, retired employees, or any combination

10 of those entities, for that program of group health benefits,

11 shall be adopted as emergency rules. The adoption of those

12 rules shall be considered an emergency and necessary for the

13 public interest, safety, and welfare.

14 (d) In order to provide for the expeditious and timely

15 implementation of the State's fiscal year 1999 budget,

16 emergency rules to implement any provision of Public Act 90-587

17 or 90-588 or any other budget initiative for fiscal year 1999

18 may be adopted in accordance with this Section by the agency

19 charged with administering that provision or initiative,

20 except that the 24-month limitation on the adoption of

21 emergency rules and the provisions of Sections 5-115 and 5-125

22 do not apply to rules adopted under this subsection (d). The

23 adoption of emergency rules authorized by this subsection (d)

24 shall be deemed to be necessary for the public interest,

25 safety, and welfare.

26 (e) In order to provide for the expeditious and timely

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1 implementation of the State's fiscal year 2000 budget,

2 emergency rules to implement any provision of this amendatory

3 Act of the 91st General Assembly or any other budget initiative

4 for fiscal year 2000 may be adopted in accordance with this

5 Section by the agency charged with administering that provision

6 or initiative, except that the 24-month limitation on the

7 adoption of emergency rules and the provisions of Sections

8 5-115 and 5-125 do not apply to rules adopted under this

9 subsection (e). The adoption of emergency rules authorized by

10 this subsection (e) shall be deemed to be necessary for the

11 public interest, safety, and welfare.

12 (f) In order to provide for the expeditious and timely

13 implementation of the State's fiscal year 2001 budget,

14 emergency rules to implement any provision of this amendatory

15 Act of the 91st General Assembly or any other budget initiative

16 for fiscal year 2001 may be adopted in accordance with this

17 Section by the agency charged with administering that provision

18 or initiative, except that the 24-month limitation on the

19 adoption of emergency rules and the provisions of Sections

20 5-115 and 5-125 do not apply to rules adopted under this

21 subsection (f). The adoption of emergency rules authorized by

22 this subsection (f) shall be deemed to be necessary for the

23 public interest, safety, and welfare.

24 (g) In order to provide for the expeditious and timely

25 implementation of the State's fiscal year 2002 budget,

26 emergency rules to implement any provision of this amendatory

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1 Act of the 92nd General Assembly or any other budget initiative

2 for fiscal year 2002 may be adopted in accordance with this

3 Section by the agency charged with administering that provision

4 or initiative, except that the 24-month limitation on the

5 adoption of emergency rules and the provisions of Sections

6 5-115 and 5-125 do not apply to rules adopted under this

7 subsection (g). The adoption of emergency rules authorized by

8 this subsection (g) shall be deemed to be necessary for the

9 public interest, safety, and welfare.

10 (h) In order to provide for the expeditious and timely

11 implementation of the State's fiscal year 2003 budget,

12 emergency rules to implement any provision of this amendatory

13 Act of the 92nd General Assembly or any other budget initiative

14 for fiscal year 2003 may be adopted in accordance with this

15 Section by the agency charged with administering that provision

16 or initiative, except that the 24-month limitation on the

17 adoption of emergency rules and the provisions of Sections

18 5-115 and 5-125 do not apply to rules adopted under this

19 subsection (h). The adoption of emergency rules authorized by

20 this subsection (h) shall be deemed to be necessary for the

21 public interest, safety, and welfare.

22 (i) In order to provide for the expeditious and timely

23 implementation of the State's fiscal year 2004 budget,

24 emergency rules to implement any provision of this amendatory

25 Act of the 93rd General Assembly or any other budget initiative

26 for fiscal year 2004 may be adopted in accordance with this

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1 Section by the agency charged with administering that provision

2 or initiative, except that the 24-month limitation on the

3 adoption of emergency rules and the provisions of Sections

4 5-115 and 5-125 do not apply to rules adopted under this

5 subsection (i). The adoption of emergency rules authorized by

6 this subsection (i) shall be deemed to be necessary for the

7 public interest, safety, and welfare.

8 (j) In order to provide for the expeditious and timely

9 implementation of the provisions of the State's fiscal year

10 2005 budget as provided under the Fiscal Year 2005 Budget

11 Implementation (Human Services) Act, emergency rules to

12 implement any provision of the Fiscal Year 2005 Budget

13 Implementation (Human Services) Act may be adopted in

14 accordance with this Section by the agency charged with

15 administering that provision, except that the 24-month

16 limitation on the adoption of emergency rules and the

17 provisions of Sections 5-115 and 5-125 do not apply to rules

18 adopted under this subsection (j). The Department of Public Aid

19 may also adopt rules under this subsection (j) necessary to

20 administer the Illinois Public Aid Code and the Children's

21 Health Insurance Program Act. The adoption of emergency rules

22 authorized by this subsection (j) shall be deemed to be

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

24 (k) In order to provide for the expeditious and timely

25 implementation of the provisions of the State's fiscal year

26 2006 budget, emergency rules to implement any provision of this

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1 amendatory Act of the 94th General Assembly or any other budget

2 initiative for fiscal year 2006 may be adopted in accordance

3 with this Section by the agency charged with administering that

4 provision or initiative, except that the 24-month limitation on

5 the adoption of emergency rules and the provisions of Sections

6 5-115 and 5-125 do not apply to rules adopted under this

7 subsection (k). The Department of Healthcare and Family

8 Services may also adopt rules under this subsection (k)

9 necessary to administer the Illinois Public Aid Code, the

10 Senior Citizens and Disabled Persons Property Tax Relief Act,

11 the Senior Citizens and Disabled Persons Prescription Drug

12 Discount Program Act (now the Illinois Prescription Drug

13 Discount Program Act), and the Children's Health Insurance

14 Program Act. The adoption of emergency rules authorized by this

15 subsection (k) shall be deemed to be necessary for the public

16 interest, safety, and welfare.

17 (l) In order to provide for the expeditious and timely

18 implementation of the provisions of the State's fiscal year

19 2007 budget, the Department of Healthcare and Family Services

20 may adopt emergency rules during fiscal year 2007, including

21 rules effective July 1, 2007, in accordance with this

22 subsection to the extent necessary to administer the

23 Department's responsibilities with respect to amendments to

24 the State plans and Illinois waivers approved by the federal

25 Centers for Medicare and Medicaid Services necessitated by the

26 requirements of Title XIX and Title XXI of the federal Social

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1 Security Act. The adoption of emergency rules authorized by

2 this subsection (l) shall be deemed to be necessary for the

3 public interest, safety, and welfare.

4 (m) In order to provide for the expeditious and timely

5 implementation of the provisions of the State's fiscal year

6 2008 budget, the Department of Healthcare and Family Services

7 may adopt emergency rules during fiscal year 2008, including

8 rules effective July 1, 2008, in accordance with this

9 subsection to the extent necessary to administer the

10 Department's responsibilities with respect to amendments to

11 the State plans and Illinois waivers approved by the federal

12 Centers for Medicare and Medicaid Services necessitated by the

13 requirements of Title XIX and Title XXI of the federal Social

14 Security Act. The adoption of emergency rules authorized by

15 this subsection (m) shall be deemed to be necessary for the

16 public interest, safety, and welfare.

17 (n) In order to provide for the expeditious and timely

18 implementation of the provisions of the State's fiscal year

19 2010 budget, emergency rules to implement any provision of this

20 amendatory Act of the 96th General Assembly or any other budget

21 initiative authorized by the 96th General Assembly for fiscal

22 year 2010 may be adopted in accordance with this Section by the

23 agency charged with administering that provision or

24 initiative. The adoption of emergency rules authorized by this

25 subsection (n) shall be deemed to be necessary for the public

26 interest, safety, and welfare. The rulemaking authority

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1 granted in this subsection (n) shall apply only to rules

2 promulgated during Fiscal Year 2010.

3 (o) In order to provide for the expeditious and timely

4 implementation of the provisions of the State's fiscal year

5 2011 budget, emergency rules to implement any provision of this

6 amendatory Act of the 96th General Assembly or any other budget

7 initiative authorized by the 96th General Assembly for fiscal

8 year 2011 may be adopted in accordance with this Section by the

9 agency charged with administering that provision or

10 initiative. The adoption of emergency rules authorized by this

11 subsection (o) is deemed to be necessary for the public

12 interest, safety, and welfare. The rulemaking authority

13 granted in this subsection (o) applies only to rules

14 promulgated on or after the effective date of this amendatory

15 Act of the 96th General Assembly through June 30, 2011.

16 (p) In order to provide for the expeditious and timely

17 implementation of the provisions of Public Act 97-689,

18 emergency rules to implement any provision of Public Act 97-689

19 may be adopted in accordance with this subsection (p) by the

20 agency charged with administering that provision or

21 initiative. The 150-day limitation of the effective period of

22 emergency rules does not apply to rules adopted under this

23 subsection (p), and the effective period may continue through

24 June 30, 2013. The 24-month limitation on the adoption of

25 emergency rules does not apply to rules adopted under this

26 subsection (p). The adoption of emergency rules authorized by

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1 this subsection (p) is deemed to be necessary for the public

2 interest, safety, and welfare.

3 (q) In order to provide for the expeditious and timely

4 implementation of the provisions of Articles 7, 8, 9, 11, and

5 12 of this amendatory Act of the 98th General Assembly,

6 emergency rules to implement any provision of Articles 7, 8, 9,

7 11, and 12 of this amendatory Act of the 98th General Assembly

8 may be adopted in accordance with this subsection (q) by the

9 agency charged with administering that provision or

10 initiative. The 24-month limitation on the adoption of

11 emergency rules does not apply to rules adopted under this

12 subsection (q). The adoption of emergency rules authorized by

13 this subsection (q) is deemed to be necessary for the public

14 interest, safety, and welfare.

15 (r) In order to provide for the expeditious and timely

16 implementation of the provisions of this amendatory Act of the

17 98th General Assembly, emergency rules to implement this

18 amendatory Act of the 98th General Assembly may be adopted in

19 accordance with this subsection (r) by the Department of

20 Healthcare and Family Services. The 24-month limitation on the

21 adoption of emergency rules does not apply to rules adopted

22 under this subsection (r). The adoption of emergency rules

23 authorized by this subsection (r) is deemed to be necessary for

24 the public interest, safety, and welfare.

25 (Source: P.A. 97-689, eff. 6-14-12; 97-695, eff. 7-1-12;

26 98-104, eff. 7-22-13; 98-463, eff. 8-16-13.)

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1 Section 20-10. The Children's Health Insurance Program Act

2 is amended by changing Section 7 as follows:

3 (215 ILCS 106/7)

4 Sec. 7. Eligibility verification. Notwithstanding any

5 other provision of this Act, with respect to applications for

6 benefits provided under the Program, eligibility shall be

7 determined in a manner that ensures program integrity and that

8 complies with federal law and regulations while minimizing

9 unnecessary barriers to enrollment. To this end, as soon as

10 practicable, and unless the Department receives written denial

11 from the federal government, this Section shall be implemented:

12 (a) The Department of Healthcare and Family Services or its

13 designees shall:

14 (1) By no later than July 1, 2011, require verification

15 of, at a minimum, one month's income from all sources

16 required for determining the eligibility of applicants to

17 the Program. Such verification shall take the form of pay

18 stubs, business or income and expense records for

19 self-employed persons, letters from employers, and any

20 other valid documentation of income including data

21 obtained electronically by the Department or its designees

22 from other sources as described in subsection (b) of this

23 Section.

24 (2) By no later than October 1, 2011, require

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1 verification of, at a minimum, one month's income from all

2 sources required for determining the continued eligibility

3 of recipients at their annual review of eligibility under

4 the Program. Such verification shall take the form of pay

5 stubs, business or income and expense records for

6 self-employed persons, letters from employers, and any

7 other valid documentation of income including data

8 obtained electronically by the Department or its designees

9 from other sources as described in subsection (b) of this

10 Section. The Department shall send a notice to the

11 recipient at least 60 days prior to the end of the period

12 of eligibility that informs them of the requirements for

13 continued eligibility. If a recipient does not fulfill the

14 requirements for continued eligibility by the deadline

15 established in the notice, a notice of cancellation shall

16 be issued to the recipient and coverage shall end on the

17 last day of the eligibility period. A recipient's

18 eligibility may be reinstated without requiring a new

19 application if the recipient fulfills the requirements for

20 continued eligibility prior to the end of the third month

21 following the last date of coverage (or longer period if

22 required by federal regulations). Nothing in this Section

23 shall prevent an individual whose coverage has been

24 cancelled from reapplying for health benefits at any time.

25 (3) By no later than July 1, 2011, require verification

26 of Illinois residency.

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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 will 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 amendatory

17 Act of the 96th General Assembly, the Department of Healthcare

18 and Family Services shall send notice to current recipients

19 informing them of the changes regarding their eligibility

20 verification.

21 (Source: P.A. 96-1501, eff. 1-25-11.)

22 Section 20-15. The Covering ALL KIDS Health Insurance Act

23 is amended by changing Sections 7 and 20 as follows:

24 (215 ILCS 170/7)

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1 (Section scheduled to be repealed on July 1, 2016)

2 Sec. 7. Eligibility verification. Notwithstanding any

3 other provision of this Act, with respect to applications for

4 benefits provided under the Program, eligibility shall be

5 determined in a manner that ensures program integrity and that

6 complies with federal law and regulations while minimizing

7 unnecessary barriers to enrollment. To this end, as soon as

8 practicable, and unless the Department receives written denial

9 from the federal government, this Section shall be implemented:

10 (a) The Department of Healthcare and Family Services or its

11 designees shall:

12 (1) By July 1, 2011, require verification of, at a

13 minimum, one month's income from all sources required for

14 determining the eligibility of applicants to the Program.

15 Such verification shall take the form of pay stubs,

16 business or income and expense records for self-employed

17 persons, letters from employers, and any other valid

18 documentation of income including data obtained

19 electronically by the Department or its designees from

20 other sources as described in subsection (b) of this

21 Section.

22 (2) By October 1, 2011, require verification of, at a

23 minimum, one month's income from all sources required for

24 determining the continued eligibility of recipients at

25 their annual review of eligibility under the Program. Such

26 verification shall take the form of pay stubs, business or

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1 income and expense records for self-employed persons,

2 letters from employers, and any other valid documentation

3 of income including data obtained electronically by the

4 Department or its designees from other sources as described

5 in subsection (b) of this Section. The Department shall

6 send a notice to recipients at least 60 days prior to the

7 end of 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 and

12 coverage shall end on the last day of the eligibility

13 period. A recipient's eligibility may be reinstated

14 without requiring a new application if the recipient

15 fulfills the requirements for continued eligibility prior

16 to the end of the third month following the last date of

17 coverage (or longer period if required by federal

18 regulations). Nothing in this Section shall prevent an

19 individual whose coverage has been cancelled from

20 reapplying for health benefits at any time.

21 (3) By July 1, 2011, require verification of Illinois

22 residency.

23 (b) The Department shall establish or continue cooperative

24 arrangements with the Social Security Administration, the

25 Illinois Secretary of State, the Department of Human Services,

26 the Department of Revenue, the Department of Employment

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1 Security, and any other appropriate entity to gain electronic

2 access, to the extent allowed by law, to information available

3 to those entities that may be appropriate for electronically

4 verifying any factor of eligibility for benefits under the

5 Program. Data relevant to eligibility shall be provided for no

6 other purpose than to verify the eligibility of new applicants

7 or current recipients of health benefits under the Program.

8 Data will be requested or provided for any new applicant or

9 current recipient only insofar as that individual's

10 circumstances are relevant to that individual's or another

11 individual's eligibility.

12 (c) Within 90 days of the effective date of this amendatory

13 Act of the 96th General Assembly, the Department of Healthcare

14 and Family Services shall send notice to current recipients

15 informing them of the changes regarding their eligibility

16 verification.

17 (Source: P.A. 96-1501, eff. 1-25-11.)

18 (215 ILCS 170/20)

19 (Section scheduled to be repealed on July 1, 2016)

20 Sec. 20. Eligibility.

21 (a) To be eligible for the Program, a person must be a

22 child:

23 (1) who is a resident of the State of Illinois;

24 (2) who is ineligible for medical assistance under the

25 Illinois Public Aid Code or benefits under the Children's

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1 Health Insurance Program Act;

2 (3) who ~~either~~ (i) effective July 1, 2014, ~~who has~~ in

3 accordance with 42 CFR 457.805 (78 FR 42313, July 15, 2013)

4 or any other federal requirement necessary to obtain

5 federal financial participation for expenditures made

6 under this Act, has been without health insurance coverage

7 for 90 days; ~~12 months, (ii) whose parent has lost~~

8 ~~employment that made available affordable dependent health~~

9 ~~insurance coverage, until such time as affordable~~

10 ~~employer-sponsored dependent health insurance coverage is~~

11 ~~again available for the child as set forth by the~~

12 ~~Department in rules, (iii)~~ (ii) ~~who~~ is a newborn whose

13 responsible relative does not have available affordable

14 private or employer-sponsored health insurance; or (iii) ~~,~~

15 ~~or (iv) who,~~ within one year of applying for coverage under

16 this Act, lost medical benefits under the Illinois Public

17 Aid Code or the Children's Health Insurance Program Act;

18 and

19 (3.5) whose household income, as determined, effective

20 October 1, 2013, by the Department, is at or below 300% of

21 the federal poverty level as determined in compliance with

22 42 U.S.C. 1397bb(b)(1)(B)(v) and applicable federal

23 regulations. ~~This item (3.5) is effective July 1, 2011.~~

24 An entity that provides health insurance coverage (as

25 defined in Section 2 of the Comprehensive Health Insurance Plan

26 Act) to Illinois residents shall provide health insurance data

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1 match to the Department of Healthcare and Family Services as

2 provided by and subject to Section 5.5 of the Illinois

3 Insurance Code. The Department of Healthcare and Family

4 Services may impose an administrative penalty as provided under

5 Section 12-4.45 of the Illinois Public Aid Code on entities

6 that have established a pattern of failure to provide the

7 information required under this Section.

8 The Department of Healthcare and Family Services, in

9 collaboration with the Department of Insurance, shall adopt

10 rules governing the exchange of information under this Section.

11 The rules shall be consistent with all laws relating to the

12 confidentiality or privacy of personal information or medical

13 records, including provisions under the Federal Health

14 Insurance Portability and Accountability Act (HIPAA).

15 (b) The Department shall monitor the availability and

16 retention of employer-sponsored dependent health insurance

17 coverage and shall modify the period described in subdivision

18 (a)(3) if necessary to promote retention of private or

19 employer-sponsored health insurance and timely access to

20 healthcare services, but at no time shall the period described

21 in subdivision (a)(3) be less than 6 months.

22 (c) The Department, at its discretion, may take into

23 account the affordability of dependent health insurance when

24 determining whether employer-sponsored dependent health

25 insurance coverage is available upon reemployment of a child's

26 parent as provided in subdivision (a)(3).

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1 (d) A child who is determined to be eligible for the

2 Program shall remain eligible for 12 months, provided that the

3 child maintains his or her residence in this State, has not yet

4 attained 19 years of age, and is not excluded under subsection

5 (e).

6 (e) A child is not eligible for coverage under the Program

7 if:

8 (1) the premium required under Section 40 has not been

9 timely paid; if the required premiums are not paid, the

10 liability of the Program shall be limited to benefits

11 incurred under the Program for the time period for which

12 premiums have been paid; re-enrollment shall be completed

13 before the next covered medical visit, and the first

14 month's required premium shall be paid in advance of the

15 next covered medical visit; or

16 (2) the child is an inmate of a public institution or

17 an institution for mental diseases.

