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

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

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

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1		counseling services and tobacco cessation medications provided
2		through the Illinois Tobacco Quitline shall be covered under
3		the medical assistance program for persons who are otherwise
4		eligible for assistance under this Article. The Department
5		shall comply with all federal requirements necessary to obtain
6		federal financial participation, as specified in 42 CFR
7		433.15(b)(7), for telephone-based counseling services provided
8		through the Illinois Tobacco Quitline, including, but not
9		limited to: (i) entering into a memorandum of understanding or
10		interagency agreement with the Department of Public Health, as
11		administrator of the Illinois Tobacco Quitline; and (ii)
12		developing a cost allocation plan for Medicaid-allowable
13		Illinois Tobacco Quitline services in accordance with 45 CFR
14		95.507. The Department shall submit the memorandum of
15		understanding or interagency agreement, the cost allocation
16		plan, and all other necessary documentation to the Centers for
17		Medicare and Medicaid Services for review and approval.
18		Coverage under this paragraph shall be contingent upon federal
19		approval.
20		Notwithstanding any other provision of this Code, the
21		Illinois Department may not require, as a condition of payment
22		for any laboratory test authorized under this Article, that a
23		physician's handwritten signature appear on the laboratory
24		test order form. The Illinois Department may, however, impose
25		other appropriate requirements regarding laboratory test order
26		documentation.

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1		Upon receipt of federal approval of an amendment to the
2		Illinois Title XIX State Plan for this purpose, the Department
3		shall authorize the Chicago Public Schools (CPS) to procure a
4		vendor or vendors to manufacture eyeglasses for individuals
5		enrolled in a school within the CPS system. CPS shall ensure
6		that its vendor or vendors are enrolled as providers in the
7		medical assistance program and in any capitated Medicaid
8		managed care entity (MCE) serving individuals enrolled in a
9		school within the CPS system. Under any contract procured
10		under this provision, the vendor or vendors must serve only
11		individuals enrolled in a school within the CPS system. Claims
12		for services provided by CPS's vendor or vendors to recipients
13		of benefits in the medical assistance program under this Code,
14		the Children's Health Insurance Program, or the Covering ALL
15		KIDS Health Insurance Program shall be submitted to the
16		Department or the MCE in which the individual is enrolled for
17		payment and shall be reimbursed at the Department's or the
18		MCE's established rates or rate methodologies for eyeglasses.
19		On and after July 1, 2012, the Department of Healthcare
20		and Family Services may provide the following services to
21		persons eligible for assistance under this Article who are
22		participating in education, training or employment programs
23		operated by the Department of Human Services as successor to
24		the Department of Public Aid:
25		(1) dental services provided by or under the
26		supervision of a dentist; and

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1		(2) eyeglasses prescribed by a physician skilled in
2		the diseases of the eye, or by an optometrist, whichever
3		the person may select.
4		On and after July 1, 2018, the Department of Healthcare
5		and Family Services shall provide dental services to any adult
6		who is otherwise eligible for assistance under the medical
7		assistance program. As used in this paragraph, "dental
8		services" means diagnostic, preventative, restorative, or
9		corrective procedures, including procedures and services for
10		the prevention and treatment of periodontal disease and dental
11		caries disease, provided by an individual who is licensed to
12		practice dentistry or dental surgery or who is under the
13		supervision of a dentist in the practice of his or her
14		profession.
15		On and after July 1, 2018, targeted dental services, as
16		set forth in Exhibit D of the Consent Decree entered by the
17		United States District Court for the Northern District of
18		Illinois, Eastern Division, in the matter of Memisovski v.
19		Maram, Case No. 92 C 1982, that are provided to adults under
20		the medical assistance program shall be established at no less
21		than the rates set forth in the "New Rate" column in Exhibit D
22		of the Consent Decree for targeted dental services that are
23		provided to persons under the age of 18 under the medical
24		assistance program.
25		Subject to federal approval, on and after January 1, 2025,
26		the rates paid for sedation evaluation and the provision of

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1		deep sedation and intravenous sedation for the purpose of
2		dental services shall be increased by 33% above the rates in
3		effect on December 31, 2024. The rates paid for nitrous oxide
4		sedation shall not be impacted by this paragraph and shall
5		remain the same as the rates in effect on December 31, 2024.
6		Notwithstanding any other provision of this Code and
7		subject to federal approval, the Department may adopt rules to
8		allow a dentist who is volunteering his or her service at no
9		cost to render dental services through an enrolled
10		not-for-profit health clinic without the dentist personally
11		enrolling as a participating provider in the medical
12		assistance program. A not-for-profit health clinic shall
13		include a public health clinic or Federally Qualified Health
14		Center or other enrolled provider, as determined by the
15		Department, through which dental services covered under this
16		Section are performed. The Department shall establish a
17		process for payment of claims for reimbursement for covered
18		dental services rendered under this provision.
19		Subject to appropriation and to federal approval, the
20		Department shall file administrative rules updating the
21		Handicapping Labio-Lingual Deviation orthodontic scoring tool
22		by January 1, 2025, or as soon as practicable.
23		On and after January 1, 2022, the Department of Healthcare
24		and Family Services shall administer and regulate a
25		school-based dental program that allows for the out-of-office
26		delivery of preventative dental services in a school setting

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1		to children under 19 years of age. The Department shall
2		establish, by rule, guidelines for participation by providers
3		and set requirements for follow-up referral care based on the
4		requirements established in the Dental Office Reference Manual
5		published by the Department that establishes the requirements
6		for dentists participating in the All Kids Dental School
7		Program. Every effort shall be made by the Department when
8		developing the program requirements to consider the different
9		geographic differences of both urban and rural areas of the
10		State for initial treatment and necessary follow-up care. No
11		provider shall be charged a fee by any unit of local government
12		to participate in the school-based dental program administered
13		by the Department. Nothing in this paragraph shall be
14		construed to limit or preempt a home rule unit's or school
15		district's authority to establish, change, or administer a
16		school-based dental program in addition to, or independent of,
17		the school-based dental program administered by the
18		Department.
19		The Illinois Department, by rule, may distinguish and
20		classify the medical services to be provided only in
21		accordance with the classes of persons designated in Section
22		5-2.
23		The Department of Healthcare and Family Services must
24		provide coverage and reimbursement for amino acid-based
25		elemental formulas, regardless of delivery method, for the
26		diagnosis and treatment of (i) eosinophilic disorders and (ii)

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1		short bowel syndrome when the prescribing physician has issued
2		a written order stating that the amino acid-based elemental
3		formula is medically necessary.
4		The Illinois Department shall authorize the provision of,
5		and shall authorize payment for, screening by low-dose
6		mammography for the presence of occult breast cancer for
7		individuals 35 years of age or older who are eligible for
8		medical assistance under this Article, as follows:
9		(A) A baseline mammogram for individuals 35 to 39
10		years of age.
11		(B) An annual mammogram for individuals 40 years of
12		age or older.
13		(C) A mammogram at the age and intervals considered
14		medically necessary by the individual's health care
15		provider for individuals under 40 years of age and having
16		a family history of breast cancer, prior personal history
17		of breast cancer, positive genetic testing, or other risk
18		factors.
19		(D) A comprehensive ultrasound screening and MRI of an
20		entire breast or breasts if a mammogram demonstrates
21		heterogeneous or dense breast tissue or when medically
22		necessary as determined by a physician licensed to
23		practice medicine in all of its branches.
24		(E) A screening MRI when medically necessary, as
25		determined by a physician licensed to practice medicine in
26		all of its branches.

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1		(F) A diagnostic mammogram when medically necessary,
2		as determined by a physician licensed to practice medicine
3		in all its branches, advanced practice registered nurse,
4		or physician assistant.
5		(G) Molecular breast imaging (MBI) and MRI of an
6		entire breast or breasts if a mammogram demonstrates
7		heterogeneous or dense breast tissue or when medically
8		necessary as determined by a physician licensed to
9		practice medicine in all of its branches, advanced
10		practice registered nurse, or physician assistant.
11		The Department shall not impose a deductible, coinsurance,
12		copayment, or any other cost-sharing requirement on the
13		coverage provided under this paragraph; except that this
14		sentence does not apply to coverage of diagnostic mammograms
15		to the extent such coverage would disqualify a high-deductible
16		health plan from eligibility for a health savings account
17		pursuant to Section 223 of the Internal Revenue Code (26
18		U.S.C. 223).
19		All screenings shall include a physical breast exam,
20		instruction on self-examination and information regarding the
21		frequency of self-examination and its value as a preventative
22		tool.
23		For purposes of this Section:
24		"Diagnostic mammogram" means a mammogram obtained using
25		diagnostic mammography.
26		"Diagnostic mammography" means a method of screening that

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1		is designed to evaluate an abnormality in a breast, including
2		an abnormality seen or suspected on a screening mammogram or a
3		subjective or objective abnormality otherwise detected in the
4		breast.
5		"Low-dose mammography" means the x-ray examination of the
6		breast using equipment dedicated specifically for mammography,
7		including the x-ray tube, filter, compression device, and
8		image receptor, with an average radiation exposure delivery of
9		less than one rad per breast for 2 views of an average size
10		breast. The term also includes digital mammography and
11		includes breast tomosynthesis.
12		"Breast tomosynthesis" means a radiologic procedure that
13		involves the acquisition of projection images over the
14		stationary breast to produce cross-sectional digital
15		three-dimensional images of the breast.
16		If, at any time, the Secretary of the United States
17		Department of Health and Human Services, or its successor
18		agency, promulgates rules or regulations to be published in
19		the Federal Register or publishes a comment in the Federal
20		Register or issues an opinion, guidance, or other action that
21		would require the State, pursuant to any provision of the
22		Patient Protection and Affordable Care Act (Public Law
23		111-148), including, but not limited to, 42 U.S.C.
24		18031(d)(3)(B) or any successor provision, to defray the cost
25		of any coverage for breast tomosynthesis outlined in this
26		paragraph, then the requirement that an insurer cover breast

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1		tomosynthesis is inoperative other than any such coverage
2		authorized under Section 1902 of the Social Security Act, 42
3		U.S.C. 1396a, and the State shall not assume any obligation
4		for the cost of coverage for breast tomosynthesis set forth in
5		this paragraph.
6		On and after January 1, 2016, the Department shall ensure
7		that all networks of care for adult clients of the Department
8		include access to at least one breast imaging Center of
9		Imaging Excellence as certified by the American College of
10		Radiology.
11		On and after January 1, 2012, providers participating in a
12		quality improvement program approved by the Department shall
13		be reimbursed for screening and diagnostic mammography at the
14		same rate as the Medicare program's rates, including the
15		increased reimbursement for digital mammography and, after
16		January 1, 2023 (the effective date of Public Act 102-1018),
17		breast tomosynthesis.
18		The Department shall convene an expert panel including
19		representatives of hospitals, free-standing mammography
20		facilities, and doctors, including radiologists, to establish
21		quality standards for mammography.
22		On and after January 1, 2017, providers participating in a
23		breast cancer treatment quality improvement program approved
24		by the Department shall be reimbursed for breast cancer
25		treatment at a rate that is no lower than 95% of the Medicare
26		program's rates for the data elements included in the breast

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1		cancer treatment quality program.
2		The Department shall convene an expert panel, including
3		representatives of hospitals, free-standing breast cancer
4		treatment centers, breast cancer quality organizations, and
5		doctors, including radiologists that are trained in all forms
6		of FDA-approved breast imaging technologies, breast surgeons,
7		reconstructive breast surgeons, oncologists, and primary care
8		providers to establish quality standards for breast cancer
9		treatment.
10		Subject to federal approval, the Department shall
11		establish a rate methodology for mammography at federally
12		qualified health centers and other encounter-rate clinics.
13		These clinics or centers may also collaborate with other
14		hospital-based mammography facilities. By January 1, 2016, the
15		Department shall report to the General Assembly on the status
16		of the provision set forth in this paragraph.
17		The Department shall establish a methodology to remind
18		individuals who are age-appropriate for screening mammography,
19		but who have not received a mammogram within the previous 18
20		months, of the importance and benefit of screening
21		mammography. The Department shall work with experts in breast
22		cancer outreach and patient navigation to optimize these
23		reminders and shall establish a methodology for evaluating
24		their effectiveness and modifying the methodology based on the
25		evaluation.
26		The Department shall establish a performance goal for

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1		primary care providers with respect to their female patients
2		over age 40 receiving an annual mammogram. This performance
3		goal shall be used to provide additional reimbursement in the
4		form of a quality performance bonus to primary care providers
5		who meet that goal.
6		The Department shall devise a means of case-managing or
7		patient navigation for beneficiaries diagnosed with breast
8		cancer. This program shall initially operate as a pilot
9		program in areas of the State with the highest incidence of
10		mortality related to breast cancer. At least one pilot program
11		site shall be in the metropolitan Chicago area and at least one
12		site shall be outside the metropolitan Chicago area. On or
13		after July 1, 2016, the pilot program shall be expanded to
14		include one site in western Illinois, one site in southern
15		Illinois, one site in central Illinois, and 4 sites within
16		metropolitan Chicago. An evaluation of the pilot program shall
17		be carried out measuring health outcomes and cost of care for
18		those served by the pilot program compared to similarly
19		situated patients who are not served by the pilot program.
20		The Department shall require all networks of care to
21		develop a means either internally or by contract with experts
22		in navigation and community outreach to navigate cancer
23		patients to comprehensive care in a timely fashion. The
24		Department shall require all networks of care to include
25		access for patients diagnosed with cancer to at least one
26		academic commission on cancer-accredited cancer program as an

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1		in-network covered benefit.
2		The Department shall provide coverage and reimbursement
3		for a human papillomavirus (HPV) vaccine that is approved for
4		marketing by the federal Food and Drug Administration for all
5		persons between the ages of 9 and 45. Subject to federal
6		approval, the Department shall provide coverage and
7		reimbursement for a human papillomavirus (HPV) vaccine for
8		persons of the age of 46 and above who have been diagnosed with
9		cervical dysplasia with a high risk of recurrence or
10		progression. The Department shall disallow any
11		preauthorization requirements for the administration of the
12		human papillomavirus (HPV) vaccine.
13		On or after July 1, 2022, individuals who are otherwise
14		eligible for medical assistance under this Article shall
15		receive coverage for perinatal depression screenings for the
16		12-month period beginning on the last day of their pregnancy.
17		Medical assistance coverage under this paragraph shall be
18		conditioned on the use of a screening instrument approved by
19		the Department.
20		Any medical or health care provider shall immediately
21		recommend, to any pregnant individual who is being provided
22		prenatal services and is suspected of having a substance use
23		disorder as defined in the Substance Use Disorder Act,
24		referral to a local substance use disorder treatment program
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
5		of Human Services.
6		All medical providers providing medical assistance to
7		pregnant individuals under this Code shall receive information
8		from the Department on the availability of services under any
9		program providing case management services for addicted
10		individuals, including information on appropriate referrals
11		for other social services that may be needed by addicted
12		individuals in addition to treatment for addiction.
13		The Illinois Department, in cooperation with the
14		Departments of Human Services (as successor to the Department
15		of Alcoholism and Substance Abuse) and Public Health, through
16		a public awareness campaign, may provide information
17		concerning treatment for alcoholism and drug abuse and
18		addiction, prenatal health care, and other pertinent programs
19		directed at reducing the number of drug-affected infants born
20		to recipients of medical assistance.
21		Neither the Department of Healthcare and Family Services
22		nor the Department of Human Services shall sanction the
23		recipient solely on the basis of the recipient's substance
24		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
12		projects in certain geographic areas. The Partnership shall be
13		represented by a sponsor organization. The Department, by
14		rule, shall develop qualifications for sponsors of
15		Partnerships. Nothing in this Section shall be construed to
16		require that the sponsor organization be a medical
17		organization.
18		The sponsor must negotiate formal written contracts with
19		medical providers for physician services, inpatient and
20		outpatient hospital care, home health services, treatment for
21		alcoholism and substance abuse, and other services determined
22		necessary by the Illinois Department by rule for delivery by
23		Partnerships. Physician services must include prenatal and
24		obstetrical care. The Illinois Department shall reimburse
25		medical services delivered by Partnership providers to clients
26		in target areas according to provisions of this Article and

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1		the Illinois Health Finance Reform Act, except that:
2		(1) Physicians participating in a Partnership and
3		providing certain services, which shall be determined by
4		the Illinois Department, to persons in areas covered by
5		the Partnership may receive an additional surcharge for
6		such services.
7		(2) The Department may elect to consider and negotiate
8		financial incentives to encourage the development of
9		Partnerships and the efficient delivery of medical care.
10		(3) Persons receiving medical services through
11		Partnerships may receive medical and case management
12		services above the level usually offered through the
13		medical assistance program.
14		Medical providers shall be required to meet certain
15		qualifications to participate in Partnerships to ensure the
16		delivery of high quality medical services. These
17		qualifications shall be determined by rule of the Illinois
18		Department and may be higher than qualifications for
19		participation in the medical assistance program. Partnership
20		sponsors may prescribe reasonable additional qualifications
21		for participation by medical providers, only with the prior
22		written approval of the Illinois Department.
23		Nothing in this Section shall limit the free choice of
24		practitioners, hospitals, and other providers of medical
25		services by clients. In order to ensure patient freedom of
26		choice, the Illinois Department shall immediately promulgate

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1		all rules and take all other necessary actions so that
2		provided services may be accessed from therapeutically
3		certified optometrists to the full extent of the Illinois
4		Optometric Practice Act of 1987 without discriminating between
5		service providers.
6		The Department shall apply for a waiver from the United
7		States Health Care Financing Administration to allow for the
8		implementation of Partnerships under this Section.
9		The Illinois Department shall require health care
10		providers to maintain records that document the medical care
11		and services provided to recipients of Medical Assistance
12		under this Article. Such records must be retained for a period
13		of not less than 6 years from the date of service or as
14		provided by applicable State law, whichever period is longer,
15		except that if an audit is initiated within the required
16		retention period then the records must be retained until the
17		audit is completed and every exception is resolved. The
18		Illinois Department shall require health care providers to
19		make available, when authorized by the patient, in writing,
20		the medical records in a timely fashion to other health care
21		providers who are treating or serving persons eligible for
22		Medical Assistance under this Article. All dispensers of
23		medical services shall be required to maintain and retain
24		business and professional records sufficient to fully and
25		accurately document the nature, scope, details and receipt of
26		the health care provided to persons eligible for medical

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1		assistance under this Code, in accordance with regulations
2		promulgated by the Illinois Department. The rules and
3		regulations shall require that proof of the receipt of
4		prescription drugs, dentures, prosthetic devices and
5		eyeglasses by eligible persons under this Section accompany
6		each claim for reimbursement submitted by the dispenser of
7		such medical services. No such claims for reimbursement shall
8		be approved for payment by the Illinois Department without
9		such proof of receipt, unless the Illinois Department shall
10		have put into effect and shall be operating a system of
11		post-payment audit and review which shall, on a sampling
12		basis, be deemed adequate by the Illinois Department to assure
13		that such drugs, dentures, prosthetic devices and eyeglasses
14		for which payment is being made are actually being received by
15		eligible recipients. Within 90 days after September 16, 1984
16		(the effective date of Public Act 83-1439), the Illinois
17		Department shall establish a current list of acquisition costs
18		for all prosthetic devices and any other items recognized as
19		medical equipment and supplies reimbursable under this Article
20		and shall update such list on a quarterly basis, except that
21		the acquisition costs of all prescription drugs shall be
22		updated no less frequently than every 30 days as required by
23		Section 5-5.12.
24		Notwithstanding any other law to the contrary, the
25		Illinois Department shall, within 365 days after July 22, 2013
26		(the effective date of Public Act 98-104), establish

SB3365 Enrolled - 21 - LRB104 18483 SSS 31925 b
1		procedures to permit skilled care facilities licensed under
2		the Nursing Home Care Act to submit monthly billing claims for
3		reimbursement purposes. Following development of these
4		procedures, the Department shall, by July 1, 2016, test the
5		viability of the new system and implement any necessary
6		operational or structural changes to its information
7		technology platforms in order to allow for the direct
8		acceptance and payment of nursing home claims.
9		Notwithstanding any other law to the contrary, the
10		Illinois Department shall, within 365 days after August 15,
11		2014 (the effective date of Public Act 98-963), establish
12		procedures to permit ID/DD facilities licensed under the ID/DD
13		Community Care Act and MC/DD facilities licensed under the
14		MC/DD Act to submit monthly billing claims for reimbursement
15		purposes. Following development of these procedures, the
16		Department shall have an additional 365 days to test the
17		viability of the new system and to ensure that any necessary
18		operational or structural changes to its information
19		technology platforms are implemented.
20		The Illinois Department shall require all dispensers of
21		medical services, other than an individual practitioner or
22		group of practitioners, desiring to participate in the Medical
23		Assistance program established under this Article to disclose
24		all financial, beneficial, ownership, equity, surety or other
25		interests in any and all firms, corporations, partnerships,
26		associations, business enterprises, joint ventures, agencies,

SB3365 Enrolled - 22 - LRB104 18483 SSS 31925 b
1		institutions or other legal entities providing any form of
2		health care services in this State under this Article.
3		The Illinois Department may require that all dispensers of
4		medical services desiring to participate in the medical
5		assistance program established under this Article disclose,
6		under such terms and conditions as the Illinois Department may
7		by rule establish, all inquiries from clients and attorneys
8		regarding medical bills paid by the Illinois Department, which
9		inquiries could indicate potential existence of claims or
10		liens for the Illinois Department.
11		Enrollment of a vendor shall be subject to a provisional
12		period and shall be conditional for one year. During the
13		period of conditional enrollment, the Department may terminate
14		the vendor's eligibility to participate in, or may disenroll
15		the vendor from, the medical assistance program without cause.
16		Unless otherwise specified, such termination of eligibility or
17		disenrollment is not subject to the Department's hearing
18		process. However, a disenrolled vendor may reapply without
19		penalty.
20		The Department has the discretion to limit the conditional
21		enrollment period for vendors based upon the category of risk
22		of the vendor.
23		Prior to enrollment and during the conditional enrollment
24		period in the medical assistance program, all vendors shall be
25		subject to enhanced oversight, screening, and review based on
26		the risk of fraud, waste, and abuse that is posed by the

SB3365 Enrolled - 23 - LRB104 18483 SSS 31925 b
1		category of risk of the vendor. The Illinois Department shall
2		establish the procedures for oversight, screening, and review,
3		which may include, but need not be limited to: criminal and
4		financial background checks; fingerprinting; license,
5		certification, and authorization verifications; unscheduled or
6		unannounced site visits; database checks; prepayment audit
7		reviews; audits; payment caps; payment suspensions; and other
8		screening as required by federal or State law.
9		The Department shall define or specify the following: (i)
10		by provider notice, the "category of risk of the vendor" for
11		each type of vendor, which shall take into account the level of
12		screening applicable to a particular category of vendor under
13		federal law and regulations; (ii) by rule or provider notice,
14		the maximum length of the conditional enrollment period for
15		each category of risk of the vendor; and (iii) by rule, the
16		hearing rights, if any, afforded to a vendor in each category
17		of risk of the vendor that is terminated or disenrolled during
18		the conditional enrollment period.
19		To be eligible for payment consideration, a vendor's
20		payment claim or bill, either as an initial claim or as a
21		resubmitted claim following prior rejection, must be received
22		by the Illinois Department, or its fiscal intermediary, no
23		later than 180 days after the latest date on the claim on which
24		medical goods or services were provided, with the following
25		exceptions:
26		(1) In the case of a provider whose enrollment is in

SB3365 Enrolled - 24 - LRB104 18483 SSS 31925 b
1		process by the Illinois Department, the 180-day period
2		shall not begin until the date on the written notice from
3		the Illinois Department that the provider enrollment is
4		complete.
5		(2) In the case of errors attributable to the Illinois
6		Department or any of its claims processing intermediaries
7		which result in an inability to receive, process, or
8		adjudicate a claim, the 180-day period shall not begin
9		until the provider has been notified of the error.
10		(3) In the case of a provider for whom the Illinois
11		Department initiates the monthly billing process.
12		(4) In the case of a provider operated by a unit of
13		local government with a population exceeding 3,000,000
14		when local government funds finance federal participation
15		for claims payments.
16		For claims for services rendered during a period for which
17		a recipient received retroactive eligibility, claims must be
18		filed within 180 days after the Department determines the
19		applicant is eligible. For claims for which the Illinois
20		Department is not the primary payer, claims must be submitted
21		to the Illinois Department within 180 days after the final
22		adjudication by the primary payer.
23		In the case of long term care facilities, within 120
24		calendar days of receipt by the facility of required
25		prescreening information, new admissions with associated
26		admission documents shall be submitted through the Medical

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1		Electronic Data Interchange (MEDI) or the Recipient
2		Eligibility Verification (REV) System or shall be submitted
3		directly to the Department of Human Services using required
4		admission forms. Effective September 1, 2014, admission
5		documents, including all prescreening information, must be
6		submitted through MEDI or REV. Confirmation numbers assigned
7		to an accepted transaction shall be retained by a facility to
8		verify timely submittal. Once an admission transaction has
9		been completed, all resubmitted claims following prior
10		rejection are subject to receipt no later than 180 days after
11		the admission transaction has been completed.
12		Claims that are not submitted and received in compliance
13		with the foregoing requirements shall not be eligible for
14		payment under the medical assistance program, and the State
15		shall have no liability for payment of those claims.
16		To the extent consistent with applicable information and
17		privacy, security, and disclosure laws, State and federal
18		agencies and departments shall provide the Illinois Department
19		access to confidential and other information and data
20		necessary to perform eligibility and payment verifications and
21		other Illinois Department functions. This includes, but is not
22		limited to: information pertaining to licensure;
23		certification; earnings; immigration status; citizenship; wage
24		reporting; unearned and earned income; pension income;
25		employment; supplemental security income; social security
26		numbers; National Provider Identifier (NPI) numbers; the

SB3365 Enrolled - 26 - LRB104 18483 SSS 31925 b
1		National Practitioner Data Bank (NPDB); program and agency
2		exclusions; taxpayer identification numbers; tax delinquency;
3		corporate information; and death records.
4		The Illinois Department shall enter into agreements with
5		State agencies and departments, and is authorized to enter
6		into agreements with federal agencies and departments, under
7		which such agencies and departments shall share data necessary
8		for medical assistance program integrity functions and
9		oversight. The Illinois Department shall develop, in
10		cooperation with other State departments and agencies, and in
11		compliance with applicable federal laws and regulations,
12		appropriate and effective methods to share such data. At a
13		minimum, and to the extent necessary to provide data sharing,
14		the Illinois Department shall enter into agreements with State
15		agencies and departments, and is authorized to enter into
16		agreements with federal agencies and departments, including,
17		but not limited to: the Secretary of State; the Department of
18		Revenue; the Department of Public Health; the Department of
19		Human Services; and the Department of Financial and
20		Professional Regulation.
21		Beginning in fiscal year 2013, the Illinois Department
22		shall set forth a request for information to identify the
23		benefits of a pre-payment, post-adjudication, and post-edit
24		claims system with the goals of streamlining claims processing
25		and provider reimbursement, reducing the number of pending or
26		rejected claims, and helping to ensure a more transparent

SB3365 Enrolled - 27 - LRB104 18483 SSS 31925 b
1		adjudication process through the utilization of: (i) provider
2		data verification and provider screening technology; and (ii)
3		clinical code editing; and (iii) pre-pay, pre-adjudicated, or
4		post-adjudicated predictive modeling with an integrated case
5		management system with link analysis. Such a request for
6		information shall not be considered as a request for proposal
7		or as an obligation on the part of the Illinois Department to
8		take any action or acquire any products or services.
9		The Illinois Department shall establish policies,
10		procedures, standards and criteria by rule for the
11		acquisition, repair and replacement of orthotic and prosthetic
12		devices and durable medical equipment. Such rules shall
13		provide, but not be limited to, the following services: (1)
14		immediate repair or replacement of such devices by recipients;
15		and (2) rental, lease, purchase or lease-purchase of durable
16		medical equipment in a cost-effective manner, taking into
17		consideration the recipient's medical prognosis, the extent of
18		the recipient's needs, and the requirements and costs for
19		maintaining such equipment. Subject to prior approval, such
20		rules shall enable a recipient to temporarily acquire and use
21		alternative or substitute devices or equipment pending repairs
22		or replacements of any device or equipment previously
23		authorized for such recipient by the Department.
24		Notwithstanding any provision of Section 5-5f to the contrary,
25		the Department may, by rule, exempt certain replacement
26		wheelchair parts from prior approval and, for wheelchairs,

SB3365 Enrolled - 28 - LRB104 18483 SSS 31925 b
1		wheelchair parts, wheelchair accessories, and related seating
2		and positioning items, determine the wholesale price by
3		methods other than actual acquisition costs.
4		The Department shall require, by rule, all providers of
5		durable medical equipment to be accredited by an accreditation
6		organization approved by the federal Centers for Medicare and
7		Medicaid Services and recognized by the Department in order to
8		bill the Department for providing durable medical equipment to
9		recipients. No later than 15 months after the effective date
10		of the rule adopted pursuant to this paragraph, all providers
11		must meet the accreditation requirement.
12		In order to promote environmental responsibility, meet the
13		needs of recipients and enrollees, and achieve significant
14		cost savings, the Department, or a managed care organization
15		under contract with the Department, may provide recipients or
16		managed care enrollees who have a prescription or Certificate
17		of Medical Necessity access to refurbished durable medical
18		equipment under this Section (excluding prosthetic and
19		orthotic devices as defined in the Orthotics, Prosthetics, and
20		Pedorthics Practice Act and complex rehabilitation technology
21		products and associated services) through the State's
22		assistive technology program's reutilization program, using
23		staff with the Assistive Technology Professional (ATP)
24		Certification if the refurbished durable medical equipment:
25		(i) is available; (ii) is less expensive, including shipping
26		costs, than new durable medical equipment of the same type;

SB3365 Enrolled - 29 - LRB104 18483 SSS 31925 b
1		(iii) is able to withstand at least 3 years of use; (iv) is
2		cleaned, disinfected, sterilized, and safe in accordance with
3		federal Food and Drug Administration regulations and guidance
4		governing the reprocessing of medical devices in health care
5		settings; and (v) equally meets the needs of the recipient or
6		enrollee. The reutilization program shall confirm that the
7		recipient or enrollee is not already in receipt of the same or
8		similar equipment from another service provider, and that the
9		refurbished durable medical equipment equally meets the needs
10		of the recipient or enrollee. Nothing in this paragraph shall
11		be construed to limit recipient or enrollee choice to obtain
12		new durable medical equipment or place any additional prior
13		authorization conditions on enrollees of managed care
14		organizations.
15		The Department shall execute, relative to the nursing home
16		prescreening project, written inter-agency agreements with the
17		Department of Human Services and the Department on Aging, to
18		effect the following: (i) intake procedures and common
19		eligibility criteria for those persons who are receiving
20		non-institutional services; and (ii) the establishment and
21		development of non-institutional services in areas of the
22		State where they are not currently available or are
23		undeveloped; and (iii) notwithstanding any other provision of
24		law, subject to federal approval, on and after July 1, 2012, an
25		increase in the determination of need (DON) scores from 29 to
26		37 for applicants for institutional and home and

SB3365 Enrolled - 30 - LRB104 18483 SSS 31925 b
1		community-based long term care; if and only if federal
2		approval is not granted, the Department may, in conjunction
3		with other affected agencies, implement utilization controls
4		or changes in benefit packages to effectuate a similar savings
5		amount for this population; and (iv) no later than July 1,
6		2013, minimum level of care eligibility criteria for
7		institutional and home and community-based long term care; and
8		(v) no later than October 1, 2013, establish procedures to
9		permit long term care providers access to eligibility scores
10		for individuals with an admission date who are seeking or
11		receiving services from the long term care provider. In order
12		to select the minimum level of care eligibility criteria, the
13		Governor shall establish a workgroup that includes affected
14		agency representatives and stakeholders representing the
15		institutional and home and community-based long term care
16		interests. This Section shall not restrict the Department from
17		implementing lower level of care eligibility criteria for
18		community-based services in circumstances where federal
19		approval has been granted.
20		The Illinois Department shall develop and operate, in
21		cooperation with other State Departments and agencies and in
22		compliance with applicable federal laws and regulations,
23		appropriate and effective systems of health care evaluation
24		and programs for monitoring of utilization of health care
25		services and facilities, as it affects persons eligible for
26		medical assistance under this Code.