18 (f) The Department may adopt rules, including, but not

19 limited to: rules regarding annual renewals of eligibility for

20 the Program in conformance with Section 7 of this Act; rules

21 providing for re-enrollment, grace periods, notice

22 requirements, and hearing procedures under subdivision (e)(1)

23 of this Section; and rules regarding what constitutes

24 availability and affordability of private or

25 employer-sponsored health insurance, with consideration of

26 such factors as the percentage of income needed to purchase

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1 children or family health insurance, the availability of

2 employer subsidies, and other relevant factors.

3 (g) Each child enrolled in the Program as of July 1, 2011

4 whose family income, as established by the Department, exceeds

5 300% of the federal poverty level may remain enrolled in the

6 Program for 12 additional months commencing July 1, 2011.

7 Continued enrollment pursuant to this subsection shall be

8 available only if the child continues to meet all eligibility

9 criteria established under the Program as of the effective date

10 of this amendatory Act of the 96th General Assembly without a

11 break in coverage. Nothing contained in this subsection shall

12 prevent a child from qualifying for any other health benefits

13 program operated by the Department.

14 (Source: P.A. 98-130, eff. 8-2-13.)

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

16 changing Sections 5-2.1a and 11-5.1 as follows:

17 (305 ILCS 5/5-2.1a)

18 Sec. 5-2.1a. Treatment of trust amounts. To the extent

19 required by federal law, theDepartment of Healthcare and

20 Family Services ~~Illinois Department~~ shall provide by rule for

21 the consideration of trusts and similar legal instruments or

22 devices established by a person in the Illinois Department's

23 determination of the person's eligibility for and the amount of

24 assistance provided under this Article.~~This Section shall be~~

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1 ~~enforced by the Department of Human Services, acting as~~

2 ~~successor to the Department of Public Aid under the Department~~

3 ~~of Human Services Act.~~

4 (Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)

5 (305 ILCS 5/11-5.1)

6 Sec. 11-5.1. Eligibility verification. Notwithstanding any

7 other provision of this Code, with respect to applications for

8 medical assistance provided under Article V of this Code,

9 eligibility shall be determined in a manner that ensures

10 program integrity and complies with federal laws and

11 regulations while minimizing unnecessary barriers to

12 enrollment. To this end, as soon as practicable, and unless the

13 Department receives written denial from the federal

14 government, this Section shall be implemented:

15 (a) The Department of Healthcare and Family Services or its

16 designees shall:

17 (1) By no later than July 1, 2011, require verification

18 of, at a minimum, one month's income from all sources

19 required for determining the eligibility of applicants for

20 medical assistance under this Code. Such verification

21 shall take the form of pay stubs, business or income and

22 expense records for self-employed persons, letters from

23 employers, and any other valid documentation of income

24 including data obtained electronically by the Department

25 or its designees from other sources as described in

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1 subsection (b) of this Section.

2 (2) By no later than October 1, 2011, require

3 verification of, at a minimum, one month's income from all

4 sources required for determining the continued eligibility

5 of recipients at their annual review of eligibility for

6 medical assistance under this Code. Such verification

7 shall take the form of pay stubs, business or income and

8 expense records for self-employed persons, letters from

9 employers, and any other valid documentation of income

10 including data obtained electronically by the Department

11 or its designees from other sources as described in

12 subsection (b) of this Section. The Department shall send a

13 notice to recipients at least 60 days prior to the end of

14 their period of eligibility that informs them of the

15 requirements for continued eligibility. If a recipient

16 does not fulfill the requirements for continued

17 eligibility by the deadline established in the notice a

18 notice of cancellation shall be issued to the recipient and

19 coverage shall end on the last day of the eligibility

20 period. A recipient's eligibility may be reinstated

21 without requiring a new application if the recipient

22 fulfills the requirements for continued eligibility prior

23 to the end of the third month following the last date of

24 coverage (or longer period if required by federal

25 regulations). Nothing in this Section shall prevent an

26 individual whose coverage has been cancelled from

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1 reapplying for health benefits at any time.

2 (3) By no later than July 1, 2011, require verification

3 of Illinois residency.

4 (b) The Department shall establish or continue cooperative

5 arrangements with the Social Security Administration, the

6 Illinois Secretary of State, the Department of Human Services,

7 the Department of Revenue, the Department of Employment

8 Security, and any other appropriate entity to gain electronic

9 access, to the extent allowed by law, to information available

10 to those entities that may be appropriate for electronically

11 verifying any factor of eligibility for benefits under the

12 Program. Data relevant to eligibility shall be provided for no

13 other purpose than to verify the eligibility of new applicants

14 or current recipients of health benefits under the Program.

15 Data shall be requested or provided for any new applicant or

16 current recipient only insofar as that individual's

17 circumstances are relevant to that individual's or another

18 individual's eligibility.

19 (c) Within 90 days of the effective date of this amendatory

20 Act of the 96th General Assembly, the Department of Healthcare

21 and Family Services shall send notice to current recipients

22 informing them of the changes regarding their eligibility

23 verification.

24 (Source: P.A. 96-1501, eff. 1-25-11.)

25 Article 25.

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1 Section 25-5. The State Finance Act is amended by changing

2 Section 6z-30 as follows:

3 (30 ILCS 105/6z-30)

4 Sec. 6z-30. University of Illinois Hospital Services Fund.

5 (a) The University of Illinois Hospital Services Fund is

6 created as a special fund in the State Treasury. The following

7 moneys shall be deposited into the Fund:

8 (1) As soon as possible after the beginning of fiscal

9 year 2010, and in no event later than July 30, the State

10 Comptroller and the State Treasurer shall automatically

11 transfer $30,000,000 from the General Revenue Fund to the

12 University of Illinois Hospital Services Fund.

13 (1.5) Starting in fiscal year 2011, as soon as possible

14 after the beginning of each fiscal year, and in no event

15 later than July 30, the State Comptroller and the State

16 Treasurer shall automatically transfer $45,000,000 from

17 the General Revenue Fund to the University of Illinois

18 Hospital Services Fund; except that, in fiscal year 2012

19 only, the State Comptroller and the State Treasurer shall

20 transfer $90,000,000 from the General Revenue Fund to the

21 University of Illinois Hospital Services Fund under this

22 paragraph, and, in fiscal year 2013 only, the State

23 Comptroller and the State Treasurer shall transfer no

24 amounts from the General Revenue Fund to the University of

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1 Illinois Hospital Services Fund under this paragraph.

2 (2) All intergovernmental transfer payments to the

3 Department of Healthcare and Family Services by the

4 University of Illinois made pursuant to an

5 intergovernmental agreement under subsection (b) or (c) of

6 Section 5A-3 of the Illinois Public Aid Code.

7 (3) All federal matching funds received by the

8 Department of Healthcare and Family Services (formerly

9 Illinois Department of Public Aid) as a result of

10 expenditures made by the Department that are attributable

11 to moneys that were deposited in the Fund.

12 (4) All other moneys received for the Fund from any

13 other source, including interest earned thereon.

14 (b) Moneys in the fund may be used by the Department of

15 Healthcare and Family Services, subject to appropriation and to

16 an interagency agreement between that Department and the Board

17 of Trustees of the University of Illinois, to reimburse the

18 University of Illinois Hospital for hospital and pharmacy

19 services, to reimburse practitioners who are employed by the

20 University of Illinois, to reimburse other health care

21 facilities and health plans operated by the University of

22 Illinois, and to pass through to the University of Illinois

23 federal financial participation earned by the State as a result

24 of expenditures made by the University of Illinois.

25 (c) (Blank).

26 (Source: P.A. 96-45, eff. 7-15-09; 96-959, eff. 7-1-10; 97-732,

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1 eff. 6-30-12.)

2 Section 25-10. The Illinois Public Aid Code is amended by

3 changing Section 12-9 as follows:

4 (305 ILCS 5/12-9) (from Ch. 23, par. 12-9)

5 Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The

6 Public Aid Recoveries Trust Fund shall consist of (1)

7 recoveries by the Department of Healthcare and Family Services

8 (formerly Illinois Department of Public Aid) authorized by this

9 Code in respect to applicants or recipients under Articles III,

10 IV, V, and VI, including recoveries made by the Department of

11 Healthcare and Family Services (formerly Illinois Department

12 of Public Aid) from the estates of deceased recipients, (2)

13 recoveries made by the Department of Healthcare and Family

14 Services (formerly Illinois Department of Public Aid) in

15 respect to applicants and recipients under the Children's

16 Health Insurance Program Act, and the Covering ALL KIDS Health

17 Insurance Act, (2.5) recoveries made by the Department of

18 Healthcare and Family Services in connection with the

19 imposition of an administrative penalty as provided under

20 Section 12-4.45, (3) federal funds received on behalf of and

21 earned by State universities and local governmental entities

22 for services provided to applicants or recipients covered under

23 this Code, the Children's Health Insurance Program Act, and the

24 Covering ALL KIDS Health Insurance Act, (3.5) federal financial

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1 participation revenue related to eligible disbursements made

2 by the Department of Healthcare and Family Services from

3 appropriations required by this Section, and (4) all other

4 moneys received to the Fund, including interest thereon. The

5 Fund shall be held as a special fund in the State Treasury.

6 Disbursements from this Fund shall be only (1) for the

7 reimbursement of claims collected by the Department of

8 Healthcare and Family Services (formerly Illinois Department

9 of Public Aid) through error or mistake, (2) for payment to

10 persons or agencies designated as payees or co-payees on any

11 instrument, whether or not negotiable, delivered to the

12 Department of Healthcare and Family Services (formerly

13 Illinois Department of Public Aid) as a recovery under this

14 Section, such payment to be in proportion to the respective

15 interests of the payees in the amount so collected, (3) for

16 payments to the Department of Human Services for collections

17 made by the Department of Healthcare and Family Services

18 (formerly Illinois Department of Public Aid) on behalf of the

19 Department of Human Services under this Code, the Children's

20 Health Insurance Program Act, and the Covering ALL KIDS Health

21 Insurance Act, (4) for payment of administrative expenses

22 incurred in performing the activities authorized under this

23 Code, the Children's Health Insurance Program Act, and the

24 Covering ALL KIDS Health Insurance Act, (5) for payment of fees

25 to persons or agencies in the performance of activities

26 pursuant to the collection of monies owed the State that are

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1 collected under this Code, the Children's Health Insurance

2 Program Act, and the Covering ALL KIDS Health Insurance Act,

3 (6) for payments of any amounts which are reimbursable to the

4 federal government which are required to be paid by State

5 warrant by either the State or federal government, and (7) for

6 payments to State universities and local governmental entities

7 of federal funds for services provided to applicants or

8 recipients covered under this Code, the Children's Health

9 Insurance Program Act, and the Covering ALL KIDS Health

10 Insurance Act. Disbursements from this Fund for purposes of

11 items (4) and (5) of this paragraph shall be subject to

12 appropriations from the Fund to the Department of Healthcare

13 and Family Services (formerly Illinois Department of Public

14 Aid).

15 The balance in this Fund ~~on the first day of each calendar~~

16 ~~quarter,~~after payment therefrom of any amounts reimbursable to

17 the federal government, and minus the amount reasonably

18 anticipated to be needed to make the disbursements~~during that~~

19 ~~quarter~~ authorized by this Section during the current and

20 following 3 calendar months, shall be certified by the Director

21 of Healthcare and Family Services and transferred by the State

22 Comptroller to the Drug Rebate Fund or the Healthcare Provider

23 Relief Fund in the State Treasury, as appropriate,on at least

24 an annual basis by June 30th of each fiscal year ~~within 30 days~~

25 ~~of the first day of each calendar quarter~~. The Director of

26 Healthcare and Family Services may certify and the State

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1 Comptroller shall transfer to the Drug Rebate Fund or the

2 Healthcare Provider Relief Fund amounts on a more frequent

3 basis.

4 On July 1, 1999, the State Comptroller shall transfer the

5 sum of $5,000,000 from the Public Aid Recoveries Trust Fund

6 (formerly the Public Assistance Recoveries Trust Fund) into the

7 DHS Recoveries Trust Fund.

8 (Source: P.A. 97-647, eff. 1-1-12; 97-689, eff. 6-14-12;

9 98-130, eff. 8-2-13.)

10 Article 30

11 Section 30-5. The Illinois Public Aid Code is amended by

12 adding Section 5A-12.5 as follows:

13 (305 ILCS 5/5A-12.5 new)

14 Sec. 5A-12.5. Affordable Care Act adults; hospital access

15 payments. The Department shall, subject to federal approval,

16 mirror the Medical Assistance hospital reimbursement

17 methodology, including hospital access payments as defined in

18 Section 5A-12.2 of this Article and hospital access improvement

19 payments as defined in Section 5A-12.4 of this Article, in

20 compliance with the equivalent rate provisions of the

21 Affordable Care Act.

22 As used in this Section, "Affordable Care Act" is the

23 collective term for the Patient Protection and Affordable Care

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1 Act (Pub. L. 111-148) and the Health Care and Education

2 Reconciliation Act of 2010 (Pub. L. 111-152).

3 Article 35

4 Section 35-5. The Hospital Licensing Act is amended by

5 changing Section 6.09 as follows:

6 (210 ILCS 85/6.09) (from Ch. 111 1/2, par. 147.09)

7 Sec. 6.09. (a) In order to facilitate the orderly

8 transition of aged and disabled patients from hospitals to

9 post-hospital care, whenever a patient who qualifies for the

10 federal Medicare program is hospitalized, the patient shall be

11 notified of discharge at least 24 hours prior to discharge from

12 the hospital. With regard to pending discharges to a skilled

13 nursing facility, the hospital must notify the case

14 coordination unit, as defined in 89 Ill. Adm. Code 240.260, at

15 least 24 hours prior to discharge. When the assessment is

16 completed in the hospital, the case coordination unit shall

17 provide the discharge planner with a copy of the prescreening

18 information and accompanying materials, which the discharge

19 planner shall transmit when the patient is discharged to a

20 skilled nursing facility. If ~~or, if~~ home health services are

21 ordered, the hospital must inform its designated case

22 coordination unit, as defined in 89 Ill. Adm. Code 240.260, of

23 the pending discharge and must provide the patient with the

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1 case coordination unit's telephone number and other contact

2 information.

3 (b) Every hospital shall develop procedures for a physician

4 with medical staff privileges at the hospital or any

5 appropriate medical staff member to provide the discharge

6 notice prescribed in subsection (a) of this Section. The

7 procedures must include prohibitions against discharging or

8 referring a patient to any of the following if unlicensed,

9 uncertified, or unregistered: (i) a board and care facility, as

10 defined in the Board and Care Home Act; (ii) an assisted living

11 and shared housing establishment, as defined in the Assisted

12 Living and Shared Housing Act; (iii) a facility licensed under

13 the Nursing Home Care Act, the Specialized Mental Health

14 Rehabilitation Act of 2013, or the ID/DD Community Care Act;

15 (iv) a supportive living facility, as defined in Section

16 5-5.01a of the Illinois Public Aid Code; or (v) a free-standing

17 hospice facility licensed under the Hospice Program Licensing

18 Act if licensure, certification, or registration is required.

19 The Department of Public Health shall annually provide

20 hospitals with a list of licensed, certified, or registered

21 board and care facilities, assisted living and shared housing

22 establishments, nursing homes, supportive living facilities,

23 facilities licensed under the ID/DD Community Care Act or the

24 Specialized Mental Health Rehabilitation Act of 2013, and

25 hospice facilities. Reliance upon this list by a hospital shall

26 satisfy compliance with this requirement. The procedure may

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1 also include a waiver for any case in which a discharge notice

2 is not feasible due to a short length of stay in the hospital

3 by the patient, or for any case in which the patient

4 voluntarily desires to leave the hospital before the expiration

5 of the 24 hour period.

6 (c) At least 24 hours prior to discharge from the hospital,

7 the patient shall receive written information on the patient's

8 right to appeal the discharge pursuant to the federal Medicare

9 program, including the steps to follow to appeal the discharge

10 and the appropriate telephone number to call in case the

11 patient intends to appeal the discharge.

12 (d) Before transfer of a patient to a long term care

13 facility licensed under the Nursing Home Care Act where elderly

14 persons reside, a hospital shall as soon as practicable

15 initiate a name-based criminal history background check by

16 electronic submission to the Department of State Police for all

17 persons between the ages of 18 and 70 years; provided, however,

18 that a hospital shall be required to initiate such a background

19 check only with respect to patients who:

20 (1) are transferring to a long term care facility for

21 the first time;

22 (2) have been in the hospital more than 5 days;

23 (3) are reasonably expected to remain at the long term

24 care facility for more than 30 days;

25 (4) have a known history of serious mental illness or

26 substance abuse; and

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1 (5) are independently ambulatory or mobile for more

2 than a temporary period of time.

3 A hospital may also request a criminal history background

4 check for a patient who does not meet any of the criteria set

5 forth in items (1) through (5).

6 A hospital shall notify a long term care facility if the

7 hospital has initiated a criminal history background check on a

8 patient being discharged to that facility. In all circumstances

9 in which the hospital is required by this subsection to

10 initiate the criminal history background check, the transfer to

11 the long term care facility may proceed regardless of the

12 availability of criminal history results. Upon receipt of the

13 results, the hospital shall promptly forward the results to the

14 appropriate long term care facility. If the results of the

15 background check are inconclusive, the hospital shall have no

16 additional duty or obligation to seek additional information

17 from, or about, the patient.

18 (Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813,

19 eff. 7-13-12; 98-104, eff. 7-22-13.)

20 Section 35-10. The Illinois Public Aid Code is amended by

21 changing Section 11-5.4 as follows:

22 (305 ILCS 5/11-5.4)

23 Sec. 11-5.4. Expedited long-term care eligibility

24 determination and enrollment.

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1 (a) An expedited long-term care eligibility determination

2 and enrollment system shall be established to reduce long-term

3 care determinations to 90 days or fewer by July 1, 2014 and

4 streamline the long-term care enrollment process.

5 Establishment of the system shall be a joint venture of the

6 Department of Human Services and Healthcare and Family Services

7 and the Department on Aging. The Governor shall name a lead

8 agency no later than 30 days after the effective date of this

9 amendatory Act of the 98th General Assembly to assume

10 responsibility for the full implementation of the

11 establishment and maintenance of the system. Project outcomes

12 shall include an enhanced eligibility determination tracking

13 system accessible to providers and a centralized application

14 review and eligibility determination with all applicants

15 reviewed within 90 days of receipt by the State of a complete

16 application. If the Department of Healthcare and Family

17 Services' Office of the Inspector General determines that there

18 is a likelihood that a non-allowable transfer of assets has

19 occurred, and the facility in which the applicant resides is

20 notified, an extension of up to 90 days shall be permissible.

21 On or before December 31, 2015, a streamlined application and

22 enrollment process shall be put in place based on the following

23 principles:

24 (1) Minimize the burden on applicants by collecting

25 only the data necessary to determine eligibility for

26 medical services, long-term care services, and spousal

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1 impoverishment offset.

2 (2) Integrate online data sources to simplify the

3 application process by reducing the amount of information

4 needed to be entered and to expedite eligibility

5 verification.

6 (3) Provide online prompts to alert the applicant that

7 information is missing or not complete.

8 (b) The Department shall, on or before July 1, 2014, assess

9 the feasibility of incorporating all information needed to

10 determine eligibility for long-term care services, including

11 asset transfer and spousal impoverishment financials, into the

12 State's integrated eligibility system identifying all

13 resources needed and reasonable timeframes for achieving the

14 specified integration.

15 (c) The lead agency shall file interim reports with the

16 Chairs and Minority Spokespersons of the House and Senate Human

17 Services Committees no later than September 1, 2013 and on

18 February 1, 2014. The Department of Healthcare and Family

19 Services shall include in the annual Medicaid report for State

20 Fiscal Year 2014 and every fiscal year thereafter information

21 concerning implementation of the provisions of this Section.

22 (d) No later than August 1, 2014, the Auditor General shall

23 report to the General Assembly concerning the extent to which

24 the timeframes specified in this Section have been met and the

25 extent to which State staffing levels are adequate to meet the

26 requirements of this Section.

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1 (e) The Department of Healthcare and Family Services, the

2 Department of Human Services, and the Department on Aging shall

3 take the following steps to achieve federally established

4 timeframes for eligibility determinations for Medicaid and

5 long-term care benefits and shall work toward the federal goal

6 of real time determinations:

7 (1) The Departments shall review, in collaboration

8 with representatives of affected providers, all forms and

9 procedures currently in use, federal guidelines either

10 suggested or mandated, and staff deployment by September

11 30, 2014 to identify additional measures that can improve

12 long-term care eligibility processing and make adjustments

13 where possible.

14 (2) No later than June 30, 2014, the Department of

15 Healthcare and Family Services shall issue vouchers for

16 advance payments not to exceed $50,000,000 to nursing

17 facilities with significant outstanding Medicaid liability

18 associated with services provided to residents with

19 Medicaid applications pending and residents facing the

20 greatest delays. Each facility with an advance payment

21 shall state in writing whether its own recoupment schedule

22 will be in 3 or 6 equal monthly installments, as long as

23 all advances are recouped by June 30, 2015.

24 (3) The Department of Healthcare and Family Services'

25 Office of Inspector General and the Department of Human

26 Services shall immediately forgo resource review and

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1 review of transfers during the relevant look-back period

2 for applications that were submitted prior to September 1,

3 2013. An applicant who applied prior to September 1, 2013,

4 who was denied for failure to cooperate in providing

5 required information, and whose application was

6 incorrectly reviewed under the wrong look-back period

7 rules may request review and correction of the denial based

8 on this subsection. If found eligible upon review, such

9 applicants shall be retroactively enrolled.

10 (4) As soon as practicable, the Department of

11 Healthcare and Family Services shall implement policies

12 and promulgate rules to simplify financial eligibility

13 verification in the following instances: (A) for

14 applicants or recipients who are receiving Supplemental

15 Security Income payments or who had been receiving such

16 payments at the time they were admitted to a nursing

17 facility and (B) for applicants or recipients with verified

18 income at or below 100% of the federal poverty level when

19 the declared value of their countable resources is no

20 greater than the allowable amounts pursuant to Section 5-2

21 of this Code for classes of eligible persons for whom a

22 resource limit applies. Such simplified verification

23 policies shall apply to community cases as well as

24 long-term care cases.

25 (5) As soon as practicable, but not later than July 1,

26 2014, the Department of Healthcare and Family Services and

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1 the Department of Human Services shall jointly begin a

2 special enrollment project by using simplified eligibility

3 verification policies and by redeploying caseworkers

4 trained to handle long-term care cases to prioritize those

5 cases, until the backlog is eliminated and processing time

6 is within 90 days. This project shall apply to applications

7 for long-term care received by the State on or before May

8 15, 2014.

9 (6) As soon as practicable, but not later than

10 September 1, 2014, the Department on Aging shall make

11 available to long-term care facilities and community

12 providers upon request, through an electronic method, the

13 information contained within the Interagency Certification

14 of Screening Results completed by the pre-screener, in a

15 form and manner acceptable to the Department of Human

16 Services.

17 (7) Effective 30 days after the completion of 3

18 regionally based trainings, nursing facilities shall

19 submit all applications for medical assistance online via

20 the Application for Benefits Eligibility (ABE) website.

21 This requirement shall extend to scanning and uploading

22 with the online application any required additional forms

23 such as the Long Term Care Facility Notification and the

24 Additional Financial Information for Long Term Care

25 Applicants as well as scanned copies of any supporting

26 documentation. Long-term care facility admission documents

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1 must be submitted as required in Section 5-5 of this Code.

2 No local Department of Human Services office shall refuse

3 to accept an electronically filed application.

4 (8) Notwithstanding any other provision of this Code,

5 the Department of Human Services and the Department of

6 Healthcare and Family Services' Office of the Inspector

7 General shall, upon request, allow an applicant additional

8 time to submit information and documents needed as part of

9 a review of available resources or resources transferred

10 during the look-back period. The initial extension shall

11 not exceed 30 days. A second extension of 30 days may be

12 granted upon request. Any request for information issued by

13 the State to an applicant shall include the following: an

14 explanation of the information required and the date by

15 which the information must be submitted; a statement that

16 failure to respond in a timely manner can result in denial

17 of the application; a statement that the applicant or the

18 facility in the name of the applicant may seek an

19 extension; and the name and contact information of a

20 caseworker in case of questions. Any such request for

21 information shall also be sent to the facility. In deciding

22 whether to grant an extension, the Department of Human

23 Services or the Department of Healthcare and Family

24 Services' Office of the Inspector General shall take into

25 account what is in the best interest of the applicant. The

26 time limits for processing an application shall be tolled

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1 during the period of any extension granted under this

2 subsection.

3 (9) The Department of Human Services and the Department

4 of Healthcare and Family Services must jointly compile data

5 on pending applications and post a monthly report on each

6 Department's website for the purposes of monitoring

7 long-term care eligibility processing. The report must

8 specify the number of applications pending long-term care

9 eligibility determination and admission in the following

10 categories:

11 (A) Length of time application is pending - 0 to 90

12 days, 91 days to 180 days, 181 days to 12 months, over

13 12 months to 18 months, over 18 months to 24 months,

14 and over 24 months.

15 (B) Percentage of applications pending in the

16 Department of Human Services' Family Community

17 Resource Centers, in the Department of Human Services'

18 long-term care hubs, with the Department of Healthcare

19 and Family Services' Office of Inspector General, and

20 those applications which are being tolled due to

21 requests for extension of time for additional

22 information.

23 (C) Status of pending applications.

24 (Source: P.A. 98-104, eff. 7-22-13.)

25 Article 40

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1 Section 40-5. The Illinois Public Aid Code is amended by

2 changing Sections 5A-2, 5A-5, 5A-10, and 5A-14 as follows:

3 (305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2)

4 (Section scheduled to be repealed on January 1, 2015)

5 Sec. 5A-2. Assessment.

6 (a) Subject to Sections 5A-3 and 5A-10, for State fiscal

7 years 2009 through 2018 ~~2014, and from July 1, 2014 through~~

8 ~~December 31, 2014~~, an annual assessment on inpatient services

9 is imposed on each hospital provider in an amount equal to

10 $218.38 multiplied by the difference of the hospital's occupied

11 bed days less the hospital's Medicare bed days, provided,

12 however, that the amount of $218.38 shall be increased by a

13 uniform percentage to generate an amount equal to 75% of the

14 State share of the payments authorized under Section 12-5, with

15 such increase only taking effect upon the date that a State

16 share for such payments is required under federal law.

17 For State fiscal years 2009 through 2014~~,~~ and after, a

18 hospital's occupied bed days and Medicare bed days shall be

19 determined using the most recent data available from each

20 hospital's 2005 Medicare cost report as contained in the

21 Healthcare Cost Report Information System file, for the quarter

22 ending on December 31, 2006, without regard to any subsequent

23 adjustments or changes to such data. If a hospital's 2005

24 Medicare cost report is not contained in the Healthcare Cost

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1 Report Information System, then the Illinois Department may

2 obtain the hospital provider's occupied bed days and Medicare

3 bed days from any source available, including, but not limited

4 to, records maintained by the hospital provider, which may be

5 inspected at all times during business hours of the day by the

6 Illinois Department or its duly authorized agents and

7 employees.

8 (b) (Blank).

9 (b-5) Subject to Sections 5A-3 and 5A-10, for the portion

10 of State fiscal year 2012, beginning June 10, 2012 through June

11 30, 2012, and for State fiscal years 2013 through 2018 ~~2014,~~

12 ~~and July 1, 2014 through December 31, 2014~~, an annual

13 assessment on outpatient services is imposed on each hospital

14 provider in an amount equal to .008766 multiplied by the

15 hospital's outpatient gross revenue, provided, however, that

16 the amount of .008766 shall be increased by a uniform

17 percentage to generate an amount equal to 25% of the State

18 share of the payments authorized under Section 12-5, with such

19 increase only taking effect upon the date that a State share

20 for such payments is required under federal law. For the period

21 beginning June 10, 2012 through June 30, 2012, the annual

22 assessment on outpatient services shall be prorated by

23 multiplying the assessment amount by a fraction, the numerator

24 of which is 21 days and the denominator of which is 365 days.

25 For the portion of State fiscal year 2012, beginning June

26 10, 2012 through June 30, 2012, and State fiscal years 2013

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1 through 2018 ~~2014, and July 1, 2014 through December 31, 2014~~,

2 a hospital's outpatient gross revenue shall be determined using

3 the most recent data available from each hospital's 2009

4 Medicare cost report as contained in the Healthcare Cost Report

5 Information System file, for the quarter ending on June 30,

6 2011, without regard to any subsequent adjustments or changes

7 to such data. If a hospital's 2009 Medicare cost report is not

8 contained in the Healthcare Cost Report Information System,

9 then the Department may obtain the hospital provider's

10 outpatient gross revenue from any source available, including,

11 but not limited to, records maintained by the hospital

12 provider, which may be inspected at all times during business

13 hours of the day by the Department or its duly authorized

14 agents and employees.

15 (c) (Blank).

16 (d) Notwithstanding any of the other provisions of this

17 Section, the Department is authorized to adopt rules to reduce

18 the rate of any annual assessment imposed under this Section,

19 as authorized by Section 5-46.2 of the Illinois Administrative

20 Procedure Act.

21 (e) Notwithstanding any other provision of this Section,

22 any plan providing for an assessment on a hospital provider as

23 a permissible tax under Title XIX of the federal Social

24 Security Act and Medicaid-eligible payments to hospital

25 providers from the revenues derived from that assessment shall

26 be reviewed by the Illinois Department of Healthcare and Family

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1 Services, as the Single State Medicaid Agency required by

2 federal law, to determine whether those assessments and

3 hospital provider payments meet federal Medicaid standards. If

4 the Department determines that the elements of the plan may

5 meet federal Medicaid standards and a related State Medicaid

6 Plan Amendment is prepared in a manner and form suitable for

7 submission, that State Plan Amendment shall be submitted in a

8 timely manner for review by the Centers for Medicare and

9 Medicaid Services of the United States Department of Health and

10 Human Services and subject to approval by the Centers for

11 Medicare and Medicaid Services of the United States Department

12 of Health and Human Services. No such plan shall become

13 effective without approval by the Illinois General Assembly by

14 the enactment into law of related legislation. Notwithstanding

15 any other provision of this Section, the Department is

16 authorized to adopt rules to reduce the rate of any annual

17 assessment imposed under this Section. Any such rules may be

18 adopted by the Department under Section 5-50 of the Illinois

19 Administrative Procedure Act.

20 (Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12;

21 98-104, eff. 7-22-13.)

22 (305 ILCS 5/5A-5) (from Ch. 23, par. 5A-5)

23 Sec. 5A-5. Notice; penalty; maintenance of records.

24 (a) The Illinois Department shall send a notice of

25 assessment to every hospital provider subject to assessment

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1 under this Article. The notice of assessment shall notify the

2 hospital of its assessment and shall be sent after receipt by

3 the Department of notification from the Centers for Medicare

4 and Medicaid Services of the U.S. Department of Health and

5 Human Services that the payment methodologies required under

6 this Article and, if necessary, the waiver granted under 42 CFR

7 433.68 have been approved. The notice shall be on a form

8 prepared by the Illinois Department and shall state the

9 following:

10 (1) The name of the hospital provider.

11 (2) The address of the hospital provider's principal

12 place of business from which the provider engages in the

13 occupation of hospital provider in this State, and the name

14 and address of each hospital operated, conducted, or

15 maintained by the provider in this State.

16 (3) The occupied bed days, occupied bed days less

17 Medicare days, adjusted gross hospital revenue, or

18 outpatient gross revenue of the hospital provider

19 (whichever is applicable), the amount of assessment

20 imposed under Section 5A-2 for the State fiscal year for

21 which the notice is sent, and the amount of each

22 installment to be paid during the State fiscal year.

23 (4) (Blank).

24 (5) Other reasonable information as determined by the

25 Illinois Department.

26 (b) If a hospital provider conducts, operates, or maintains

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1 more than one hospital licensed by the Illinois Department of

2 Public Health, the provider shall pay the assessment for each

3 hospital separately.

4 (c) Notwithstanding any other provision in this Article, in

5 the case of a person who ceases to conduct, operate, or

6 maintain a hospital in respect of which the person is subject

7 to assessment under this Article as a hospital provider, the

8 assessment for the State fiscal year in which the cessation

9 occurs shall be adjusted by multiplying the assessment computed

10 under Section 5A-2 by a fraction, the numerator of which is the

11 number of days in the year during which the provider conducts,

12 operates, or maintains the hospital and the denominator of

13 which is 365. Immediately upon ceasing to conduct, operate, or

14 maintain a hospital, the person shall pay the assessment for

15 the year as so adjusted (to the extent not previously paid).

16 (d) Notwithstanding any other provision in this Article, a

17 provider who commences conducting, operating, or maintaining a

18 hospital, upon notice by the Illinois Department, shall pay the

19 assessment computed under Section 5A-2 and subsection (e) in

20 installments on the due dates stated in the notice and on the

21 regular installment due dates for the State fiscal year

22 occurring after the due dates of the initial notice.

23 (e) Notwithstanding any other provision in this Article,

24 for State fiscal years 2009 through 2018 ~~2014~~, in the case of a

25 hospital provider that did not conduct, operate, or maintain a

26 hospital in 2005, the assessment for that State fiscal year

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1 shall be computed on the basis of hypothetical occupied bed

2 days for the full calendar year as determined by the Illinois

3 Department. Notwithstanding any other provision in this

4 Article, for the portion of State fiscal year 2012 beginning

5 June 10, 2012 through June 30, 2012, and for State fiscal years

6 2013 through 2018 ~~2014, and for July 1, 2014 through December~~

7 ~~31, 2014~~, in the case of a hospital provider that did not

8 conduct, operate, or maintain a hospital in 2009, the

9 assessment under subsection (b-5) of Section 5A-2 for that

10 State fiscal year shall be computed on the basis of

11 hypothetical gross outpatient revenue for the full calendar

12 year as determined by the Illinois Department.

13 (f) Every hospital provider subject to assessment under

14 this Article shall keep sufficient records to permit the

15 determination of adjusted gross hospital revenue for the

16 hospital's fiscal year. All such records shall be kept in the

17 English language and shall, at all times during regular

18 business hours of the day, be subject to inspection by the

19 Illinois Department or its duly authorized agents and

20 employees.

21 (g) The Illinois Department may, by rule, provide a

22 hospital provider a reasonable opportunity to request a

23 clarification or correction of any clerical or computational

24 errors contained in the calculation of its assessment, but such

25 corrections shall not extend to updating the cost report

26 information used to calculate the assessment.

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1 (h) (Blank).

2 (Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12;

3 98-104, eff. 7-22-13; 98-463, eff. 8-16-13; revised 10-21-13.)

4 (305 ILCS 5/5A-10) (from Ch. 23, par. 5A-10)

5 Sec. 5A-10. Applicability.

6 (a) The assessment imposed by subsection (a) of Section

7 5A-2 shall cease to be imposed and the Department's obligation

8 to make payments shall immediately cease, and any moneys

9 remaining in the Fund shall be refunded to hospital providers

10 in proportion to the amounts paid by them, if:

11 (1) The payments to hospitals required under this

12 Article are not eligible for federal matching funds under

13 Title XIX or XXI of the Social Security Act;

14 (2) For State fiscal years 2009 through 2018 ~~2014, and~~

15 ~~July 1, 2014 through December 31, 2014~~, the Department of

16 Healthcare and Family Services adopts any administrative

17 rule change to reduce payment rates or alters any payment

18 methodology that reduces any payment rates made to

19 operating hospitals under the approved Title XIX or Title

20 XXI State plan in effect January 1, 2008 except for:

21 (A) any changes for hospitals described in

22 subsection (b) of Section 5A-3;

23 (B) any rates for payments made under this Article

24 V-A;

25 (C) any changes proposed in State plan amendment

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1 transmittal numbers 08-01, 08-02, 08-04, 08-06, and

2 08-07;

3 (D) in relation to any admissions on or after

4 January 1, 2011, a modification in the methodology for

5 calculating outlier payments to hospitals for

6 exceptionally costly stays, for hospitals reimbursed

7 under the diagnosis-related grouping methodology in

8 effect on July 1, 2011; provided that the Department

9 shall be limited to one such modification during the

10 36-month period after the effective date of this

11 amendatory Act of the 96th General Assembly; ~~or~~

12 (E) any changes affecting hospitals authorized by

13 Public Act 97-689; or ~~.~~

14 (F) any changes authorized by Section 14-12 of this

15 Code, or for any changes authorized under Section 5A-15

16 of this Code.

17 (b) The assessment imposed by Section 5A-2 shall not take

18 effect or shall cease to be imposed, and the Department's

19 obligation to make payments shall immediately cease, if the

20 assessment is determined to be an impermissible tax under Title

21 XIX of the Social Security Act. Moneys in the Hospital Provider

22 Fund derived from assessments imposed prior thereto shall be

23 disbursed in accordance with Section 5A-8 to the extent federal

24 financial participation is not reduced due to the

25 impermissibility of the assessments, and any remaining moneys

26 shall be refunded to hospital providers in proportion to the

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1 amounts paid by them.

2 (c) The assessments imposed by subsection (b-5) of Section

3 5A-2 shall not take effect or shall cease to be imposed, the

4 Department's obligation to make payments shall immediately

5 cease, and any moneys remaining in the Fund shall be refunded

6 to hospital providers in proportion to the amounts paid by

7 them, if the payments to hospitals required under Section

8 5A-12.4 are not eligible for federal matching funds under Title

9 XIX of the Social Security Act.

10 (d) The assessments imposed by Section 5A-2 shall not take

11 effect or shall cease to be imposed, the Department's

12 obligation to make payments shall immediately cease, and any

13 moneys remaining in the Fund shall be refunded to hospital

14 providers in proportion to the amounts paid by them, if:

15 (1) for State fiscal years 2013 through 2018 ~~2014, and~~

16 ~~July 1, 2014 through December 31, 2014~~, the Department

17 reduces any payment rates to hospitals as in effect on May

18 1, 2012, or alters any payment methodology as in effect on

19 May 1, 2012, that has the effect of reducing payment rates

20 to hospitals, except for any changes affecting hospitals

21 authorized in Public Act 97-689 and any changes authorized

22 by Section 14-12 of this Code, and except for any changes

23 authorized under Section 5A-15; ~~or~~

24 (2) for State fiscal years 2013 through 2018 ~~2014, and~~

25 ~~July 1, 2014 through December 31, 2014~~, the Department

26 reduces any supplemental payments made to hospitals below

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1 the amounts paid for services provided in State fiscal year

2 2011 as implemented by administrative rules adopted and in

3 effect on or prior to June 30, 2011, except for any changes

4 affecting hospitals authorized in Public Act 97-689 and any

5 changes authorized by Section 14-12 of this Code, and

6 except for any changes authorized under Section 5A-15; or ~~.~~

7 (3) for State fiscal years 2015 through 2018, the

8 Department reduces the overall effective rate of

9 reimbursement to hospitals below the level authorized

10 under Section 14-12 of this Code, except for any changes

11 under Section 14-12 or Section 5A-15 of this Code.