SB3365 Enrolled - 31 - LRB104 18483 SSS 31925 b
1		The Illinois Department shall report annually to the
2		General Assembly, no later than the second Friday in April of
3		1979 and each year thereafter, in regard to:
4		(a) actual statistics and trends in utilization of
5		medical services by public aid recipients;
6		(b) actual statistics and trends in the provision of
7		the various medical services by medical vendors;
8		(c) current rate structures and proposed changes in
9		those rate structures for the various medical vendors; and
10		(d) efforts at utilization review and control by the
11		Illinois Department.
12		The period covered by each report shall be the 3 years
13		ending on the June 30 prior to the report. The report shall
14		include suggested legislation for consideration by the General
15		Assembly. The requirement for reporting to the General
16		Assembly shall be satisfied by filing copies of the report as
17		required by Section 3.1 of the General Assembly Organization
18		Act, and filing such additional copies with the State
19		Government Report Distribution Center for the General Assembly
20		as is required under paragraph (t) of Section 7 of the State
21		Library Act.
22		Rulemaking authority to implement Public Act 95-1045, if
23		any, is conditioned on the rules being adopted in accordance
24		with all provisions of the Illinois Administrative Procedure
25		Act and all rules and procedures of the Joint Committee on
26		Administrative Rules; any purported rule not so adopted, for

SB3365 Enrolled - 32 - LRB104 18483 SSS 31925 b
1		whatever reason, is unauthorized.
2		On and after July 1, 2012, the Department shall reduce any
3		rate of reimbursement for services or other payments or alter
4		any methodologies authorized by this Code to reduce any rate
5		of reimbursement for services or other payments in accordance
6		with Section 5-5e.
7		Because kidney transplantation can be an appropriate,
8		cost-effective alternative to renal dialysis when medically
9		necessary and notwithstanding the provisions of Section 1-11
10		of this Code, beginning October 1, 2014, the Department shall
11		cover kidney transplantation for noncitizens with end-stage
12		renal disease who are not eligible for comprehensive medical
13		benefits, who meet the residency requirements of Section 5-3
14		of this Code, and who would otherwise meet the financial
15		requirements of the appropriate class of eligible persons
16		under Section 5-2 of this Code. To qualify for coverage of
17		kidney transplantation, such person must be receiving
18		emergency renal dialysis services covered by the Department.
19		Providers under this Section shall be prior approved and
20		certified by the Department to perform kidney transplantation
21		and the services under this Section shall be limited to
22		services associated with kidney transplantation.
23		Notwithstanding any other provision of this Code to the
24		contrary, on or after July 1, 2015, all FDA-approved forms of
25		medication assisted treatment prescribed for the treatment of
26		alcohol dependence or treatment of opioid dependence shall be

SB3365 Enrolled - 33 - LRB104 18483 SSS 31925 b
1		covered under both fee-for-service and managed care medical
2		assistance programs for persons who are otherwise eligible for
3		medical assistance under this Article and shall not be subject
4		to any (1) utilization control, other than those established
5		under the American Society of Addiction Medicine patient
6		placement criteria, (2) prior authorization mandate, (3)
7		lifetime restriction limit mandate, or (4) limitations on
8		dosage.
9		On or after July 1, 2015, opioid antagonists prescribed
10		for the treatment of an opioid overdose, including the
11		medication product, administration devices, and any pharmacy
12		fees or hospital fees related to the dispensing, distribution,
13		and administration of the opioid antagonist, shall be covered
14		under the medical assistance program for persons who are
15		otherwise eligible for medical assistance under this Article.
16		As used in this Section, "opioid antagonist" means a drug that
17		binds to opioid receptors and blocks or inhibits the effect of
18		opioids acting on those receptors, including, but not limited
19		to, naloxone hydrochloride or any other similarly acting drug
20		approved by the U.S. Food and Drug Administration. The
21		Department shall not impose a copayment on the coverage
22		provided for naloxone hydrochloride under the medical
23		assistance program.
24		Upon federal approval, the Department shall provide
25		coverage and reimbursement for all drugs that are approved for
26		marketing by the federal Food and Drug Administration and that

SB3365 Enrolled - 34 - LRB104 18483 SSS 31925 b
1		are recommended by the federal Public Health Service or the
2		United States Centers for Disease Control and Prevention for
3		pre-exposure prophylaxis and related pre-exposure prophylaxis
4		services, including, but not limited to, HIV and sexually
5		transmitted infection screening, treatment for sexually
6		transmitted infections, medical monitoring, assorted labs, and
7		counseling to reduce the likelihood of HIV infection among
8		individuals who are not infected with HIV but who are at high
9		risk of HIV infection.
10		A federally qualified health center, as defined in Section
11		1905(l)(2)(B) of the federal Social Security Act, shall be
12		reimbursed by the Department in accordance with the federally
13		qualified health center's encounter rate for services provided
14		to medical assistance recipients that are performed by a
15		dental hygienist, as defined under the Illinois Dental
16		Practice Act, working under the general supervision of a
17		dentist and employed by a federally qualified health center.
18		Within 90 days after October 8, 2021 (the effective date
19		of Public Act 102-665), the Department shall seek federal
20		approval of a State Plan amendment to expand coverage for
21		family planning services that includes presumptive eligibility
22		to individuals whose income is at or below 208% of the federal
23		poverty level. Coverage under this Section shall be effective
24		beginning no later than December 1, 2022.
25		Subject to approval by the federal Centers for Medicare
26		and Medicaid Services of a Title XIX State Plan amendment

SB3365 Enrolled - 35 - LRB104 18483 SSS 31925 b
1		electing the Program of All-Inclusive Care for the Elderly
2		(PACE) as a State Medicaid option, as provided for by Subtitle
3		I (commencing with Section 4801) of Title IV of the Balanced
4		Budget Act of 1997 (Public Law 105-33) and Part 460
5		(commencing with Section 460.2) of Subchapter E of Title 42 of
6		the Code of Federal Regulations, PACE program services shall
7		become a covered benefit of the medical assistance program,
8		subject to criteria established in accordance with all
9		applicable laws.
10		Notwithstanding any other provision of this Code,
11		community-based pediatric palliative care from a trained
12		interdisciplinary team shall be covered under the medical
13		assistance program as provided in Section 15 of the Pediatric
14		Palliative Care Act.
15		Notwithstanding any other provision of this Code, within
16		12 months after June 2, 2022 (the effective date of Public Act
17		102-1037) and subject to federal approval, acupuncture
18		services performed by an acupuncturist licensed under the
19		Acupuncture Practice Act who is acting within the scope of his
20		or her license shall be covered under the medical assistance
21		program. The Department shall apply for any federal waiver or
22		State Plan amendment, if required, to implement this
23		paragraph. The Department may adopt any rules, including
24		standards and criteria, necessary to implement this paragraph.
25		Notwithstanding any other provision of this Code, the
26		medical assistance program shall, subject to federal approval,

SB3365 Enrolled - 36 - LRB104 18483 SSS 31925 b
1		reimburse hospitals for costs associated with a newborn
2		screening test for the presence of metachromatic
3		leukodystrophy, as required under the Newborn Metabolic
4		Screening Act, at a rate not less than the fee charged by the
5		Department of Public Health. Notwithstanding any other
6		provision of this Code, the medical assistance program shall,
7		subject to appropriation and federal approval, also reimburse
8		hospitals for costs associated with all newborn screening
9		tests added on and after August 9, 2024 (the effective date of
10		Public Act 103-909) to the Newborn Metabolic Screening Act and
11		required to be performed under that Act at a rate not less than
12		the fee charged by the Department of Public Health. The
13		Department shall seek federal approval before the
14		implementation of the newborn screening test fees by the
15		Department of Public Health.
16		Notwithstanding any other provision of this Code,
17		beginning on January 1, 2024, subject to federal approval,
18		cognitive assessment and care planning services provided to a
19		person who experiences signs or symptoms of cognitive
20		impairment, as defined by the Diagnostic and Statistical
21		Manual of Mental Disorders, Fifth Edition, shall be covered
22		under the medical assistance program for persons who are
23		otherwise eligible for medical assistance under this Article.
24		Notwithstanding any other provision of this Code,
25		medically necessary reconstructive services that are intended
26		to restore physical appearance shall be covered under the

SB3365 Enrolled - 37 - LRB104 18483 SSS 31925 b
1		medical assistance program for persons who are otherwise
2		eligible for medical assistance under this Article. As used in
3		this paragraph, "reconstructive services" means treatments
4		performed on structures of the body damaged by trauma to
5		restore physical appearance.
6		Subject to federal approval, for dates of services on and
7		after January 1, 2026, over-the-counter choline dietary
8		supplements for pregnant persons shall be covered under the
9		medical assistance program.
10		(Source: P.A. 103-102, Article 15, Section 15-5, eff. 1-1-24;
11		103-102, Article 95, Section 95-15, eff. 1-1-24; 103-123, eff.
12		1-1-24; 103-154, eff. 6-30-23; 103-368, eff. 1-1-24; 103-593,
13		Article 5, Section 5-5, eff. 6-7-24; 103-593, Article 90,
14		Section 90-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-808, eff.
15		1-1-26; 103-909, eff. 8-9-24; 103-1040, eff. 8-9-24; 104-9,
16		eff. 6-16-25; 104-417, eff. 8-15-25.)
17		ARTICLE 6.
18		Section 6-5. The Illinois Public Aid Code is amended by
19		adding Article V-J as follows:
20		(305 ILCS 5/Art. V-J heading new)
21		ARTICLE V-J. DISTRESSED HOSPITAL LOAN PROGRAM
22		(305 ILCS 5/5J-1 new)

SB3365 Enrolled - 38 - LRB104 18483 SSS 31925 b
1		Sec. 5J-1. References to Article. This Article may be
2		referred to as the Distressed Hospital Loan Program Law.
3		(305 ILCS 5/5J-5 new)
4		Sec. 5J-5. Distressed Hospital Loan Program. The
5		Distressed Hospital Loan Program is created. The purpose of
6		the Program is to provide, subject to appropriation and the
7		availability of funds, interest-free cash flow loans to
8		public, not-for-profit, and for-profit hospitals in
9		significant financial distress to prevent the closure of or to
10		facilitate the reopening of those hospitals.
11		(305 ILCS 5/5J-10 new)
12		Sec. 5J-10. Definitions. As used in this Article:
13		"Closed hospital" means a hospital that closed after
14		January 1, 2019.
15		"Department" means the Department of Healthcare and Family
16		Services.
17		"Program" means the Distressed Hospital Loan Program.
18		"Public hospital" means a hospital that is licensed by the
19		Hospital Licensing Act and is either owned or operated by a
20		governmental body in Illinois, excluding a State agency, a
21		State university, or a county with a population of 3,000,000
22		or more.
23		(305 ILCS 5/5J-15 new)

SB3365 Enrolled - 39 - LRB104 18483 SSS 31925 b
1		Sec. 5J-15. Administration. The Department shall
2		administer the Distressed Hospital Loan Program in
3		coordination with the Department of Public Health and the
4		Governor's Office of Management and Budget. The Department
5		shall adopt rules to implement this Program.
6		(305 ILCS 5/5J-18 new)
7		Sec. 5J-18. Application requirements. A hospital applying
8		for aid under this Program shall provide the Department with
9		financial information, in a format determined by the
10		Department, demonstrating the hospital's need for bridge
11		financing due to financial hardship.
12		(1) Before receiving bridge financing under this
13		Program, an eligible hospital shall submit a plan to the
14		Department, with projections detailing the uses of the
15		proposed loan and a structured plan proposed by the
16		hospital's governing body to regain financial viability
17		and continue operations.
18		(2) Before issuing a loan under this Program, the
19		Department shall review the plan submitted by an eligible
20		hospital and make a determination both that the plan is
21		viable and that there is a reasonable likelihood that the
22		hospital will be able to regain financial viability,
23		continue to operate as a hospital, and be able to repay the
24		loan. The Department shall not issue a loan award if the
25		Department is unable to make these determinations.

SB3365 Enrolled - 40 - LRB104 18483 SSS 31925 b
1		(3) All funds loaned in accordance with this Article
2		shall be used as described in the application approved by
3		the Department, which shall be incorporated into any
4		resulting loan agreement. Any misused funds shall be
5		recouped by the Department subject to the recoupment
6		methods under Section 5J-25. In addition to any other
7		remedies provided for by law and without sending a notice
8		of liability, the Department may withhold, as payment of
9		any amounts due and owing as repayment of loans issued in
10		accordance with this Article, reimbursements or other
11		amounts otherwise payable by the Department to the loan
12		recipient, including, but not limited to, amounts
13		otherwise payable from a managed care organization
14		performing duties under contract with the Department.
15		(305 ILCS 5/5J-20 new)
16		Sec. 5J-20. Application evaluation.
17		(a) In collaboration with the Governor's Office of
18		Management and Budget and the Department of Public Health, the
19		Department shall develop a methodology to evaluate a
20		hospital's application for a loan through the Program.
21		(b) The methodology shall consider factors including, but
22		not limited to, whether the hospital is in financial distress
23		as solely determined by the State; whether the hospital is
24		small, rural, a safety-net hospital, a critical access
25		hospital, a trauma center, an urban hospital providing access

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1		for an underserved area, a hospital that serves a
2		disproportionate share of Medicaid patients, or serving a
3		rural catchment area; and whether closure of the hospital or
4		service line reduction as a result of the financial distress
5		would significantly impact access to services in the
6		hospital's health service area.
7		(c) The methodology for determining financial distress may
8		consider such factors as the hospital's prior and projected
9		performance on financial metrics, including the amount of cash
10		on hand, and whether the hospital has experienced, or is
11		projected to experience, negative operating margins.
12		(d) Subject to appropriation and the availability of
13		funds, any loan to a hospital with an approved loan
14		application shall be issued as soon as reasonably practicable
15		following approval of an application. Approved applications
16		shall receive funding on a first-come, first-served basis
17		until funding appropriated by the General Assembly for this
18		purpose has been expended. The Department maintains discretion
19		to determine the amount of a loan approved for a hospital and
20		may approve less than the amount requested by a hospital. The
21		Department may consider the amount of appropriations available
22		to this Program in the exercise of its discretion.
23		(e) Hospitals ineligible for State assistance under the
24		Program include:
25		(1) Hospitals that belong to integrated health care
26		systems with more than 3 separately licensed hospital

SB3365 Enrolled - 42 - LRB104 18483 SSS 31925 b
1		facilities.
2		(2) A hospital that maintains unpaid hospital
3		assessment liability owed to the State and either does not
4		have a negotiated tax repayment agreement with the State
5		or is delinquent under an existing negotiated assessment
6		repayment agreement.
7		(3) A hospital that is not current on a repayment
8		schedule for a prior advance issued in accordance with 89
9		Ill. Adm. Code 140.71.
10		(4) A hospital that has not provided required
11		reporting on its finances as mandated by State law or
12		administrative rule.
13		(5) A hospital that is subject to a stop payment
14		order, as defined by the Grant Accountability and
15		Transparency Act, with the State for any reason.
16		(6) A hospital that has been under investigation or
17		been issued an immediate jeopardy by the Centers for
18		Medicare and Medicaid Services in the prior 12 months from
19		the time of loan application.
20		(f) The Department shall give preference to not-for-profit
21		and public hospitals. Hospitals owned and operated by a
22		for-profit entity shall be subject to a maximum funding limit,
23		expedited repayment time frames, and additional financial and
24		operational transparency requirements as defined in rule.
25		(g) The Department shall determine the application
26		process, underwriting review, and methodology for approval and

SB3365 Enrolled - 43 - LRB104 18483 SSS 31925 b
1		distribution of the loans under the Program.
2		(h) The Department shall have the authority to determine
3		service provision requirements in approving, and for the
4		duration of, loans to eligible hospitals. In making its
5		determination, the Department shall consider the impact of any
6		changes to the hospital's service delivery or access to
7		necessary medical care, particularly for beneficiaries of the
8		State's medical assistance Program.
9		(i) The application process shall allow for at least 30
10		days for the Department to issue an initial response to any
11		loan application.
12		(305 ILCS 5/5J-25 new)
13		Sec. 5J-25. Repayment agreement.
14		(a) A hospital shall be required to enter into a repayment
15		agreement with the Department to execute the approved loan.
16		Terms must include, but are not limited to, monthly repayments
17		of the loan beginning no later than 18 months after receipt of
18		the loan and discharge of the loan within 36 months of the date
19		of the loan.
20		(b) Notwithstanding any other law and to the extent
21		permissible under federal rules, security for the cash flow
22		loans in this Article shall, at a minimum, include
23		reimbursements due to the hospital from the Department,
24		including, but not limited to, any reimbursements under this
25		Code. The repayment agreement may provide for additional

SB3365 Enrolled - 44 - LRB104 18483 SSS 31925 b
1		security for any cash flow loans under this Article.
2		(c) If the hospital provider fails to comply with the
3		repayment terms of the agreement, the remaining balance of the
4		loan shall be immediately recouped from reimbursements or
5		other amounts otherwise payable by the Department to the loan
6		recipient, including, but not limited to, amounts otherwise
7		payable from a managed care organization performing duties
8		under contract with the Department. The Department may also
9		recoup amounts otherwise payable by any State agency to the
10		provider, including, but not limited to, State grants and
11		grant appropriations, and apply such amounts as repayment of
12		the unpaid advance. If such reimbursements or other amounts
13		otherwise payable to the loan recipient are insufficient for
14		complete recovery, the remaining balance shall become
15		immediately due and payable by check to the Department of
16		Healthcare and Family Services. Failure by the provider to
17		remit such check shall result in the Department pursuing other
18		collection methods.
19		(d) Any unpaid loan under this Article shall become a lien
20		upon the assets of the hospital that received the loan. If any
21		hospital provider, outside the usual course of its business,
22		sells or transfers the major part of any one or more of (A) the
23		real property and improvements, (B) the machinery and
24		equipment, or (C) the furniture or fixtures, of any hospital
25		that is subject to the provisions of this Article, the seller
26		or transferor shall pay the Department the amount of any loan,

SB3365 Enrolled - 45 - LRB104 18483 SSS 31925 b
1		penalty, and interest (if any) due from it under this Article
2		up to the date of the sale or transfer. The Department may, in
3		its discretion, foreclose on such a lien, but shall do so in a
4		manner that is consistent with Section 5e of the Retailers'
5		Occupation Tax Act. If the seller or transferor fails to pay
6		any loan, penalty, and interest (if any) due, the purchaser or
7		transferee of such asset shall be liable for the amount of the
8		loan, penalties, and interest (if any) up to the amount of the
9		reasonable value of the property acquired by the purchaser or
10		transferee. The purchaser or transferee shall continue to be
11		liable until the purchaser or transferee pays the full amount
12		of the loan, penalties, and interest (if any) up to the amount
13		of the reasonable value of the property acquired by the
14		purchaser or transferee or until the purchaser or transferee
15		receives from the Department a certificate showing that such
16		loan, penalty, and interest have been paid or a certificate
17		from the Department showing that no loan, penalty, or interest
18		is due from the seller or transferor under this Article.
19		(e) If a hospital provider fails to pay any monthly
20		installment repayments, there shall, unless waived by the
21		Department for reasonable cause, be added to the loan
22		repayment obligation a penalty equal to the lesser of (i) 5% of
23		the amount of the installment not paid on or before the due
24		date plus 5% of the portion thereof remaining unpaid on the
25		last day of each 30-day period thereafter or (ii) 100% of the
26		installment amount not paid on or before the due date.

SB3365 Enrolled - 46 - LRB104 18483 SSS 31925 b
1		(305 ILCS 5/5J-30 new)
2		Sec. 5J-30. Distressed Hospital Loan Program Fund.
3		(a) The Distressed Hospital Loan Program Fund is created
4		as a special fund in the State treasury.
5		(b) Subject to appropriation, the Department may make
6		secured and unsecured loans from amounts in the Distressed
7		Hospital Loan Program Fund to a hospital, or a governmental
8		entity representing a closed hospital, for purposes of
9		preventing the hospital's closure in accordance with the
10		provisions of this Article.
11		(c) On January 1, 2027, or as soon thereafter as
12		practical, the State Comptroller shall direct and the State
13		Treasurer shall transfer, at the direction of the Director of
14		the Department, an amount not to exceed $85,000,000 from the
15		Healthcare Provider Relief Fund to the Distressed Hospital
16		Loan Program Fund.
17		(d) All moneys accruing to the Department under this
18		Article from any source, including, but not limited to, all
19		amounts repaid under the terms of any loan agreements, shall
20		be deposited into the Fund.
21		(e) On June 30, 2033, or as soon thereafter as practical,
22		the State Comptroller shall direct and the State Treasurer
23		shall transfer the remaining balance in the Distressed
24		Hospital Loan Program Fund to the Healthcare Provider Relief
25		Fund. Upon completion of the transfers, the Distressed

SB3365 Enrolled - 47 - LRB104 18483 SSS 31925 b
1		Hospital Loan Program Fund is dissolved and any outstanding
2		obligations or liabilities of the Fund pass to the Healthcare
3		Provider Relief Fund. The Department shall deposit all
4		subsequent loan repayments or medical assistance program or
5		other reimbursements withheld for due cause in accordance with
6		this Article into the Healthcare Provider Relief Fund.
7		(f) The Department may require any hospital receiving a
8		loan under this Article to provide the Department with an
9		independent financial audit of the hospital's operations for
10		any fiscal year in which a loan is outstanding.
11		(305 ILCS 5/5J-35 new)
12		Sec. 5J-35. Implementation. The Program described in this
13		Article shall be operative on and after January 1, 2027 and
14		shall be implemented upon administrative rules being in
15		effect.
16		(305 ILCS 5/5J-40 new)
17		Sec. 5J-40. Repealer. This Article is repealed on June 30,
18		2033.
19		Section 6-70. The State Finance Act is amended by adding
20		Section 5.1038 as follows:
21		(30 ILCS 105/5.1038 new)
22		Sec. 5.1038. The Distressed Hospital Loan Program Fund.

SB3365 Enrolled - 48 - LRB104 18483 SSS 31925 b
1		This Section is repealed June 30, 2033.
2		Section 6-72. The Illinois Administrative Procedure Act is
3		amended by adding Section 5-45.71 as follows:
4		(5 ILCS 100/5-45.71 new)
5		Sec. 5-45.71. Emergency rulemaking; Health Facilities and
6		Services Review Board. To provide for the expeditious and
7		timely implementation of the changes made by this amendatory
8		Act of the 104th General Assembly to Section 13 of the Illinois
9		Health Facilities Planning Act, emergency rules may be adopted
10		in accordance with Section 5-45 by the Health Facilities and
11		Services Review Board. The adoption of emergency rules
12		authorized by Section 5-45 and this Section is deemed to be
13		necessary for the public interest, safety, and welfare.
14		This Section is repealed one year after the effective date
15		of this amendatory Act of the 104th General Assembly.
16		Section 6-73. The Freedom of Information Act is amended by
17		changing Section 7.5 as follows:
18		(5 ILCS 140/7.5)
19		(Text of Section before amendment by P.A. 104-441 and
20		104-457)
21		Sec. 7.5. Statutory exemptions. To the extent provided for
22		by the statutes referenced below, the following shall be

SB3365 Enrolled - 49 - LRB104 18483 SSS 31925 b
1		exempt from inspection and copying:
2		(a) All information determined to be confidential
3		under Section 4002 of the Technology Advancement and
4		Development Act.
5		(b) Library circulation and order records identifying
6		library users with specific materials under the Library
7		Records Confidentiality Act.
8		(c) Applications, related documents, and medical
9		records received by the Experimental Organ Transplantation
10		Procedures Board and any and all documents or other
11		records prepared by the Experimental Organ Transplantation
12		Procedures Board or its staff relating to applications it
13		has received.
14		(d) Information and records held by the Department of
15		Public Health and its authorized representatives relating
16		to known or suspected cases of sexually transmitted
17		infection or any information the disclosure of which is
18		restricted under the Illinois Sexually Transmitted
19		Infection Control Act.
20		(e) Information the disclosure of which is exempted
21		under Section 30 of the Radon Industry Licensing Act.
22		(f) Firm performance evaluations under Section 55 of
23		the Architectural, Engineering, and Land Surveying
24		Qualifications Based Selection Act.
25		(g) Information the disclosure of which is restricted
26		and exempted under Section 50 of the Illinois Prepaid

SB3365 Enrolled - 50 - LRB104 18483 SSS 31925 b
1		Tuition Act.
2		(h) Information the disclosure of which is exempted
3		under the State Officials and Employees Ethics Act, and
4		records of any lawfully created State or local inspector
5		general's office that would be exempt if created or
6		obtained by an Executive Inspector General's office under
7		that Act.
8		(i) Information contained in a local emergency energy
9		plan submitted to a municipality in accordance with a
10		local emergency energy plan ordinance that is adopted
11		under Section 11-21.5-5 of the Illinois Municipal Code.
12		(j) Information and data concerning the distribution
13		of surcharge moneys collected and remitted by carriers
14		under the Emergency Telephone System Act.
15		(k) Law enforcement officer identification information
16		or driver identification information compiled by a law
17		enforcement agency or the Department of Transportation
18		under Section 11-212 of the Illinois Vehicle Code.
19		(l) Records and information provided to a residential
20		health care facility resident sexual assault and death
21		review team or the Executive Council under the Abuse
22		Prevention Review Team Act.
23		(m) Information provided to the predatory lending
24		database created pursuant to Article 3 of the Residential
25		Real Property Disclosure Act, except to the extent
26		authorized under that Article.