12 (Source: P.A. 97-72, eff. 7-1-11; 97-74, eff. 6-30-11; 97-688,

13 eff. 6-14-12; 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)

14 (305 ILCS 5/5A-14)

15 Sec. 5A-14. Repeal of assessments and disbursements.

16 (a) Section 5A-2 is repealed on July 1, 2018 ~~January 1,~~

17 ~~2015~~.

18 (b) Section 5A-12 is repealed on July 1, 2005.

19 (c) Section 5A-12.1 is repealed on July 1, 2008.

20 (d) Section 5A-12.2 and Section 5A-12.4 are repealed on

21 July 1, 2018 ~~January 1, 2015~~.

22 (e) Section 5A-12.3 is repealed on July 1, 2011.

23 (Source: P.A. 96-821, eff. 11-20-09; 96-1530, eff. 2-16-11;

24 97-688, eff. 6-14-12; 97-689, eff. 6-14-12.)

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1 Article 45

2 Section 45-5. The Illinois Public Aid Code is amended by

3 changing Section 14-8 and by adding Section 14-12 as follows:

4 (305 ILCS 5/14-8) (from Ch. 23, par. 14-8)

5 Sec. 14-8. Disbursements to Hospitals.

6 (a) For inpatient hospital services rendered on and after

7 September 1, 1991, the Illinois Department shall reimburse

8 hospitals for inpatient services at an inpatient payment rate

9 calculated for each hospital based upon the Medicare

10 Prospective Payment System as set forth in Sections 1886(b),

11 (d), (g), and (h) of the federal Social Security Act, and the

12 regulations, policies, and procedures promulgated thereunder,

13 except as modified by this Section. Payment rates for inpatient

14 hospital services rendered on or after September 1, 1991 and on

15 or before September 30, 1992 shall be calculated using the

16 Medicare Prospective Payment rates in effect on September 1,

17 1991. Payment rates for inpatient hospital services rendered on

18 or after October 1, 1992 and on or before March 31, 1994 shall

19 be calculated using the Medicare Prospective Payment rates in

20 effect on September 1, 1992. Payment rates for inpatient

21 hospital services rendered on or after April 1, 1994 shall be

22 calculated using the Medicare Prospective Payment rates

23 (including the Medicare grouping methodology and weighting

24 factors as adjusted pursuant to paragraph (1) of this

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1 subsection) in effect 90 days prior to the date of admission.

2 For services rendered on or after July 1, 1995, the

3 reimbursement methodology implemented under this subsection

4 shall not include those costs referred to in Sections

5 1886(d)(5)(B) and 1886(h) of the Social Security Act. The

6 additional payment amounts required under Section

7 1886(d)(5)(F) of the Social Security Act, for hospitals serving

8 a disproportionate share of low-income or indigent patients,

9 are not required under this Section. For hospital inpatient

10 services rendered on or after July 1, 1995and on or before

11 June 30, 2014, the Illinois Department shall reimburse

12 hospitals using the relative weighting factors and the base

13 payment rates calculated for each hospital that were in effect

14 on June 30, 1995, less the portion of such rates attributed by

15 the Illinois Department to the cost of medical education.

16 (1) The weighting factors established under Section

17 1886(d)(4) of the Social Security Act shall not be used in

18 the reimbursement system established under this Section.

19 Rather, the Illinois Department shall establish by rule

20 Medicaid weighting factors to be used in the reimbursement

21 system established under this Section.

22 (2) The Illinois Department shall define by rule those

23 hospitals or distinct parts of hospitals that shall be

24 exempt from the reimbursement system established under

25 this Section. In defining such hospitals, the Illinois

26 Department shall take into consideration those hospitals

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1 exempt from the Medicare Prospective Payment System as of

2 September 1, 1991. For hospitals defined as exempt under

3 this subsection, the Illinois Department shall by rule

4 establish a reimbursement system for payment of inpatient

5 hospital services rendered on and after September 1, 1991.

6 For all hospitals that are children's hospitals as defined

7 in Section 5-5.02 of this Code, the reimbursement

8 methodology shall, through June 30, 1992, net of all

9 applicable fees, at least equal each children's hospital

10 1990 ICARE payment rates, indexed to the current year by

11 application of the DRI hospital cost index from 1989 to the

12 year in which payments are made. Excepting county providers

13 as defined in Article XV of this Code, hospitals licensed

14 under the University of Illinois Hospital Act, and

15 facilities operated by the Department of Mental Health and

16 Developmental Disabilities (or its successor, the

17 Department of Human Services) for hospital inpatient

18 services rendered on or after July 1, 1995and on or before

19 June 30, 2014, the Illinois Department shall reimburse

20 children's hospitals, as defined in 89 Illinois

21 Administrative Code Section 149.50(c)(3), at the rates in

22 effect on June 30, 1995, and shall reimburse all other

23 hospitals at the rates in effect on June 30, 1995, less the

24 portion of such rates attributed by the Illinois Department

25 to the cost of medical education. For inpatient hospital

26 services provided on or after August 1, 1998, the Illinois

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1 Department may establish by rule a means of adjusting the

2 rates of children's hospitals, as defined in 89 Illinois

3 Administrative Code Section 149.50(c)(3), that did not

4 meet that definition on June 30, 1995, in order for the

5 inpatient hospital rates of such hospitals to take into

6 account the average inpatient hospital rates of those

7 children's hospitals that did meet the definition of

8 children's hospitals on June 30, 1995.

9 (3) (Blank).

10 (4) Notwithstanding any other provision of this

11 Section, hospitals that on August 31, 1991, have a contract

12 with the Illinois Department under Section 3-4 of the

13 Illinois Health Finance Reform Act may elect to continue to

14 be reimbursed at rates stated in such contracts for general

15 and specialty care.

16 (5) In addition to any payments made under this

17 subsection (a), the Illinois Department shall make the

18 adjustment payments required by Section 5-5.02 of this

19 Code; provided, that in the case of any hospital reimbursed

20 under a per case methodology, the Illinois Department shall

21 add an amount equal to the product of the hospital's

22 average length of stay, less one day, multiplied by 20, for

23 inpatient hospital services rendered on or after September

24 1, 1991 and on or before September 30, 1992.

25 (b) (Blank).

26 (b-5) Excepting county providers as defined in Article XV

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1 of this Code, hospitals licensed under the University of

2 Illinois Hospital Act, and facilities operated by the Illinois

3 Department of Mental Health and Developmental Disabilities (or

4 its successor, the Department of Human Services), for

5 outpatient services rendered on or after July 1, 1995 and

6 before July 1, 1998 the Illinois Department shall reimburse

7 children's hospitals, as defined in the Illinois

8 Administrative Code Section 149.50(c)(3), at the rates in

9 effect on June 30, 1995, less that portion of such rates

10 attributed by the Illinois Department to the outpatient

11 indigent volume adjustment and shall reimburse all other

12 hospitals at the rates in effect on June 30, 1995, less the

13 portions of such rates attributed by the Illinois Department to

14 the cost of medical education and attributed by the Illinois

15 Department to the outpatient indigent volume adjustment. For

16 outpatient services provided on or after July 1, 1998 and on or

17 before June 30, 2014, reimbursement rates shall be established

18 by rule.

19 (c) In addition to any other payments under this Code, the

20 Illinois Department shall develop a hospital disproportionate

21 share reimbursement methodology that, effective July 1, 1991,

22 through September 30, 1992, shall reimburse hospitals

23 sufficiently to expend the fee monies described in subsection

24 (b) of Section 14-3 of this Code and the federal matching funds

25 received by the Illinois Department as a result of expenditures

26 made by the Illinois Department as required by this subsection

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1 (c) and Section 14-2 that are attributable to fee monies

2 deposited in the Fund, less amounts applied to adjustment

3 payments under Section 5-5.02.

4 (d) Critical Care Access Payments.

5 (1) In addition to any other payments made under this

6 Code, the Illinois Department shall develop a

7 reimbursement methodology that shall reimburse Critical

8 Care Access Hospitals for the specialized services that

9 qualify them as Critical Care Access Hospitals. No

10 adjustment payments shall be made under this subsection on

11 or after July 1, 1995.

12 (2) "Critical Care Access Hospitals" includes, but is

13 not limited to, hospitals that meet at least one of the

14 following criteria:

15 (A) Hospitals located outside of a metropolitan

16 statistical area that are designated as Level II

17 Perinatal Centers and that provide a disproportionate

18 share of perinatal services to recipients; or

19 (B) Hospitals that are designated as Level I Trauma

20 Centers (adult or pediatric) and certain Level II

21 Trauma Centers as determined by the Illinois

22 Department; or

23 (C) Hospitals located outside of a metropolitan

24 statistical area and that provide a disproportionate

25 share of obstetrical services to recipients.

26 (e) Inpatient high volume adjustment. For hospital

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1 inpatient services, effective with rate periods beginning on or

2 after October 1, 1993, in addition to rates paid for inpatient

3 services by the Illinois Department, the Illinois Department

4 shall make adjustment payments for inpatient services

5 furnished by Medicaid high volume hospitals. The Illinois

6 Department shall establish by rule criteria for qualifying as a

7 Medicaid high volume hospital and shall establish by rule a

8 reimbursement methodology for calculating these adjustment

9 payments to Medicaid high volume hospitals. No adjustment

10 payment shall be made under this subsection for services

11 rendered on or after July 1, 1995.

12 (f) The Illinois Department shall modify its current rules

13 governing adjustment payments for targeted access, critical

14 care access, and uncompensated care to classify those

15 adjustment payments as not being payments to disproportionate

16 share hospitals under Title XIX of the federal Social Security

17 Act. Rules adopted under this subsection shall not be effective

18 with respect to services rendered on or after July 1, 1995. The

19 Illinois Department has no obligation to adopt or implement any

20 rules or make any payments under this subsection for services

21 rendered on or after July 1, 1995.

22 (f-5) The State recognizes that adjustment payments to

23 hospitals providing certain services or incurring certain

24 costs may be necessary to assure that recipients of medical

25 assistance have adequate access to necessary medical services.

26 These adjustments include payments for teaching costs and

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1 uncompensated care, trauma center payments, rehabilitation

2 hospital payments, perinatal center payments, obstetrical care

3 payments, targeted access payments, Medicaid high volume

4 payments, and outpatient indigent volume payments. On or before

5 April 1, 1995, the Illinois Department shall issue

6 recommendations regarding (i) reimbursement mechanisms or

7 adjustment payments to reflect these costs and services,

8 including methods by which the payments may be calculated and

9 the method by which the payments may be financed, and (ii)

10 reimbursement mechanisms or adjustment payments to reflect

11 costs and services of federally qualified health centers with

12 respect to recipients of medical assistance.

13 (g) If one or more hospitals file suit in any court

14 challenging any part of this Article XIV, payments to hospitals

15 under this Article XIV shall be made only to the extent that

16 sufficient monies are available in the Fund and only to the

17 extent that any monies in the Fund are not prohibited from

18 disbursement under any order of the court.

19 (h) Payments under the disbursement methodology described

20 in this Section are subject to approval by the federal

21 government in an appropriate State plan amendment.

22 (i) The Illinois Department may by rule establish criteria

23 for and develop methodologies for adjustment payments to

24 hospitals participating under this Article.

25 (j) Hospital Residing Long Term Care Services. In addition

26 to any other payments made under this Code, the Illinois

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1 Department may by rule establish criteria and develop

2 methodologies for payments to hospitals for Hospital Residing

3 Long Term Care Services.

4 (k) Critical Access Hospital outpatient payments. In

5 addition to any other payments authorized under this Code, the

6 Illinois Department shall reimburse critical access hospitals,

7 as designated by the Illinois Department of Public Health in

8 accordance with 42 CFR 485, Subpart F, for outpatient services

9 at an amount that is no less than the cost of providing such

10 services, based on Medicare cost principles. Payments under

11 this subsection shall be subject to appropriation.

12 (l) On and after July 1, 2012, the Department shall reduce

13 any rate of reimbursement for services or other payments or

14 alter any methodologies authorized by this Code to reduce any

15 rate of reimbursement for services or other payments in

16 accordance with Section 5-5e.

17 (Source: P.A. 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)

18 (305 ILCS 5/14-12 new)

19 Sec. 14-12. Hospital rate reform payment system. The

20 hospital payment system pursuant to Section 14-11 of this

21 Article shall be as follows:

22 (a) Inpatient hospital services. Effective for discharges

23 on and after July 1, 2014, reimbursement for inpatient general

24 acute care services shall utilize the All Patient Refined

25 Diagnosis Related Grouping (APR-DRG) software, version 30,

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1 distributed by 3M^TM Health Information System.

2 (1) The Department shall establish Medicaid weighting

3 factors to be used in the reimbursement system established

4 under this subsection. Initial weighting factors shall be

5 the weighting factors as published by 3M Health Information

6 System, associated with Version 30.0 adjusted for the

7 Illinois experience.

8 (2) The Department shall establish a

9 statewide-standardized amount to be used in the inpatient

10 reimbursement system. The Department shall publish these

11 amounts on its website no later than 10 calendar days prior

12 to their effective date.

13 (3) In addition to the statewide-standardized amount,

14 the Department shall develop adjusters to adjust the rate

15 of reimbursement for critical Medicaid providers or

16 services for trauma, transplantation services, perinatal

17 care, and Graduate Medical Education (GME).

18 (4) The Department shall develop add-on payments to

19 account for exceptionally costly inpatient stays,

20 consistent with Medicare outlier principles. Outlier fixed

21 loss thresholds may be updated to control for excessive

22 growth in outlier payments no more frequently than on an

23 annual basis, but at least triennially. Upon updating the

24 fixed loss thresholds, the Department shall be required to

25 update base rates within 12 months.

26 (5) The Department shall define those hospitals or

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1 distinct parts of hospitals that shall be exempt from the

2 APR-DRG reimbursement system established under this

3 Section. The Department shall publish these hospitals'

4 inpatient rates on its website no later than 10 calendar

5 days prior to their effective date.

6 (6) Beginning July 1, 2014 and ending on June 30, 2018,

7 in addition to the statewide-standardized amount, the

8 Department shall develop an adjustor to adjust the rate of

9 reimbursement for safety-net hospitals defined in Section

10 5-5e.1 of this Code excluding pediatric hospitals.

11 (7) Beginning July 1, 2014 and ending on June 30, 2018,

12 in addition to the statewide-standardized amount, the

13 Department shall develop an adjustor to adjust the rate of

14 reimbursement for Illinois freestanding inpatient

15 psychiatric hospitals that are not designated as

16 children's hospitals by the Department but are primarily

17 treating patients under the age of 21.

18 (b) Outpatient hospital services. Effective for dates of

19 service on and after July 1, 2014, reimbursement for outpatient

20 services shall utilize the Enhanced Ambulatory Procedure

21 Grouping (E-APG) software, version 3.7 distributed by 3M^TM

22 Health Information System.

23 (1) The Department shall establish Medicaid weighting

24 factors to be used in the reimbursement system established

25 under this subsection. The initial weighting factors shall

26 be the weighting factors as published by 3M Health

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1 Information System, associated with Version 3.7.

2 (2) The Department shall establish service specific

3 statewide-standardized amounts to be used in the

4 reimbursement system.

5 (A) The initial statewide standardized amounts,

6 with the labor portion adjusted by the Calendar Year

7 2013 Medicare Outpatient Prospective Payment System

8 wage index with reclassifications, shall be published

9 by the Department on its website no later than 10

10 calendar days prior to their effective date.

11 (B) The Department shall establish adjustments to

12 the statewide-standardized amounts for each Critical

13 Access Hospital, as designated by the Department of

14 Public Health in accordance with 42 CFR 485, Subpart F.

15 The EAPG standardized amounts are determined

16 separately for each critical access hospital such that

17 simulated EAPG payments using outpatient base period

18 paid claim data plus payments under Section 5A-12.4 of

19 this Code net of the associated tax costs are equal to

20 the estimated costs of outpatient base period claims

21 data with a rate year cost inflation factor applied.

22 (3) In addition to the statewide-standardized amounts,

23 the Department shall develop adjusters to adjust the rate

24 of reimbursement for critical Medicaid hospital outpatient

25 providers or services, including outpatient high volume or

26 safety-net hospitals.

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1 (c) In consultation with the hospital community, the

2 Department is authorized to replace 89 Ill. Admin. Code 152.150

3 as published in 38 Ill. Reg. 4980 through 4986 within 12 months

4 of the effective date of this amendatory Act of the 98th

5 General Assembly. If the Department does not replace these

6 rules within 12 months of the effective date of this amendatory

7 Act of the 98th General Assembly, the rules in effect for

8 152.150 as published in 38 Ill. Reg. 4980 through 4986 shall

9 remain in effect until modified by rule by the Department.

10 Nothing in this subsection shall be construed to mandate that

11 the Department file a replacement rule.

12 (d) Transition period. There shall be a transition period

13 to the reimbursement systems authorized under this Section that

14 shall begin on the effective date of these systems and continue

15 until June 30, 2018, unless extended by rule by the Department.

16 To help provide an orderly and predictable transition to the

17 new reimbursement systems and to preserve and enhance access to

18 the hospital services during this transition, the Department

19 shall allocate a transitional hospital access pool of at least

20 $290,000,000 annually so that transitional hospital access

21 payments are made to hospitals.

22 (1) After the transition period, the Department may

23 begin incorporating the transitional hospital access pool

24 into the base rate structure.

25 (2) After the transition period, if the Department

26 reduces payments from the transitional hospital access

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1 pool, it shall increase base rates, develop new adjustors,

2 adjust current adjustors, develop new hospital access

3 payments based on updated information, or any combination

4 thereof by an amount equal to the decreases proposed in the

5 transitional hospital access pool payments, ensuring that

6 the entire transitional hospital access pool amount shall

7 continue to be used for hospital payments.

8 (e) Beginning 36 months after initial implementation, the

9 Department shall update the reimbursement components in

10 subsections (a) and (b), including standardized amounts and

11 weighting factors, and at least triennially and no more

12 frequently than annually thereafter. The Department shall

13 publish these updates on its website no later than 30 calendar

14 days prior to their effective date.

15 (f) Continuation of supplemental payments. Any

16 supplemental payments authorized under Illinois Administrative

17 Code 148 effective January 1, 2014 and that continue during the

18 period of July 1, 2014 through December 31, 2014 shall remain

19 in effect as long as the assessment imposed by Section 5A-2 is

20 in effect.

21 (g) Notwithstanding subsections (a) through (f) of this

22 Section, any updates to the system shall not result in any

23 diminishment of the overall effective rates of reimbursement as

24 of the implementation date of the new system (July 1, 2014).

25 These updates shall not preclude variations in any individual

26 component of the system or hospital rate variations. Nothing in

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1 this Section shall prohibit the Department from increasing the

2 rates of reimbursement or developing payments to ensure access

3 to hospital services. Nothing in this Section shall be

4 construed to guarantee a minimum amount of spending in the

5 aggregate or per hospital as spending may be impacted by

6 factors including but not limited to the number of individuals

7 in the medical assistance program and the severity of illness

8 of the individuals.

9 (h) The Department shall have the authority to modify by

10 rulemaking any changes to the rates or methodologies in this

11 Section as required by the federal government to obtain federal

12 financial participation for expenditures made under this

13 Section.

14 (i) Except for subsections (g) and (h) of this Section, the

15 Department shall, pursuant to subsection (c) of Section 5-40 of

16 the Illinois Administrative Procedure Act, provide for

17 presentation at the June 2014 hearing of the Joint Committee on

18 Administrative Rules (JCAR) additional written notice to JCAR

19 of the following rules in order to commence the second notice

20 period for the following rules: rules published in the Illinois

21 Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559

22 (Medical Payment), 4628 (Specialized Health Care Delivery

23 Systems), 4640 (Hospital Services), 4932 (Diagnostic Related

24 Grouping (DRG) Prospective Payment System (PPS)), and 4977

25 (Hospital Reimbursement Changes), and published in the

26 Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499

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1 (Specialized Health Care Delivery Systems) and 6505 (Hospital

2 Services).

3 Article 50

4 Section 50-5. The Specialized Mental Health Rehabilitation

5 Act of 2013 is amended by changing Sections 3-116 and 3-205 as

6 follows:

7 (210 ILCS 49/3-116)

8 Sec. 3-116. Experimental research. No consumer shall be

9 subjected to experimental research or treatment without first

10 obtaining his or her informed, written consent. The conduct of

11 any experimental research or treatment shall be authorized and

12 monitored by an institutional review board appointed by the

13 Director of the Department ~~executive director~~. The membership,

14 operating procedures and review criteria for the institutional

15 review board shall be prescribed under rules and regulations of

16 the Department and shall comply with the requirements for

17 institutional review boards established by the federal Food and

18 Drug Administration. No person who has received compensation in

19 the prior 3 years from an entity that manufactures,

20 distributes, or sells pharmaceuticals, biologics, or medical

21 devices may serve on the institutional review board.

22 No facility shall permit experimental research or

23 treatment to be conducted on a consumer, or give access to any

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1 person or person's records for a retrospective study about the

2 safety or efficacy of any care or treatment, without the prior

3 written approval of the institutional review board. No

4 executive director, or person licensed by the State to provide

5 medical care or treatment to any person, may assist or

6 participate in any experimental research on or treatment of a

7 consumer, including a retrospective study, that does not have

8 the prior written approval of the board. Such conduct shall be

9 grounds for professional discipline by the Department of

10 Financial and Professional Regulation.

11 The institutional review board may exempt from ongoing

12 review research or treatment initiated on a consumer before the

13 individual's admission to a facility and for which the board

14 determines there is adequate ongoing oversight by another

15 institutional review board. Nothing in this Section shall

16 prevent a facility, any facility employee, or any other person

17 from assisting or participating in any experimental research on

18 or treatment of a consumer, if the research or treatment began

19 before the person's admission to a facility, until the board

20 has reviewed the research or treatment and decided to grant or

21 deny approval or to exempt the research or treatment from

22 ongoing review.

23 (Source: P.A. 98-104, eff. 7-22-13.)

24 (210 ILCS 49/3-205)

25 Sec. 3-205. Disclosure of information to public. Standards

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1 for the disclosure of information to the public shall be

2 established by rule. These information disclosure standards

3 shall include, but are not limited to, the following: staffing

4 and personnel levels, licensure and inspection information,

5 national accreditation information, consumer charges ~~cost and~~

6 ~~reimbursement information~~, and consumer complaint information.

7 Rules for the public disclosure of information shall be in

8 accordance with the provisions for inspection and copying of

9 public records in the Freedom of Information Act. The

10 Department of Healthcare and Family Services shall make

11 facility cost reports available on its website.

12 (Source: P.A. 98-104, eff. 7-22-13.)

13 Article 55

14 Section 55-5. The State Finance Act is amended by adding

15 Section 5.855 as follows:

16 (30 ILCS 105/5.855 new)

17 Sec. 5.855. The Supportive Living Facility Fund.

18 Section 55-10. The Specialized Mental Health

19 Rehabilitation Act of 2013 is amended by adding Section 5-102

20 as follows:

21 (210 ILCS 49/5-102 new)

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1 Sec. 5-102. Transition payments. In addition to payments

2 already required by law, the Department of Healthcare and

3 Family Services shall make payments to facilities licensed

4 under this Act in the amount of $29.43 per licensed bed, per

5 day, for the period beginning June 1, 2014 and ending June 30,

6 2014.

7 Section 55-15. The Illinois Public Aid Code is amended by

8 changing Sections 5-5, 5-5.01a, 5-5.2, 5-5.4h, 5-5e, 5-5e.1,

9 5-5f, 5B-1, 5C-1, 5C-2, and 5C-7 and by adding Section 5C-10

10 and Article V-G as follows:

11 (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)

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

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

14 of reimbursement for the medical assistance for which payment

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

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

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

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

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

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

21 or elsewhere; (6) medical care, or any other type of remedial

22 care furnished by licensed practitioners; (7) home health care

23 services; (8) private duty nursing service; (9) clinic

24 services; (10) dental services, including prevention and

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1 treatment of periodontal disease and dental caries disease for

2 pregnant women, provided by an individual licensed to practice

3 dentistry or dental surgery; for purposes of this item (10),

4 "dental services" means diagnostic, preventive, or corrective

5 procedures provided by or under the supervision of a dentist in

6 the practice of his or her profession; (11) physical therapy

7 and related services; (12) prescribed drugs, dentures, and

8 prosthetic devices; and eyeglasses prescribed by a physician

9 skilled in the diseases of the eye, or by an optometrist,

10 whichever the person may select; (13) other diagnostic,

11 screening, preventive, and rehabilitative services, including

12 to ensure that the individual's need for intervention or

13 treatment of mental disorders or substance use disorders or

14 co-occurring mental health and substance use disorders is

15 determined using a uniform screening, assessment, and

16 evaluation process inclusive of criteria, for children and

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

18 assessment, and evaluation process refers to a process that

19 includes an appropriate evaluation and, as warranted, a

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

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

22 transportation and such other expenses as may be necessary;

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

24 in Section 1a of the Sexual Assault Survivors Emergency

25 Treatment Act, for injuries sustained as a result of the sexual

26 assault, including examinations and laboratory tests to

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1 discover evidence which may be used in criminal proceedings

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

3 treatment of sickle cell anemia; and (17) any other medical

4 care, and any other type of remedial care recognized under the

5 laws of this State, but not including abortions, or induced

6 miscarriages or premature births, unless, in the opinion of a

7 physician, such procedures are necessary for the preservation

8 of the life of the woman seeking such treatment, or except an

9 induced premature birth intended to produce a live viable child

10 and such procedure is necessary for the health of the mother or

11 her unborn child. The Illinois Department, by rule, shall

12 prohibit any physician from providing medical assistance to

13 anyone eligible therefor under this Code where such physician

14 has been found guilty of performing an abortion procedure in a

15 wilful and wanton manner upon a woman who was not pregnant at

16 the time such abortion procedure was performed. The term "any

17 other type of remedial care" shall include nursing care and

18 nursing home service for persons who rely on treatment by

19 spiritual means alone through prayer for healing.

20 Notwithstanding any other provision of this Section, a

21 comprehensive tobacco use cessation program that includes

22 purchasing prescription drugs or prescription medical devices

23 approved by the Food and Drug Administration shall be covered

24 under the medical assistance program under this Article for

25 persons who are otherwise eligible for assistance under this

26 Article.

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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 under

17 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 and

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1 Family Services may provide the following services to persons

2 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 the

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

10 person may select.

11 Notwithstanding any other provision of this Code and

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

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

14 cost to render dental services through an enrolled

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

16 enrolling as a participating provider in the medical assistance

17 program. A not-for-profit health clinic shall include a public

18 health clinic or Federally Qualified Health Center or other

19 enrolled provider, as determined by the Department, through

20 which dental services covered under this Section are performed.

21 The Department shall establish a process for payment of claims

22 for reimbursement for covered dental services rendered under

23 this provision.

24 The Illinois Department, by rule, may distinguish and

25 classify the medical services to be provided only in accordance

26 with the classes of persons designated in Section 5-2.

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1 The Department of Healthcare and Family Services must

2 provide coverage and reimbursement for amino acid-based

3 elemental formulas, regardless of delivery method, for the

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

5 short bowel syndrome when the prescribing physician has issued

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

7 formula is medically necessary.

8 The Illinois Department shall authorize the provision of,

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

10 mammography for the presence of occult breast cancer for women

11 35 years of age or older who are eligible for medical

12 assistance under this Article, as follows:

13 (A) A baseline mammogram for women 35 to 39 years of

14 age.

15 (B) An annual mammogram for women 40 years of age or

16 older.

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

18 medically necessary by the woman's health care provider for

19 women under 40 years of age and having a family history of

20 breast cancer, prior personal history of breast cancer,

21 positive genetic testing, or other risk factors.

22 (D) A comprehensive ultrasound screening of an entire

23 breast or breasts if a mammogram demonstrates

24 heterogeneous or dense breast tissue, when medically

25 necessary as determined by a physician licensed to practice

26 medicine in all of its branches.

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1 All screenings shall include a physical breast exam,

2 instruction on self-examination and information regarding the

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

4 tool. For purposes of this Section, "low-dose mammography"

5 means the x-ray examination of the breast using equipment

6 dedicated specifically for mammography, including the x-ray

7 tube, filter, compression device, and image receptor, with an

8 average radiation exposure delivery of less than one rad per

9 breast for 2 views of an average size breast. The term also

10 includes digital mammography.

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

12 quality improvement program approved by the Department shall be

13 reimbursed for screening and diagnostic mammography at the same

14 rate as the Medicare program's rates, including the increased

15 reimbursement for digital mammography.

16 The Department shall convene an expert panel including

17 representatives of hospitals, free-standing mammography

18 facilities, and doctors, including radiologists, to establish

19 quality standards.

20 Subject to federal approval, the Department shall

21 establish a rate methodology for mammography at federally

22 qualified health centers and other encounter-rate clinics.

23 These clinics or centers may also collaborate with other

24 hospital-based mammography facilities.

25 The Department shall establish a methodology to remind

26 women who are age-appropriate for screening mammography, but

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1 who have not received a mammogram within the previous 18

2 months, of the importance and benefit of screening mammography.

3 The Department shall establish a performance goal for

4 primary care providers with respect to their female patients

5 over age 40 receiving an annual mammogram. This performance

6 goal shall be used to provide additional reimbursement in the

7 form of a quality performance bonus to primary care providers

8 who meet that goal.

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

10 patient navigation for beneficiaries diagnosed with breast

11 cancer. This program shall initially operate as a pilot program

12 in areas of the State with the highest incidence of mortality

13 related to breast cancer. At least one pilot program site shall

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

15 be outside the metropolitan Chicago area. An evaluation of the

16 pilot program shall be carried out measuring health outcomes

17 and cost of care for those served by the pilot program compared

18 to similarly situated patients who are not served by the pilot

19 program.

20 Any medical or health care provider shall immediately

21 recommend, to any pregnant woman who is being provided prenatal

22 services and is suspected of drug abuse or is addicted as

23 defined in the Alcoholism and Other Drug Abuse and Dependency

24 Act, referral to a local substance abuse treatment provider

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

26 hospital which provides substance abuse treatment services.

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1 The Department of Healthcare and Family Services shall assure

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

3 addiction for pregnant recipients in accordance with the

4 Illinois Medicaid Program in conjunction with the Department of

5 Human Services.

6 All medical providers providing medical assistance to

7 pregnant women under this Code shall receive information from

8 the Department on the availability of services under the Drug

9 Free Families with a Future or any comparable program providing

10 case management services for addicted women, including

11 information on appropriate referrals for other social services

12 that may be needed by addicted women in addition to treatment

13 for addiction.

14 The Illinois Department, in cooperation with the

15 Departments of Human Services (as successor to the Department

16 of Alcoholism and Substance Abuse) and Public Health, through a

17 public awareness campaign, may provide information concerning

18 treatment for alcoholism and drug abuse and addiction, prenatal

19 health care, and other pertinent programs directed at reducing

20 the number of drug-affected infants born to recipients of

21 medical assistance.

22 Neither the Department of Healthcare and Family Services

23 nor the Department of Human Services shall sanction the

24 recipient solely on the basis of her substance abuse.

25 The Illinois Department shall establish such regulations

26 governing the dispensing of health services under this Article

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

2 advice of formal professional advisory committees appointed by

3 the Director of the Illinois Department for the purpose of

4 providing regular advice on policy and administrative matters,

5 information dissemination and educational activities for

6 medical and health care providers, and consistency in

7 procedures to the Illinois Department.

8 The Illinois Department may develop and contract with

9 Partnerships of medical providers to arrange medical services

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

11 Implementation of this Section may be by demonstration projects

12 in certain geographic areas. The Partnership shall be

13 represented by a sponsor organization. The Department, by rule,

14 shall develop qualifications for sponsors of Partnerships.

15 Nothing in this Section shall be construed to require that the

16 sponsor organization be a medical organization.

17 The sponsor must negotiate formal written contracts with

18 medical providers for physician services, inpatient and

19 outpatient hospital care, home health services, treatment for

20 alcoholism and substance abuse, and other services determined

21 necessary by the Illinois Department by rule for delivery by

22 Partnerships. Physician services must include prenatal and

23 obstetrical care. The Illinois Department shall reimburse

24 medical services delivered by Partnership providers to clients

25 in target areas according to provisions of this Article and the

26 Illinois Health Finance Reform Act, except that:

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1 (1) Physicians participating in a Partnership and

2 providing certain services, which shall be determined by

3 the Illinois Department, to persons in areas covered by the

4 Partnership may receive an additional surcharge for such

5 services.

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

7 financial incentives to encourage the development of

8 Partnerships and the efficient delivery of medical care.

9 (3) Persons receiving medical services through

10 Partnerships may receive medical and case management

11 services above the level usually offered through the

12 medical assistance program.

13 Medical providers shall be required to meet certain

14 qualifications to participate in Partnerships to ensure the

15 delivery of high quality medical services. These

16 qualifications shall be determined by rule of the Illinois

17 Department and may be higher than qualifications for

18 participation in the medical assistance program. Partnership

19 sponsors may prescribe reasonable additional qualifications

20 for participation by medical providers, only with the prior

21 written approval of the Illinois Department.

22 Nothing in this Section shall limit the free choice of

23 practitioners, hospitals, and other providers of medical

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

25 choice, the Illinois Department shall immediately promulgate

26 all rules and take all other necessary actions so that provided

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1 services may be accessed from therapeutically certified

2 optometrists to the full extent of the Illinois Optometric

3 Practice Act of 1987 without discriminating between service

4 providers.

5 The Department shall apply for a waiver from the United

6 States Health Care Financing Administration to allow for the

7 implementation of Partnerships under this Section.

8 The Illinois Department shall require health care

9 providers to maintain records that document the medical care

10 and services provided to recipients of Medical Assistance under

11 this Article. Such records must be retained for a period of not

12 less than 6 years from the date of service or as provided by

13 applicable State law, whichever period is longer, except that

14 if an audit is initiated within the required retention period

15 then the records must be retained until the audit is completed

16 and every exception is resolved. The Illinois Department shall

17 require health care providers to make available, when

18 authorized by the patient, in writing, the medical records in a

19 timely fashion to other health care providers who are treating

20 or serving persons eligible for Medical Assistance under this

21 Article. All dispensers of medical services shall be required

22 to maintain and retain business and professional records

23 sufficient to fully and accurately document the nature, scope,

24 details and receipt of the health care provided to persons

25 eligible for medical assistance under this Code, in accordance

26 with regulations promulgated by the Illinois Department. The

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1 rules and regulations shall require that proof of the receipt

2 of prescription drugs, dentures, prosthetic devices and

3 eyeglasses by eligible persons under this Section accompany

4 each claim for reimbursement submitted by the dispenser of such

5 medical services. No such claims for reimbursement shall be

6 approved for payment by the Illinois Department without such

7 proof of receipt, unless the Illinois Department shall have put

8 into effect and shall be operating a system of post-payment

9 audit and review which shall, on a sampling basis, be deemed

10 adequate by the Illinois Department to assure that such drugs,

11 dentures, prosthetic devices and eyeglasses for which payment

12 is being made are actually being received by eligible

13 recipients. Within 90 days after the effective date of this

14 amendatory Act of 1984, the Illinois Department shall establish

15 a current list of acquisition costs for all prosthetic devices

16 and any other items recognized as medical equipment and

17 supplies reimbursable under this Article and shall update such

18 list on a quarterly basis, except that the acquisition costs of

19 all prescription drugs shall be updated no less frequently than

20 every 30 days as required by Section 5-5.12.

21 The rules and regulations of the Illinois Department shall

22 require that a written statement including the required opinion

23 of a physician shall accompany any claim for reimbursement for

24 abortions, or induced miscarriages or premature births. This

25 statement shall indicate what procedures were used in providing

26 such medical services.

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1 Notwithstanding any other law to the contrary, the Illinois

2 Department shall, within 365 days after July 22, 2013, the

3 effective date of Public Act 98-104 ~~this amendatory Act of the~~

4 ~~98th General Assembly~~, establish procedures to permit skilled

5 care facilities licensed under the Nursing Home Care Act to

6 submit monthly billing claims for reimbursement purposes.

7 Following development of these procedures, the Department

8 shall have an additional 365 days to test the viability of the

9 new system and to ensure that any necessary operational or

10 structural changes to its information technology platforms are

11 implemented.

12 The Illinois Department shall require all dispensers of

13 medical services, other than an individual practitioner or

14 group of practitioners, desiring to participate in the Medical

15 Assistance program established under this Article to disclose

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

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

18 associations, business enterprises, joint ventures, agencies,

19 institutions or other legal entities providing any form of

20 health care services in this State under this Article.

21 The Illinois Department may require that all dispensers of

22 medical services desiring to participate in the medical

23 assistance program established under this Article disclose,

24 under such terms and conditions as the Illinois Department may

25 by rule establish, all inquiries from clients and attorneys

26 regarding medical bills paid by the Illinois Department, which

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1 inquiries could indicate potential existence of claims or liens

2 for the Illinois Department.

3 Enrollment of a vendor shall be subject to a provisional

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

5 of conditional enrollment, the Department may terminate the

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

7 vendor from, the medical assistance program without cause.

8 Unless otherwise specified, such termination of eligibility or

9 disenrollment is not subject to the Department's hearing

10 process. However, a disenrolled vendor may reapply without

11 penalty.

12 The Department has the discretion to limit the conditional

13 enrollment period for vendors based upon category of risk of

14 the vendor.

15 Prior to enrollment and during the conditional enrollment

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

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

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

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

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

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

22 financial background checks; fingerprinting; license,

23 certification, and authorization verifications; unscheduled or

24 unannounced site visits; database checks; prepayment audit

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

26 screening as required by federal or State law.

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

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

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

4 screening applicable to a particular category of vendor under

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

6 the maximum length of the conditional enrollment period for

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

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

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

10 the conditional enrollment period.

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

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

13 resubmitted claim following prior rejection, must be received

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

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

16 medical goods or services were provided, with the following

17 exceptions:

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

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

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

21 the Illinois Department that the provider enrollment is

22 complete.

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

24 Department or any of its claims processing intermediaries

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

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

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1 until the provider has been notified of the error.