SB3365 Enrolled - 51 - LRB104 18483 SSS 31925 b
1		(n) Defense budgets and petitions for certification of
2		compensation and expenses for court appointed trial
3		counsel as provided under Sections 10 and 15 of the
4		Capital Crimes Litigation Act (repealed). This subsection
5		(n) shall apply until the conclusion of the trial of the
6		case, even if the prosecution chooses not to pursue the
7		death penalty prior to trial or sentencing.
8		(o) Information that is prohibited from being
9		disclosed under Section 4 of the Illinois Health and
10		Hazardous Substances Registry Act.
11		(p) Security portions of system safety program plans,
12		investigation reports, surveys, schedules, lists, data, or
13		information compiled, collected, or prepared by or for the
14		Department of Transportation under Sections 2705-300 and
15		2705-616 of the Department of Transportation Law of the
16		Civil Administrative Code of Illinois, the Regional
17		Transportation Authority under Section 2.11 of the
18		Regional Transportation Authority Act, or the St. Clair
19		County Transit District under the Bi-State Transit Safety
20		Act (repealed).
21		(q) Information prohibited from being disclosed by the
22		Personnel Record Review Act.
23		(r) Information prohibited from being disclosed by the
24		Illinois School Student Records Act.
25		(s) Information the disclosure of which is restricted
26		under Section 5-108 of the Public Utilities Act.

SB3365 Enrolled - 52 - LRB104 18483 SSS 31925 b
1		(t) (Blank).
2		(u) Records and information provided to an independent
3		team of experts under the Developmental Disability and
4		Mental Health Safety Act (also known as Brian's Law).
5		(v) Names and information of people who have applied
6		for or received Firearm Owner's Identification Cards under
7		the Firearm Owners Identification Card Act or applied for
8		or received a concealed carry license under the Firearm
9		Concealed Carry Act, unless otherwise authorized by the
10		Firearm Concealed Carry Act; and databases under the
11		Firearm Concealed Carry Act, records of the Concealed
12		Carry Licensing Review Board under the Firearm Concealed
13		Carry Act, and law enforcement agency objections under the
14		Firearm Concealed Carry Act.
15		(v-5) Records of the Firearm Owner's Identification
16		Card Review Board that are exempted from disclosure under
17		Section 10 of the Firearm Owners Identification Card Act.
18		(w) Personally identifiable information which is
19		exempted from disclosure under subsection (g) of Section
20		19.1 of the Toll Highway Act.
21		(x) Information which is exempted from disclosure
22		under Section 5-1014.3 of the Counties Code or Section
23		8-11-21 of the Illinois Municipal Code.
24		(y) Confidential information under the Adult
25		Protective Services Act and its predecessor enabling
26		statute, the Elder Abuse and Neglect Act, including

SB3365 Enrolled - 53 - LRB104 18483 SSS 31925 b
1		information about the identity and administrative finding
2		against any caregiver of a verified and substantiated
3		decision of abuse, neglect, or financial exploitation of
4		an eligible adult maintained in the Registry established
5		under Section 7.5 of the Adult Protective Services Act.
6		(z) Records and information provided to a fatality
7		review team or the Illinois Fatality Review Team Advisory
8		Council under Section 15 of the Adult Protective Services
9		Act.
10		(aa) Information which is exempted from disclosure
11		under Section 2.37 of the Wildlife Code.
12		(bb) Information which is or was prohibited from
13		disclosure by the Juvenile Court Act of 1987.
14		(cc) Recordings made under the Law Enforcement
15		Officer-Worn Body Camera Act, except to the extent
16		authorized under that Act.
17		(dd) Information that is prohibited from being
18		disclosed under Section 45 of the Condominium and Common
19		Interest Community Ombudsperson Act.
20		(ee) Information that is exempted from disclosure
21		under Section 30.1 of the Pharmacy Practice Act.
22		(ff) Information that is exempted from disclosure
23		under the Revised Uniform Unclaimed Property Act.
24		(gg) Information that is prohibited from being
25		disclosed under Section 7-603.5 of the Illinois Vehicle
26		Code.

SB3365 Enrolled - 54 - LRB104 18483 SSS 31925 b
1		(hh) Records that are exempt from disclosure under
2		Section 1A-16.7 of the Election Code.
3		(ii) Information which is exempted from disclosure
4		under Section 2505-800 of the Department of Revenue Law of
5		the Civil Administrative Code of Illinois.
6		(jj) Information and reports that are required to be
7		submitted to the Department of Labor by registering day
8		and temporary labor service agencies but are exempt from
9		disclosure under subsection (a-1) of Section 45 of the Day
10		and Temporary Labor Services Act.
11		(kk) Information prohibited from disclosure under the
12		Seizure and Forfeiture Reporting Act.
13		(ll) Information the disclosure of which is restricted
14		and exempted under Section 5-30.8 of the Illinois Public
15		Aid Code.
16		(mm) Records that are exempt from disclosure under
17		Section 4.2 of the Crime Victims Compensation Act.
18		(nn) Information that is exempt from disclosure under
19		Section 70 of the Higher Education Student Assistance Act.
20		(oo) Communications, notes, records, and reports
21		arising out of a peer support counseling session
22		prohibited from disclosure under the First Responders
23		Suicide Prevention Act.
24		(pp) Names and all identifying information relating to
25		an employee of an emergency services provider or law
26		enforcement agency under the First Responders Suicide

SB3365 Enrolled - 55 - LRB104 18483 SSS 31925 b
1		Prevention Act.
2		(qq) Information and records held by the Department of
3		Public Health and its authorized representatives collected
4		under the Reproductive Health Act.
5		(rr) Information that is exempt from disclosure under
6		the Cannabis Regulation and Tax Act.
7		(ss) Data reported by an employer to the Department of
8		Human Rights pursuant to Section 2-108 of the Illinois
9		Human Rights Act.
10		(tt) Recordings made under the Children's Advocacy
11		Center Act, except to the extent authorized under that
12		Act.
13		(uu) Information that is exempt from disclosure under
14		Section 50 of the Sexual Assault Evidence Submission Act.
15		(vv) Information that is exempt from disclosure under
16		subsections (f) and (j) of Section 5-36 of the Illinois
17		Public Aid Code.
18		(ww) Information that is exempt from disclosure under
19		Section 16.8 of the State Treasurer Act.
20		(xx) Information that is exempt from disclosure or
21		information that shall not be made public under the
22		Illinois Insurance Code.
23		(yy) Information prohibited from being disclosed under
24		the Illinois Educational Labor Relations Act.
25		(zz) Information prohibited from being disclosed under
26		the Illinois Public Labor Relations Act.

SB3365 Enrolled - 56 - LRB104 18483 SSS 31925 b
1		(aaa) Information prohibited from being disclosed
2		under Section 1-167 of the Illinois Pension Code.
3		(bbb) Information that is prohibited from disclosure
4		by the Illinois Police Training Act and the Illinois State
5		Police Act.
6		(ccc) Records exempt from disclosure under Section
7		2605-304 of the Illinois State Police Law of the Civil
8		Administrative Code of Illinois.
9		(ddd) Information prohibited from being disclosed
10		under Section 35 of the Address Confidentiality for
11		Victims of Domestic Violence, Sexual Assault, Human
12		Trafficking, or Stalking Act.
13		(eee) Information prohibited from being disclosed
14		under subsection (b) of Section 75 of the Domestic
15		Violence Fatality Review Act.
16		(fff) Images from cameras under the Expressway Camera
17		Act and all automated license plate reader (ALPR)
18		information used and collected by the Illinois State
19		Police. "ALPR information" means information gathered by
20		an ALPR or created from the analysis of data generated by
21		an ALPR. This subsection (fff) is inoperative on and after
22		July 1, 2028.
23		(ggg) Information prohibited from disclosure under
24		paragraph (3) of subsection (a) of Section 14 of the Nurse
25		Agency Licensing Act.
26		(hhh) Information submitted to the Illinois State

SB3365 Enrolled - 57 - LRB104 18483 SSS 31925 b
1		Police in an affidavit or application for an assault
2		weapon endorsement, assault weapon attachment endorsement,
3		.50 caliber rifle endorsement, or .50 caliber cartridge
4		endorsement under the Firearm Owners Identification Card
5		Act.
6		(iii) Data exempt from disclosure under Section 50 of
7		the School Safety Drill Act.
8		(jjj) Information exempt from disclosure under Section
9		30 of the Insurance Data Security Law.
10		(kkk) Confidential business information prohibited
11		from disclosure under Section 45 of the Paint Stewardship
12		Act.
13		(lll) Data exempt from disclosure under Section
14		2-3.196 of the School Code.
15		(mmm) Information prohibited from being disclosed
16		under subsection (e) of Section 1-129 of the Illinois
17		Power Agency Act.
18		(nnn) Materials received by the Department of Commerce
19		and Economic Opportunity that are confidential under the
20		Music and Musicians Tax Credit and Jobs Act.
21		(ooo) Data or information provided pursuant to Section
22		20 of the Statewide Recycling Needs and Assessment Act.
23		(ppp) Information that is exempt from disclosure under
24		Section 28-11 of the Lawful Health Care Activity Act.
25		(qqq) Information that is exempt from disclosure under
26		Section 7-101 of the Illinois Human Rights Act.

SB3365 Enrolled - 58 - LRB104 18483 SSS 31925 b
1		(rrr) Information prohibited from being disclosed
2		under Section 4-2 of the Uniform Money Transmission
3		Modernization Act.
4		(sss) Information exempt from disclosure under Section
5		40 of the Student-Athlete Endorsement Rights Act.
6		(ttt) Audio recordings made under Section 30 of the
7		Illinois State Police Act, except to the extent authorized
8		under that Section.
9		(uuu) Information prohibited from being disclosed
10		under Section 30-5 of the Digital Assets Regulation Act.
11		(Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
12		103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
13		8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
14		eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
15		103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
16		8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
17		eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
18		104-417, eff. 8-15-25; 104-428, eff. 8-18-25; revised
19		9-10-25.)
20		(Text of Section after amendment by P.A. 104-457 but
21		before 104-441)
22		Sec. 7.5. Statutory exemptions. To the extent provided for
23		by the statutes referenced below, the following shall be
24		exempt from inspection and copying:
25		(a) All information determined to be confidential

SB3365 Enrolled - 59 - LRB104 18483 SSS 31925 b
1		under Section 4002 of the Technology Advancement and
2		Development Act.
3		(b) Library circulation and order records identifying
4		library users with specific materials under the Library
5		Records Confidentiality Act.
6		(c) Applications, related documents, and medical
7		records received by the Experimental Organ Transplantation
8		Procedures Board and any and all documents or other
9		records prepared by the Experimental Organ Transplantation
10		Procedures Board or its staff relating to applications it
11		has received.
12		(d) Information and records held by the Department of
13		Public Health and its authorized representatives relating
14		to known or suspected cases of sexually transmitted
15		infection or any information the disclosure of which is
16		restricted under the Illinois Sexually Transmitted
17		Infection Control Act.
18		(e) Information the disclosure of which is exempted
19		under Section 30 of the Radon Industry Licensing Act.
20		(f) Firm performance evaluations under Section 55 of
21		the Architectural, Engineering, and Land Surveying
22		Qualifications Based Selection Act.
23		(g) Information the disclosure of which is restricted
24		and exempted under Section 50 of the Illinois Prepaid
25		Tuition Act.
26		(h) Information the disclosure of which is exempted

SB3365 Enrolled - 60 - LRB104 18483 SSS 31925 b
1		under the State Officials and Employees Ethics Act, and
2		records of any lawfully created State or local inspector
3		general's office that would be exempt if created or
4		obtained by an Executive Inspector General's office under
5		that Act.
6		(i) Information contained in a local emergency energy
7		plan submitted to a municipality in accordance with a
8		local emergency energy plan ordinance that is adopted
9		under Section 11-21.5-5 of the Illinois Municipal Code.
10		(j) Information and data concerning the distribution
11		of surcharge moneys collected and remitted by carriers
12		under the Emergency Telephone System Act.
13		(k) Law enforcement officer identification information
14		or driver identification information compiled by a law
15		enforcement agency or the Department of Transportation
16		under Section 11-212 of the Illinois Vehicle Code.
17		(l) Records and information provided to a residential
18		health care facility resident sexual assault and death
19		review team or the Executive Council under the Abuse
20		Prevention Review Team Act.
21		(m) Information provided to the predatory lending
22		database created pursuant to Article 3 of the Residential
23		Real Property Disclosure Act, except to the extent
24		authorized under that Article.
25		(n) Defense budgets and petitions for certification of
26		compensation and expenses for court appointed trial

SB3365 Enrolled - 61 - LRB104 18483 SSS 31925 b
1		counsel as provided under Sections 10 and 15 of the
2		Capital Crimes Litigation Act (repealed). This subsection
3		(n) shall apply until the conclusion of the trial of the
4		case, even if the prosecution chooses not to pursue the
5		death penalty prior to trial or sentencing.
6		(o) Information that is prohibited from being
7		disclosed under Section 4 of the Illinois Health and
8		Hazardous Substances Registry Act.
9		(p) Security portions of system safety program plans,
10		investigation reports, surveys, schedules, lists, data, or
11		information compiled, collected, or prepared by or for the
12		Department of Transportation under Sections 2705-300 and
13		2705-616 of the Department of Transportation Law of the
14		Civil Administrative Code of Illinois, the Northern
15		Illinois Transit Authority under Section 2.11 of the
16		Northern Illinois Transit Authority Act, or the St. Clair
17		County Transit District under the Bi-State Transit Safety
18		Act (repealed).
19		(q) Information prohibited from being disclosed by the
20		Personnel Record Review Act.
21		(r) Information prohibited from being disclosed by the
22		Illinois School Student Records Act.
23		(s) Information the disclosure of which is restricted
24		under Section 5-108 of the Public Utilities Act.
25		(t) (Blank).
26		(u) Records and information provided to an independent

SB3365 Enrolled - 62 - LRB104 18483 SSS 31925 b
1		team of experts under the Developmental Disability and
2		Mental Health Safety Act (also known as Brian's Law).
3		(v) Names and information of people who have applied
4		for or received Firearm Owner's Identification Cards under
5		the Firearm Owners Identification Card Act or applied for
6		or received a concealed carry license under the Firearm
7		Concealed Carry Act, unless otherwise authorized by the
8		Firearm Concealed Carry Act; and databases under the
9		Firearm Concealed Carry Act, records of the Concealed
10		Carry Licensing Review Board under the Firearm Concealed
11		Carry Act, and law enforcement agency objections under the
12		Firearm Concealed Carry Act.
13		(v-5) Records of the Firearm Owner's Identification
14		Card Review Board that are exempted from disclosure under
15		Section 10 of the Firearm Owners Identification Card Act.
16		(w) Personally identifiable information which is
17		exempted from disclosure under subsection (g) of Section
18		19.1 of the Toll Highway Act.
19		(x) Information which is exempted from disclosure
20		under Section 5-1014.3 of the Counties Code or Section
21		8-11-21 of the Illinois Municipal Code.
22		(y) Confidential information under the Adult
23		Protective Services Act and its predecessor enabling
24		statute, the Elder Abuse and Neglect Act, including
25		information about the identity and administrative finding
26		against any caregiver of a verified and substantiated

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1		decision of abuse, neglect, or financial exploitation of
2		an eligible adult maintained in the Registry established
3		under Section 7.5 of the Adult Protective Services Act.
4		(z) Records and information provided to a fatality
5		review team or the Illinois Fatality Review Team Advisory
6		Council under Section 15 of the Adult Protective Services
7		Act.
8		(aa) Information which is exempted from disclosure
9		under Section 2.37 of the Wildlife Code.
10		(bb) Information which is or was prohibited from
11		disclosure by the Juvenile Court Act of 1987.
12		(cc) Recordings made under the Law Enforcement
13		Officer-Worn Body Camera Act, except to the extent
14		authorized under that Act.
15		(dd) Information that is prohibited from being
16		disclosed under Section 45 of the Condominium and Common
17		Interest Community Ombudsperson Act.
18		(ee) Information that is exempted from disclosure
19		under Section 30.1 of the Pharmacy Practice Act.
20		(ff) Information that is exempted from disclosure
21		under the Revised Uniform Unclaimed Property Act.
22		(gg) Information that is prohibited from being
23		disclosed under Section 7-603.5 of the Illinois Vehicle
24		Code.
25		(hh) Records that are exempt from disclosure under
26		Section 1A-16.7 of the Election Code.

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1		(ii) Information which is exempted from disclosure
2		under Section 2505-800 of the Department of Revenue Law of
3		the Civil Administrative Code of Illinois.
4		(jj) Information and reports that are required to be
5		submitted to the Department of Labor by registering day
6		and temporary labor service agencies but are exempt from
7		disclosure under subsection (a-1) of Section 45 of the Day
8		and Temporary Labor Services Act.
9		(kk) Information prohibited from disclosure under the
10		Seizure and Forfeiture Reporting Act.
11		(ll) Information the disclosure of which is restricted
12		and exempted under Section 5-30.8 of the Illinois Public
13		Aid Code.
14		(mm) Records that are exempt from disclosure under
15		Section 4.2 of the Crime Victims Compensation Act.
16		(nn) Information that is exempt from disclosure under
17		Section 70 of the Higher Education Student Assistance Act.
18		(oo) Communications, notes, records, and reports
19		arising out of a peer support counseling session
20		prohibited from disclosure under the First Responders
21		Suicide Prevention Act.
22		(pp) Names and all identifying information relating to
23		an employee of an emergency services provider or law
24		enforcement agency under the First Responders Suicide
25		Prevention Act.
26		(qq) Information and records held by the Department of

SB3365 Enrolled - 65 - LRB104 18483 SSS 31925 b
1		Public Health and its authorized representatives collected
2		under the Reproductive Health Act.
3		(rr) Information that is exempt from disclosure under
4		the Cannabis Regulation and Tax Act.
5		(ss) Data reported by an employer to the Department of
6		Human Rights pursuant to Section 2-108 of the Illinois
7		Human Rights Act.
8		(tt) Recordings made under the Children's Advocacy
9		Center Act, except to the extent authorized under that
10		Act.
11		(uu) Information that is exempt from disclosure under
12		Section 50 of the Sexual Assault Evidence Submission Act.
13		(vv) Information that is exempt from disclosure under
14		subsections (f) and (j) of Section 5-36 of the Illinois
15		Public Aid Code.
16		(ww) Information that is exempt from disclosure under
17		Section 16.8 of the State Treasurer Act.
18		(xx) Information that is exempt from disclosure or
19		information that shall not be made public under the
20		Illinois Insurance Code.
21		(yy) Information prohibited from being disclosed under
22		the Illinois Educational Labor Relations Act.
23		(zz) Information prohibited from being disclosed under
24		the Illinois Public Labor Relations Act.
25		(aaa) Information prohibited from being disclosed
26		under Section 1-167 of the Illinois Pension Code.

SB3365 Enrolled - 66 - LRB104 18483 SSS 31925 b
1		(bbb) Information that is prohibited from disclosure
2		by the Illinois Police Training Act and the Illinois State
3		Police Act.
4		(ccc) Records exempt from disclosure under Section
5		2605-304 of the Illinois State Police Law of the Civil
6		Administrative Code of Illinois.
7		(ddd) Information prohibited from being disclosed
8		under Section 35 of the Address Confidentiality for
9		Victims of Domestic Violence, Sexual Assault, Human
10		Trafficking, or Stalking Act.
11		(eee) Information prohibited from being disclosed
12		under subsection (b) of Section 75 of the Domestic
13		Violence Fatality Review Act.
14		(fff) Images from cameras under the Expressway Camera
15		Act and all automated license plate reader (ALPR)
16		information used and collected by the Illinois State
17		Police. "ALPR information" means information gathered by
18		an ALPR or created from the analysis of data generated by
19		an ALPR. This subsection (fff) is inoperative on and after
20		July 1, 2028.
21		(ggg) Information prohibited from disclosure under
22		paragraph (3) of subsection (a) of Section 14 of the Nurse
23		Agency Licensing Act.
24		(hhh) Information submitted to the Illinois State
25		Police in an affidavit or application for an assault
26		weapon endorsement, assault weapon attachment endorsement,

SB3365 Enrolled - 67 - LRB104 18483 SSS 31925 b
1		.50 caliber rifle endorsement, or .50 caliber cartridge
2		endorsement under the Firearm Owners Identification Card
3		Act.
4		(iii) Data exempt from disclosure under Section 50 of
5		the School Safety Drill Act.
6		(jjj) Information exempt from disclosure under Section
7		30 of the Insurance Data Security Law.
8		(kkk) Confidential business information prohibited
9		from disclosure under Section 45 of the Paint Stewardship
10		Act.
11		(lll) Data exempt from disclosure under Section
12		2-3.196 of the School Code.
13		(mmm) Information prohibited from being disclosed
14		under subsection (e) of Section 1-129 of the Illinois
15		Power Agency Act.
16		(nnn) Materials received by the Department of Commerce
17		and Economic Opportunity that are confidential under the
18		Music and Musicians Tax Credit and Jobs Act.
19		(ooo) Data or information provided pursuant to Section
20		20 of the Statewide Recycling Needs and Assessment Act.
21		(ppp) Information that is exempt from disclosure under
22		Section 28-11 of the Lawful Health Care Activity Act.
23		(qqq) Information that is exempt from disclosure under
24		Section 7-101 of the Illinois Human Rights Act.
25		(rrr) Information prohibited from being disclosed
26		under Section 4-2 of the Uniform Money Transmission

SB3365 Enrolled - 68 - LRB104 18483 SSS 31925 b
1		Modernization Act.
2		(sss) Information exempt from disclosure under Section
3		40 of the Student-Athlete Endorsement Rights Act.
4		(ttt) Audio recordings made under Section 30 of the
5		Illinois State Police Act, except to the extent authorized
6		under that Section.
7		(uuu) Information prohibited from being disclosed
8		under Section 30-5 of the Digital Assets Regulation Act.
9		(www) Annual summary financial and utilization data
10		reports submitted to the Health Facilities and Services
11		Review Board under Section 13 of the Illinois Health
12		Facilities Planning Act.
13		(Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
14		103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
15		8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
16		eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
17		103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
18		8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
19		eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
20		104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-457, eff.
21		6-1-26; revised 1-7-26.)
22		(Text of Section after amendment by P.A. 104-441)
23		Sec. 7.5. Statutory exemptions. To the extent provided for
24		by the statutes referenced below, the following shall be
25		exempt from inspection and copying:

SB3365 Enrolled - 69 - LRB104 18483 SSS 31925 b
1		(a) All information determined to be confidential
2		under Section 4002 of the Technology Advancement and
3		Development Act.
4		(b) Library circulation and order records identifying
5		library users with specific materials under the Library
6		Records Confidentiality Act.
7		(c) Applications, related documents, and medical
8		records received by the Experimental Organ Transplantation
9		Procedures Board and any and all documents or other
10		records prepared by the Experimental Organ Transplantation
11		Procedures Board or its staff relating to applications it
12		has received.
13		(d) Information and records held by the Department of
14		Public Health and its authorized representatives relating
15		to known or suspected cases of sexually transmitted
16		infection or any information the disclosure of which is
17		restricted under the Illinois Sexually Transmitted
18		Infection Control Act.
19		(e) Information the disclosure of which is exempted
20		under Section 30 of the Radon Industry Licensing Act.
21		(f) Firm performance evaluations under Section 55 of
22		the Architectural, Engineering, and Land Surveying
23		Qualifications Based Selection Act.
24		(g) Information the disclosure of which is restricted
25		and exempted under Section 50 of the Illinois Prepaid
26		Tuition Act.

SB3365 Enrolled - 70 - LRB104 18483 SSS 31925 b
1		(h) Information the disclosure of which is exempted
2		under the State Officials and Employees Ethics Act, and
3		records of any lawfully created State or local inspector
4		general's office that would be exempt if created or
5		obtained by an Executive Inspector General's office under
6		that Act.
7		(i) Information contained in a local emergency energy
8		plan submitted to a municipality in accordance with a
9		local emergency energy plan ordinance that is adopted
10		under Section 11-21.5-5 of the Illinois Municipal Code.
11		(j) Information and data concerning the distribution
12		of surcharge moneys collected and remitted by carriers
13		under the Emergency Telephone System Act.
14		(k) Law enforcement officer identification information
15		or driver identification information compiled by a law
16		enforcement agency or the Department of Transportation
17		under Section 11-212 of the Illinois Vehicle Code.
18		(l) Records and information provided to a residential
19		health care facility resident sexual assault and death
20		review team or the Executive Council under the Abuse
21		Prevention Review Team Act.
22		(m) Information provided to the predatory lending
23		database created pursuant to Article 3 of the Residential
24		Real Property Disclosure Act, except to the extent
25		authorized under that Article.
26		(n) Defense budgets and petitions for certification of

SB3365 Enrolled - 71 - LRB104 18483 SSS 31925 b
1		compensation and expenses for court appointed trial
2		counsel as provided under Sections 10 and 15 of the
3		Capital Crimes Litigation Act (repealed). This subsection
4		(n) shall apply until the conclusion of the trial of the
5		case, even if the prosecution chooses not to pursue the
6		death penalty prior to trial or sentencing.
7		(o) Information that is prohibited from being
8		disclosed under Section 4 of the Illinois Health and
9		Hazardous Substances Registry Act.
10		(p) Security portions of system safety program plans,
11		investigation reports, surveys, schedules, lists, data, or
12		information compiled, collected, or prepared by or for the
13		Department of Transportation under Sections 2705-300 and
14		2705-616 of the Department of Transportation Law of the
15		Civil Administrative Code of Illinois, the Northern
16		Illinois Transit Authority under Section 2.11 of the
17		Northern Illinois Transit Authority Act, or the St. Clair
18		County Transit District under the Bi-State Transit Safety
19		Act (repealed).
20		(q) Information prohibited from being disclosed by the
21		Personnel Record Review Act.
22		(r) Information prohibited from being disclosed by the
23		Illinois School Student Records Act.
24		(s) Information the disclosure of which is restricted
25		under Section 5-108 of the Public Utilities Act.
26		(t) (Blank).

SB3365 Enrolled - 72 - LRB104 18483 SSS 31925 b
1		(u) Records and information provided to an independent
2		team of experts under the Developmental Disability and
3		Mental Health Safety Act (also known as Brian's Law).
4		(v) Names and information of people who have applied
5		for or received Firearm Owner's Identification Cards under
6		the Firearm Owners Identification Card Act or applied for
7		or received a concealed carry license under the Firearm
8		Concealed Carry Act, unless otherwise authorized by the
9		Firearm Concealed Carry Act; and databases under the
10		Firearm Concealed Carry Act, records of the Concealed
11		Carry Licensing Review Board under the Firearm Concealed
12		Carry Act, and law enforcement agency objections under the
13		Firearm Concealed Carry Act.
14		(v-5) Records of the Firearm Owner's Identification
15		Card Review Board that are exempted from disclosure under
16		Section 10 of the Firearm Owners Identification Card Act.
17		(w) Personally identifiable information which is
18		exempted from disclosure under subsection (g) of Section
19		19.1 of the Toll Highway Act.
20		(x) Information which is exempted from disclosure
21		under Section 5-1014.3 of the Counties Code or Section
22		8-11-21 of the Illinois Municipal Code.
23		(y) Confidential information under the Adult
24		Protective Services Act and its predecessor enabling
25		statute, the Elder Abuse and Neglect Act, including
26		information about the identity and administrative finding

SB3365 Enrolled - 73 - LRB104 18483 SSS 31925 b
1		against any caregiver of a verified and substantiated
2		decision of abuse, neglect, or financial exploitation of
3		an eligible adult maintained in the Registry established
4		under Section 7.5 of the Adult Protective Services Act.
5		(z) Records and information provided to a fatality
6		review team or the Illinois Fatality Review Team Advisory
7		Council under Section 15 of the Adult Protective Services
8		Act.
9		(aa) Information which is exempted from disclosure
10		under Section 2.37 of the Wildlife Code.
11		(bb) Information which is or was prohibited from
12		disclosure by the Juvenile Court Act of 1987.
13		(cc) Recordings made under the Law Enforcement
14		Officer-Worn Body Camera Act, except to the extent
15		authorized under that Act.
16		(dd) Information that is prohibited from being
17		disclosed under Section 45 of the Condominium and Common
18		Interest Community Ombudsperson Act.
19		(ee) Information that is exempted from disclosure
20		under Section 30.1 of the Pharmacy Practice Act.
21		(ff) Information that is exempted from disclosure
22		under the Revised Uniform Unclaimed Property Act.
23		(gg) Information that is prohibited from being
24		disclosed under Section 7-603.5 of the Illinois Vehicle
25		Code.
26		(hh) Records that are exempt from disclosure under

SB3365 Enrolled - 74 - LRB104 18483 SSS 31925 b
1		Section 1A-16.7 of the Election Code.
2		(ii) Information which is exempted from disclosure
3		under Section 2505-800 of the Department of Revenue Law of
4		the Civil Administrative Code of Illinois.
5		(jj) Information and reports that are required to be
6		submitted to the Department of Labor by registering day
7		and temporary labor service agencies but are exempt from
8		disclosure under subsection (a-1) of Section 45 of the Day
9		and Temporary Labor Services Act.
10		(kk) Information prohibited from disclosure under the
11		Seizure and Forfeiture Reporting Act.
12		(ll) Information the disclosure of which is restricted
13		and exempted under Section 5-30.8 of the Illinois Public
14		Aid Code.
15		(mm) Records that are exempt from disclosure under
16		Section 4.2 of the Crime Victims Compensation Act.
17		(nn) Information that is exempt from disclosure under
18		Section 70 of the Higher Education Student Assistance Act.
19		(oo) Communications, notes, records, and reports
20		arising out of a peer support counseling session
21		prohibited from disclosure under the First Responders
22		Suicide Prevention Act.
23		(pp) Names and all identifying information relating to
24		an employee of an emergency services provider or law
25		enforcement agency under the First Responders Suicide
26		Prevention Act.

SB3365 Enrolled - 75 - LRB104 18483 SSS 31925 b
1		(qq) Information and records held by the Department of
2		Public Health and its authorized representatives collected
3		under the Reproductive Health Act.
4		(rr) Information that is exempt from disclosure under
5		the Cannabis Regulation and Tax Act.
6		(ss) Data reported by an employer to the Department of
7		Human Rights pursuant to Section 2-108 of the Illinois
8		Human Rights Act.
9		(tt) Recordings made under the Children's Advocacy
10		Center Act, except to the extent authorized under that
11		Act.
12		(uu) Information that is exempt from disclosure under
13		Section 50 of the Sexual Assault Evidence Submission Act.
14		(vv) Information that is exempt from disclosure under
15		subsections (f) and (j) of Section 5-36 of the Illinois
16		Public Aid Code.
17		(ww) Information that is exempt from disclosure under
18		Section 16.8 of the State Treasurer Act.
19		(xx) Information that is exempt from disclosure or
20		information that shall not be made public under the
21		Illinois Insurance Code.
22		(yy) Information prohibited from being disclosed under
23		the Illinois Educational Labor Relations Act.
24		(zz) Information prohibited from being disclosed under
25		the Illinois Public Labor Relations Act.
26		(aaa) Information prohibited from being disclosed

SB3365 Enrolled - 76 - LRB104 18483 SSS 31925 b
1		under Section 1-167 of the Illinois Pension Code.
2		(bbb) Information that is prohibited from disclosure
3		by the Illinois Police Training Act and the Illinois State
4		Police Act.
5		(ccc) Records exempt from disclosure under Section
6		2605-304 of the Illinois State Police Law of the Civil
7		Administrative Code of Illinois.
8		(ddd) Information prohibited from being disclosed
9		under Section 35 of the Address Confidentiality for
10		Victims of Domestic Violence, Sexual Assault, Human
11		Trafficking, or Stalking Act.
12		(eee) Information prohibited from being disclosed
13		under subsection (b) of Section 75 of the Domestic
14		Violence Fatality Review Act.
15		(fff) Images from cameras under the Expressway Camera
16		Act and all automated license plate reader (ALPR)
17		information used and collected by the Illinois State
18		Police. "ALPR information" means information gathered by
19		an ALPR or created from the analysis of data generated by
20		an ALPR. This subsection (fff) is inoperative on and after
21		July 1, 2028.
22		(ggg) Information prohibited from disclosure under
23		paragraph (3) of subsection (a) of Section 14 of the Nurse
24		Agency Licensing Act.
25		(hhh) Information submitted to the Illinois State
26		Police in an affidavit or application for an assault

SB3365 Enrolled - 77 - LRB104 18483 SSS 31925 b
1		weapon endorsement, assault weapon attachment endorsement,
2		.50 caliber rifle endorsement, or .50 caliber cartridge
3		endorsement under the Firearm Owners Identification Card
4		Act.
5		(iii) Data exempt from disclosure under Section 50 of
6		the School Safety Drill Act.
7		(jjj) Information exempt from disclosure under Section
8		30 of the Insurance Data Security Law.
9		(kkk) Confidential business information prohibited
10		from disclosure under Section 45 of the Paint Stewardship
11		Act.
12		(lll) Data exempt from disclosure under Section
13		2-3.196 of the School Code.
14		(mmm) Information prohibited from being disclosed
15		under subsection (e) of Section 1-129 of the Illinois
16		Power Agency Act.
17		(nnn) Materials received by the Department of Commerce
18		and Economic Opportunity that are confidential under the
19		Music and Musicians Tax Credit and Jobs Act.
20		(ooo) Data or information provided pursuant to Section
21		20 of the Statewide Recycling Needs and Assessment Act.
22		(ppp) Information that is exempt from disclosure under
23		Section 28-11 of the Lawful Health Care Activity Act.
24		(qqq) Information that is exempt from disclosure under
25		Section 7-101 of the Illinois Human Rights Act.
26		(rrr) Information prohibited from being disclosed

SB3365 Enrolled - 78 - LRB104 18483 SSS 31925 b
1		under Section 4-2 of the Uniform Money Transmission
2		Modernization Act.
3		(sss) Information exempt from disclosure under Section
4		40 of the Student-Athlete Endorsement Rights Act.
5		(ttt) Audio recordings made under Section 30 of the
6		Illinois State Police Act, except to the extent authorized
7		under that Section.
8		(uuu) Information prohibited from being disclosed
9		under Section 30-5 of the Digital Assets Regulation Act.
10		(vvv) (uuu) Information exempt from disclosure under
11		Section 70 of the End-of-Life Options for Terminally Ill
12		Patients Act.
13		(www) Annual summary financial and utilization data
14		reports submitted to the Health Facilities and Services
15		Review Board under Section 13 of the Illinois Health
16		Facilities Planning Act.
17		(Source: P.A. 103-8, eff. 6-7-23; 103-34, eff. 6-9-23;
18		103-142, eff. 1-1-24; 103-372, eff. 1-1-24; 103-472, eff.
19		8-1-24; 103-508, eff. 8-4-23; 103-580, eff. 12-8-23; 103-592,
20		eff. 6-7-24; 103-605, eff. 7-1-24; 103-636, eff. 7-1-24;
21		103-724, eff. 1-1-25; 103-786, eff. 8-7-24; 103-859, eff.
22		8-9-24; 103-991, eff. 8-9-24; 103-1049, eff. 8-9-24; 103-1081,
23		eff. 3-21-25; 104-10, eff. 6-16-25; 104-18, eff. 6-30-25;
24		104-417, eff. 8-15-25; 104-428, eff. 8-18-25; 104-441, eff.
25		9-12-26; 104-457, eff. 6-1-26; revised 1-7-26.)

SB3365 Enrolled - 79 - LRB104 18483 SSS 31925 b
1		Section 6-75. The Illinois Health Facilities Planning Act
2		is amended by changing Sections 2 and 13 as follows:
3		(20 ILCS 3960/2)  (from Ch. 111 1/2, par. 1152)
4		(Section scheduled to be repealed on December 31, 2029)
5		Sec. 2. Purpose of the Act. This Act shall establish a
6		procedure (1) which requires a person establishing,
7		constructing or modifying a health care facility, as herein
8		defined, to have the qualifications, background, character and
9		financial resources to adequately provide a proper service for
10		the community; (2) that promotes the orderly and economic
11		development of health care facilities in the State of Illinois
12		that avoids unnecessary duplication of such facilities; and
13		(3) that promotes planning for and development of health care
14		facilities needed for comprehensive health care especially in
15		areas where the health planning process has identified unmet
16		needs.
17		The changes made to this Act by this amendatory Act of the
18		96th General Assembly are intended to accomplish the following
19		objectives: to improve the financial ability of the public to
20		obtain necessary health services; to establish an orderly and
21		comprehensive health care delivery system that will guarantee
22		the availability of quality health care to the general public;
23		to maintain and improve the provision of essential health care
24		services and increase the accessibility of those services to
25		the medically underserved and indigent; to assure that the

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1		reduction and closure of health care services or facilities is
2		performed in an orderly and timely manner, and that these
3		actions are deemed to be in the best interests of the public;
4		and to assess the financial burden to patients caused by
5		unnecessary health care construction and modification.
6		Evidence-based assessments, projections and decisions will be
7		applied regarding capacity, quality, value and equity in the
8		delivery of health care services in Illinois. The integrity of
9		the Certificate of Need process is ensured through revised
10		ethics and communications procedures. Cost containment and
11		support for safety net services must continue to be central
12		tenets of the Certificate of Need process.
13		The changes made to this Act by this amendatory Act of the
14		104th General Assembly are intended to allow the State to
15		collect additional information regarding the financial ability
16		for health care facilities to deliver services in Illinois.
17		(Source: P.A. 99-527, eff. 1-1-17.)
18		(20 ILCS 3960/13)  (from Ch. 111 1/2, par. 1163)
19		(Section scheduled to be repealed on December 31, 2029)
20		Sec. 13. Investigation of applications for permits.
21		(a) Investigations. The State Board shall make or cause to
22		be made such investigations as it deems necessary in
23		connection with an application for a permit, or in connection
24		with a determination of whether or not construction or
25		modification that has been commenced is in accord with the

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1		permit issued by the State Board, or whether construction or
2		modification has been commenced without a permit having been
3		obtained. The State Board may issue subpoenas duces tecum
4		requiring the production of records and may administer oaths
5		to such witnesses.
6		Any circuit court of this State, upon the application of
7		the State Board or upon the application of any party to such
8		proceedings, may, in its discretion, compel the attendance of
9		witnesses, the production of books, papers, records, or
10		memoranda and the giving of testimony before the State Board,
11		by a proceeding as for contempt, or otherwise, in the same
12		manner as production of evidence may be compelled before the
13		court.
14		(b) Reports from health facilities. The State Board shall
15		require all health facilities operating in this State to
16		provide such reasonable reports at such times and containing
17		such information as is needed by it to carry out the purposes
18		and provisions of this Act. Prior to collecting information
19		from health facilities, the State Board shall make reasonable
20		efforts through a public process to consult with health
21		facilities and associations that represent them to determine
22		whether data and information requests will result in useful
23		information for health planning, whether sufficient
24		information is available from other sources, and whether data
25		requested is routinely collected by health facilities and is
26		available without retrospective record review. Data and

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1		information requests shall not impose undue paperwork burdens
2		on health care facilities and personnel. Health facilities not
3		complying with this requirement shall be reported to
4		licensing, accrediting, certifying, or payment agencies as
5		being in violation of State law. Health care facilities and
6		other parties at interest shall have reasonable access, under
7		rules established by the State Board, to all planning
8		information submitted in accord with this Act pertaining to
9		their area.
10		(1) Questionnaires. Among the reports to be required
11		by the State Board are facility questionnaires for health
12		care facilities licensed under the Ambulatory Surgical
13		Treatment Center Act, the Hospital Licensing Act, the
14		Nursing Home Care Act, the ID/DD Community Care Act, the
15		MC/DD Act, or the Specialized Mental Health Rehabilitation
16		Act of 2013 and health care facilities that are required
17		to meet the requirements of 42 CFR 494 in order to be
18		certified for participation in Medicare and Medicaid under
19		Titles XVIII and XIX of the federal Social Security Act.
20		These questionnaires shall be conducted on an annual basis
21		and compiled by the State Board. For health care
22		facilities licensed under the Nursing Home Care Act or the
23		Specialized Mental Health Rehabilitation Act of 2013,
24		these reports shall include, but not be limited to, the
25		identification of specialty services provided by the
26		facility to patients, residents, and the community at

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1		large. Annual reports for facilities licensed under the
2		ID/DD Community Care Act and facilities licensed under the
3		MC/DD Act shall be different from the annual reports
4		required of other health care facilities and shall be
5		specific to those facilities licensed under the ID/DD
6		Community Care Act or the MC/DD Act. The Health Facilities
7		and Services Review Board shall consult with associations
8		representing facilities licensed under the ID/DD Community
9		Care Act and associations representing facilities licensed
10		under the MC/DD Act when developing the information
11		requested in these annual reports. For health care
12		facilities that contain long term care beds, the reports
13		shall also include the number of staffed long term care
14		beds, physical capacity for long term care beds at the
15		facility, and long term care beds available for immediate
16		occupancy. For purposes of this paragraph, "long term care
17		beds" means beds (i) licensed under the Nursing Home Care
18		Act, (ii) licensed under the ID/DD Community Care Act,
19		(iii) licensed under the MC/DD Act, (iv) licensed under
20		the Hospital Licensing Act, or (v) licensed under the
21		Specialized Mental Health Rehabilitation Act of 2013 and
22		certified as skilled nursing or nursing facility beds
23		under Medicaid or Medicare.
24		For health care facilities licensed under the Hospital
25		Licensing Act, the health care facilities operating in
26		this State shall report the following financial and

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1		utilization data annually: (i) the most recent audited
2		financial statements; (ii) the most recent month-end
3		balance sheet detailing the assets, liabilities, and net
4		worth at the end of the month immediately preceding the
5		annual reporting cycle; (iii) the most recent income
6		statement for the month immediately preceding the annual
7		reporting cycle summarizing the revenues, expenses, and
8		net income; (iv) the total number of inpatient days,
9		outpatient visits, and discharges by payer, including, but
10		not limited to, Medicare, Medicaid fee-for-service,
11		Medicaid managed care, commercial coverage, and other
12		payers; (v) the total inpatient gross revenues by payer,
13		including, but not limited to, Medicare, Medicaid
14		fee-for-service, Medicaid managed care, commercial
15		coverage, and other payers; and (vi) the total outpatient
16		gross revenues by payer, including, but not limited to,
17		Medicare, Medicaid fee-for-service, Medicaid managed care,
18		commercial coverage, and other payers. The transmission of
19		the financial and utilization data shall be due to the
20		State Board within 90 days after the effective date of
21		this amendatory Act of the 104th General Assembly, and
22		thereafter, the data shall be due annually on the regular
23		schedule set by the State Board for questionnaires. The
24		State Board, in coordination with the Department of
25		Healthcare and Family Services and the Department of
26		Public Health, shall administer the collection of the

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1		financial and utilization data submitted under this
2		Section. The State Board may adopt any administrative
3		rules, including emergency rules, necessary to implement
4		this Section, including requesting additional information
5		or removing information from the reporting requirements.
6		If a health care facility has not filed the required
7		financial and utilization data within 90 days after the
8		close of the annual reporting period, the State Board
9		shall impose fines of not more than $5,000 per week for
10		failure to comply with the provisions of this Section.
11		(2) Confidentiality.
12		(A) The State Board shall keep confidential the
13		annual summary financial and utilization data report
14		submitted under this Section and all information in
15		the report as required by this Section. The financial
16		and utilization data shall remain confidential, is not
17		subject to subpoena, is not subject to discovery or
18		admissible as evidence in private civil litigation, is
19		not subject to disclosure under the Freedom of
20		Information Act, and must not be made public at any
21		time or used by the State Board or any other person,
22		except as provided in subparagraphs (B), (D), and (E)
23		of this paragraph (2).
24		(B) Notwithstanding subparagraph (A), the State
25		Board may:
26		(i) share the financial and utilization data

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1		submitted under this Section with other State
2		agencies;
3		(ii) share the financial and utilization data
4		submitted under this Section with third-party
5		vendors or contractors of a State agency, federal
6		regulatory agencies, or law enforcement
7		authorities, if the recipient agrees to and
8		verifies in writing its legal authority to
9		maintain the confidentiality and privileged status
10		of the financial and utilization data;
11		(iii) enter into agreements governing the
12		sharing and use of information consistent with
13		this Section.
14		(C) Disclosure of the financial and utilization
15		data to the State Board and by the State Board under
16		this Section does not waive any applicable privilege
17		or claim of confidentiality in the report or
18		information.
19		(D) Notwithstanding the confidentiality
20		requirements of this Section or otherwise imposed by
21		State law, relevant State agencies may make public
22		financial and utilization data submitted under this
23		Section in an aggregated format that does not disclose
24		information or data attributed to any specific
25		facility.
26		(E) Notwithstanding the confidentiality

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1		requirements of this Section, a State agency may
2		disclose the financial and utilization data submitted
3		under this Section with the written consent of the
4		hospital that submitted the report.
5		(Source: P.A. 100-681, eff. 8-3-18; 100-957, eff. 8-19-18;
6		101-81, eff. 7-12-19.)
7		Section 6-80. The Hospital Licensing Act is amended by
8		adding Section 4.8 as follows:
9		(210 ILCS 85/4.8 new)
10		Sec. 4.8. Additional licensing requirements.
11		(a) Hospital emergency and financial contingency plan. Any
12		hospital licensed under this Act that has outstanding debts to
13		the State in the form of tax arrears or that maintains debt
14		through the Distressed Hospital Loan Program or other Medicaid
15		advance payments shall submit to the Department a hospital
16		emergency and financial contingency plan for the rapid and
17		orderly resolution of finances and operations in the event of
18		material financial distress. The plan shall be submitted on an
19		annual basis until any outstanding assessment or advance
20		balances have been fully paid. The plan shall include, but not
21		be limited to, procedures for the safe and orderly transfer
22		and continuity of care for patients if closure of at least one
23		category of service, or a temporary suspension of such service
24		for any reason, were to occur. Potential events precipitating

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1		closure or suspended services that shall be addressed in the
2		plan, include, but are not limited to: financial distress,
3		regulatory and compliance issues, operational or workforce
4		challenges, infrastructure and facility issues, emergency or
5		disaster related causes, and strategic organizational
6		decisions. The plan shall contemplate (i) the identification
7		of potential service area gaps created due to emergency
8		closure and suspension of services and (ii) the orderly
9		preservation and transfer of medical records in accordance
10		with the Medical Patient Rights Act, the Health Insurance
11		Portability and Accountability Act of 1996, and other
12		applicable medical privacy laws.
13		(b) Hospital emergency and financial contingency plans for
14		hospitals with multiple locations operating under a single
15		license. Any hospital licensed by the Department under Section
16		4.5 of this Act and required to submit a hospital emergency and
17		financial contingency plan shall submit a hospital emergency
18		and financial contingency plan as outlined in subsection (a)
19		considering each location, campus, or facility administered
20		under the license that could reasonably be affected.
21		(c) Annual filing. Hospital emergency and financial
22		contingency plans shall be filed with the Department no later
23		than 3 months after the effective date of this amendatory Act
24		of the 104th General Assembly. Hospital emergency and
25		financial contingency plans, or annual affirmations of
26		previously filed hospital emergency and financial contingency

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1		plans, as outlined in this Section shall be submitted on an
2		annual basis as determined by the Department through
3		administrative rule.
4		(d) Penalties for noncompliance. The Department may impose
5		fines of not more than $500 per week for failure to comply with
6		the provisions of this Section.
7		(e) This Section is operative on and after January 1,
8		2027.
9		ARTICLE 10.
10		Section 10-5. The Rebuild Illinois Mental Health Workforce
11		Act is amended by changing Section 20-10 as follows:
12		(305 ILCS 66/20-10)
13		Sec. 20-10. Medicaid funding for community mental health
14		services. Medicaid funding for the specific community mental
15		health services listed in this Act shall be adjusted and paid
16		as set forth in this Act. Such payments shall be paid in
17		addition to the base Medicaid reimbursement rate and add-on
18		payment rates per service unit.
19		(a) The following payment adjustments shall begin on July
20		1, 2022 for State Fiscal Year 2023 and shall continue for every
21		State fiscal year thereafter.
22		(1) Individual Therapy Medicaid Payment rate for
23		services provided under the H0004 Code:

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1		(A) The Medicaid total payment rate for individual
2		therapy provided by a qualified mental health
3		professional shall be increased by no less than $9 per
4		service unit.
5		(B) The Medicaid total payment rate for individual
6		therapy provided by a mental health professional shall
7		be increased by no less than $9 per service unit.
8		(2) Community Support - Individual Medicaid Payment
9		rate for services provided under the H2015 Code: All
10		community support - individual services shall be increased
11		by no less than $15 per service unit.
12		(3) Case Management Medicaid Add-on Payment for
13		services provided under the T1016 code: All case
14		management services rates shall be increased by no less
15		than $15 per service unit.
16		(4) Assertive Community Treatment Medicaid Add-on
17		Payment for services provided under the H0039 code: The
18		Medicaid total payment rate for assertive community
19		treatment services shall increase by no less than $8 per
20		service unit.
21		(b) (5) Medicaid user-based directed payments. The
22		following directed payments shall be paid to qualifying
23		providers for State Fiscal Year 2023 through State Fiscal Year
24		2026. This subsection does not prevent the Department from
25		making payments in future State fiscal years to correct errors
26		or omissions made in State Fiscal Year 2023 through State

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1		Fiscal Year 2026 payments.
2		(1) (A) For each State fiscal year, a monthly directed
3		payment shall be paid to a community mental health
4		provider of community support team services based on the
5		number of Medicaid users of community support team
6		services documented by Medicaid fee-for-service and
7		managed care encounter claims delivered by that provider
8		in the base year. The Department of Healthcare and Family
9		Services shall make the monthly directed payment to each
10		provider entitled to directed payments under this Act by
11		no later than the last day of each month throughout each
12		State fiscal year.
13		(A) (i) The monthly directed payment for a
14		community support team provider shall be calculated as
15		follows: The sum total number of individual Medicaid
16		users of community support team services delivered by
17		that provider throughout the base year, multiplied by
18		$4,200 per Medicaid user, divided into 12 equal
19		monthly payments for the State fiscal year.
20		(B) (ii) As used in this subparagraph, "user"
21		means an individual who received at least 200 units of
22		community support team services (H2016) during the
23		base year.
24		(2) (B) For each State fiscal year, a monthly directed
25		payment shall be paid to each community mental health
26		provider of assertive community treatment services based

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1		on the number of Medicaid users of assertive community
2		treatment services documented by Medicaid fee-for-service
3		and managed care encounter claims delivered by the
4		provider in the base year.
5		(A) (i) The monthly direct payment for an
6		assertive community treatment provider shall be
7		calculated as follows: The sum total number of
8		Medicaid users of assertive community treatment
9		services provided by that provider throughout the base
10		year, multiplied by $6,000 per Medicaid user, divided
11		into 12 equal monthly payments for that State fiscal
12		year.
13		(B) (ii) As used in this subparagraph, "user"
14		means an individual that received at least 300 units
15		of assertive community treatment services during the
16		base year.
17		(3) (C) The base year for directed payments under this
18		Section shall be calendar year 2019 for State Fiscal Year
19		2023 and State Fiscal Year 2024. For the State fiscal year
20		beginning on July 1, 2024, and for every State fiscal year
21		thereafter, the base year shall be the calendar year that
22		ended 18 months prior to the start of the State fiscal year
23		in which payments are made.
24		(b-5) (b) Subject to federal approval, a one-time directed
25		payment must be made in calendar year 2023 for community
26		mental health services provided by community mental health

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1		providers. The one-time directed payment shall be for an
2		amount appropriated for these purposes. The one-time directed
3		payment shall be for services for Integrated Assessment and
4		Treatment Planning and other intensive services, including,
5		but not limited to, services for Mobile Crisis Response,
6		crisis intervention, and medication monitoring. The amounts
7		and services used for designing and distributing these
8		one-time directed payments shall not be construed to require
9		any future rate or funding increases for the same or other
10		mental health services.
11		(b-6) Subject to federal approval, for dates of service on
12		and after July 1, 2026, the Medicaid reimbursement rates for
13		Assertive Community Treatment and Community Support Team
14		services shall be increased by an amount no less than the
15		following targeted pools. The Department must use service
16		units delivered under the fee-for-service and managed care
17		programs by community mental health centers during State
18		Fiscal Year 2024 for distributing the targeted pools and
19		setting rates.
20		(1) Assertive Community Treatment, $10,600,000; and
21		(2) Community Support Team services, $17,500,000.
22		(c) The following payment adjustments shall be made:
23		(1) Subject to federal approval, beginning on January
24		1, 2024, the Department shall introduce rate increases to
25		behavioral health services no less than by the following
26		targeted pool for the specified services provided by

SB3365 Enrolled - 94 - LRB104 18483 SSS 31925 b
1		community mental health centers:
2		(A) Mobile Crisis Response, $6,800,000;
3		(B) Crisis Intervention, $4,000,000;
4		(C) Integrative Assessment and Treatment Planning
5		services, $10,500,000;
6		(D) Group Therapy, $1,200,000;
7		(E) Family Therapy, $500,000;
8		(F) Community Support Group, $4,000,000; and
9		(G) Medication Monitoring, $3,000,000.
10		(2) Rate increases shall be determined with
11		significant input from Illinois behavioral health trade
12		associations and advocates. The Department must use
13		service units delivered under the fee-for-service and
14		managed care programs by community mental health centers
15		during State Fiscal Year 2022. These services are used for
16		distributing the targeted pools and setting rates but do
17		not prohibit the Department from paying providers not
18		enrolled as community mental health centers the same rate
19		if providing the same services.
20		(d) Rate simplification for team-based services.
21		(1) The Department shall work with stakeholders to
22		redesign reimbursement rates for behavioral health
23		team-based services established under the Rehabilitation
24		Option of the Illinois Medicaid State Plan supporting
25		individuals with chronic or complex behavioral health
26		conditions and crisis services. Subject to federal

SB3365 Enrolled - 95 - LRB104 18483 SSS 31925 b
1		approval, the redesigned rates shall seek to introduce
2		bundled payment systems that minimize provider claiming
3		activities while transitioning the focus of treatment
4		towards metrics and outcomes. Federally approved rate
5		models shall seek to ensure reimbursement levels are no
6		less than the State's total reimbursement for similar
7		services in calendar year 2023, including all service
8		level payments, add-ons, and all other payments specified
9		in this Section.
10		(2) In State Fiscal Year 2024, the Department shall
11		identify an existing, or establish a new, Behavioral
12		Health Outcomes Stakeholder Workgroup to help inform the
13		identification of metrics and outcomes for team-based
14		services.
15		(3) In State Fiscal Year 2025, subject to federal
16		approval, the Department shall introduce a
17		pay-for-performance model for team-based services to be
18		informed by the Behavioral Health Outcomes Stakeholder
19		Workgroup.
20		(Source: P.A. 102-699, eff. 4-19-22; 102-1118, eff. 1-18-23;
21		103-102, eff. 7-1-23; 103-154, eff. 6-30-23.)
22		ARTICLE 15.
23		Section 15-5. The State Finance Act is amended by changing
24		Section 5.945 as follows:

SB3365 Enrolled - 96 - LRB104 18483 SSS 31925 b
1		(30 ILCS 105/5.945)
2		Sec. 5.945. The Medicaid Technical Assistance Center Fund.
3		Notwithstanding any other provision of law, in addition to any
4		other transfers that may be provided by law, on July 1, 2026,
5		or as soon thereafter as practical, the State Comptroller
6		shall direct and the State Treasurer shall transfer the
7		remaining balance from the Medicaid Technical Assistance
8		Center Fund into the Healthcare Provider Relief Fund. Upon
9		completion of the transfers, the Medicaid Technical Assistance
10		Center Fund is dissolved, and any future deposits due to that
11		Fund and any outstanding obligations or liabilities of that
12		Fund pass to the Healthcare Provider Relief Fund.
13		(Source: P.A. 102-4, Article 185, Section 185-90, eff.
14		4-27-21; 102-813, eff. 5-13-22.)
15		Section 15-10. The Medicaid Technical Assistance Act is
16		amended by changing Sections 185-5 and 185-15 as follows:
17		(305 ILCS 75/185-5)
18		Sec. 185-5. Definitions. As used in this Act:
19		"Behavioral health providers" includes providers of mental
20		health, substance use disorder, developmental disabilities,
21		and autism services for purposes of this Act, but does not
22		change any other legal, programmatic, diagnostic, or clinical
23		provisions defining or relating to coverage of such services.