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

3 Department initiates the monthly billing process.

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

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

6 when local government funds finance federal participation

7 for claims payments.

8 For claims for services rendered during a period for which

9 a recipient received retroactive eligibility, claims must be

10 filed within 180 days after the Department determines the

11 applicant is eligible. For claims for which the Illinois

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

13 to the Illinois Department within 180 days after the final

14 adjudication by the primary payer.

15 In the case of long term care facilities, within 5 days of

16 receipt by the facility of required prescreening information,

17 data for new admissions shall be entered into the Medical

18 Electronic Data Interchange (MEDI) or the Recipient

19 Eligibility Verification (REV) System or successor system, and

20 within 15 days of receipt by the facility of required

21 prescreening information, admission documents shall be

22 submitted ~~within 30 days of an admission to the facility~~

23 through MEDI or REV ~~the Medical Electronic Data Interchange~~

24 ~~(MEDI) or the Recipient Eligibility Verification (REV) System,~~

25 or shall be submitted directly to the Department of Human

26 Services using required admission forms. Effective September

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1 1, 2014, admission documents, including all prescreening

2 information, must be submitted through MEDI or REV.

3 Confirmation numbers assigned to an accepted transaction shall

4 be retained by a facility to verify timely submittal. Once an

5 admission transaction has been completed, all resubmitted

6 claims following prior rejection are subject to receipt no

7 later than 180 days after the admission transaction has been

8 completed.

9 Claims that are not submitted and received in compliance

10 with the foregoing requirements shall not be eligible for

11 payment under the medical assistance program, and the State

12 shall have no liability for payment of those claims.

13 To the extent consistent with applicable information and

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

15 agencies and departments shall provide the Illinois Department

16 access to confidential and other information and data necessary

17 to perform eligibility and payment verifications and other

18 Illinois Department functions. This includes, but is not

19 limited to: information pertaining to licensure;

20 certification; earnings; immigration status; citizenship; wage

21 reporting; unearned and earned income; pension income;

22 employment; supplemental security income; social security

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

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

25 exclusions; taxpayer identification numbers; tax delinquency;

26 corporate information; and death records.

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1 The Illinois Department shall enter into agreements with

2 State agencies and departments, and is authorized to enter into

3 agreements with federal agencies and departments, under which

4 such agencies and departments shall share data necessary for

5 medical assistance program integrity functions and oversight.

6 The Illinois Department shall develop, in cooperation with

7 other State departments and agencies, and in compliance with

8 applicable federal laws and regulations, appropriate and

9 effective methods to share such data. At a minimum, and to the

10 extent necessary to provide data sharing, the Illinois

11 Department shall enter into agreements with State agencies and

12 departments, and is authorized to enter into agreements with

13 federal agencies and departments, including but not limited to:

14 the Secretary of State; the Department of Revenue; the

15 Department of Public Health; the Department of Human Services;

16 and the Department of Financial and Professional Regulation.

17 Beginning in fiscal year 2013, the Illinois Department

18 shall set forth a request for information to identify the

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

20 claims system with the goals of streamlining claims processing

21 and provider reimbursement, reducing the number of pending or

22 rejected claims, and helping to ensure a more transparent

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

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

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

26 post-adjudicated predictive modeling with an integrated case

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1 management system with link analysis. Such a request for

2 information shall not be considered as a request for proposal

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

4 take any action or acquire any products or services.

5 The Illinois Department shall establish policies,

6 procedures, standards and criteria by rule for the acquisition,

7 repair and replacement of orthotic and prosthetic devices and

8 durable medical equipment. Such rules shall provide, but not be

9 limited to, the following services: (1) immediate repair or

10 replacement of such devices by recipients; and (2) rental,

11 lease, purchase or lease-purchase of durable medical equipment

12 in a cost-effective manner, taking into consideration the

13 recipient's medical prognosis, the extent of the recipient's

14 needs, and the requirements and costs for maintaining such

15 equipment. Subject to prior approval, such rules shall enable a

16 recipient to temporarily acquire and use alternative or

17 substitute devices or equipment pending repairs or

18 replacements of any device or equipment previously authorized

19 for such recipient by the Department.

20 The Department shall execute, relative to the nursing home

21 prescreening project, written inter-agency agreements with the

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

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

24 eligibility criteria for those persons who are receiving

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

26 development of non-institutional services in areas of the State

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1 where they are not currently available or are undeveloped; and

2 (iii) notwithstanding any other provision of law, subject to

3 federal approval, on and after July 1, 2012, an increase in the

4 determination of need (DON) scores from 29 to 37 for applicants

5 for institutional and home and community-based long term care;

6 if and only if federal approval is not granted, the Department

7 may, in conjunction with other affected agencies, implement

8 utilization controls or changes in benefit packages to

9 effectuate a similar savings amount for this population; and

10 (iv) no later than July 1, 2013, minimum level of care

11 eligibility criteria for institutional and home and

12 community-based long term care; and (v) no later than October

13 1, 2013, establish procedures to permit long term care

14 providers access to eligibility scores for individuals with an

15 admission date who are seeking or receiving services from the

16 long term care provider. In order to select the minimum level

17 of care eligibility criteria, the Governor shall establish a

18 workgroup that includes affected agency representatives and

19 stakeholders representing the institutional and home and

20 community-based long term care interests. This Section shall

21 not restrict the Department from implementing lower level of

22 care eligibility criteria for community-based services in

23 circumstances where federal approval has been granted.

24 The Illinois Department shall develop and operate, in

25 cooperation with other State Departments and agencies and in

26 compliance with applicable federal laws and regulations,

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1 appropriate and effective systems of health care evaluation and

2 programs for monitoring of utilization of health care services

3 and facilities, as it affects persons eligible for medical

4 assistance under this Code.

5 The Illinois Department shall report annually to the

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

7 1979 and each year thereafter, in regard to:

8 (a) actual statistics and trends in utilization of

9 medical services by public aid recipients;

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

11 the various medical services by medical vendors;

12 (c) current rate structures and proposed changes in

13 those rate structures for the various medical vendors; and

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

15 Illinois Department.

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

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

18 include suggested legislation for consideration by the General

19 Assembly. The filing of one copy of the report with the

20 Speaker, one copy with the Minority Leader and one copy with

21 the Clerk of the House of Representatives, one copy with the

22 President, one copy with the Minority Leader and one copy with

23 the Secretary of the Senate, one copy with the Legislative

24 Research Unit, and such additional copies with the State

25 Government Report Distribution Center for the General Assembly

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

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1 Library Act shall be deemed sufficient to comply with this

2 Section.

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 of

12 reimbursement for services or other payments in accordance with

13 Section 5-5e.

14 Because kidney transplantation can be an appropriate, cost

15 effective alternative to renal dialysis when medically

16 necessary and notwithstanding the provisions of Section 1-11 of

17 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 of

21 this Code, and who would otherwise meet the financial

22 requirements of the appropriate class of eligible persons under

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

24 transplantation, such person must be receiving emergency renal

25 dialysis services covered by the Department. Providers under

26 this Section shall be prior approved and certified by the

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1 Department to perform kidney transplantation and the services

2 under this Section shall be limited to services associated with

3 kidney transplantation.

4 (Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,

5 eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section

6 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.

7 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; revised

8 9-19-13.)

9 (305 ILCS 5/5-5.01a)

10 Sec. 5-5.01a. Supportive living facilities program. The

11 Department shall establish and provide oversight for a program

12 of supportive living facilities that seek to promote resident

13 independence, dignity, respect, and well-being in the most

14 cost-effective manner.

15 A supportive living facility is either a free-standing

16 facility or a distinct physical and operational entity within a

17 nursing facility. A supportive living facility integrates

18 housing with health, personal care, and supportive services and

19 is a designated setting that offers residents their own

20 separate, private, and distinct living units.

21 Sites for the operation of the program shall be selected by

22 the Department based upon criteria that may include the need

23 for services in a geographic area, the availability of funding,

24 and the site's ability to meet the standards.

25 Beginning July 1, 2014, subject to federal approval, the

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1 Medicaid rates for supportive living facilities shall be equal

2 to the supportive living facility Medicaid rate effective on

3 June 30, 2014 increased by 8.85%. Once the assessment imposed

4 at Article V-G of this Code is determined to be a permissible

5 tax under Title XIX of the Social Security Act, the Department

6 shall increase the Medicaid rates for supportive living

7 facilities effective on July 1, 2014 by 9.09%. The Department

8 shall apply this increase retroactively to coincide with the

9 imposition of the assessment in Article V-G of this Code in

10 accordance with the approval for federal financial

11 participation by the Centers for Medicare and Medicaid

12 Services.

13 The Department may adopt rules to implement this Section.

14 Rules that establish or modify the services, standards, and

15 conditions for participation in the program shall be adopted by

16 the Department in consultation with the Department on Aging,

17 the Department of Rehabilitation Services, and the Department

18 of Mental Health and Developmental Disabilities (or their

19 successor agencies).

20 Facilities or distinct parts of facilities which are

21 selected as supportive living facilities and are in good

22 standing with the Department's rules are exempt from the

23 provisions of the Nursing Home Care Act and the Illinois Health

24 Facilities Planning Act.

25 (Source: P.A. 94-342, eff. 7-26-05.)

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1 (305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)

2 Sec. 5-5.2. Payment.

3 (a) All nursing facilities that are grouped pursuant to

4 Section 5-5.1 of this Act shall receive the same rate of

5 payment for similar services.

6 (b) It shall be a matter of State policy that the Illinois

7 Department shall utilize a uniform billing cycle throughout the

8 State for the long-term care providers.

9 (c) Notwithstanding any other provisions of this Code, the

10 methodologies for reimbursement of nursing services as

11 provided under this Article shall no longer be applicable for

12 bills payable for nursing services rendered on or after a new

13 reimbursement system based on the Resource Utilization Groups

14 (RUGs) has been fully operationalized, which shall take effect

15 for services provided on or after January 1, 2014.

16 (d) The new nursing services reimbursement methodology

17 utilizing RUG-IV 48 grouper model, which shall be referred to

18 as the RUGs reimbursement system, taking effect January 1,

19 2014, shall be based on the following:

20 (1) The methodology shall be resident-driven,

21 facility-specific, and cost-based.

22 (2) Costs shall be annually rebased and case mix index

23 quarterly updated. The nursing services methodology will

24 be assigned to the Medicaid enrolled residents on record as

25 of 30 days prior to the beginning of the rate period in the

26 Department's Medicaid Management Information System (MMIS)

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1 as present on the last day of the second quarter preceding

2 the rate period.

3 (3) Regional wage adjustors based on the Health Service

4 Areas (HSA) groupings and adjusters in effect on April 30,

5 2012 shall be included.

6 (4) Case mix index shall be assigned to each resident

7 class based on the Centers for Medicare and Medicaid

8 Services staff time measurement study in effect on July 1,

9 2013, utilizing an index maximization approach.

10 (5) The pool of funds available for distribution by

11 case mix and the base facility rate shall be determined

12 using the formula contained in subsection (d-1).

13 (d-1) Calculation of base year Statewide RUG-IV nursing

14 base per diem rate.

15 (1) Base rate spending pool shall be:

16 (A) The base year resident days which are

17 calculated by multiplying the number of Medicaid

18 residents in each nursing home as indicated in the MDS

19 data defined in paragraph (4) by 365.

20 (B) Each facility's nursing component per diem in

21 effect on July 1, 2012 shall be multiplied by

22 subsection (A).

23 (C) Thirteen million is added to the product of

24 subparagraph (A) and subparagraph (B) to adjust for the

25 exclusion of nursing homes defined in paragraph (5).

26 (2) For each nursing home with Medicaid residents as

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1 indicated by the MDS data defined in paragraph (4),

2 weighted days adjusted for case mix and regional wage

3 adjustment shall be calculated. For each home this

4 calculation is the product of:

5 (A) Base year resident days as calculated in

6 subparagraph (A) of paragraph (1).

7 (B) The nursing home's regional wage adjustor

8 based on the Health Service Areas (HSA) groupings and

9 adjustors in effect on April 30, 2012.

10 (C) Facility weighted case mix which is the number

11 of Medicaid residents as indicated by the MDS data

12 defined in paragraph (4) multiplied by the associated

13 case weight for the RUG-IV 48 grouper model using

14 standard RUG-IV procedures for index maximization.

15 (D) The sum of the products calculated for each

16 nursing home in subparagraphs (A) through (C) above

17 shall be the base year case mix, rate adjusted weighted

18 days.

19 (3) The Statewide RUG-IV nursing base per diem rate:

20 (A) on January 1, 2014 shall be the quotient of the

21 paragraph (1) divided by the sum calculated under

22 subparagraph (D) of paragraph (2); and ~~.~~

23 (B) on and after July 1, 2014, shall be the amount

24 calculated under subparagraph (A) of this paragraph

25 (3) plus $1.76.

26 (4) Minimum Data Set (MDS) comprehensive assessments

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1 for Medicaid residents on the last day of the quarter used

2 to establish the base rate.

3 (5) Nursing facilities designated as of July 1, 2012 by

4 the Department as "Institutions for Mental Disease" shall

5 be excluded from all calculations under this subsection.

6 The data from these facilities shall not be used in the

7 computations described in paragraphs (1) through (4) above

8 to establish the base rate.

9 (e) Beginning July 1, 2014, the Department shall allocate

10 funding in the amount up to $10,000,000 for per diem add-ons to

11 the RUGS methodology for dates of service on and after July 1,

12 2014:

13 (1) $0.63 for each resident who scores in I4200

14 Alzheimer's Disease or I4800 non-Alzheimer's Dementia.

15 (2) $2.67 for each resident who scores either a "1" or

16 "2" in any items S1200A through S1200I and also scores in

17 RUG groups PA1, PA2, BA1, or BA2.

18 ~~Notwithstanding any other provision of this Code, the~~

19 ~~Department shall by rule develop a reimbursement methodology~~

20 ~~reflective of the intensity of care and services requirements~~

21 ~~of low need residents in the lowest RUG IV groupers and~~

22 ~~corresponding regulations. Only that portion of the RUGs~~

23 ~~Reimbursement System spending pool described in subsection~~

24 ~~(d-1) attributed to the groupers as of July 1, 2013 for which~~

25 ~~the methodology in this Section is developed may be diverted~~

26 ~~for this purpose. The Department shall submit the rules no~~

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1 ~~later than January 1, 2014 for an implementation date no later~~

2 ~~than January 1, 2015.~~

3 ~~If the Department does not implement this reimbursement~~

4 ~~methodology by the required date, the nursing component per~~

5 ~~diem on January 1, 2015 for residents classified in RUG-IV~~

6 ~~groups PA1, PA2, BA1, and BA2 shall be the blended rate of the~~

7 ~~calculated RUG-IV nursing component per diem and the nursing~~

8 ~~component per diem in effect on July 1, 2012. This blended rate~~

9 ~~shall be applied only to nursing homes whose resident~~

10 ~~population is greater than or equal to 70% of the total~~

11 ~~residents served and whose RUG-IV nursing component per diem~~

12 ~~rate is less than the nursing component per diem in effect on~~

13 ~~July 1, 2012. This blended rate shall be in effect until the~~

14 ~~reimbursement methodology is implemented or until July 1, 2019,~~

15 ~~whichever is sooner.~~

16 (e-1) (Blank). ~~Notwithstanding any other provision of this~~

17 ~~Article, rates established pursuant to this subsection shall~~

18 ~~not apply to any and all nursing facilities designated by the~~

19 ~~Department as "Institutions for Mental Disease" and shall be~~

20 ~~excluded from the RUGs Reimbursement System applicable to~~

21 ~~facilities not designated as "Institutions for the Mentally~~

22 ~~Diseased" by the Department.~~

23 (e-2) For dates of services beginning January 1, 2014, the

24 RUG-IV nursing component per diem for a nursing home shall be

25 the product of the statewide RUG-IV nursing base per diem rate,

26 the facility average case mix index, and the regional wage

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1 adjustor. Transition rates for services provided between

2 January 1, 2014 and December 31, 2014 shall be as follows:

3 (1) The transition RUG-IV per diem nursing rate for

4 nursing homes whose rate calculated in this subsection

5 (e-2) is greater than the nursing component rate in effect

6 July 1, 2012 shall be paid the sum of:

7 (A) The nursing component rate in effect July 1,

8 2012; plus

9 (B) The difference of the RUG-IV nursing component

10 per diem calculated for the current quarter minus the

11 nursing component rate in effect July 1, 2012

12 multiplied by 0.88.

13 (2) The transition RUG-IV per diem nursing rate for

14 nursing homes whose rate calculated in this subsection

15 (e-2) is less than the nursing component rate in effect

16 July 1, 2012 shall be paid the sum of:

17 (A) The nursing component rate in effect July 1,

18 2012; plus

19 (B) The difference of the RUG-IV nursing component

20 per diem calculated for the current quarter minus the

21 nursing component rate in effect July 1, 2012

22 multiplied by 0.13.

23 (f) Notwithstanding any other provision of this Code, on

24 and after July 1, 2012, reimbursement rates associated with the

25 nursing or support components of the current nursing facility

26 rate methodology shall not increase beyond the level effective

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1 May 1, 2011 until a new reimbursement system based on the RUGs

2 IV 48 grouper model has been fully operationalized.

3 (g) Notwithstanding any other provision of this Code, on

4 and after July 1, 2012, for facilities not designated by the

5 Department of Healthcare and Family Services as "Institutions

6 for Mental Disease", rates effective May 1, 2011 shall be

7 adjusted as follows:

8 (1) Individual nursing rates for residents classified

9 in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter

10 ending March 31, 2012 shall be reduced by 10%;

11 (2) Individual nursing rates for residents classified

12 in all other RUG IV groups shall be reduced by 1.0%;

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 (Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section

4 6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff.

5 7-22-13; revised 9-19-13.)

6 (305 ILCS 5/5-5.4h)

7 Sec. 5-5.4h. Medicaid reimbursement for long-term care

8 facilities for persons under 22 years of age ~~pediatric skilled~~

9 ~~nursing facilities~~.

10 (a) Facilities licensed as long-term care facilities for

11 persons under 22 years of age ~~uniquely licensed as pediatric~~

12 ~~skilled nursing facilities~~ that serve severely and chronically

13 ill pediatric patients shall have a specific reimbursement

14 system designed to recognize the characteristics and needs of

15 the patients they serve.

16 (b) For dates of services starting July 1, 2013 and until a

17 new reimbursement system is designed, long-term care

18 facilities for persons under 22 years of age ~~pediatric skilled~~

19 ~~nursing facilities~~ that meet the following criteria:

20 (1) serve exceptional care patients; and

21 (2) have 30% or more of their patients receiving

22 ventilator care;

23 shall receive Medicaid reimbursement on a 30-day expedited

24 schedule.

25 (c) Subject to federal approval of changes to the Title XIX

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1 State Plan, for dates of services starting July 1, 2014 and

2 until a new reimbursement system is designed, long-term care

3 facilities for persons under 22 years of age which meet the

4 criteria in subsection (b) of this Section shall receive a per

5 diem rate for clinically complex residents of $304. Clinically

6 complex residents on a ventilator shall receive a per diem rate

7 of $669.

8 (d) To qualify for the per diem rate of $669 for clinically

9 complex residents on a ventilator pursuant to subsection (c),

10 facilities shall have a policy documenting their method of

11 routine assessment of a resident's weaning potential with

12 interventions implemented noted in the resident's record.

13 (e) For the purposes of this Section, a resident is

14 considered clinically complex if the resident requires at least

15 one of the following medical services:

16 (1) Tracheostomy care with dependence on mechanical

17 ventilation for a minimum of 6 hours each day.