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1		means mental health and substance use disorder providers.
2		"Department" means the Department of Healthcare and Family
3		Services.
4		"Health care providers" means individuals and
5		organizations that who provide physical, mental, or substance
6		use disorder services, or services supporting social
7		determinants determinant of health services.
8		"Health equity" means providing care that does not vary in
9		quality because of personal characteristics such as gender,
10		ethnicity, geographic location, and socioeconomic status.
11		"Network adequacy" means a Medicaid beneficiaries' ability
12		to access all necessary provider types within time and
13		distance standards as defined in the Managed Care Organization
14		model contract.
15		"Service deserts" means geographic areas of the State with
16		no or limited Medicaid providers that accept Medicaid.
17		"Social determinants of health" means any conditions that
18		impact an individual's health, including, but not limited to,
19		access to healthy food, safety, education, and housing
20		stability.
21		"Stakeholders" means, but are not limited to, health care
22		providers, advocacy organizations, managed care organizations,
23		Medicaid beneficiaries, and State and city partners.
24		(Source: P.A. 102-4, eff. 4-27-21.)
25		(305 ILCS 75/185-15)

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1		Sec. 185-15. Collaboration. The Medicaid Technical
2		Assistance Center shall collaborate with public and private
3		partners throughout the State to identify, establish, and
4		maintain best practices necessary for health providers to
5		ensure their capacity to participate in the Illinois Medical
6		Assistance Program. The Medicaid Technical Assistance Center
7		shall promote equitable delivery systems, remaining committed
8		to the principle that all Medicaid recipients have accessible
9		and equitable physical and mental health care services
10		HealthChoice Illinois or YouthCare. The Medicaid Technical
11		Assistance Center shall administer the following:
12		(1) Outreach and engagement: The Medicaid Technical
13		Assistance Center shall undertake efforts to identify and
14		engage community-based providers offering services to
15		customers funded by the Department, including, but not
16		limited to, behavioral health services and or services
17		addressing the social determinants of health, especially
18		those predominantly serving communities of color or those
19		operating within or near service deserts, for the purpose
20		of offering training and technical assistance to them
21		through the Medicaid Technical Assistance Center. Outreach
22		and engagement services may be subcontracted.
23		(2) Trainings: The Medicaid Technical Assistance
24		Center shall create and administer ongoing trainings for
25		health care providers. Trainings may be subcontracted. The
26		Medicaid Technical Assistance Center shall provide

SB3365 Enrolled - 99 - LRB104 18483 SSS 31925 b
1		in-person and web-based trainings. In-person training
2		shall be conducted throughout the State. All trainings
3		must be free of charge. The Medicaid Technical Assistance
4		Center shall administer post-training surveys and
5		incorporate feedback. Training content and delivery must
6		be reflective of Illinois providers' varying levels of
7		readiness, resources, and client populations.
8		(3) Web-based resources: The Medicaid Technical
9		Assistance Center shall maintain an independent, easy to
10		navigate, and up-to-date website that includes, but is not
11		limited to: recorded training archives, a training
12		calendar, provider resources and tools, up-to-date
13		explanations of Department and managed care organization
14		guidance, a running database of frequently asked questions
15		and contact information for key staff members of the
16		Department, managed care organizations, and the Medicaid
17		Technical Assistance Center.
18		(4) Learning collaboratives: The Medicaid Technical
19		Assistance Center shall host regional learning
20		collaboratives that will supplement the Medicaid Technical
21		Assistance Center training curriculum to bring together
22		groups of stakeholders to share issues and best practices,
23		and to escalate issues. Leadership of the Department and
24		managed care organizations shall attend learning
25		collaboratives on a quarterly basis.
26		(5) Network recruitment plan: Using reports and data

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1		provided by the Department's External Quality Review
2		Organization on adequacy reports: The Medicaid Technical
3		Assistance Center shall publicly release a report on
4		Medicaid provider network adequacy, within the first 3
5		years of implementation and annually thereafter. The
6		reports shall identify provider service deserts, and
7		health care disparities by race and ethnicity, the
8		Medicaid Technical Assistance Center shall propose for
9		Department review and approval an annual plan for
10		recruiting providers to participate in the Illinois
11		Medical Assistance Program and report on outcomes of its
12		recruitment efforts to the Department for continuous
13		improvement. Recruitment plans shall prioritize efforts to
14		bolster access in provider service deserts and in
15		communities experiencing health care disparities by race
16		and ethnicity, with a special focus on behavioral health
17		services and services that address social determinants of
18		health.
19		(6) Equitable delivery system: The Medicaid Technical
20		Assistance Center is committed to the principle that all
21		Medicaid recipients have accessible and equitable physical
22		and mental health care services. All providers served
23		through the Medicaid Technical Assistance Center shall
24		deliver services notwithstanding the patient's race,
25		color, gender, gender identity, age, ancestry, marital
26		status, military status, religion, national origin,

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1		disability status, sexual orientation, order of protection
2		status, as defined under Section 1-103 of the Illinois
3		Human Rights Act, or immigration status.
4		(Source: P.A. 102-4, eff. 4-27-21.)
5		(305 ILCS 75/185-20 rep.)
6		(305 ILCS 75/185-25 rep.)
7		Section 15-15. The Medicaid Technical Assistance Act is
8		amended by repealing Sections 185-20 and 185-25.
9		ARTICLE 20.
10		Section 20-5. The Illinois Public Aid Code is amended by
11		changing Section 5-5f as follows:
12		(305 ILCS 5/5-5f)
13		Sec. 5-5f. Elimination and limitations of medical
14		assistance services. Notwithstanding any other provision of
15		this Code to the contrary, on and after July 1, 2012:
16		(a) The following service shall no longer be a covered
17		service available under this Code: group psychotherapy for
18		residents of any facility licensed under the Nursing Home
19		Care Act or the Specialized Mental Health Rehabilitation
20		Act of 2013.
21		(b) The Department shall place the following
22		limitations on services: (i) the Department shall limit

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1		adult eyeglasses to one pair every 2 years; however, the
2		limitation does not apply to an individual who needs
3		different eyeglasses following a surgical procedure such
4		as cataract surgery; (ii) the Department shall set an
5		annual limit of a maximum of 20 visits for each of the
6		following services: adult speech, hearing, and language
7		therapy services, adult occupational therapy services, and
8		physical therapy services; on or after October 1, 2014,
9		the annual maximum limit of 20 visits shall expire but the
10		Department may require prior approval for all individuals
11		for speech, hearing, and language therapy services,
12		occupational therapy services, and physical therapy
13		services; (iii) the Department shall limit adult podiatry
14		services to individuals with diabetes; on or after October
15		1, 2014, podiatry services shall not be limited to
16		individuals with diabetes; (iv) the Department shall pay
17		for caesarean sections at the normal vaginal delivery rate
18		unless a caesarean section was medically necessary; (v)
19		the Department shall limit adult dental services to
20		emergencies; beginning July 1, 2013, the Department shall
21		ensure that the following conditions are recognized as
22		emergencies: (A) dental services necessary for an
23		individual in order for the individual to be cleared for a
24		medical procedure, such as a transplant; (B) extractions
25		and dentures necessary for a diabetic to receive proper
26		nutrition; (C) extractions and dentures necessary as a

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1		result of cancer treatment; and (D) dental services
2		necessary for the health of a pregnant woman prior to
3		delivery of her baby; on or after July 1, 2014, adult
4		dental services shall no longer be limited to emergencies,
5		and dental services necessary for the health of a pregnant
6		woman prior to delivery of her baby shall continue to be
7		covered; and (vi) effective July 1, 2012 through June 30,
8		2021, the Department shall place limitations and require
9		concurrent review on every inpatient detoxification stay
10		to prevent repeat admissions to any hospital for
11		detoxification within 60 days of a previous inpatient
12		detoxification stay. The Department shall convene a
13		workgroup of hospitals, substance abuse providers, care
14		coordination entities, managed care plans, and other
15		stakeholders to develop recommendations for quality
16		standards, diversion to other settings, and admission
17		criteria for patients who need inpatient detoxification,
18		which shall be published on the Department's website no
19		later than September 1, 2013.
20		(c) The Department shall require prior approval of the
21		following services: wheelchair repairs costing more than
22		$750, coronary artery bypass graft, and bariatric surgery
23		consistent with Medicare standards concerning patient
24		responsibility. Wheelchair repair prior approval requests
25		shall be adjudicated within one business day of receipt of
26		complete supporting documentation. Providers may not break

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1		wheelchair repairs into separate claims for purposes of
2		staying under the $750 threshold for requiring prior
3		approval. The wholesale price of manual and power
4		wheelchairs, durable medical equipment and supplies, and
5		complex rehabilitation technology products and services
6		shall be defined as actual acquisition cost including all
7		discounts.
8		(d) (Blank). The Department shall establish benchmarks
9		for hospitals to measure and align payments to reduce
10		potentially preventable hospital readmissions, inpatient
11		complications, and unnecessary emergency room visits. In
12		doing so, the Department shall consider items, including,
13		but not limited to, historic and current acuity of care
14		and historic and current trends in readmission. The
15		Department shall publish provider-specific historical
16		readmission data and anticipated potentially preventable
17		targets 60 days prior to the start of the program. In the
18		instance of readmissions, the Department shall adopt
19		policies and rates of reimbursement for services and other
20		payments provided under this Code to ensure that, by June
21		30, 2013, expenditures to hospitals are reduced by, at a
22		minimum, $40,000,000.
23		(e) The Department shall establish utilization
24		controls for the hospice program such that it shall not
25		pay for other care services when an individual is in
26		hospice.

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1		(f) For home health services, the Department shall
2		require Medicare certification of providers participating
3		in the program and implement the Medicare face-to-face
4		encounter rule. The Department shall require providers to
5		implement auditable electronic service verification based
6		on global positioning systems or other cost-effective
7		technology.
8		(g) For the Home Services Program operated by the
9		Department of Human Services and the Community Care
10		Program operated by the Department on Aging, the
11		Department of Human Services, in cooperation with the
12		Department on Aging, shall implement an electronic service
13		verification based on global positioning systems or other
14		cost-effective technology.
15		(h) Effective with inpatient hospital admissions on or
16		after July 1, 2012, the Department shall reduce the
17		payment for a claim that indicates the occurrence of a
18		provider-preventable condition during the admission as
19		specified by the Department in rules. The Department shall
20		not pay for services related to an other
21		provider-preventable condition.
22		As used in this subsection (h):
23		"Provider-preventable condition" means a health care
24		acquired condition as defined under the federal Medicaid
25		regulation found at 42 CFR 447.26 or an other
26		provider-preventable condition.

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1		"Other provider-preventable condition" means a wrong
2		surgical or other invasive procedure performed on a
3		patient, a surgical or other invasive procedure performed
4		on the wrong body part, or a surgical procedure or other
5		invasive procedure performed on the wrong patient.
6		(i) The Department shall implement cost savings
7		initiatives for advanced imaging services, cardiac imaging
8		services, pain management services, and back surgery. Such
9		initiatives shall be designed to achieve annual costs
10		savings.
11		(j) The Department shall ensure that beneficiaries
12		with a diagnosis of epilepsy or seizure disorder in
13		Department records will not require prior approval for
14		anticonvulsants.
15		(Source: P.A. 101-209, eff. 8-5-19; 102-43, Article 5, Section
16		5-5, eff. 7-6-21; 102-43, Article 30, Section 30-5, eff.
17		7-6-21; 102-43, Article 80, Section 80-5, eff. 7-6-21;
18		102-813, eff. 5-13-22.)
19		ARTICLE 25.
20		Section 25-5. The Illinois Public Aid Code is amended by
21		changing Section 14-12 as follows:
22		(305 ILCS 5/14-12)
23		Sec. 14-12. Hospital rate reform payment system. The

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1		hospital payment system pursuant to Section 14-11 of this
2		Article shall be as follows:
3		(a) Inpatient hospital services. Effective on and after
4		the effective date of this amendatory Act of the 104th General
5		Assembly, reimbursement for inpatient general acute care
6		services shall utilize the All Patient Refined Diagnosis
7		Related Grouping (APR-DRG) software distributed by SolventumTM
8		previously known as 3MTM Health Information System. SolventumTM
9		shall be the exclusive provider of this software unless the
10		Department determines that SolventumTM is unable to meet the
11		required operational or contractual terms. Only under these
12		circumstances may an alternative authorized provider of the
13		software be considered.
14		(1) The Department shall establish Medicaid weighting
15		factors to be used in the reimbursement system established
16		under this subsection. Initial weighting factors shall be
17		the weighting factors as published by the authorized
18		provider of this software adjusted for the Illinois
19		experience.
20		(2) The Department shall establish a
21		statewide-standardized amount to be used in the inpatient
22		reimbursement system. The Department shall publish these
23		amounts on its website no later than 10 calendar days
24		prior to their effective date.
25		(3) In addition to the statewide-standardized amount,
26		the Department shall develop adjusters to adjust the rate

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1		of reimbursement for critical Medicaid providers or
2		services for trauma, transplantation services, perinatal
3		care, and Graduate Medical Education (GME).
4		(4) The Department shall develop add-on payments to
5		account for exceptionally costly inpatient stays,
6		consistent with Medicare outlier principles. Outlier fixed
7		loss thresholds may be updated to control for excessive
8		growth in outlier payments no more frequently than on an
9		annual basis, but at least once every 4 years. Upon
10		updating the fixed loss thresholds, the Department shall
11		be required to update base rates within 12 months.
12		(5) The Department shall define those hospitals or
13		distinct parts of hospitals that shall be exempt from the
14		APR-DRG reimbursement system established under this
15		Section. The Department shall publish these hospitals'
16		inpatient rates on its website no later than 10 calendar
17		days prior to their effective date.
18		(6) Beginning July 1, 2014 and ending on December 31,
19		2023, in addition to the statewide-standardized amount,
20		the Department shall develop an adjustor to adjust the
21		rate of reimbursement for safety-net hospitals defined in
22		Section 5-5e.1 of this Code excluding pediatric hospitals.
23		(7) Beginning July 1, 2014, in addition to the
24		statewide-standardized amount, the Department shall
25		develop an adjustor to adjust the rate of reimbursement
26		for Illinois freestanding inpatient psychiatric hospitals

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1		that are not designated as children's hospitals by the
2		Department but are primarily treating patients under the
3		age of 21.
4		(7.5) (Blank).
5		(8) Beginning July 1, 2018, in addition to the
6		statewide-standardized amount, the Department shall adjust
7		the rate of reimbursement for hospitals designated by the
8		Department of Public Health as a Perinatal Level II or II+
9		center by applying the same adjustor that is applied to
10		Perinatal and Obstetrical care cases for Perinatal Level
11		III centers, as of December 31, 2017.
12		(9) Beginning July 1, 2018, in addition to the
13		statewide-standardized amount, the Department shall apply
14		the same adjustor that is applied to trauma cases as of
15		December 31, 2017 to inpatient claims to treat patients
16		with burns, including, but not limited to, APR-DRGs 841,
17		842, 843, and 844.
18		(10) Beginning July 1, 2018, the
19		statewide-standardized amount for inpatient general acute
20		care services shall be uniformly increased so that base
21		claims projected reimbursement is increased by an amount
22		equal to the funds allocated in paragraph (1) of
23		subsection (b) of Section 5A-12.6, less the amount
24		allocated under paragraphs (8) and (9) of this subsection
25		and paragraphs (3) and (4) of subsection (b) multiplied by
26		40%.

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1		(11) Beginning July 1, 2018, the reimbursement for
2		inpatient rehabilitation services shall be increased by
3		the addition of a $96 per day add-on.
4		(b) Outpatient hospital services. Effective on and after
5		the effective date of this amendatory Act of the 104th General
6		Assembly, reimbursement for outpatient services shall utilize
7		the Enhanced Ambulatory Procedure Grouping (EAPG) software
8		distributed by SolventumTM previously known as 3MTM Health
9		Information System. SolventumTM shall be the exclusive
10		provider of this software unless the Agency determines that
11		SolventumTM is unable to meet the required operational or
12		contractual terms. Only under these circumstances may an
13		alternative authorized provider of the software be considered.
14		(1) The Department shall establish Medicaid weighting
15		factors to be used in the reimbursement system established
16		under this subsection. The initial weighting factors shall
17		be the weighting factors as published by the authorized
18		provider.
19		(2) The Department shall establish service specific
20		statewide-standardized amounts to be used in the
21		reimbursement system.
22		(A) The initial statewide standardized amounts,
23		with the labor portion adjusted by the Calendar Year
24		2013 Medicare Outpatient Prospective Payment System
25		wage index with reclassifications, shall be published
26		by the Department on its website no later than 10

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1		calendar days prior to their effective date.
2		(B) The Department shall establish adjustments to
3		the statewide-standardized amounts for each Critical
4		Access Hospital, as designated by the Department of
5		Public Health in accordance with 42 CFR 485, Subpart
6		F. For outpatient services provided on or before June
7		30, 2018, the EAPG standardized amounts are determined
8		separately for each critical access hospital such that
9		simulated EAPG payments using outpatient base period
10		paid claim data plus payments under Section 5A-12.4 of
11		this Code net of the associated tax costs are equal to
12		the estimated costs of outpatient base period claims
13		data with a rate year cost inflation factor applied.
14		(3) In addition to the statewide-standardized amounts,
15		the Department shall develop adjusters to adjust the rate
16		of reimbursement for critical Medicaid hospital outpatient
17		providers or services, including outpatient high volume or
18		safety-net hospitals. Beginning July 1, 2018, the
19		outpatient high volume adjustor shall be increased to
20		increase annual expenditures associated with this adjustor
21		by $79,200,000, based on the State Fiscal Year 2015 base
22		year data and this adjustor shall apply to public
23		hospitals, except for large public hospitals, as defined
24		under 89 Ill. Adm. Code 148.25(a).
25		(4) Beginning July 1, 2018, in addition to the
26		statewide standardized amounts, the Department shall make

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1		an add-on payment for outpatient expensive devices and
2		drugs. This add-on payment shall at least apply to claim
3		lines that: (i) are assigned with one of the following
4		EAPGs: 490, 1001 to 1020, and coded with one of the
5		following revenue codes: 0274 to 0276, 0278; or (ii) are
6		assigned with one of the following EAPGs: 430 to 441, 443,
7		444, 460 to 465, 495, 496, 1090. The add-on payment shall
8		be calculated as follows: the claim line's covered charges
9		multiplied by the hospital's total acute cost to charge
10		ratio, less the claim line's EAPG payment plus $1,000,
11		multiplied by 0.8.
12		(5) Beginning July 1, 2018, the statewide-standardized
13		amounts for outpatient services shall be increased by a
14		uniform percentage so that base claims projected
15		reimbursement is increased by an amount equal to no less
16		than the funds allocated in paragraph (1) of subsection
17		(b) of Section 5A-12.6, less the amount allocated under
18		paragraphs (8) and (9) of subsection (a) and paragraphs
19		(3) and (4) of this subsection multiplied by 46%.
20		(6) Effective for dates of service on or after July 1,
21		2018, the Department shall establish adjustments to the
22		statewide-standardized amounts for each Critical Access
23		Hospital, as designated by the Department of Public Health
24		in accordance with 42 CFR 485, Subpart F, such that each
25		Critical Access Hospital's standardized amount for
26		outpatient services shall be increased by the applicable

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1		uniform percentage determined pursuant to paragraph (5) of
2		this subsection. It is the intent of the General Assembly
3		that the adjustments required under this paragraph (6) by
4		Public Act 100-1181 shall be applied retroactively to
5		claims for dates of service provided on or after July 1,
6		2018.
7		(7) Effective for dates of service on or after March
8		8, 2019 (the effective date of Public Act 100-1181), the
9		Department shall recalculate and implement an updated
10		statewide-standardized amount for outpatient services
11		provided by hospitals that are not Critical Access
12		Hospitals to reflect the applicable uniform percentage
13		determined pursuant to paragraph (5).
14		(1) Any recalculation to the
15		statewide-standardized amounts for outpatient services
16		provided by hospitals that are not Critical Access
17		Hospitals shall be the amount necessary to achieve the
18		increase in the statewide-standardized amounts for
19		outpatient services increased by a uniform percentage,
20		so that base claims projected reimbursement is
21		increased by an amount equal to no less than the funds
22		allocated in paragraph (1) of subsection (b) of
23		Section 5A-12.6, less the amount allocated under
24		paragraphs (8) and (9) of subsection (a) and
25		paragraphs (3) and (4) of this subsection, for all
26		hospitals that are not Critical Access Hospitals,

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1		multiplied by 46%.
2		(2) It is the intent of the General Assembly that
3		the recalculations required under this paragraph (7)
4		by Public Act 100-1181 shall be applied prospectively
5		to claims for dates of service provided on or after
6		March 8, 2019 (the effective date of Public Act
7		100-1181) and that no recoupment or repayment by the
8		Department or an MCO of payments attributable to
9		recalculation under this paragraph (7), issued to the
10		hospital for dates of service on or after July 1, 2018
11		and before March 8, 2019 (the effective date of Public
12		Act 100-1181), shall be permitted.
13		(8) The Department shall ensure that all necessary
14		adjustments to the managed care organization capitation
15		base rates necessitated by the adjustments under
16		subparagraph (6) or (7) of this subsection are completed
17		and applied retroactively in accordance with Section
18		5-30.8 of this Code within 90 days of March 8, 2019 (the
19		effective date of Public Act 100-1181).
20		(9) Within 60 days after federal approval of the
21		change made to the assessment in Section 5A-2 by Public
22		Act 101-650, the Department shall incorporate into the
23		EAPG system for outpatient services those services
24		performed by hospitals currently billed through the
25		Non-Institutional Provider billing system.
26		(b-5) Notwithstanding any other provision of this Section,

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1		beginning with dates of service on and after January 1, 2023,
2		any general acute care hospital with more than 500 outpatient
3		psychiatric Medicaid services to persons under 19 years of age
4		in any calendar year shall be paid the outpatient add-on
5		payment of no less than $113.
6		(c) In consultation with the hospital community, the
7		Department is authorized to replace 89 Ill. Adm. Code 152.150
8		as published in 38 Ill. Reg. 4980 through 4986 within 12 months
9		of June 16, 2014 (the effective date of Public Act 98-651). If
10		the Department does not replace these rules within 12 months
11		of June 16, 2014 (the effective date of Public Act 98-651), the
12		rules in effect for 152.150 as published in 38 Ill. Reg. 4980
13		through 4986 shall remain in effect until modified by rule by
14		the Department. Nothing in this subsection shall be construed
15		to mandate that the Department file a replacement rule.
16		(d) Transition period. There shall be a transition period
17		to the reimbursement systems authorized under this Section
18		that shall begin on the effective date of these systems and
19		continue until June 30, 2018, unless extended by rule by the
20		Department. To help provide an orderly and predictable
21		transition to the new reimbursement systems and to preserve
22		and enhance access to the hospital services during this
23		transition, the Department shall allocate a transitional
24		hospital access pool of at least $290,000,000 annually so that
25		transitional hospital access payments are made to hospitals.
26		(1) After the transition period, the Department may

SB3365 Enrolled - 116 - LRB104 18483 SSS 31925 b
1		begin incorporating the transitional hospital access pool
2		into the base rate structure; however, the transitional
3		hospital access payments in effect on June 30, 2018 shall
4		continue to be paid, if continued under Section 5A-16.
5		(2) After the transition period, if the Department
6		reduces payments from the transitional hospital access
7		pool, it shall increase base rates, develop new adjustors,
8		adjust current adjustors, develop new hospital access
9		payments based on updated information, or any combination
10		thereof by an amount equal to the decreases proposed in
11		the transitional hospital access pool payments, ensuring
12		that the entire transitional hospital access pool amount
13		shall continue to be used for hospital payments.
14		(d-5) Hospital and health care transformation program. The
15		Department shall develop a hospital and health care
16		transformation program to provide financial assistance to
17		hospitals in transforming their services and care models to
18		better align with the needs of the communities they serve. The
19		payments authorized in this Section shall be subject to
20		approval by the federal government.
21		(1) Phase 1. In State fiscal years 2019 through 2020,
22		the Department shall allocate funds from the transitional
23		access hospital pool to create a hospital transformation
24		pool of at least $262,906,870 annually and make hospital
25		transformation payments to hospitals. Subject to Section
26		5A-16, in State fiscal years 2019 and 2020, an Illinois

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1		hospital that received either a transitional hospital
2		access payment under subsection (d) or a supplemental
3		payment under subsection (f) of this Section in State
4		fiscal year 2018, shall receive a hospital transformation
5		payment as follows:
6		(A) If the hospital's Rate Year 2017 Medicaid
7		inpatient utilization rate is equal to or greater than
8		45%, the hospital transformation payment shall be
9		equal to 100% of the sum of its transitional hospital
10		access payment authorized under subsection (d) and any
11		supplemental payment authorized under subsection (f).
12		(B) If the hospital's Rate Year 2017 Medicaid
13		inpatient utilization rate is equal to or greater than
14		25% but less than 45%, the hospital transformation
15		payment shall be equal to 75% of the sum of its
16		transitional hospital access payment authorized under
17		subsection (d) and any supplemental payment authorized
18		under subsection (f).
19		(C) If the hospital's Rate Year 2017 Medicaid
20		inpatient utilization rate is less than 25%, the
21		hospital transformation payment shall be equal to 50%
22		of the sum of its transitional hospital access payment
23		authorized under subsection (d) and any supplemental
24		payment authorized under subsection (f).
25		(2) Phase 2.
26		(A) The funding amount from phase one shall be

SB3365 Enrolled - 118 - LRB104 18483 SSS 31925 b
1		incorporated into directed payment and pass-through
2		payment methodologies described in Section 5A-12.7.
3		(B) Because there are communities in Illinois that
4		experience significant health care disparities due to
5		systemic racism, as recently emphasized by the
6		COVID-19 pandemic, aggravated by social determinants
7		of health and a lack of sufficiently allocated health
8		care resources, particularly community-based services,
9		preventive care, obstetric care, chronic disease
10		management, and specialty care, the Department shall
11		establish a health care transformation program that
12		shall be supported by the transformation funding pool.
13		It is the intention of the General Assembly that
14		innovative partnerships funded by the pool must be
15		designed to establish or improve integrated health
16		care delivery systems that will provide significant
17		access to the Medicaid and uninsured populations in
18		their communities, as well as improve health care
19		equity. It is also the intention of the General
20		Assembly that partnerships recognize and address the
21		disparities revealed by the COVID-19 pandemic, as well
22		as the need for post-COVID care. During State fiscal
23		years 2021 through 2027, the hospital and health care
24		transformation program shall be supported by an annual
25		transformation funding pool of up to $150,000,000,
26		pending federal matching funds, to be allocated during

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1		the specified fiscal years for the purpose of
2		facilitating hospital and health care transformation.
3		Funds that had been budgeted but unexpended in State
4		fiscal years 2021 through 2027 may be allocated in
5		State fiscal year 2028 in an amount not to exceed
6		$150,000,000. No disbursement of moneys for
7		transformation projects from the transformation
8		funding pool described under this Section shall be
9		considered an award, a grant, or an expenditure of
10		grant funds. Funding agreements made in accordance
11		with the transformation program shall be considered
12		purchases of care under the Illinois Procurement Code,
13		and funds shall be expended by the Department in a
14		manner that maximizes federal funding to expend the
15		entire allocated amount.
16		The Department shall convene, within 30 days after
17		March 12, 2021 (the effective date of Public Act
18		101-655), a workgroup that includes subject matter
19		experts on health care disparities and stakeholders
20		from distressed communities, which could be a
21		subcommittee of the Medicaid Advisory Committee, to
22		review and provide recommendations on how Department
23		policy, including health care transformation, can
24		improve health disparities and the impact on
25		communities disproportionately affected by COVID-19.
26		The workgroup shall consider and make recommendations

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1		on the following issues: a community safety-net
2		designation of certain hospitals, racial equity, and a
3		regional partnership to bring additional specialty
4		services to communities.
5		(C) As provided in paragraph (9) of Section 3 of
6		the Illinois Health Facilities Planning Act, any
7		hospital participating in the transformation program
8		may be excluded from the requirements of the Illinois
9		Health Facilities Planning Act for those projects
10		related to the hospital's transformation. To be
11		eligible, the hospital must submit to the Health
12		Facilities and Services Review Board approval from the
13		Department that the project is a part of the
14		hospital's transformation.
15		(D) As provided in subsection (a-20) of Section
16		32.5 of the Emergency Medical Services (EMS) Systems
17		Act, a hospital that received hospital transformation
18		payments under this Section may convert to a
19		freestanding emergency center. To be eligible for such
20		a conversion, the hospital must submit to the
21		Department of Public Health approval from the
22		Department that the project is a part of the
23		hospital's transformation.
24		(E) Criteria for proposals. To be eligible for
25		funding under this Section, a transformation proposal
26		shall meet all of the following criteria:

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1		(i) the proposal shall be designed based on
2		community needs assessment completed by either a
3		University partner or other qualified entity with
4		significant community input;
5		(ii) the proposal shall be a collaboration
6		among providers across the care and community
7		spectrum, including preventative care, primary
8		care, specialty care, hospital services, mental
9		health and substance abuse services, as well as
10		community-based entities that address the social
11		determinants of health;
12		(iii) the proposal shall be specifically
13		designed to improve health care outcomes and
14		reduce health care disparities, and improve the
15		coordination, effectiveness, and efficiency of
16		care delivery;
17		(iv) the proposal shall have specific
18		measurable metrics related to disparities that
19		will be tracked by the Department and made public
20		by the Department;
21		(v) the proposal shall include a commitment to
22		include Business Enterprise Program certified
23		vendors or other entities controlled and managed
24		by minorities or women; and
25		(vi) the proposal shall specifically increase
26		access to primary, preventive, or specialty care.

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1		(F) Entities eligible to be funded.
2		(i) Proposals for funding should come from
3		collaborations operating in one of the most
4		distressed communities in Illinois as determined
5		by the U.S. Centers for Disease Control and
6		Prevention's Social Vulnerability Index for
7		Illinois and areas disproportionately impacted by
8		COVID-19 or from rural areas of Illinois.
9		(ii) The Department shall prioritize
10		partnerships from distressed communities, which
11		include Business Enterprise Program certified
12		vendors or other entities controlled and managed
13		by minorities or women and also include one or
14		more of the following: safety-net hospitals,
15		critical access hospitals, the campuses of
16		hospitals that have closed since January 1, 2018,
17		or other health care providers designed to address
18		specific health care disparities, including the
19		impact of COVID-19 on individuals and the
20		community and the need for post-COVID care. All
21		funded proposals must include specific measurable
22		goals and metrics related to improved outcomes and
23		reduced disparities which shall be tracked by the
24		Department.
25		(iii) The Department should target the funding
26		in the following ways: $30,000,000 of

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1		transformation funds to projects that are a
2		collaboration between a safety-net hospital,
3		particularly community safety-net hospitals, and
4		other providers and designed to address specific
5		health care disparities, $20,000,000 of
6		transformation funds to collaborations between
7		safety-net hospitals and a larger hospital partner
8		that increases specialty care in distressed
9		communities, $30,000,000 of transformation funds
10		to projects that are a collaboration between
11		hospitals and other providers in distressed areas
12		of the State designed to address specific health
13		care disparities, $15,000,000 to collaborations
14		between critical access hospitals and other
15		providers designed to address specific health care
16		disparities, and $15,000,000 to cross-provider
17		collaborations designed to address specific health
18		care disparities, and $5,000,000 to collaborations
19		that focus on workforce development.
20		(iv) The Department may allocate up to
21		$5,000,000 for planning, racial equity analysis,
22		or consulting resources for the Department or
23		entities without the resources to develop a plan
24		to meet the criteria of this Section. Any contract
25		for consulting services issued by the Department
26		under this subparagraph shall comply with the

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1		provisions of Section 5-45 of the State Officials
2		and Employees Ethics Act. Based on availability of
3		federal funding, the Department may directly
4		procure consulting services or provide funding to
5		the collaboration. The provision of resources
6		under this subparagraph is not a guarantee that a
7		project will be approved.
8		(v) The Department shall take steps to ensure
9		that safety-net hospitals operating in
10		under-resourced communities receive priority
11		access to hospital and health care transformation
12		funds, including consulting funds, as provided
13		under this Section.
14		(G) Process for submitting and approving projects
15		for distressed communities. The Department shall issue
16		a template for application. The Department shall post
17		any proposal received on the Department's website for
18		at least 2 weeks for public comment, and any such
19		public comment shall also be considered in the review
20		process. Applicants may request that proprietary
21		financial information be redacted from publicly posted
22		proposals and the Department in its discretion may
23		agree. Proposals for each distressed community must
24		include all of the following:
25		(i) A detailed description of how the project
26		intends to affect the goals outlined in this

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1		subsection, describing new interventions, new
2		technology, new structures, and other changes to
3		the health care delivery system planned.
4		(ii) A detailed description of the racial and
5		ethnic makeup of the entities' board and
6		leadership positions and the salaries of the
7		executive staff of entities in the partnership
8		that is seeking to obtain funding under this
9		Section.
10		(iii) A complete budget, including an overall
11		timeline and a detailed pathway to sustainability
12		within a 5-year period, specifying other sources
13		of funding, such as in-kind, cost-sharing, or
14		private donations, particularly for capital needs.
15		There is an expectation that parties to the
16		transformation project dedicate resources to the
17		extent they are able and that these expectations
18		are delineated separately for each entity in the
19		proposal.
20		(iv) A description of any new entities formed
21		or other legal relationships between collaborating
22		entities and how funds will be allocated among
23		participants.
24		(v) A timeline showing the evolution of sites
25		and specific services of the project over a 5-year
26		period, including services available to the

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1		community by site.
2		(vi) Clear milestones indicating progress
3		toward the proposed goals of the proposal as
4		checkpoints along the way to continue receiving
5		funding. The Department is authorized to refine
6		these milestones in agreements, and is authorized
7		to impose reasonable penalties, including
8		repayment of funds, for substantial lack of
9		progress.
10		(vii) A clear statement of the level of
11		commitment the project will include for minorities
12		and women in contracting opportunities, including
13		as equity partners where applicable, or as
14		subcontractors and suppliers in all phases of the
15		project.
16		(viii) If the community study utilized is not
17		the study commissioned and published by the
18		Department, the applicant must define the
19		methodology used, including documentation of clear
20		community participation.
21		(ix) A description of the process used in
22		collaborating with all levels of government in the
23		community served in the development of the
24		project, including, but not limited to,
25		legislators and officials of other units of local
26		government.

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1		(x) Documentation of a community input process
2		in the community served, including links to
3		proposal materials on public websites.
4		(xi) Verifiable project milestones and quality
5		metrics that will be impacted by transformation.
6		These project milestones and quality metrics must
7		be identified with improvement targets that must
8		be met.
9		(xii) Data on the number of existing employees
10		by various job categories and wage levels by the
11		zip code of the employees' residence and
12		benchmarks for the continued maintenance and
13		improvement of these levels. The proposal must
14		also describe any retraining or other workforce
15		development planned for the new project.
16		(xiii) If a new entity is created by the
17		project, a description of how the board will be
18		reflective of the community served by the
19		proposal.
20		(xiv) An explanation of how the proposal will
21		address the existing disparities that exacerbated
22		the impact of COVID-19 and the need for post-COVID
23		care in the community, if applicable.
24		(xv) An explanation of how the proposal is
25		designed to increase access to care, including
26		specialty care based upon the community's needs.

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1		(H) The Department shall evaluate proposals for
2		compliance with the criteria listed under subparagraph
3		(G). Proposals meeting all of the criteria may be
4		eligible for funding with the areas of focus
5		prioritized as described in item (ii) of subparagraph
6		(F). Based on the funds available, the Department may
7		negotiate funding agreements with approved applicants
8		to maximize federal funding. Nothing in this
9		subsection requires that an approved project be funded
10		to the level requested. Agreements shall specify the
11		amount of funding anticipated annually, the
12		methodology of payments, the limit on the number of
13		years such funding may be provided, and the milestones
14		and quality metrics that must be met by the projects in
15		order to continue to receive funding during each year
16		of the program. Agreements shall specify the terms and
17		conditions under which a health care facility that
18		receives funds under a purchase of care agreement and
19		closes in violation of the terms of the agreement must
20		pay an early closure fee no greater than 50% of the
21		funds it received under the agreement, prior to the
22		Health Facilities and Services Review Board
23		considering an application for closure of the
24		facility. Any project that is funded shall be required
25		to provide quarterly written progress reports, in a
26		form prescribed by the Department, and at a minimum

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1		shall include the progress made in achieving any
2		milestones or metrics or Business Enterprise Program
3		commitments in its plan. The Department may reduce or
4		end payments, as set forth in transformation plans, if
5		milestones or metrics or Business Enterprise Program
6		commitments are not achieved. The Department shall
7		seek to make payments from the transformation fund in
8		a manner that is eligible for federal matching funds.
9		In reviewing the proposals, the Department shall
10		take into account the needs of the community, data
11		from the study commissioned by the Department from the
12		University of Illinois-Chicago if applicable, feedback
13		from public comment on the Department's website, as
14		well as how the proposal meets the criteria listed
15		under subparagraph (G). Alignment with the
16		Department's overall strategic initiatives shall be an
17		important factor. To the extent that fiscal year
18		funding is not adequate to fund all eligible projects
19		that apply, the Department shall prioritize
20		applications that most comprehensively and effectively
21		address the criteria listed under subparagraph (G).
22		(3) (Blank).
23		(4) Hospital Transformation Review Committee. There is
24		created the Hospital Transformation Review Committee. The
25		Committee shall consist of 14 members. No later than 30
26		days after March 12, 2018 (the effective date of Public

SB3365 Enrolled - 130 - LRB104 18483 SSS 31925 b
1		Act 100-581), the 4 legislative leaders shall each appoint
2		3 members; the Governor shall appoint the Director of
3		Healthcare and Family Services, or his or her designee, as
4		a member; and the Director of Healthcare and Family
5		Services shall appoint one member. Any vacancy shall be
6		filled by the applicable appointing authority within 15
7		calendar days. The members of the Committee shall select a
8		Chair and a Vice-Chair from among its members, provided
9		that the Chair and Vice-Chair cannot be appointed by the
10		same appointing authority and must be from different
11		political parties. The Chair shall have the authority to
12		establish a meeting schedule and convene meetings of the
13		Committee, and the Vice-Chair shall have the authority to
14		convene meetings in the absence of the Chair. The
15		Committee may establish its own rules with respect to
16		meeting schedule, notice of meetings, and the disclosure
17		of documents; however, the Committee shall not have the
18		power to subpoena individuals or documents and any rules
19		must be approved by 9 of the 14 members. The Committee
20		shall perform the functions described in this Section and
21		advise and consult with the Director in the administration
22		of this Section. In addition to reviewing and approving
23		the policies, procedures, and rules for the hospital and
24		health care transformation program, the Committee shall
25		consider and make recommendations related to qualifying
26		criteria and payment methodologies related to safety-net

SB3365 Enrolled - 131 - LRB104 18483 SSS 31925 b
1		hospitals and children's hospitals. Members of the
2		Committee appointed by the legislative leaders shall be
3		subject to the jurisdiction of the Legislative Ethics
4		Commission, not the Executive Ethics Commission, and all
5		requests under the Freedom of Information Act shall be
6		directed to the applicable Freedom of Information officer
7		for the General Assembly. The Department shall provide
8		operational support to the Committee as necessary. The
9		Committee is dissolved on April 1, 2019.
10		(e) Beginning 36 months after initial implementation, the
11		Department shall update the reimbursement components in
12		subsections (a) and (b), including standardized amounts and
13		weighting factors, and at least once every 4 years and no more
14		frequently than annually thereafter. The Department shall
15		publish these updates on its website no later than 30 calendar
16		days prior to their effective date.
17		(f) Continuation of supplemental payments. Any
18		supplemental payments authorized under 89 Illinois
19		Administrative Code 148 effective January 1, 2014 and that
20		continue during the period of July 1, 2014 through December
21		31, 2014 shall remain in effect as long as the assessment
22		imposed by Section 5A-2 that is in effect on December 31, 2017
23		remains in effect.
24		(g) Notwithstanding subsections (a) through (f) of this
25		Section and notwithstanding the changes authorized under
26		Section 5-5b.1, any updates to the system shall not result in

SB3365 Enrolled - 132 - LRB104 18483 SSS 31925 b
1		any diminishment of the overall effective rates of
2		reimbursement as of the implementation date of the new system
3		(July 1, 2014). These updates shall not preclude variations in
4		any individual component of the system or hospital rate
5		variations. Nothing in this Section shall prohibit the
6		Department from increasing the rates of reimbursement or
7		developing payments to ensure access to hospital services.
8		Nothing in this Section shall be construed to guarantee a
9		minimum amount of spending in the aggregate or per hospital as
10		spending may be impacted by factors, including, but not
11		limited to, the number of individuals in the medical
12		assistance program and the severity of illness of the
13		individuals.
14		(h) The Department shall have the authority to modify by
15		rulemaking any changes to the rates or methodologies in this
16		Section as required by the federal government to obtain
17		federal financial participation for expenditures made under
18		this Section.
19		(i) Except for subsections (g) and (h) of this Section,
20		the Department shall, pursuant to subsection (c) of Section
21		5-40 of the Illinois Administrative Procedure Act, provide for
22		presentation at the June 2014 hearing of the Joint Committee
23		on Administrative Rules (JCAR) additional written notice to
24		JCAR of the following rules in order to commence the second
25		notice period for the following rules: rules published in the
26		Illinois Register, rule dated February 21, 2014 at 38 Ill.

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1		Reg. 4559 (Medical Payment), 4628 (Specialized Health Care
2		Delivery Systems), 4640 (Hospital Services), 4932 (Diagnostic
3		Related Grouping (DRG) Prospective Payment System (PPS)), and
4		4977 (Hospital Reimbursement Changes), and published in the
5		Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
6		(Specialized Health Care Delivery Systems) and 6505 (Hospital
7		Services).
8		(j) Out-of-state hospitals. Beginning July 1, 2018, for
9		purposes of determining for State fiscal years 2019 and 2020
10		and subsequent fiscal years the hospitals eligible for the
11		payments authorized under subsections (a) and (b) of this
12		Section, the Department shall include out-of-state hospitals
13		that are designated a Level I pediatric trauma center or a
14		Level I trauma center by the Department of Public Health as of
15		December 1, 2017.
16		(k) The Department shall notify each hospital and managed
17		care organization, in writing, of the impact of the updates
18		under this Section at least 30 calendar days prior to their
19		effective date.
20		(k-5) The Department shall adopt amended rules, in advance
21		of the development of annual Calendar Year 2027 hospital
22		rates, to address the standardized process and time frame for
23		updates to the reimbursement components described in
24		subsections (a) and (b), including, but not limited to, the
25		definition of "excessive growth" in paragraph (4) of
26		subsection (a), in consultation with a statewide association

SB3365 Enrolled - 134 - LRB104 18483 SSS 31925 b
1		representing a majority of hospitals, to be undertaken prior
2		to initiating rulemaking in accordance with the Illinois
3		Administrative Procedure Act.
4		(l) This Section is subject to Section 14-12.5.
5		(Source: P.A. 103-102, eff. 6-16-23; 103-154, eff. 6-30-23;
6		104-9, eff. 6-16-25; 104-417, eff. 8-15-25.)
7		ARTICLE 30.
8		Section 30-5. The Illinois Public Aid Code is amended by
9		changing Section 12-9 as follows:
10		(305 ILCS 5/12-9)  (from Ch. 23, par. 12-9)
11		Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The
12		Public Aid Recoveries Trust Fund shall consist of (1)
13		recoveries by the Department of Healthcare and Family Services
14		(formerly Illinois Department of Public Aid) authorized by
15		this Code in respect to applicants or recipients under
16		Articles III, IV, V, and VI, including recoveries made by the
17		Department of Healthcare and Family Services (formerly
18		Illinois Department of Public Aid) from the estates of
19		deceased recipients, (2) recoveries made by the Department of
20		Healthcare and Family Services (formerly Illinois Department
21		of Public Aid) in respect to applicants and recipients under
22		the Children's Health Insurance Program Act, and the Covering
23		ALL KIDS Health Insurance Act, (2.5) recoveries made by the

SB3365 Enrolled - 135 - LRB104 18483 SSS 31925 b
1		Department of Healthcare and Family Services in connection
2		with the imposition of an administrative penalty as provided
3		under Section 12-4.45, (3) federal funds received on behalf of
4		and earned by State universities, other State agencies or
5		departments, and local governmental entities for services
6		provided to applicants or recipients covered under this Code,
7		the Children's Health Insurance Program Act, and the Covering
8		ALL KIDS Health Insurance Act, (3.5) federal financial
9		participation revenue related to eligible disbursements made
10		by the Department of Healthcare and Family Services from
11		appropriations required by this Section, and (4) all other
12		moneys received to the Fund, including interest thereon. The
13		Fund shall be held as a special fund in the State Treasury.
14		Disbursements from this Fund shall be only (1) for the
15		reimbursement of claims collected by the Department of
16		Healthcare and Family Services (formerly Illinois Department
17		of Public Aid) through error or mistake, (2) for payment to
18		persons or agencies designated as payees or co-payees on any
19		instrument, whether or not negotiable, delivered to the
20		Department of Healthcare and Family Services (formerly
21		Illinois Department of Public Aid) as a recovery under this
22		Section, such payment to be in proportion to the respective
23		interests of the payees in the amount so collected, (3) for
24		payments to the Department of Human Services for collections
25		made by the Department of Healthcare and Family Services
26		(formerly Illinois Department of Public Aid) on behalf of the

SB3365 Enrolled - 136 - LRB104 18483 SSS 31925 b
1		Department of Human Services under this Code, the Children's
2		Health Insurance Program Act, and the Covering ALL KIDS Health
3		Insurance Act, (4) for payment of administrative expenses
4		incurred in performing the activities authorized under this
5		Code, the Children's Health Insurance Program Act, and the
6		Covering ALL KIDS Health Insurance Act, (5) for payment of
7		fees to persons or agencies in the performance of activities
8		pursuant to the collection of monies owed the State that are
9		collected under this Code, the Children's Health Insurance
10		Program Act, and the Covering ALL KIDS Health Insurance Act,
11		(6) separate from those disbursements allowed under items (4)
12		and (5), for payment of contingency fees to third-party
13		entities that the Office of Inspector General authorizes to
14		conduct audits under Sections 12-4.25 and 12-4.40, or any
15		similar audits required by State or federal law, (7) for
16		payments of any amounts which are reimbursable to the federal
17		government which are required to be paid by State warrant by
18		either the State or federal government, and (8) (7) for
19		payments to State universities, other State agencies or
20		departments, and local governmental entities of federal funds
21		for services provided to applicants or recipients covered
22		under this Code, the Children's Health Insurance Program Act,
23		and the Covering ALL KIDS Health Insurance Act. Disbursements
24		from this Fund for purposes of items (4) and (5) of this
25		paragraph shall be subject to appropriations from the Fund to
26		the Department of Healthcare and Family Services (formerly

SB3365 Enrolled - 137 - LRB104 18483 SSS 31925 b
1		Illinois Department of Public Aid).
2		The balance in this Fund after payment therefrom of any
3		amounts reimbursable to the federal government, and minus the
4		amount anticipated to be needed to make the disbursements
5		authorized by this Section, shall be certified by the Director
6		of Healthcare and Family Services and transferred by the State
7		Comptroller to the Drug Rebate Fund or the Healthcare Provider
8		Relief Fund in the State Treasury, as appropriate, on at least
9		an annual basis by June 30th of each fiscal year. The Director
10		of Healthcare and Family Services may certify and the State
11		Comptroller shall transfer to the Drug Rebate Fund or the
12		Healthcare Provider Relief Fund amounts on a more frequent
13		basis.
14		(Source: P.A. 103-593, eff. 6-7-24.)
15		ARTICLE 35.
16		Section 35-5. The Illinois Public Aid Code is amended by
17		changing Section 5-5.4 as follows:
18		(305 ILCS 5/5-5.4)  (from Ch. 23, par. 5-5.4)
19		Sec. 5-5.4. Standards of payment; Department of Healthcare
20		and Family Services. The Department of Healthcare and Family
21		Services shall develop standards of payment of nursing
22		facility and ICF/DD services in facilities providing such
23		services under this Article which:

SB3365 Enrolled - 138 - LRB104 18483 SSS 31925 b
1		(1) Provide for the determination of a facility's payment
2		for nursing facility or ICF/DD services on a prospective
3		basis. The amount of the payment rate for all nursing
4		facilities certified by the Department of Public Health under
5		the ID/DD Community Care Act or the Nursing Home Care Act as
6		Intermediate Care for the Developmentally Disabled facilities,
7		Long Term Care for Under Age 22 facilities, Skilled Nursing
8		facilities, or Intermediate Care facilities under the medical
9		assistance program shall be prospectively established annually
10		on the basis of historical, financial, and statistical data
11		reflecting actual costs from prior years, which shall be
12		applied to the current rate year and updated for inflation,
13		except that the capital cost element for newly constructed
14		facilities shall be based upon projected budgets. The annually
15		established payment rate shall take effect on July 1 in 1984
16		and subsequent years. No rate increase and no update for
17		inflation shall be provided on or after July 1, 1994, unless
18		specifically provided for in this Section. The changes made by
19		Public Act 93-841 extending the duration of the prohibition
20		against a rate increase or update for inflation are effective
21		retroactive to July 1, 2004.
22		For facilities licensed by the Department of Public Health
23		under the Nursing Home Care Act as Intermediate Care for the
24		Developmentally Disabled facilities or Long Term Care for
25		Under Age 22 facilities, the rates taking effect on July 1,
26		1998 shall include an increase of 3%. For facilities licensed

SB3365 Enrolled - 139 - LRB104 18483 SSS 31925 b
1		by the Department of Public Health under the Nursing Home Care
2		Act as Skilled Nursing facilities or Intermediate Care
3		facilities, the rates taking effect on July 1, 1998 shall
4		include an increase of 3% plus $1.10 per resident-day, as
5		defined by the Department. For facilities licensed by the
6		Department of Public Health under the Nursing Home Care Act as
7		Intermediate Care Facilities for the Developmentally Disabled
8		or Long Term Care for Under Age 22 facilities, the rates taking
9		effect on January 1, 2006 shall include an increase of 3%. For
10		facilities licensed by the Department of Public Health under
11		the Nursing Home Care Act as Intermediate Care Facilities for
12		the Developmentally Disabled or Long Term Care for Under Age
13		22 facilities, the rates taking effect on January 1, 2009
14		shall include an increase sufficient to provide a $0.50 per
15		hour wage increase for non-executive staff. For facilities
16		licensed by the Department of Public Health under the ID/DD
17		Community Care Act as ID/DD Facilities the rates taking effect
18		within 30 days after July 6, 2017 (the effective date of Public
19		Act 100-23) shall include an increase sufficient to provide a
20		$0.75 per hour wage increase for non-executive staff. The
21		Department shall adopt rules, including emergency rules under
22		subsection (y) of Section 5-45 of the Illinois Administrative
23		Procedure Act, to implement the provisions of this paragraph.
24		For facilities licensed by the Department of Public Health
25		under the ID/DD Community Care Act as ID/DD Facilities and
26		under the MC/DD Act as MC/DD Facilities, the rates taking

SB3365 Enrolled - 140 - LRB104 18483 SSS 31925 b
1		effect within 30 days after June 5, 2019 (the effective date of
2		Public Act 101-10) shall include an increase sufficient to
3		provide a $0.50 per hour wage increase for non-executive
4		frontline personnel, including, but not limited to, direct
5		support persons, aides, frontline supervisors, qualified
6		intellectual disabilities professionals, nurses, and
7		non-administrative support staff. The Department shall adopt
8		rules, including emergency rules under subsection (bb) of
9		Section 5-45 of the Illinois Administrative Procedure Act, to
10		implement the provisions of this paragraph.
11		For facilities licensed by the Department of Public Health
12		under the Nursing Home Care Act as Intermediate Care for the
13		Developmentally Disabled facilities or Long Term Care for
14		Under Age 22 facilities, the rates taking effect on July 1,
15		1999 shall include an increase of 1.6% plus $3.00 per
16		resident-day, as defined by the Department. For facilities
17		licensed by the Department of Public Health under the Nursing
18		Home Care Act as Skilled Nursing facilities or Intermediate
19		Care facilities, the rates taking effect on July 1, 1999 shall
20		include an increase of 1.6% and, for services provided on or
21		after October 1, 1999, shall be increased by $4.00 per
22		resident-day, as defined by the Department.
23		For facilities licensed by the Department of Public Health
24		under the Nursing Home Care Act as Intermediate Care for the
25		Developmentally Disabled facilities or Long Term Care for
26		Under Age 22 facilities, the rates taking effect on July 1,

SB3365 Enrolled - 141 - LRB104 18483 SSS 31925 b
1		2000 shall include an increase of 2.5% per resident-day, as
2		defined by the Department. For facilities licensed by the
3		Department of Public Health under the Nursing Home Care Act as
4		Skilled Nursing facilities or Intermediate Care facilities,
5		the rates taking effect on July 1, 2000 shall include an
6		increase of 2.5% per resident-day, as defined by the
7		Department.
8		For facilities licensed by the Department of Public Health
9		under the Nursing Home Care Act as skilled nursing facilities
10		or intermediate care facilities, a new payment methodology
11		must be implemented for the nursing component of the rate
12		effective July 1, 2003. The Department of Public Aid (now
13		Healthcare and Family Services) shall develop the new payment
14		methodology using the Minimum Data Set (MDS) as the instrument
15		to collect information concerning nursing home resident
16		condition necessary to compute the rate. The Department shall
17		develop the new payment methodology to meet the unique needs
18		of Illinois nursing home residents while remaining subject to
19		the appropriations provided by the General Assembly. A
20		transition period from the payment methodology in effect on
21		June 30, 2003 to the payment methodology in effect on July 1,
22		2003 shall be provided for a period not exceeding 3 years and
23		184 days after implementation of the new payment methodology
24		as follows:
25		(A) For a facility that would receive a lower nursing
26		component rate per patient day under the new system than