18 (2) Tracheostomy care requiring suctioning at least

19 every 6 hours, room air mist or oxygen as needed, and

20 dependence on one of the treatment procedures listed under

21 paragraph (4) excluding the procedure listed in

22 subparagraph (A) of paragraph (4).

23 (3) Total parenteral nutrition or other intravenous

24 nutritional support and one of the treatment procedures

25 listed under paragraph (4).

26 (4) The following treatment procedures apply to the

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1 conditions in paragraphs (2) and (3) of this subsection:

2 (A) Intermittent suctioning at least every 8 hours

3 and room air mist or oxygen as needed.

4 (B) Continuous intravenous therapy including

5 administration of therapeutic agents necessary for

6 hydration or of intravenous pharmaceuticals; or

7 intravenous pharmaceutical administration of more than

8 one agent via a peripheral or central line, without

9 continuous infusion.

10 (C) Peritoneal dialysis treatments requiring at

11 least 4 exchanges every 24 hours.

12 (D) Tube feeding via nasogastric or gastrostomy

13 tube.

14 (E) Other medical technologies required

15 continuously, which in the opinion of the attending

16 physician require the services of a professional

17 nurse.

18 (Source: P.A. 98-104, eff. 7-22-13.)

19 (305 ILCS 5/5-5e)

20 Sec. 5-5e. Adjusted rates of reimbursement.

21 (a) Rates or payments for services in effect on June 30,

22 2012 shall be adjusted and services shall be affected as

23 required by any other provision of this amendatory Act of the

24 97th General Assembly. In addition, the Department shall do the

25 following:

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1 (1) Delink the per diem rate paid for supportive living

2 facility services from the per diem rate paid for nursing

3 facility services, effective for services provided on or

4 after May 1, 2011.

5 (2) Cease payment for bed reserves in nursing

6 facilities and specialized mental health rehabilitation

7 facilities.

8 (2.5) Cease payment for bed reserves for purposes of

9 inpatient hospitalizations to intermediate care facilities

10 for persons with development disabilities, except in the

11 instance of residents who are under 21 years of age.

12 (3) Cease payment of the $10 per day add-on payment to

13 nursing facilities for certain residents with

14 developmental disabilities.

15 (b) After the application of subsection (a),

16 notwithstanding any other provision of this Code to the

17 contrary and to the extent permitted by federal law, on and

18 after July 1, 2012, the rates of reimbursement for services and

19 other payments provided under this Code shall further be

20 reduced as follows:

21 (1) Rates or payments for physician services, dental

22 services, or community health center services reimbursed

23 through an encounter rate, and services provided under the

24 Medicaid Rehabilitation Option of the Illinois Title XIX

25 State Plan shall not be further reduced.

26 (2) Rates or payments, or the portion thereof, paid to

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1 a provider that is operated by a unit of local government

2 or State University that provides the non-federal share of

3 such services shall not be further reduced.

4 (3) Rates or payments for hospital services delivered

5 by a hospital defined as a Safety-Net Hospital under

6 Section 5-5e.1 of this Code shall not be further reduced.

7 (4) Rates or payments for hospital services delivered

8 by a Critical Access Hospital, which is an Illinois

9 hospital designated as a critical care hospital by the

10 Department of Public Health in accordance with 42 CFR 485,

11 Subpart F, shall not be further reduced.

12 (5) Rates or payments for Nursing Facility Services

13 shall only be further adjusted pursuant to Section 5-5.2 of

14 this Code.

15 (6) Rates or payments for services delivered by long

16 term care facilities licensed under the ID/DD Community

17 Care Act and developmental training services shall not be

18 further reduced.

19 (7) Rates or payments for services provided under

20 capitation rates shall be adjusted taking into

21 consideration the rates reduction and covered services

22 required by this amendatory Act of the 97th General

23 Assembly.

24 (8) For hospitals not previously described in this

25 subsection, the rates or payments for hospital services

26 shall be further reduced by 3.5%, except for payments

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1 authorized under Section 5A-12.4 of this Code.

2 (9) For all other rates or payments for services

3 delivered by providers not specifically referenced in

4 paragraphs (1) through (8), rates or payments shall be

5 further reduced by 2.7%.

6 (c) Any assessment imposed by this Code shall continue and

7 nothing in this Section shall be construed to cause it to

8 cease.

9 (d) Notwithstanding any other provision of this Code to the

10 contrary, subject to federal approval under Title XIX of the

11 Social Security Act, for dates of service on and after July 1,

12 2014, rates or payments for services provided for the purpose

13 of transitioning children from a hospital to home placement or

14 other appropriate setting by a children's community-based

15 health care center authorized under the Alternative Health Care

16 Delivery Act shall be $683 per day.

17 (e) Notwithstanding any other provision of this Code to the

18 contrary, subject to federal approval under Title XIX of the

19 Social Security Act, for dates of service on and after July 1,

20 2014, rates or payments for home health visits shall be $72.

21 (f) Notwithstanding any other provision of this Code to the

22 contrary, subject to federal approval under Title XIX of the

23 Social Security Act, for dates of service on and after July 1,

24 2014, rates or payments for the certified nursing assistant

25 component of the home health agency rate shall be $20.

26 (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)

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1 (305 ILCS 5/5-5e.1)

2 Sec. 5-5e.1. Safety-Net Hospitals.

3 (a) A Safety-Net Hospital is an Illinois hospital that:

4 (1) is licensed by the Department of Public Health as a

5 general acute care or pediatric hospital; and

6 (2) is a disproportionate share hospital, as described

7 in Section 1923 of the federal Social Security Act, as

8 determined by the Department; and

9 (3) meets one of the following:

10 (A) has a MIUR of at least 40% and a charity

11 percent of at least 4%; or

12 (B) has a MIUR of at least 50%.

13 (b) Definitions. As used in this Section:

14 (1) "Charity percent" means the ratio of (i) the

15 hospital's charity charges for services provided to

16 individuals without health insurance or another source of

17 third party coverage to (ii) the Illinois total hospital

18 charges, each as reported on the hospital's OBRA form.

19 (2) "MIUR" means Medicaid Inpatient Utilization Rate

20 and is defined as a fraction, the numerator of which is the

21 number of a hospital's inpatient days provided in the

22 hospital's fiscal year ending 3 years prior to the rate

23 year, to patients who, for such days, were eligible for

24 Medicaid under Title XIX of the federal Social Security

25 Act, 42 USC 1396a et seq., excluding those persons eligible

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1 for medical assistance pursuant to 42 U.S.C.

2 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of

3 Section 5-2 of this Article, and the denominator of which

4 is the total number of the hospital's inpatient days in

5 that same period, excluding those persons eligible for

6 medical assistance pursuant to 42 U.S.C.

7 1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of

8 Section 5-2 of this Article.

9 (3) "OBRA form" means form HFS-3834, OBRA '93 data

10 collection form, for the rate year.

11 (4) "Rate year" means the 12-month period beginning on

12 October 1.

13 (c) Beginning July 1, 2012 and ending on June 30, 2018, ~~For~~

14 ~~the 27-month period beginning July 1, 2012,~~ a hospital that

15 would have qualified for the rate year beginning October 1,

16 2011, shall be a Safety-Net Hospital.

17 (d) No later than August 15 preceding the rate year, each

18 hospital shall submit the OBRA form to the Department. Prior to

19 October 1, the Department shall notify each hospital whether it

20 has qualified as a Safety-Net Hospital.

21 (e) The Department may promulgate rules in order to

22 implement this Section.

23 (f) Nothing in this Section shall be construed as limiting

24 the ability of the Department to include the Safety-Net

25 Hospitals in the hospital rate reform mandated by Section 14-11

26 of this Code and implemented under Section 14-12 of this Code

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1 and by administrative rulemaking.

2 (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)

3 (305 ILCS 5/5-5f)

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

5 assistance services. Notwithstanding any other provision of

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

7 (a) The following services shall no longer be a covered

8 service available under this Code: group psychotherapy for

9 residents of any facility licensed under the Nursing Home Care

10 Act or the Specialized Mental Health Rehabilitation Act of

11 2013; and adult chiropractic services.

12 (b) The Department shall place the following limitations on

13 services: (i) the Department shall limit adult eyeglasses to

14 one pair every 2 years; (ii) the Department shall set an annual

15 limit of a maximum of 20 visits for each of the following

16 services: adult speech, hearing, and language therapy

17 services, adult occupational therapy services, and physical

18 therapy services; on or after October 1, 2014, the annual

19 maximum limit of 20 visits shall expire but the Department

20 shall require prior approval for all individuals for speech,

21 hearing, and language therapy services, occupational therapy

22 services, and physical therapy services; (iii) the Department

23 shall limit adult podiatry services to individuals with

24 diabetes; on or after October 1, 2014, podiatry services shall

25 not be limited to individuals with diabetes; (iv) the

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1 Department shall pay for caesarean sections at the normal

2 vaginal delivery rate unless a caesarean section was medically

3 necessary; (v) the Department shall limit adult dental services

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

5 ensure that the following conditions are recognized as

6 emergencies: (A) dental services necessary for an individual in

7 order for the individual to be cleared for a medical procedure,

8 such as a transplant; (B) extractions and dentures necessary

9 for a diabetic to receive proper nutrition; (C) extractions and

10 dentures necessary as a result of cancer treatment; and (D)

11 dental services necessary for the health of a pregnant woman

12 prior to delivery of her baby; on or after July 1, 2014, adult

13 dental services shall no longer be limited to emergencies, and

14 dental services necessary for the health of a pregnant woman

15 prior to delivery of her baby shall continue to be covered; and

16 (vi) effective July 1, 2012, the Department shall place

17 limitations and require concurrent review on every inpatient

18 detoxification stay to prevent repeat admissions to any

19 hospital for detoxification within 60 days of a previous

20 inpatient detoxification stay. The Department shall convene a

21 workgroup of hospitals, substance abuse providers, care

22 coordination entities, managed care plans, and other

23 stakeholders to develop recommendations for quality standards,

24 diversion to other settings, and admission criteria for

25 patients who need inpatient detoxification, which shall be

26 published on the Department's website no later than September

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1 1, 2013.

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

3 following services: wheelchair repairs costing more than $400,

4 coronary artery bypass graft, and bariatric surgery consistent

5 with Medicare standards concerning patient responsibility.

6 Wheelchair repair prior approval requests shall be adjudicated

7 within one business day of receipt of complete supporting

8 documentation. Providers may not break wheelchair repairs into

9 separate claims for purposes of staying under the $400

10 threshold for requiring prior approval. The wholesale price of

11 manual and power wheelchairs, durable medical equipment and

12 supplies, and complex rehabilitation technology products and

13 services shall be defined as actual acquisition cost including

14 all discounts.

15 (d) The Department shall establish benchmarks for

16 hospitals to measure and align payments to reduce potentially

17 preventable hospital readmissions, inpatient complications,

18 and unnecessary emergency room visits. In doing so, the

19 Department shall consider items, including, but not limited to,

20 historic and current acuity of care and historic and current

21 trends in readmission. The Department shall publish

22 provider-specific historical readmission data and anticipated

23 potentially preventable targets 60 days prior to the start of

24 the program. In the instance of readmissions, the Department

25 shall adopt policies and rates of reimbursement for services

26 and other payments provided under this Code to ensure that, by

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1 June 30, 2013, expenditures to hospitals are reduced by, at a

2 minimum, $40,000,000.

3 (e) The Department shall establish utilization controls

4 for the hospice program such that it shall not pay for other

5 care services when an individual is in hospice.

6 (f) For home health services, the Department shall require

7 Medicare certification of providers participating in the

8 program and implement the Medicare face-to-face encounter

9 rule. The Department shall require providers to implement

10 auditable electronic service verification based on global

11 positioning systems or other cost-effective technology.

12 (g) For the Home Services Program operated by the

13 Department of Human Services and the Community Care Program

14 operated by the Department on Aging, the Department of Human

15 Services, in cooperation with the Department on Aging, shall

16 implement an electronic service verification based on global

17 positioning systems or other cost-effective technology.

18 (h) Effective with inpatient hospital admissions on or

19 after July 1, 2012, the Department shall reduce the payment for

20 a claim that indicates the occurrence of a provider-preventable

21 condition during the admission as specified by the Department

22 in rules. The Department shall not pay for services related to

23 an other provider-preventable condition.

24 As used in this subsection (h):

25 "Provider-preventable condition" means a health care

26 acquired condition as defined under the federal Medicaid

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1 regulation found at 42 CFR 447.26 or an other

2 provider-preventable condition.

3 "Other provider-preventable condition" means a wrong

4 surgical or other invasive procedure performed on a patient, a

5 surgical or other invasive procedure performed on the wrong

6 body part, or a surgical procedure or other invasive procedure

7 performed on the wrong patient.

8 (i) The Department shall implement cost savings

9 initiatives for advanced imaging services, cardiac imaging

10 services, pain management services, and back surgery. Such

11 initiatives shall be designed to achieve annual costs savings.

12 (j) The Department shall ensure that beneficiaries with a

13 diagnosis of epilepsy or seizure disorder in Department records

14 will not require prior approval for anticonvulsants.

15 (Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section

16 6-240, eff. 7-22-13; 98-104, Article 9, Section 9-5, eff.

17 7-22-13; revised 9-19-13.)

18 (305 ILCS 5/5B-1) (from Ch. 23, par. 5B-1)

19 Sec. 5B-1. Definitions. As used in this Article, unless the

20 context requires otherwise:

21 "Fund" means the Long-Term Care Provider Fund.

22 "Long-term care facility" means (i) a nursing facility,

23 whether public or private and whether organized for profit or

24 not-for-profit, that is subject to licensure by the Illinois

25 Department of Public Health under the Nursing Home Care Act or

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1 the ID/DD Community Care Act, including a county nursing home

2 directed and maintained under Section 5-1005 of the Counties

3 Code, and (ii) a part of a hospital in which skilled or

4 intermediate long-term care services within the meaning of

5 Title XVIII or XIX of the Social Security Act are provided;

6 except that the term "long-term care facility" does not include

7 a facility operated by a State agency or operated solely as an

8 intermediate care facility for the mentally retarded within the

9 meaning of Title XIX of the Social Security Act.

10 "Long-term care provider" means (i) a person licensed by

11 the Department of Public Health to operate and maintain a

12 skilled nursing or intermediate long-term care facility or (ii)

13 a hospital provider that provides skilled or intermediate

14 long-term care services within the meaning of Title XVIII or

15 XIX of the Social Security Act. For purposes of this paragraph,

16 "person" means any political subdivision of the State,

17 municipal corporation, individual, firm, partnership,

18 corporation, company, limited liability company, association,

19 joint stock association, or trust, or a receiver, executor,

20 trustee, guardian, or other representative appointed by order

21 of any court. "Hospital provider" means a person licensed by

22 the Department of Public Health to conduct, operate, or

23 maintain a hospital.

24 "Occupied bed days" shall be computed separately for each

25 long-term care facility operated or maintained by a long-term

26 care provider, and means the sum for all beds of the number of

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1 days during the month on which each bed was occupied by a

2 resident, other than a resident for whom Medicare Part A is the

3 primary payer. For a resident whose care is covered by the

4 Medicare Medicaid Alignment initiative demonstration, Medicare

5 Part A is considered the primary payer.

6 (Source: P.A. 96-339, eff. 7-1-10; 96-1530, eff. 2-16-11;

7 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813, eff.

8 7-13-12.)

9 (305 ILCS 5/5C-1) (from Ch. 23, par. 5C-1)

10 Sec. 5C-1. Definitions. As used in this Article, unless the

11 context requires otherwise:

12 "Fund" means the Care Provider Fund for Persons with a

13 Developmental Disability.

14 "Developmentally disabled care facility" means an

15 intermediate care facility for the intellectually disabled

16 within the meaning of Title XIX of the Social Security Act,

17 whether public or private and whether organized for profit or

18 not-for-profit, but shall not include any facility operated by

19 the State.

20 "Developmentally disabled care provider" means a person

21 conducting, operating, or maintaining a developmentally

22 disabled care facility. For this purpose, "person" means any

23 political subdivision of the State, municipal corporation,

24 individual, firm, partnership, corporation, company, limited

25 liability company, association, joint stock association, or

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1 trust, or a receiver, executor, trustee, guardian or other

2 representative appointed by order of any court.

3 "Adjusted gross developmentally disabled care revenue"

4 shall be computed separately for each developmentally disabled

5 care facility conducted, operated, or maintained by a

6 developmentally disabled care provider, and means the

7 developmentally disabled care provider's total revenue for

8 inpatient residential services less contractual allowances and

9 discounts on patients' accounts, but does not include

10 non-patient revenue from sources such as contributions,

11 donations or bequests, investments, day training services,

12 television and telephone service, and rental of facility space.

13 "Long-term care facility for persons under 22 years of age

14 serving clinically complex residents" means a facility

15 licensed by the Department of Public Health as a long-term care

16 facility for persons under 22 meeting the qualifications of

17 Section 5-5.4h of this Code.

18 (Source: P.A. 97-227, eff. 1-1-12; 98-463, eff. 8-16-13.)

19 (305 ILCS 5/5C-2) (from Ch. 23, par. 5C-2)

20 Sec. 5C-2. Assessment; no local authorization to tax.

21 (a) For the privilege of engaging in the occupation of

22 developmentally disabled care provider, an assessment is

23 imposed upon each developmentally disabled care provider in an

24 amount equal to 6%, or the maximum allowed under federal

25 regulation, whichever is less, of its adjusted gross

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1 developmentally disabled care revenue for the prior State

2 fiscal year. Notwithstanding any provision of any other Act to

3 the contrary, this assessment shall be construed as a tax, but

4 may not be added to the charges of an individual's nursing home

5 care that is paid for in whole, or in part, by a federal,

6 State, or combined federal-state medical care program, except

7 those individuals receiving Medicare Part B benefits solely.

8 (b) Nothing in this amendatory Act of 1995 shall be

9 construed to authorize any home rule unit or other unit of

10 local government to license for revenue or impose a tax or

11 assessment upon a developmentally disabled care provider or the

12 occupation of developmentally disabled care provider, or a tax

13 or assessment measured by the income or earnings of a

14 developmentally disabled care provider.

15 (c) Effective July 1, 2013, for the privilege of engaging

16 in the occupation of long-term care facility for persons under

17 22 years of age serving clinically complex residents provider,

18 an assessment is imposed upon each long-term care facility for

19 persons under 22 years of age serving clinically complex

20 residents provider in the same amount and upon the same

21 conditions and requirements as imposed in Article V-B of this

22 Code and a license fee is imposed in the same amount and upon

23 the same conditions and requirements as imposed in Article V-E

24 of this Code. Notwithstanding any provision of any other Act to

25 the contrary, the assessment and license fee imposed by this

26 subsection (c) shall be construed as a tax, but may not be

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1 added to the charges of an individual's nursing home care that

2 is paid for in whole, or in part, by a federal, State, or

3 combined federal-State medical care program, except for those

4 individuals receiving Medicare Part B benefits solely.

5 (Source: P.A. 95-707, eff. 1-11-08.)

6 (305 ILCS 5/5C-7) (from Ch. 23, par. 5C-7)

7 Sec. 5C-7. Care Provider Fund for Persons with a

8 Developmental Disability.

9 (a) There is created in the State Treasury the Care

10 Provider Fund for Persons with a Developmental Disability.

11 Interest earned by the Fund shall be credited to the Fund. The

12 Fund shall not be used to replace any moneys appropriated to

13 the Medicaid program by the General Assembly.

14 (b) The Fund is created for the purpose of receiving and

15 disbursing assessment moneys in accordance with this Article.

16 Disbursements from the Fund shall be made only as follows:

17 (1) For payments to intermediate care facilities for

18 the developmentally disabled under Title XIX of the Social

19 Security Act and Article V of this Code.

20 (2) For the reimbursement of moneys collected by the

21 Illinois Department through error or mistake, and to make

22 required payments under Section 5-4.28(a)(1) of this Code

23 if there are no moneys available for such payments in the

24 Medicaid Developmentally Disabled Provider Participation

25 Fee Trust Fund.

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1 (3) For payment of administrative expenses incurred by

2 the Department of Human Services or its agent or the

3 Illinois Department or its agent in performing the

4 activities authorized by this Article.

5 (4) For payments of any amounts which are reimbursable

6 to the federal government for payments from this Fund which

7 are required to be paid by State warrant.

8 (5) For making transfers to the General Obligation Bond

9 Retirement and Interest Fund as those transfers are

10 authorized in the proceedings authorizing debt under the

11 Short Term Borrowing Act, but transfers made under this

12 paragraph (5) shall not exceed the principal amount of debt

13 issued in anticipation of the receipt by the State of

14 moneys to be deposited into the Fund.

15 (6) For making refunds as required under Section 5C-10

16 of this Article.

17 Disbursements from the Fund, other than transfers to the

18 General Obligation Bond Retirement and Interest Fund, shall be

19 by warrants drawn by the State Comptroller upon receipt of

20 vouchers duly executed and certified by the Illinois

21 Department.

22 (c) The Fund shall consist of the following:

23 (1) All moneys collected or received by the Illinois

24 Department from the developmentally disabled care provider

25 assessment imposed by this Article.

26 (2) All federal matching funds received by the Illinois

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1 Department as a result of expenditures made by the Illinois

2 Department that are attributable to moneys deposited in the

3 Fund.

4 (3) Any interest or penalty levied in conjunction with

5 the administration of this Article.

6 (4) Any balance in the Medicaid Developmentally

7 Disabled Care Provider Participation Fee Trust Fund in the

8 State Treasury. The balance shall be transferred to the

9 Fund upon certification by the Illinois Department to the

10 State Comptroller that all of the disbursements required by

11 Section 5-4.21(b) of this Code have been made.

12 (5) All other moneys received for the Fund from any

13 other source, including interest earned thereon.

14 (Source: P.A. 98-463, eff. 8-16-13.)

15 (305 ILCS 5/5C-10 new)

16 Sec. 5C-10. Adjustments. For long-term care facilities for

17 persons under 22 years of age serving clinically complex

18 residents previously classified as developmentally disabled

19 care facilities under this Article, the Department shall refund

20 any amounts paid under this Article in State fiscal year 2014

21 by the end of State fiscal year 2015 with at least half the

22 refund amount being made prior to December 31, 2014. The

23 amounts refunded shall be based on amounts paid by the

24 facilities to the Department as the assessment under subsection

25 (a) of Section 5C-2 less any assessment and license fee due for

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1 State fiscal year 2014.

2 (305 ILCS 5/Art. V-G heading new)

3 ARTICLE V-G. SUPPORTIVE LIVING FACILITY FUNDING.

4 (305 ILCS 5/5G-5 new)

5 Sec. 5G-5. Definitions. As used in this Article, unless the

6 context requires otherwise:

7 "Care days" shall be computed separately for each

8 supportive living facility, and means the sum for all apartment

9 units, the number of days during the month which each apartment

10 unit was occupied by a resident.

11 "Department" means the Department of Healthcare and Family

12 Services.

13 "Fund" means the Supportive Living Facility Fund.

14 "Supportive living facility" means an enrolled supportive

15 living site as described under Section 5-5.01a of this Code

16 that meets the participation requirements under Section

17 146.215 of Title 89 of the Illinois Administrative Code.

18 (305 ILCS 5/5G-10 new)

19 Sec. 5G-10. Assessment.

20 (a) Subject to Section 5G-45, beginning July 1, 2014, an

21 annual assessment on health care services is imposed on each

22 supportive living facility in an amount equal to $2.30

23 multiplied by the supportive living facility's care days. This

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1 assessment shall not be billed or passed on to any resident of

2 a supportive living facility.

3 (b) Nothing in this Section shall be construed to authorize

4 any home rule unit or other unit of local government to license

5 for revenue or impose a tax or assessment upon supportive

6 living facilities or the occupation of operating a supportive

7 living facility, or a tax or assessment measured by the income

8 or earnings or care days of a supportive living facility.

9 (c) The assessment imposed by this Section shall not be due

10 and payable, however, until after the Department notifies the

11 supportive living facilities, in writing, that the payment

12 methodologies to supportive living facilities required under

13 Section 5-5.01a of this Code have been approved by the Centers

14 for Medicare and Medicaid Services of the U.S. Department of

15 Health and Human Services and the waivers under 42 CFR 433.68

16 for the assessment imposed by this Section, if necessary, have

17 been granted by the Centers for Medicare and Medicaid Services

18 of the U.S. Department of Health and Human Services.

19 (305 ILCS 5/5G-15 new)

20 Sec. 5G-15. Payment of assessment; penalty.

21 (a) The assessment imposed by Section 5G-10 shall be due

22 and payable in monthly installments on the last State business

23 day of the month for care days reported for the preceding third

24 month prior to the month in which the assessment is payable and

25 due. A facility that has delayed payment due to the State's

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1 failure to reimburse for services rendered may request an

2 extension on the due date for payment pursuant to subsection

3 (c) and shall pay the assessment within 30 days of

4 reimbursement by the Department.

5 (b) The Department shall provide for an electronic

6 submission process for each supportive living facility to

7 report at a minimum the number of care days of the supportive

8 living facility for the reporting period and other reasonable

9 information the Department requires for the administration of

10 its responsibilities under this Code. The Department shall

11 prepare an assessment bill stating the amount due and payable

12 each month and submit it to each supportive living facility via

13 an electronic process. To the extent practicable, the

14 Department shall coordinate the assessment reporting

15 requirements with other reporting required of supportive

16 living facilities.

17 (c) The Department is authorized to establish delayed

18 payment schedules for supportive living facilities that are

19 unable to make assessment payments when due under this Section

20 due to financial difficulties, as determined by the Department.

21 The Department may not deny a request for delay of payment of

22 the assessment imposed under this Article if the supportive

23 living facility has not been paid for services provided during

24 the month in which the assessment is levied.

25 (d) If a supportive living facility fails to pay the full

26 amount of an assessment payment when due (including any

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1 extensions granted under subsection (c)), there shall, unless

2 waived by the Department for reasonable cause, be added to the

3 assessment imposed by Section 5G-10 a penalty assessment equal

4 to the lesser of (i) 1% of the amount of the assessment payment

5 not paid on or before the due date plus 1% of the portion

6 thereof remaining unpaid on the last day of each month

7 thereafter or (ii) 100% of the assessment payment amount not

8 paid on or before the due date. For purposes of this

9 subsection, payments will be credited first to unpaid

10 assessment payment amounts (rather than to penalty or

11 interest), beginning with the most delinquent assessment

12 payments. Payment cycles of longer than 30 days shall be one

13 factor the Director takes into account in granting a waiver

14 under this Section.

15 (e) No installment of the assessment imposed by Section

16 5G-10 shall be due and payable until after the Department

17 notifies the supportive living facilities, in writing, that the

18 payment methodologies to supportive living facilities required

19 under Section 5-5.01a of this Code have been approved by the

20 Centers for Medicare and Medicaid Services of the U.S.

21 Department of Health and Human Services and the waivers under

22 42 CFR 433.68 for the assessment imposed by this Section, if

23 necessary, have been granted by the Centers for Medicare and

24 Medicaid Services of the U.S. Department of Health and Human

25 Services. Upon notification to the Department of approval of

26 the payment methodologies required under Section 5-5.01a of

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1 this Code and the waivers granted under 42 CFR 433.68, all

2 installments otherwise due under this Section prior to the date

3 of notification shall be due and payable to the Department upon

4 written direction from the Department within 90 days after

5 issuance by the Comptroller of the payments required under

6 Section 5-5.01a of this Code.

7 (305 ILCS 5/5G-20 new)

8 Sec. 5G-20. Reporting; penalty; maintenance of records.

9 (a) Every supportive living facility subject to assessment

10 under this Article shall report the number care days of the

11 supportive living facility for the reporting period on or

12 before the last business day of the month following the

13 reporting period. Each supportive living facility shall ensure

14 that an accurate e-mail address is on file with the Department

15 in order for the Department to prepare and send an electronic

16 bill to the supportive living facility.

17 (b) If a supportive living facility fails to file its

18 monthly report with the Department when due, there shall,

19 unless waived by the Illinois Department for reasonable cause,

20 be added to the assessment due a penalty assessment equal to

21 25% of the assessment due.

22 (c) Every supportive living facility subject to assessment

23 under this Article shall keep records and books that will

24 permit the determination of care days on a calendar year basis.

25 All such books and records shall be kept in the English

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1 language and shall, at all times during business hours of the

2 day, be subject to inspection by the Department or its duly

3 authorized agents and employees.

4 (d) Notwithstanding any other provision of this Article, a

5 facility that commences operating or maintaining a supportive

6 living facility that was under a prior ownership and remained

7 enrolled as a Medicaid facility by the Department shall notify

8 the Department of the change in ownership and shall be

9 responsible to immediately pay any prior amounts owed by the

10 facility.

11 (e) The Department shall develop a procedure for sharing

12 with a potential buyer of a facility information regarding

13 outstanding assessments and penalties owed by that facility.

14 (305 ILCS 5/5G-25 new)

15 Sec. 5G-25. Disposition of proceeds. The Department shall

16 pay all moneys received from supportive living facilities under

17 this Article into the Supportive Living Facility Fund. Upon

18 certification by the Department to the State Comptroller of its

19 intent to withhold from a facility under Section 5G-30(b), the

20 State Comptroller shall draw a warrant on the treasury or other

21 fund held by the State Treasurer, as appropriate. The warrant

22 shall state the amount for which the facility is entitled to a

23 warrant, the amount of the deduction, and the reason therefor

24 and shall direct the State Treasurer to pay the balance to the

25 facility, all in accordance with Section 10.05 of the State

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1 Comptroller Act. The warrant also shall direct the State

2 Treasurer to transfer the amount of the deduction so ordered

3 from the treasury or other fund into the Supportive Living

4 Facility Fund.

5 (305 ILCS 5/5G-30 new)

6 Sec. 5G-30. Administration; enforcement provisions.

7 (a) The Department shall administer and enforce this

8 Article and collect the assessments and penalty assessments

9 imposed under this Article using procedures employed in its

10 administration of this Code generally and as follows:

11 (1) The Department may initiate either administrative

12 or judicial proceedings, or both, to enforce provisions of

13 this Article. Administrative enforcement proceedings

14 initiated hereunder shall be governed by the Department's

15 administrative rules. Judicial enforcement proceedings

16 initiated hereunder shall be governed by the rules of

17 procedure applicable in the courts of this State.

18 (2) No proceedings for collection, refund, credit, or

19 other adjustment of an assessment amount shall be issued

20 more than 3 years after the due date of the assessment,

21 except in the case of an extended period agreed to in

22 writing by the Department and the supportive living

23 facility before the expiration of this limitation period.

24 (3) Any unpaid assessment under this Article shall

25 become a lien upon the assets of the supportive living

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1 facility upon which it was assessed. If any supportive

2 living facility, outside the usual course of its business,

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

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

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

6 supportive living facility that is subject to the

7 provisions of this Article, the seller or transferor shall

8 pay the Department the amount of any assessment, assessment

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

10 Article up to the date of the sale or transfer. If the

11 seller or transferor fails to pay any assessment,

12 assessment penalty, and interest (if any) due, the

13 purchaser or transferee of such asset shall be liable for

14 the amount of the assessment, penalty, and interest (if

15 any) up to the amount of the reasonable value of the

16 property acquired by the purchaser or transferee. The

17 purchaser or transferee shall continue to be liable until

18 the purchaser or transferee pays the full amount of the

19 assessment, penalty, 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

22 transferee receives from the Department a certificate

23 showing that such assessment, penalty, and interest have

24 been paid or a certificate from the Department showing that

25 no assessment, penalty, or interest is due from the seller

26 or transferor under this Article.

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1 (b) In addition to any other remedy provided for and

2 without sending a notice of assessment liability, the

3 Department may collect an unpaid assessment by withholding, as

4 payment of the assessment, reimbursements or other amounts

5 otherwise payable by the Department to the supportive living

6 facility.

7 (305 ILCS 5/5G-35 new)

8 Sec. 5G-35. Supportive Living Facility Fund.

9 (a) There is created in the State treasury the Supportive

10 Living Facility Fund. Interest earned by the Fund shall be

11 credited to the Fund. The Fund shall not be used to replace any

12 moneys appropriated to the Medicaid program by the General

13 Assembly.

14 (b) The Fund is created for the purpose of receiving and

15 disbursing moneys in accordance with this Article.

16 Disbursements from the Fund, other than transfers authorized

17 under paragraphs (5) and (6) of this subsection, shall be by

18 warrants drawn by the State Comptroller upon receipt of

19 vouchers duly executed and certified by the Department.

20 Disbursements from the Fund shall be made only as follows:

21 (1) For making payments to supportive living

22 facilities as required under this Code, under the

23 Children's Health Insurance Program Act, under the

24 Covering ALL KIDS Health Insurance Act, and under the Long

25 Term Acute Care Hospital Quality Improvement Transfer

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1 Program Act.

2 (2) For the reimbursement of moneys collected by the

3 Department from supportive living facilities through error

4 or mistake in performing the activities authorized under

5 this Code.

6 (3) For payment of administrative expenses incurred by

7 the Department or its agent in performing administrative

8 oversight activities for the supportive living program or

9 review of new supportive living facility applications.

10 (4) For payments of any amounts which are reimbursable

11 to the federal government for payments from this Fund which

12 are required to be paid by State warrant.

13 (5) For making transfers, as those transfers are

14 authorized in the proceedings authorizing debt under the

15 Short Term Borrowing Act, but transfers made under this

16 paragraph (5) shall not exceed the principal amount of debt

17 issued in anticipation of the receipt by the State of

18 moneys to be deposited into the Fund.

19 (6) For making transfers to any other fund in the State

20 treasury, but transfers made under this paragraph (6) shall

21 not exceed the amount transferred previously from that

22 other fund into the Supportive Living Facility Fund plus

23 any interest that would have been earned by that fund on

24 the money that had been transferred.

25 (c) The Fund shall consist of the following:

26 (1) All moneys collected or received by the Department

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1 from the supportive living facility assessment imposed by

2 this Article.

3 (2) All moneys collected or received by the Department

4 from the supportive living facility certification fee

5 imposed by this Article.

6 (3) All federal matching funds received by the

7 Department as a result of expenditures made by the

8 Department that are attributable to moneys deposited in the

9 Fund.

10 (4) Any interest or penalty levied in conjunction with

11 the administration of this Article.

12 (5) Moneys transferred from another fund in the State

13 treasury.

14 (6) All other moneys received for the Fund from any

15 other source, including interest earned thereon.

16 (305 ILCS 5/5G-40 new)

17 Sec. 5G-40. Certification fee.

18 (a) The Department shall collect an annual certification

19 fee of $100 per each operational or approved supportive living

20 facility for the purposes of funding the administrative process

21 of reviewing new supportive living facility applications and

22 administrative oversight of the health care services delivered

23 by supportive living facilities.

24 (b) The certification fee shall be deposited into the

25 Supportive Living Facility Fund. The Department shall maintain

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1 a separate accounting of amounts collected under this Section.

2 (305 ILCS 5/5G-45 new)

3 Sec. 5G-45. Applicability.

4 (a) The Department must submit any necessary documentation

5 to the Centers for Medicare and Medicaid Services which allows

6 for an effective date of July 1, 2014 for the requirements of

7 this Article. The documents shall include any necessary

8 documents that satisfy federal public notice requirements,

9 Medicaid state plan amendments, and any Medicaid waiver

10 amendments.

11 (b) The assessment imposed by Section 5G-10 shall cease to

12 be imposed if the amount of matching federal funds under Title

13 XIX of the Social Security Act is eliminated or significantly

14 reduced on account of the assessment. Any remaining assessments

15 shall be refunded to supportive living facilities in proportion

16 to the amounts of the assessments paid by them.

17 (c) The certification fee imposed by Section 5G-40 shall

18 cease to be imposed if the amount of matching federal funds

19 under Title XIX of the Social Security Act is eliminated or

20 significantly reduced on account of the certification fee.

21 Section 55-20. The Immunization Data Registry Act is

22 amended by changing Section 20 as follows:

23 (410 ILCS 527/20)

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1 Sec. 20. Confidentiality of information; release of

2 information; statistics; panel on expanding access.

3 (a) Records maintained as part of the immunization data

4 registry are confidential.

5 (b) The Department may release an individual's

6 confidential information to the individual or to the

7 individual's parent or guardian if the individual is less than

8 18 years of age.

9 (c) Subject to subsection (d) of this Section, the

10 Department may release information in the immunization data

11 registry concerning an individual to the following entities:

12 (1) The immunization data registry of another state.

13 (2) A health care provider or a health care provider's

14 designee.

15 (3) A local health department.

16 (4) An elementary or secondary school that is attended

17 by the individual.

18 (5) A licensed child care center in which the

19 individual is enrolled.

20 (6) A licensed child-placing agency.

21 (7) A college or university that is attended by the

22 individual.

23 (8) The Department of Healthcare and Family Services or

24 a managed care entity contracted with the Department of

25 Healthcare and Family Services to coordinate the provision

26 of medical care to enrollees of the medical assistance

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1 program.

2 (d) Before immunization data may be released to an entity,

3 the entity must enter into an agreement with the Department

4 that provides that information that identifies a patient will

5 not be released to any other person without the written consent

6 of the patient.

7 (e) The Department may release summary statistics

8 regarding information in the immunization data registry if the

9 summary statistics do not reveal the identity of an individual.

10 (Source: P.A. 97-117, eff. 7-14-11.)

11 Article 60

12 Section 60-5. The Lead Poisoning Prevention Act is amended

13 by adding Section 15.1 as follows:

14 (410 ILCS 45/15.1 new)

15 Sec. 15.1. Funding. Beginning July 1, 2014 and ending June

16 30, 2018, a hospital satisfying the definition, as of July 1,

17 2014, of Section 5-5e.1 of the Illinois Public Aid Code and

18 located in DuPage County shall pay the sum of $2,000,000

19 annually in 4 equal quarterly installments to the human poison

20 control center in existence as of July 1, 2014 and established

21 under the authority of this Act.

22 Article 99

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1 Section 99-1. Severability. If any clause, sentence,

2 Section, exemption, provision, or part of this Act or the

3 application thereof to any person or circumstance shall be

4 adjudged to be unconstitutional or otherwise invalid, the

5 remainder of this Act or its application to persons or

6 circumstances other than those to which it is held invalid

7 shall not be affected thereby and to this end the provisions of

8 this Act are declared to be severable.

9 Section 99-2. Any action required by this Act to occur

10 prior to or on June 30, 2014 shall be completed within 30 days

11 after the effective date of this Act.

12 Section 99-99. Effective date. This Act takes effect upon

13 becoming law.".