SB3365 Enrolled - 142 - LRB104 18483 SSS 31925 b
1		the facility received effective on the date immediately
2		preceding the date that the Department implements the new
3		payment methodology, the nursing component rate per
4		patient day for the facility shall be held at the level in
5		effect on the date immediately preceding the date that the
6		Department implements the new payment methodology until a
7		higher nursing component rate of reimbursement is achieved
8		by that facility.
9		(B) For a facility that would receive a higher nursing
10		component rate per patient day under the payment
11		methodology in effect on July 1, 2003 than the facility
12		received effective on the date immediately preceding the
13		date that the Department implements the new payment
14		methodology, the nursing component rate per patient day
15		for the facility shall be adjusted.
16		(C) Notwithstanding paragraphs (A) and (B), the
17		nursing component rate per patient day for the facility
18		shall be adjusted subject to appropriations provided by
19		the General Assembly.
20		For facilities licensed by the Department of Public Health
21		under the Nursing Home Care Act as Intermediate Care for the
22		Developmentally Disabled facilities or Long Term Care for
23		Under Age 22 facilities, the rates taking effect on March 1,
24		2001 shall include a statewide increase of 7.85%, as defined
25		by the Department.
26		Notwithstanding any other provision of this Section, for

SB3365 Enrolled - 143 - LRB104 18483 SSS 31925 b
1		facilities licensed by the Department of Public Health under
2		the Nursing Home Care Act as skilled nursing facilities or
3		intermediate care facilities, except facilities participating
4		in the Department's demonstration program pursuant to the
5		provisions of Title 77, Part 300, Subpart T of the Illinois
6		Administrative Code, the numerator of the ratio used by the
7		Department of Healthcare and Family Services to compute the
8		rate payable under this Section using the Minimum Data Set
9		(MDS) methodology shall incorporate the following annual
10		amounts as the additional funds appropriated to the Department
11		specifically to pay for rates based on the MDS nursing
12		component methodology in excess of the funding in effect on
13		December 31, 2006:
14		(i) For rates taking effect January 1, 2007,
15		$60,000,000.
16		(ii) For rates taking effect January 1, 2008,
17		$110,000,000.
18		(iii) For rates taking effect January 1, 2009,
19		$194,000,000.
20		(iv) For rates taking effect April 1, 2011, or the
21		first day of the month that begins at least 45 days after
22		February 16, 2011 (the effective date of Public Act
23		96-1530), $416,500,000 or an amount as may be necessary to
24		complete the transition to the MDS methodology for the
25		nursing component of the rate. Increased payments under
26		this item (iv) are not due and payable, however, until (i)

SB3365 Enrolled - 144 - LRB104 18483 SSS 31925 b
1		the methodologies described in this paragraph are approved
2		by the federal government in an appropriate State Plan
3		amendment and (ii) the assessment imposed by Section 5B-2
4		of this Code is determined to be a permissible tax under
5		Title XIX of the Social Security Act.
6		Notwithstanding any other provision of this Section, for
7		facilities licensed by the Department of Public Health under
8		the Nursing Home Care Act as skilled nursing facilities or
9		intermediate care facilities, the support component of the
10		rates taking effect on January 1, 2008 shall be computed using
11		the most recent cost reports on file with the Department of
12		Healthcare and Family Services no later than April 1, 2005,
13		updated for inflation to January 1, 2006.
14		For facilities licensed by the Department of Public Health
15		under the Nursing Home Care Act as Intermediate Care for the
16		Developmentally Disabled facilities or Long Term Care for
17		Under Age 22 facilities, the rates taking effect on April 1,
18		2002 shall include a statewide increase of 2.0%, as defined by
19		the Department. This increase terminates on July 1, 2002;
20		beginning July 1, 2002 these rates are reduced to the level of
21		the rates in effect on March 31, 2002, as defined by the
22		Department.
23		For facilities licensed by the Department of Public Health
24		under the Nursing Home Care Act as skilled nursing facilities
25		or intermediate care facilities, the rates taking effect on
26		July 1, 2001 shall be computed using the most recent cost

SB3365 Enrolled - 145 - LRB104 18483 SSS 31925 b
1		reports on file with the Department of Public Aid no later than
2		April 1, 2000, updated for inflation to January 1, 2001. For
3		rates effective July 1, 2001 only, rates shall be the greater
4		of the rate computed for July 1, 2001 or the rate effective on
5		June 30, 2001.
6		Notwithstanding any other provision of this Section, for
7		facilities licensed by the Department of Public Health under
8		the Nursing Home Care Act as skilled nursing facilities or
9		intermediate care facilities, the Illinois Department shall
10		determine by rule the rates taking effect on July 1, 2002,
11		which shall be 5.9% less than the rates in effect on June 30,
12		2002.
13		Notwithstanding any other provision of this Section, for
14		facilities licensed by the Department of Public Health under
15		the Nursing Home Care Act as skilled nursing facilities or
16		intermediate care facilities, if the payment methodologies
17		required under Section 5A-12 and the waiver granted under 42
18		CFR 433.68 are approved by the United States Centers for
19		Medicare and Medicaid Services, the rates taking effect on
20		July 1, 2004 shall be 3.0% greater than the rates in effect on
21		June 30, 2004. These rates shall take effect only upon
22		approval and implementation of the payment methodologies
23		required under Section 5A-12.
24		Notwithstanding any other provisions of this Section, for
25		facilities licensed by the Department of Public Health under
26		the Nursing Home Care Act as skilled nursing facilities or

SB3365 Enrolled - 146 - LRB104 18483 SSS 31925 b
1		intermediate care facilities, the rates taking effect on
2		January 1, 2005 shall be 3% more than the rates in effect on
3		December 31, 2004.
4		Notwithstanding any other provision of this Section, for
5		facilities licensed by the Department of Public Health under
6		the Nursing Home Care Act as skilled nursing facilities or
7		intermediate care facilities, effective January 1, 2009, the
8		per diem support component of the rates effective on January
9		1, 2008, computed using the most recent cost reports on file
10		with the Department of Healthcare and Family Services no later
11		than April 1, 2005, updated for inflation to January 1, 2006,
12		shall be increased to the amount that would have been derived
13		using standard Department of Healthcare and Family Services
14		methods, procedures, and inflators.
15		Notwithstanding any other provisions of this Section, for
16		facilities licensed by the Department of Public Health under
17		the Nursing Home Care Act as intermediate care facilities that
18		are federally defined as Institutions for Mental Disease, or
19		facilities licensed by the Department of Public Health under
20		the Specialized Mental Health Rehabilitation Act of 2013, a
21		socio-development component rate equal to 6.6% of the
22		facility's nursing component rate as of January 1, 2006 shall
23		be established and paid effective July 1, 2006. The
24		socio-development component of the rate shall be increased by
25		a factor of 2.53 on the first day of the month that begins at
26		least 45 days after January 11, 2008 (the effective date of

SB3365 Enrolled - 147 - LRB104 18483 SSS 31925 b
1		Public Act 95-707). As of August 1, 2008, the
2		socio-development component rate shall be equal to 6.6% of the
3		facility's nursing component rate as of January 1, 2006,
4		multiplied by a factor of 3.53. For services provided on or
5		after April 1, 2011, or the first day of the month that begins
6		at least 45 days after February 16, 2011 (the effective date of
7		Public Act 96-1530), whichever is later, the Illinois
8		Department may by rule adjust these socio-development
9		component rates, and may use different adjustment
10		methodologies for those facilities participating, and those
11		not participating, in the Illinois Department's demonstration
12		program pursuant to the provisions of Title 77, Part 300,
13		Subpart T of the Illinois Administrative Code, but in no case
14		may such rates be diminished below those in effect on August 1,
15		2008.
16		For facilities licensed by the Department of Public Health
17		under the Nursing Home Care Act as Intermediate Care for the
18		Developmentally Disabled facilities or as long-term care
19		facilities for residents under 22 years of age, the rates
20		taking effect on July 1, 2003 shall include a statewide
21		increase of 4%, as defined by the Department.
22		For facilities licensed by the Department of Public Health
23		under the Nursing Home Care Act as Intermediate Care for the
24		Developmentally Disabled facilities or Long Term Care for
25		Under Age 22 facilities, the rates taking effect on the first
26		day of the month that begins at least 45 days after January 11,

SB3365 Enrolled - 148 - LRB104 18483 SSS 31925 b
1		2008 (the effective date of Public Act 95-707) shall include a
2		statewide increase of 2.5%, as defined by the Department.
3		Notwithstanding any other provision of this Section, for
4		facilities licensed by the Department of Public Health under
5		the Nursing Home Care Act as skilled nursing facilities or
6		intermediate care facilities, effective January 1, 2005,
7		facility rates shall be increased by the difference between
8		(i) a facility's per diem property, liability, and malpractice
9		insurance costs as reported in the cost report filed with the
10		Department of Public Aid and used to establish rates effective
11		July 1, 2001 and (ii) those same costs as reported in the
12		facility's 2002 cost report. These costs shall be passed
13		through to the facility without caps or limitations, except
14		for adjustments required under normal auditing procedures.
15		Rates established effective each July 1 shall govern
16		payment for services rendered throughout that fiscal year,
17		except that rates established on July 1, 1996 shall be
18		increased by 6.8% for services provided on or after January 1,
19		1997. Such rates will be based upon the rates calculated for
20		the year beginning July 1, 1990, and for subsequent years
21		thereafter until June 30, 2001 shall be based on the facility
22		cost reports for the facility fiscal year ending at any point
23		in time during the previous calendar year, updated to the
24		midpoint of the rate year. The cost report shall be on file
25		with the Department no later than April 1 of the current rate
26		year. Should the cost report not be on file by April 1, the

SB3365 Enrolled - 149 - LRB104 18483 SSS 31925 b
1		Department shall base the rate on the latest cost report filed
2		by each skilled care facility and intermediate care facility,
3		updated to the midpoint of the current rate year. In
4		determining rates for services rendered on and after July 1,
5		1985, fixed time shall not be computed at less than zero. The
6		Department shall not make any alterations of regulations which
7		would reduce any component of the Medicaid rate to a level
8		below what that component would have been utilizing in the
9		rate effective on July 1, 1984.
10		(2) Shall take into account the actual costs incurred by
11		facilities in providing services for recipients of skilled
12		nursing and intermediate care services under the medical
13		assistance program.
14		(3) Shall take into account the medical and psycho-social
15		characteristics and needs of the patients.
16		(4) Shall take into account the actual costs incurred by
17		facilities in meeting licensing and certification standards
18		imposed and prescribed by the State of Illinois, any of its
19		political subdivisions or municipalities and by the U.S.
20		Department of Health and Human Services pursuant to Title XIX
21		of the Social Security Act.
22		The Department of Healthcare and Family Services shall
23		develop precise standards for payments to reimburse nursing
24		facilities for any utilization of appropriate rehabilitative
25		personnel for the provision of rehabilitative services which
26		is authorized by federal regulations, including reimbursement

SB3365 Enrolled - 150 - LRB104 18483 SSS 31925 b
1		for services provided by qualified therapists or qualified
2		assistants, and which is in accordance with accepted
3		professional practices. Reimbursement also may be made for
4		utilization of other supportive personnel under appropriate
5		supervision.
6		The Department shall develop enhanced payments to offset
7		the additional costs incurred by a facility serving
8		exceptional need residents and shall allocate at least
9		$4,000,000 of the funds collected from the assessment
10		established by Section 5B-2 of this Code for such payments.
11		For the purpose of this Section, "exceptional needs" means,
12		but need not be limited to, ventilator care and traumatic
13		brain injury care. The enhanced payments for exceptional need
14		residents under this paragraph are not due and payable,
15		however, until (i) the methodologies described in this
16		paragraph are approved by the federal government in an
17		appropriate State Plan amendment and (ii) the assessment
18		imposed by Section 5B-2 of this Code is determined to be a
19		permissible tax under Title XIX of the Social Security Act.
20		Beginning January 1, 2014 the methodologies for
21		reimbursement of nursing facility services as provided under
22		this Section 5-5.4 shall no longer be applicable for services
23		provided on or after January 1, 2014.
24		No payment increase under this Section for the MDS
25		methodology, exceptional care residents, or the
26		socio-development component rate established by Public Act

SB3365 Enrolled - 151 - LRB104 18483 SSS 31925 b
1		96-1530 of the 96th General Assembly and funded by the
2		assessment imposed under Section 5B-2 of this Code shall be
3		due and payable until after the Department notifies the
4		long-term care providers, in writing, that the payment
5		methodologies to long-term care providers required under this
6		Section have been approved by the Centers for Medicare and
7		Medicaid Services of the U.S. Department of Health and Human
8		Services and the waivers under 42 CFR 433.68 for the
9		assessment imposed by this Section, if necessary, have been
10		granted by the Centers for Medicare and Medicaid Services of
11		the U.S. Department of Health and Human Services. Upon
12		notification to the Department of approval of the payment
13		methodologies required under this Section and the waivers
14		granted under 42 CFR 433.68, all increased payments otherwise
15		due under this Section prior to the date of notification shall
16		be due and payable within 90 days of the date federal approval
17		is received.
18		On and after July 1, 2012, the Department shall reduce any
19		rate of reimbursement for services or other payments or alter
20		any methodologies authorized by this Code to reduce any rate
21		of reimbursement for services or other payments in accordance
22		with Section 5-5e.
23		For facilities licensed by the Department of Public Health
24		under the ID/DD Community Care Act as ID/DD Facilities and
25		under the MC/DD Act as MC/DD Facilities, subject to federal
26		approval, the rates taking effect for services delivered on or

SB3365 Enrolled - 152 - LRB104 18483 SSS 31925 b
1		after August 1, 2019 shall be increased by 3.5% over the rates
2		in effect on June 30, 2019. The Department shall adopt rules,
3		including emergency rules under subsection (ii) of Section
4		5-45 of the Illinois Administrative Procedure Act, to
5		implement the provisions of this Section, including wage
6		increases for direct care staff.
7		For facilities licensed by the Department of Public Health
8		under the ID/DD Community Care Act as ID/DD Facilities and
9		under the MC/DD Act as MC/DD Facilities, subject to federal
10		approval, the rates taking effect on the latter of the
11		approval date of the State Plan Amendment for these facilities
12		or the Waiver Amendment for the home and community-based
13		services settings shall include an increase sufficient to
14		provide a $0.26 per hour wage increase to the base wage for
15		non-executive staff. The Department shall adopt rules,
16		including emergency rules as authorized by Section 5-45 of the
17		Illinois Administrative Procedure Act, to implement the
18		provisions of this Section, including wage increases for
19		direct care staff.
20		For facilities licensed by the Department of Public Health
21		under the ID/DD Community Care Act as ID/DD Facilities and
22		under the MC/DD Act as MC/DD Facilities, subject to federal
23		approval of the State Plan Amendment and the Waiver Amendment
24		for the home and community-based services settings, the rates
25		taking effect for the services delivered on or after July 1,
26		2020 shall include an increase sufficient to provide a $1.00

SB3365 Enrolled - 153 - LRB104 18483 SSS 31925 b
1		per hour wage increase for non-executive staff. For services
2		delivered on or after January 1, 2021, subject to federal
3		approval of the State Plan Amendment and the Waiver Amendment
4		for the home and community-based services settings, shall
5		include an increase sufficient to provide a $0.50 per hour
6		increase for non-executive staff. The Department shall adopt
7		rules, including emergency rules as authorized by Section 5-45
8		of the Illinois Administrative Procedure Act, to implement the
9		provisions of this Section, including wage increases for
10		direct care staff.
11		For facilities licensed by the Department of Public Health
12		under the ID/DD Community Care Act as ID/DD Facilities and
13		under the MC/DD Act as MC/DD Facilities, subject to federal
14		approval of the State Plan Amendment, the rates taking effect
15		for the residential services delivered on or after July 1,
16		2021, shall include an increase sufficient to provide a $0.50
17		per hour increase for aides in the rate methodology. For
18		facilities licensed by the Department of Public Health under
19		the ID/DD Community Care Act as ID/DD Facilities and under the
20		MC/DD Act as MC/DD Facilities, subject to federal approval of
21		the State Plan Amendment, the rates taking effect for the
22		residential services delivered on or after January 1, 2022
23		shall include an increase sufficient to provide a $1.00 per
24		hour increase for aides in the rate methodology. In addition,
25		for residential services delivered on or after January 1, 2022
26		such rates shall include an increase sufficient to provide

SB3365 Enrolled - 154 - LRB104 18483 SSS 31925 b
1		wages for all residential non-executive direct care staff,
2		excluding aides, at the federal Department of Labor, Bureau of
3		Labor Statistics' average wage as defined in rule by the
4		Department. The Department shall adopt rules, including
5		emergency rules as authorized by Section 5-45 of the Illinois
6		Administrative Procedure Act, to implement the provisions of
7		this Section.
8		For facilities licensed by the Department of Public Health
9		under the ID/DD Community Care Act as ID/DD facilities and
10		under the MC/DD Act as MC/DD facilities, subject to federal
11		approval of the State Plan Amendment, the rates taking effect
12		for services delivered on or after January 1, 2023, shall
13		include a $1.00 per hour wage increase for all direct support
14		personnel and all other frontline personnel who are not
15		subject to the Bureau of Labor Statistics' average wage
16		increases, who work in residential and community day services
17		settings, with at least $0.50 of those funds to be provided as
18		a direct increase to all aide base wages, with the remaining
19		$0.50 to be used flexibly for base wage increases to the rate
20		methodology for aides. In addition, for residential services
21		delivered on or after January 1, 2023 the rates shall include
22		an increase sufficient to provide wages for all residential
23		non-executive direct care staff, excluding aides, at the
24		federal Department of Labor, Bureau of Labor Statistics'
25		average wage as determined by the Department. Also, for
26		services delivered on or after January 1, 2023, the rates will

SB3365 Enrolled - 155 - LRB104 18483 SSS 31925 b
1		include adjustments to employment-related expenses as defined
2		in rule by the Department. The Department shall adopt rules,
3		including emergency rules as authorized by Section 5-45 of the
4		Illinois Administrative Procedure Act, to implement the
5		provisions of this Section.
6		For facilities licensed by the Department of Public Health
7		under the ID/DD Community Care Act as ID/DD facilities and
8		under the MC/DD Act as MC/DD facilities, subject to federal
9		approval of the State Plan Amendment, the rates taking effect
10		for services delivered on or after January 1, 2024 shall
11		include a $2.50 per hour wage increase for all direct support
12		personnel and all other frontline personnel who are not
13		subject to the Bureau of Labor Statistics' average wage
14		increases and who work in residential and community day
15		services settings. At least $1.25 of the per hour wage
16		increase shall be provided as a direct increase to all aide
17		base wages, and the remaining $1.25 of the per hour wage
18		increase shall be used flexibly for base wage increases to the
19		rate methodology for aides. In addition, for residential
20		services delivered on or after January 1, 2024, the rates
21		shall include an increase sufficient to provide wages for all
22		residential non-executive direct care staff, excluding aides,
23		at the federal Department of Labor, Bureau of Labor
24		Statistics' average wage as determined by the Department.
25		Also, for services delivered on or after January 1, 2024, the
26		rates will include adjustments to employment-related expenses

SB3365 Enrolled - 156 - LRB104 18483 SSS 31925 b
1		as defined in rule by the Department. The Department shall
2		adopt rules, including emergency rules as authorized by
3		Section 5-45 of the Illinois Administrative Procedure Act, to
4		implement the provisions of this Section.
5		For facilities licensed by the Department of Public Health
6		under the ID/DD Community Care Act as ID/DD facilities and
7		under the MC/DD Act as MC/DD facilities, subject to federal
8		approval of a State Plan Amendment, the rates taking effect
9		for services delivered on or after January 1, 2025 shall
10		include a $1.00 per hour wage increase for all direct support
11		personnel and all other frontline personnel who are not
12		subject to the Bureau of Labor Statistics' average wage
13		increases and who work in residential and community day
14		services settings, with at least $0.75 of those funds to be
15		provided as a direct increase to all aide base wages and the
16		remaining $0.25 to be used flexibly for base wage increases to
17		the rate methodology for aides. These increases shall not be
18		used by facilities for operational and administrative
19		expenses. In addition, for residential services delivered on
20		or after January 1, 2025, the rates shall include an increase
21		sufficient to provide wages for all residential non-executive
22		direct care staff, excluding aides, at the federal Department
23		of Labor, Bureau of Labor Statistics' average wage as
24		determined by the Department. Also, for services delivered on
25		or after January 1, 2025, the rates will include adjustments
26		to employment-related expenses as defined in rule by the

SB3365 Enrolled - 157 - LRB104 18483 SSS 31925 b
1		Department. The Department shall adopt rules, including
2		emergency rules as authorized by Section 5-45 of the Illinois
3		Administrative Procedure Act, to implement the provisions of
4		this Section.
5		For facilities licensed by the Department of Public Health
6		under the ID/DD Community Care Act as ID/DD facilities and
7		under the MC/DD Act as MC/DD facilities, subject to federal
8		approval of a State Plan Amendment, the rates taking effect
9		for services delivered on or after January 1, 2026 shall
10		include a $0.80 per hour wage increase for all direct support
11		personnel and all other frontline personnel who are not
12		subject to the Bureau of Labor Statistics' average wage
13		increases and who work in residential and community day
14		services settings, with at least $0.60 of those funds to be
15		provided as a direct increase to all aide base wages and the
16		remaining $0.20 to be used flexibly for base wage increases to
17		the rate methodology for aides. These increases shall not be
18		used by facilities for operational and administrative
19		expenses. In addition, for residential services delivered on
20		or after January 1, 2026, the rates shall include an increase
21		sufficient to provide wages for all residential non-executive
22		direct care staff, excluding aides, at the federal Department
23		of Labor, Bureau of Labor Statistics' average wage as
24		determined by the Department. Also, for services delivered on
25		or after January 1, 2026, the rates will include adjustments
26		to employment-related expenses as defined in rule by the

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1		Department. The Department shall adopt rules, including
2		emergency rules as authorized by Section 5-45 of the Illinois
3		Administrative Procedure Act, to implement the provisions of
4		this Section.
5		Notwithstanding any other provision of this Section to the
6		contrary, any regional wage adjuster for facilities located
7		outside of the counties of Cook, DuPage, Kane, Lake, McHenry,
8		and Will shall be no lower than 1.00, and any regional wage
9		adjuster for facilities located within the counties of Cook,
10		DuPage, Kane, Lake, McHenry, and Will shall be no lower than
11		1.15.
12		(5) For dates of service starting July 1, 2027,
13		reimbursement calculations and direct payments for services
14		provided by facilities licensed under the ID/DD Community Care
15		Act are the responsibility of the Department of Healthcare and
16		Family Services. Appropriations for facilities licensed under
17		the ID/DD Community Care Act must be shifted from the
18		Department of Human Services to the Department of Healthcare
19		and Family Services. Nothing in this Section shall prohibit
20		the Department of Healthcare and Family Services from paying
21		more than the rates specified in this Section. Nothing in this
22		Section shall affect the requirements of Section 3-213 of the
23		ID/DD Community Care Act.
24		(Source: P.A. 103-8, eff. 6-7-23; 103-588, eff. 7-1-24; 104-2,
25		eff. 6-16-25.)

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1		ARTICLE 40.
2		Section 40-5. The Illinois Public Aid Code is amended by
3		changing Section 5-5e.1 as follows:
4		(305 ILCS 5/5-5e.1)
5		Sec. 5-5e.1. Safety-Net Hospitals.
6		(a) A Safety-Net Hospital is an Illinois hospital that:
7		(1) is licensed by the Department of Public Health as
8		a general acute care or pediatric hospital; and
9		(2) is a disproportionate share hospital, as described
10		in Section 1923 of the federal Social Security Act, as
11		determined by the Department; and
12		(3) meets one of the following:
13		(A) has a MIUR of at least 40% and a charity
14		percent of at least 4%; or
15		(B) has a MIUR of at least 50%.
16		(b) Definitions. As used in this Section:
17		(1) "Charity percent" means the ratio of (i) the
18		hospital's charity charges for services provided to
19		individuals without health insurance or another source of
20		third party coverage to (ii) the Illinois total hospital
21		charges, each as reported on the hospital's OBRA form.
22		(2) "MIUR" means Medicaid Inpatient Utilization Rate
23		and is defined as a fraction, the numerator of which is the
24		number of a hospital's inpatient days provided in the

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1		hospital's fiscal year ending 3 years prior to the rate
2		year, to patients who, for such days, were eligible for
3		Medicaid under Title XIX of the federal Social Security
4		Act, 42 USC 1396a et seq., excluding those persons
5		eligible for medical assistance pursuant to 42 U.S.C.
6		1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
7		Section 5-2 of this Article, and the denominator of which
8		is the total number of the hospital's inpatient days in
9		that same period, excluding those persons eligible for
10		medical assistance pursuant to 42 U.S.C.
11		1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
12		Section 5-2 of this Article.
13		(3) "OBRA form" means form HFS-3834, OBRA '93 data
14		collection form, for the rate year.
15		(4) "Rate year" means the 12-month period beginning on
16		October 1.
17		(c) Beginning July 1, 2012 and ending on December 31, 2028
18		2026, a hospital that would have qualified for the rate year
19		beginning October 1, 2011 or October 1, 2012 shall be a
20		Safety-Net Hospital.
21		(c-5) Beginning July 1, 2020 and ending on December 31,
22		2026, a hospital that would have qualified for the rate year
23		beginning October 1, 2020 and was designated a federal rural
24		referral center under 42 CFR 412.96 as of October 1, 2020 shall
25		be a Safety-Net Hospital.
26		(d) No later than August 15 preceding the rate year, each

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1		hospital shall submit the OBRA form to the Department. Prior
2		to October 1, the Department shall notify each hospital
3		whether it has qualified as a Safety-Net Hospital.
4		(e) The Department may promulgate rules in order to
5		implement this Section.
6		(f) Nothing in this Section shall be construed as limiting
7		the ability of the Department to include the Safety-Net
8		Hospitals in the hospital rate reform mandated by Section
9		14-11 of this Code and implemented under Section 14-12 of this
10		Code and by administrative rulemaking.
11		(Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;
12		102-886, eff. 5-17-22.)
13		ARTICLE 45.
14		Section 45-5. The Hospital Licensing Act is amended by
15		changing Section 6.09 as follows:
16		(210 ILCS 85/6.09)  (from Ch. 111 1/2, par. 147.09)
17		Sec. 6.09. (a) In order to facilitate the orderly
18		transition of aged patients and patients with disabilities
19		from hospitals to post-hospital care, whenever a patient who
20		qualifies for the federal Medicare program is hospitalized,
21		the patient shall be notified of discharge at least 24 hours
22		prior to discharge from the hospital. With regard to pending
23		discharges to a skilled nursing facility, the hospital must

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1		notify the case coordination unit, as defined in 89 Ill. Adm.
2		Code 240.260, at least 24 hours prior to discharge. When the
3		assessment is completed in the hospital, the case coordination
4		unit shall provide a copy of the required assessment
5		documentation directly to the nursing home to which the
6		patient is being discharged prior to discharge. The Department
7		on Aging shall provide notice of this requirement to case
8		coordination units. When a case coordination unit is unable to
9		complete an assessment in a hospital prior to the discharge of
10		a patient, 60 years of age or older, to a nursing home, the
11		case coordination unit shall notify the Department on Aging
12		which shall notify the Department of Healthcare and Family
13		Services. The Department on Aging shall adopt rules to address
14		these instances to ensure that the patient is able to access
15		nursing home care, the nursing home is not penalized for
16		accepting the admission, and the patient's timely discharge
17		from the hospital is not delayed, to the extent permitted
18		under federal law or regulation. Nothing in this subsection
19		shall preclude federal requirements for a pre-admission
20		screening/mental health (PAS/MH) as required under Section
21		2-201.5 of the Nursing Home Care Act or State or federal law or
22		regulation. If home health services are ordered, the hospital
23		must inform its designated case coordination unit, as defined
24		in 89 Ill. Adm. Code 240.260, of the pending discharge and must
25		provide the patient with the case coordination unit's
26		telephone number and other contact information.

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1		(b) Every hospital shall develop procedures for a
2		physician with medical staff privileges at the hospital or any
3		appropriate medical staff member to provide the discharge
4		notice prescribed in subsection (a) of this Section. The
5		procedures must include prohibitions against discharging or
6		referring a patient to any of the following if unlicensed,
7		uncertified, or unregistered: (i) a board and care facility,
8		as defined in the Board and Care Home Act; (ii) an assisted
9		living and shared housing establishment, as defined in the
10		Assisted Living and Shared Housing Act; (iii) a facility
11		licensed under the Nursing Home Care Act, the Specialized
12		Mental Health Rehabilitation Act of 2013, the ID/DD Community
13		Care Act, or the MC/DD Act; (iv) a supportive living facility,
14		as defined in Section 5-5.01a of the Illinois Public Aid Code;
15		or (v) a free-standing hospice facility licensed under the
16		Hospice Program Licensing Act if licensure, certification, or
17		registration is required. The Department of Public Health
18		shall annually provide hospitals with a list of licensed,
19		certified, or registered board and care facilities, assisted
20		living and shared housing establishments, nursing homes,
21		supportive living facilities, facilities licensed under the
22		ID/DD Community Care Act, the MC/DD Act, or the Specialized
23		Mental Health Rehabilitation Act of 2013, and hospice
24		facilities. Reliance upon this list by a hospital shall
25		satisfy compliance with this requirement. The procedure may
26		also include a waiver for any case in which a discharge notice

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1		is not feasible due to a short length of stay in the hospital
2		by the patient, or for any case in which the patient
3		voluntarily desires to leave the hospital before the
4		expiration of the 24 hour period.
5		(c) At least 24 hours prior to discharge from the
6		hospital, the patient shall receive written information on the
7		patient's right to appeal the discharge pursuant to the
8		federal Medicare program, including the steps to follow to
9		appeal the discharge and the appropriate telephone number to
10		call in case the patient intends to appeal the discharge.
11		(d) Before transfer of a patient to a long term care
12		facility licensed under the Nursing Home Care Act where
13		elderly persons reside, a hospital shall as soon as
14		practicable initiate a name-based criminal history background
15		check by electronic submission to the Illinois State Police
16		for all persons between the ages of 18 and 70 years; provided,
17		however, that a hospital shall be required to initiate such a
18		background check only with respect to patients who:
19		(1) are transferring to a long term care facility for
20		the first time;
21		(2) have been in the hospital more than 5 days;
22		(3) are reasonably expected to remain at the long term
23		care facility for more than 30 days;
24		(4) have a known history of serious mental illness or
25		substance abuse; and
26		(5) are independently ambulatory or mobile for more

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1		than a temporary period of time.
2		A hospital may also request a criminal history background
3		check for a patient who does not meet any of the criteria set
4		forth in items (1) through (5).
5		A hospital shall notify a long term care facility if the
6		hospital has initiated a criminal history background check on
7		a patient being discharged to that facility. In all
8		circumstances in which the hospital is required by this
9		subsection to initiate the criminal history background check,
10		the transfer to the long term care facility may proceed
11		regardless of the availability of criminal history results.
12		Upon receipt of the results, the hospital shall promptly
13		forward the results to the appropriate long term care
14		facility. If the results of the background check are
15		inconclusive, the hospital shall have no additional duty or
16		obligation to seek additional information from, or about, the
17		patient.
18		(Source: P.A. 102-538, eff. 8-20-21; 103-102, eff. 1-1-24.)
19		ARTICLE 50.
20		Section 50-5. The Illinois Public Aid Code is amended by
21		changing Section 5-5.24 as follows:
22		(305 ILCS 5/5-5.24)
23		Sec. 5-5.24. Prenatal and perinatal care.

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1		(a) The Department of Healthcare and Family Services may
2		provide reimbursement under this Article for all prenatal and
3		perinatal health care services that are provided for the
4		purpose of preventing low-birthweight infants, reducing the
5		need for neonatal intensive care hospital services, and
6		promoting perinatal and maternal health. These services may
7		include comprehensive risk assessments for pregnant
8		individuals, individuals with infants, and infants, lactation
9		counseling, nutrition counseling, childbirth support,
10		psychosocial counseling, treatment and prevention of
11		periodontal disease, language translation, nurse home
12		visitation, and other support services that have been proven
13		to improve birth and maternal health outcomes. The Department
14		shall maximize the use of preventive prenatal and perinatal
15		health care services consistent with federal statutes, rules,
16		and regulations. The Department of Public Aid (now Department
17		of Healthcare and Family Services) shall develop a plan for
18		prenatal and perinatal preventive health care and shall
19		present the plan to the General Assembly by January 1, 2004. On
20		or before January 1, 2006 and every 2 years thereafter, the
21		Department shall report to the General Assembly concerning the
22		effectiveness of prenatal and perinatal health care services
23		reimbursed under this Section in preventing low-birthweight
24		infants and reducing the need for neonatal intensive care
25		hospital services. Each such report shall include an
26		evaluation of how the ratio of expenditures for treating

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1		low-birthweight infants compared with the investment in
2		promoting healthy births and infants in local community areas
3		throughout Illinois relates to healthy infant development in
4		those areas.
5		On and after July 1, 2012, the Department shall reduce any
6		rate of reimbursement for services or other payments or alter
7		any methodologies authorized by this Code to reduce any rate
8		of reimbursement for services or other payments in accordance
9		with Section 5-5e.
10		(b)(1) As used in this subsection:
11		"Affiliated provider" means a provider who is enrolled in
12		the medical assistance program and has an active contract with
13		a managed care organization.
14		"Non-affiliated provider" means a provider who is enrolled
15		in the medical assistance program but does not have a contract
16		with an MCO.
17		"Preventive prenatal and perinatal health care services"
18		means services described in subsection (a) including the
19		following non-emergent diagnostic and ancillary services:
20		(i) Diagnostic labs and imaging, including level II
21		ultrasounds.
22		(ii) RhoGAM injections.
23		(iii) Injectable 17-alpha-hydroxyprogesterone
24		caproate (commonly called 17P).
25		(iv) Intrapartum (labor and delivery) services.
26		(v) Any other outpatient or inpatient service relating

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1		to pregnancy or the 12 months following childbirth or
2		fetal loss.
3		(2) In order to maximize the accessibility of preventive
4		prenatal and perinatal health care services, the Department of
5		Healthcare and Family Services shall amend its managed care
6		contracts such that an MCO must pay for preventive prenatal
7		services, perinatal healthcare services, and postpartum
8		services rendered by a non-affiliated provider, for which the
9		health plan would pay if rendered by an affiliated provider,
10		at the rate paid under the Illinois Medicaid fee-for-service
11		program methodology for such services, including all policy
12		adjusters, including, but not limited to, Medicaid High Volume
13		Adjustments, Medicaid Percentage Adjustments, Outpatient High
14		Volume Adjustments, and all outlier add-on adjustments to the
15		extent such adjustments are incorporated in the development of
16		the applicable MCO capitated rates, unless a different rate
17		was agreed upon by the health plan and the non-affiliated
18		provider.
19		(3) In cases where a managed care organization must pay
20		for preventive prenatal services, perinatal healthcare
21		services, and postpartum services rendered by a non-affiliated
22		provider, the requirements under paragraph (2) shall not apply
23		if the services were not emergency services, as defined in
24		Section 5-30.1, and:
25		(A) the non-affiliated provider is a perinatal
26		hospital and has, within the 12 months preceding the date

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1		of service, rejected a contract that was offered in good
2		faith by the health plan as determined by the Department;
3		or
4		(B) the health plan has terminated a contract with the
5		non-affiliated provider for cause, and the Department has
6		not deemed the termination to have been without merit. The
7		Department may deem that a determination for cause has
8		merit if:
9		(i) an institutional provider has repeatedly
10		failed to conduct discharge planning; or
11		(ii) the provider's conduct adversely and
12		substantially impacts the health of Medicaid patients;
13		or
14		(iii) the provider's conduct constitutes fraud,
15		waste, or abuse; or
16		(iv) the provider's conduct violates the code of
17		ethics governing his or her profession.
18		(4) For dates of service on and after January 1, 2026, the
19		medical assistance program shall provide coverage, without
20		imposing a deductible, coinsurance, copayment, or any other
21		cost-sharing requirement, for preeclampsia biomarker testing
22		for predictive screening in asymptomatic individuals, or for
23		diagnosis and management when symptoms are present.
24		(Source: P.A. 102-665, eff. 10-8-21; 102-964, eff. 1-1-23.)
25		ARTICLE 55.

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1		Section 55-5. The Specialized Mental Health Rehabilitation
2		Act of 2013 is amended by changing Sections 2-101 and 3-104 as
3		follows:
4		(210 ILCS 49/2-101)
5		Sec. 2-101. Standards for facilities.
6		(a) The Department shall, by rule, prescribe minimum
7		standards for each level of care for facilities to be in place
8		during the provisional licensure period and thereafter. These
9		standards shall include, but are not limited to, the
10		following:
11		(1) life safety standards that will ensure the health,
12		safety and welfare of residents and their protection from
13		hazards;
14		(2) number and qualifications of all personnel,
15		including management and clinical personnel, having
16		responsibility for any part of the care given to
17		consumers; specifically, the Department shall establish
18		staffing ratios for facilities which shall specify the
19		number of staff hours per consumer of care that are needed
20		for each level of care offered within the facility;
21		(3) all sanitary conditions within the facility and
22		its surroundings, including water supply, sewage disposal,
23		food handling, and general hygiene which shall ensure the
24		health and comfort of consumers;

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1		(4) a program for adequate maintenance of physical
2		plant and equipment;
3		(5) adequate accommodations, staff, and services for
4		the number and types of services being offered to
5		consumers for whom the facility is licensed to care;
6		(6) development of evacuation and other appropriate
7		safety plans for use during weather, health, fire,
8		physical plant, environmental, and national defense
9		emergencies;
10		(7) maintenance of minimum financial or other
11		resources necessary to meet the standards established
12		under this Section, and to operate and conduct the
13		facility in accordance with this Act;
14		(8) standards for coercive free environment,
15		restraint, and therapeutic separation; and
16		(9) each multiple bedroom shall have at least 55
17		square feet of net floor area per consumer, not including
18		space for closets, bathrooms, and clearly defined entryway
19		areas. A minimum of 3 feet of clearance at the foot and one
20		side of each bed shall be provided.
21		(b) Any requirement contained in administrative rule
22		concerning a percentage of single occupancy rooms shall be
23		calculated based on the total number of licensed or
24		provisionally licensed beds under this Act on January 1, 2019
25		and shall not be calculated on a per-facility basis.
26		(c) A facility licensed under this Act shall not accept

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1		any person experiencing an acute medical condition liable to
2		cause death, severe injury, or serious illness.
3		(Source: P.A. 101-10, eff. 6-5-19; 102-558, eff. 8-20-21.)
4		(210 ILCS 49/3-104)
5		Sec. 3-104. Care, treatment, and records. Facilities shall
6		provide, at a minimum, the following services: physician,
7		nursing, pharmaceutical, rehabilitative, and dietary services.
8		To provide these services, the facility shall adhere to the
9		following:
10		(1) Each consumer shall be encouraged and assisted to
11		achieve and maintain the highest level of self-care and
12		independence. Every effort shall be made to keep consumers
13		active and out of bed for reasonable periods of time,
14		except when contraindicated by physician orders.
15		(2) Every consumer shall be engaged in a
16		person-centered planning process regarding his or her
17		total care and treatment.
18		(3) All medical treatment and procedures shall be
19		administered as ordered by a physician. All new physician
20		orders shall be reviewed by the facility's director of
21		nursing or charge nurse designee within 24 hours after
22		such orders have been issued to ensure facility compliance
23		with such orders. According to rules adopted by the
24		Department, every woman consumer of child bearing age
25		shall receive routine obstetrical and gynecological

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1		evaluations as well as necessary prenatal care.
2		(4) Each consumer shall be provided with good
3		nutrition and with necessary fluids for hydration.
4		(5) Each consumer shall be provided visual privacy
5		during treatment and personal care.
6		(6) Every consumer or consumer's guardian shall be
7		permitted to inspect and copy all his or her clinical and
8		other records concerning his or her care kept by the
9		facility or by his or her physician. The facility may
10		charge a reasonable fee for duplication of a record.
11		(7) Each consumer shall be offered at least 15 hours
12		of treatment programming per week and shall be encouraged
13		to attend the treatment domains that meet the consumer's
14		needs, as reflected in the consumer's treatment plans.
15		Each consumer's program engagement and attendance shall be
16		documented in the consumer's clinical record, and each
17		consumer shall be prompted to attend programming regularly
18		as documented in the consumer's clinical record at least
19		quarterly.
20		(Source: P.A. 98-104, eff. 7-22-13.)
21		ARTICLE 60.
22		Section 60-5. The Illinois Public Aid Code is amended by
23		adding Section 5-5.25a as follows:

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1		(305 ILCS 5/5-5.25a new)
2		Sec. 5-5.25a. Coverage for seizure detection devices.
3		(a) As used in this Section, "seizure detection device"
4		means a monitoring device cleared by the United States Food
5		and Drug Administration, and any related technology,
6		application, service, or subscription supporting the
7		prescribed use of the device, that provides the following:
8		(1) individual monitoring and alert services relating
9		to seizure activity;
10		(2) detection or prediction of seizure activity and
11		transmission of notification of the seizure activity to
12		the individual or a caregiver for appropriate medical
13		response; or
14		(3) collection of data of the seizure activity of the
15		individual that can be used by a health care provider to
16		diagnose or appropriately treat a health care condition
17		that causes the seizure activity.
18		(b) All seizure detection devices covered under this
19		Section shall be approved for use by individuals, provided
20		that the device has been prescribed and determined to be
21		medically necessary. The choice of device shall be made based
22		upon the individual's circumstances and medical needs in
23		consultation with the individual's medical provider.
24		(c) Any individual who has been prescribed a seizure
25		detection device shall not be required to obtain prior
26		authorization for coverage for a seizure detection device, and

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1		coverage shall be continuous once the seizure detection device
2		is prescribed.
3		(d) Notwithstanding any other provision of this Section,
4		commencing July 1, 2027, all seizure detection devices cleared
5		by the United States Food and Drug Administration shall be
6		covered under the medical assistance program for persons who
7		have been prescribed a seizure detection device and who are
8		otherwise eligible for assistance under this Article.
9		(e) The Department shall not adopt rules or classification
10		policies that would limit the ability of individuals covered
11		by this Section to obtain seizure detection devices.
12		ARTICLE 65.
13		Section 65-5. The Community-Integrated Living Arrangements
14		Licensure and Certification Act is amended by changing Section
15		13.3 as follows:
16		(210 ILCS 135/13.3)
17		Sec. 13.3. Community-integrated living arrangement per
18		diem reimbursement. As used in this Section, "medical absence"
19		means a situation in which a resident is temporarily absent
20		from a community-integrated living arrangement to receive
21		medical treatment or for other reasons that have been
22		recommended by third-party medical personnel, including, but
23		not limited to, hospitalizations, placements in short-term

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1		stabilization homes or State-operated facilities, stays in
2		nursing facilities, rehabilitation in long-term care
3		facilities, or other absences for legitimate medical reasons.
4		Beginning January 1, 2025, the Department's Division of
5		Developmental Disabilities shall provide 100% of the per diem
6		reimbursement to a 24-hour community-integrated living
7		arrangement provider for up to 20 days for any resident
8		requiring a medical absence. During the medical absence, the
9		provider shall hold the bed for the resident. After the
10		medical absence, the resident shall return to the
11		community-integrated living arrangement when the resident is
12		medically able to return in order for the provider to receive
13		the full per diem reimbursement for the absent days. However,
14		if it is determined by a treating physician that the resident
15		is unable to return to the community-integrated living
16		arrangement, or if the resident dies during the medical
17		absence, the provider shall receive 100% of the per diem
18		reimbursement for up to 20 medical absence days. The per diem
19		reimbursement shall be in addition to the existing occupancy
20		factor policy set by the Division of Developmental
21		Disabilities. Any Department policy or rulemaking issued to
22		implement this Section shall provide that for medical absences
23		a resident's termination date is the date the resident either
24		passes away or the date it is determined by a treating
25		physician that the resident is unable to return to the
26		community-integrated living arrangement.

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1		(Source: P.A. 103-593, eff. 6-7-24.)
2		ARTICLE 75.
3		Section 75-5. The Illinois Public Aid Code is amended by
4		changing Section 5-5.02 as follows:
5		(305 ILCS 5/5-5.02)  (from Ch. 23, par. 5-5.02)
6		Sec. 5-5.02. Hospital reimbursements.
7		(a) Reimbursement to hospitals; July 1, 1992 through
8		September 30, 1992. Notwithstanding any other provisions of
9		this Code or the Illinois Department's Rules promulgated under
10		the Illinois Administrative Procedure Act, reimbursement to
11		hospitals for services provided during the period July 1, 1992
12		through September 30, 1992, shall be as follows:
13		(1) For inpatient hospital services rendered, or if
14		applicable, for inpatient hospital discharges occurring,
15		on or after July 1, 1992 and on or before September 30,
16		1992, the Illinois Department shall reimburse hospitals
17		for inpatient services under the reimbursement
18		methodologies in effect for each hospital, and at the
19		inpatient payment rate calculated for each hospital, as of
20		June 30, 1992. For purposes of this paragraph,
21		"reimbursement methodologies" means all reimbursement
22		methodologies that pertain to the provision of inpatient
23		hospital services, including, but not limited to, any

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1		adjustments for disproportionate share, targeted access,
2		critical care access and uncompensated care, as defined by
3		the Illinois Department on June 30, 1992.
4		(2) For the purpose of calculating the inpatient
5		payment rate for each hospital eligible to receive
6		quarterly adjustment payments for targeted access and
7		critical care, as defined by the Illinois Department on
8		June 30, 1992, the adjustment payment for the period July
9		1, 1992 through September 30, 1992, shall be 25% of the
10		annual adjustment payments calculated for each eligible
11		hospital, as of June 30, 1992. The Illinois Department
12		shall determine by rule the adjustment payments for
13		targeted access and critical care beginning October 1,
14		1992.
15		(3) For the purpose of calculating the inpatient
16		payment rate for each hospital eligible to receive
17		quarterly adjustment payments for uncompensated care, as
18		defined by the Illinois Department on June 30, 1992, the
19		adjustment payment for the period August 1, 1992 through
20		September 30, 1992, shall be one-sixth of the total
21		uncompensated care adjustment payments calculated for each
22		eligible hospital for the uncompensated care rate year, as
23		defined by the Illinois Department, ending on July 31,
24		1992. The Illinois Department shall determine by rule the
25		adjustment payments for uncompensated care beginning
26		October 1, 1992.

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1		(b) Inpatient payments. For inpatient services provided on
2		or after October 1, 1993, in addition to rates paid for
3		hospital inpatient services pursuant to the Illinois Health
4		Finance Reform Act, as now or hereafter amended, or the
5		Illinois Department's prospective reimbursement methodology,
6		or any other methodology used by the Illinois Department for
7		inpatient services, the Illinois Department shall make
8		adjustment payments, in an amount calculated pursuant to the
9		methodology described in paragraph (c) of this Section, to
10		hospitals that the Illinois Department determines satisfy any
11		one of the following requirements:
12		(1) Hospitals that are described in Section 1923 of
13		the federal Social Security Act, as now or hereafter
14		amended, except that for rate year 2015 and after a
15		hospital described in Section 1923(b)(1)(B) of the federal
16		Social Security Act and qualified for the payments
17		described in subsection (c) of this Section for rate year
18		2014 provided the hospital continues to meet the
19		description in Section 1923(b)(1)(B) in the current
20		determination year; or
21		(2) Illinois hospitals that have a Medicaid inpatient
22		utilization rate which is at least one-half a standard
23		deviation above the mean Medicaid inpatient utilization
24		rate for all hospitals in Illinois receiving Medicaid
25		payments from the Illinois Department; or
26		(3) Illinois hospitals that on July 1, 1991 had a

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1		Medicaid inpatient utilization rate, as defined in
2		paragraph (h) of this Section, that was at least the mean
3		Medicaid inpatient utilization rate for all hospitals in
4		Illinois receiving Medicaid payments from the Illinois
5		Department and which were located in a planning area with
6		one-third or fewer excess beds as determined by the Health
7		Facilities and Services Review Board, and that, as of June
8		30, 1992, were located in a federally designated Health
9		Manpower Shortage Area; or
10		(4) Illinois hospitals that:
11		(A) have a Medicaid inpatient utilization rate
12		that is at least equal to the mean Medicaid inpatient
13		utilization rate for all hospitals in Illinois
14		receiving Medicaid payments from the Department; and
15		(B) also have a Medicaid obstetrical inpatient
16		utilization rate that is at least one standard
17		deviation above the mean Medicaid obstetrical
18		inpatient utilization rate for all hospitals in
19		Illinois receiving Medicaid payments from the
20		Department for obstetrical services; or
21		(5) Any children's hospital, which means a hospital
22		devoted exclusively to caring for children. A hospital
23		which includes a facility devoted exclusively to caring
24		for children shall be considered a children's hospital to
25		the degree that the hospital's Medicaid care is provided
26		to children if either (i) the facility devoted exclusively

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1		to caring for children is separately licensed as a
2		hospital by a municipality prior to February 28, 2013;
3		(ii) the hospital has been designated by the State as a
4		Level III perinatal care facility, has a Medicaid
5		Inpatient Utilization rate greater than 55% for the rate
6		year 2003 disproportionate share determination, and has
7		more than 10,000 qualified children days as defined by the
8		Department in rulemaking; (iii) the hospital has been
9		designated as a Perinatal Level III center by the State as
10		of December 1, 2017, is a Pediatric Critical Care Center
11		designated by the State as of December 1, 2017 and has a
12		2017 Medicaid inpatient utilization rate equal to or
13		greater than 45%; or (iv) the hospital has been designated
14		as a Perinatal Level II center by the State as of December
15		1, 2017, has a 2017 Medicaid Inpatient Utilization Rate
16		greater than 70%, and has at least 10 pediatric beds as
17		listed on the IDPH 2015 calendar year hospital profile; or
18		(6) A hospital that reopens a previously closed
19		hospital facility within 4 calendar years of the hospital
20		facility's closure, if the previously closed hospital
21		facility qualified for payments under paragraph (c) at the
22		time of closure, until utilization data for the new
23		facility is available for the Medicaid inpatient
24		utilization rate calculation. For purposes of this clause,
25		a "closed hospital facility" shall include hospitals that
26		have been terminated from participation in the medical

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1		assistance program in accordance with Section 12-4.25 of
2		this Code.
3		(c) Inpatient adjustment payments. The adjustment payments
4		required by paragraph (b) shall be calculated based upon the
5		hospital's Medicaid inpatient utilization rate as follows:
6		(1) hospitals with a Medicaid inpatient utilization
7		rate below the mean shall receive a per day adjustment
8		payment equal to $25;
9		(2) hospitals with a Medicaid inpatient utilization
10		rate that is equal to or greater than the mean Medicaid
11		inpatient utilization rate but less than one standard
12		deviation above the mean Medicaid inpatient utilization
13		rate shall receive a per day adjustment payment equal to
14		the sum of $25 plus $1 for each one percent that the
15		hospital's Medicaid inpatient utilization rate exceeds the
16		mean Medicaid inpatient utilization rate;
17		(3) hospitals with a Medicaid inpatient utilization
18		rate that is equal to or greater than one standard
19		deviation above the mean Medicaid inpatient utilization
20		rate but less than 1.5 standard deviations above the mean
21		Medicaid inpatient utilization rate shall receive a per
22		day adjustment payment equal to the sum of $40 plus $7 for
23		each one percent that the hospital's Medicaid inpatient
24		utilization rate exceeds one standard deviation above the
25		mean Medicaid inpatient utilization rate;
26		(4) hospitals with a Medicaid inpatient utilization

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1		rate that is equal to or greater than 1.5 standard
2		deviations above the mean Medicaid inpatient utilization
3		rate shall receive a per day adjustment payment equal to
4		the sum of $90 plus $2 for each one percent that the
5		hospital's Medicaid inpatient utilization rate exceeds 1.5
6		standard deviations above the mean Medicaid inpatient
7		utilization rate; and
8		(5) hospitals qualifying under clause (6) of paragraph
9		(b) shall have the rate assigned to the previously closed
10		hospital facility at the date of closure, until
11		utilization data for the new facility is available for the
12		Medicaid inpatient utilization rate calculation.
13		(c-1) Beginning October 1, 2026, for rate year 2027 and
14		thereafter, the Medicaid inpatient utilization rate used in
15		the determination of eligibility for payments under paragraph
16		(c) shall be modified to exclude from both the numerator and
17		denominator all days of care funded by the U.S. Department of
18		Veterans Affairs at a hospital approved to conduct its
19		operations from more than one location within contiguous
20		counties under a single license, if at the time of its
21		licensing application the hospital was located in a county
22		with fewer than 125,000 inhabitants and the hospital's second
23		facility is located in a contiguous county with fewer than
24		235,000 inhabitants. For purposes of this subsection, days of
25		care funded by the U.S. Department of Veterans Affairs include
26		authorized VA community care provided at non-VA hospitals.

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1		(d) Supplemental adjustment payments. In addition to the
2		adjustment payments described in paragraph (c), hospitals as
3		defined in clauses (1) through (6) of paragraph (b), excluding
4		county hospitals (as defined in subsection (c) of Section 15-1
5		of this Code) and a hospital organized under the University of
6		Illinois Hospital Act, shall be paid supplemental inpatient
7		adjustment payments of $60 per day. For purposes of Title XIX
8		of the federal Social Security Act, these supplemental
9		adjustment payments shall not be classified as adjustment
10		payments to disproportionate share hospitals.
11		(e) The inpatient adjustment payments described in
12		paragraphs (c) and (d) shall be increased on October 1, 1993
13		and annually thereafter by a percentage equal to the lesser of
14		(i) the increase in the DRI hospital cost index for the most
15		recent 12 month period for which data are available, or (ii)
16		the percentage increase in the statewide average hospital
17		payment rate over the previous year's statewide average
18		hospital payment rate. The sum of the inpatient adjustment
19		payments under paragraphs (c) and (d) to a hospital, other
20		than a county hospital (as defined in subsection (c) of
21		Section 15-1 of this Code) or a hospital organized under the
22		University of Illinois Hospital Act, however, shall not exceed
23		$275 per day; that limit shall be increased on October 1, 1993
24		and annually thereafter by a percentage equal to the lesser of
25		(i) the increase in the DRI hospital cost index for the most
26		recent 12-month period for which data are available or (ii)

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1		the percentage increase in the statewide average hospital
2		payment rate over the previous year's statewide average
3		hospital payment rate.
4		(f) Children's hospital inpatient adjustment payments. For
5		children's hospitals, as defined in clause (5) of paragraph
6		(b), the adjustment payments required pursuant to paragraphs
7		(c) and (d) shall be multiplied by 2.0.
8		(g) County hospital inpatient adjustment payments. For
9		county hospitals, as defined in subsection (c) of Section 15-1
10		of this Code, there shall be an adjustment payment as
11		determined by rules issued by the Illinois Department.
12		(h) For the purposes of this Section the following terms
13		shall be defined as follows:
14		(1) "Medicaid inpatient utilization rate" means a
15		fraction, the numerator of which is the number of a
16		hospital's inpatient days provided in a given 12-month
17		period to patients who, for such days, were eligible for
18		Medicaid under Title XIX of the federal Social Security
19		Act, and the denominator of which is the total number of
20		the hospital's inpatient days in that same period.
21		(2) "Mean Medicaid inpatient utilization rate" means
22		the total number of Medicaid inpatient days provided by
23		all Illinois Medicaid-participating hospitals divided by
24		the total number of inpatient days provided by those same
25		hospitals.
26		(3) "Medicaid obstetrical inpatient utilization rate"

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1		means the ratio of Medicaid obstetrical inpatient days to
2		total Medicaid inpatient days for all Illinois hospitals
3		receiving Medicaid payments from the Illinois Department.
4		(i) Inpatient adjustment payment limit. In order to meet
5		the limits of Public Law 102-234 and Public Law 103-66, the
6		Illinois Department shall by rule adjust disproportionate
7		share adjustment payments.
8		(j) University of Illinois Hospital inpatient adjustment
9		payments. For hospitals organized under the University of
10		Illinois Hospital Act, there shall be an adjustment payment as
11		determined by rules adopted by the Illinois Department.
12		(k) The Illinois Department may by rule establish criteria
13		for and develop methodologies for adjustment payments to
14		hospitals participating under this Article.
15		(l) On and after July 1, 2012, the Department shall reduce
16		any rate of reimbursement for services or other payments or
17		alter any methodologies authorized by this Code to reduce any
18		rate of reimbursement for services or other payments in
19		accordance with Section 5-5e.
20		(m) The Department shall establish a cost-based
21		reimbursement methodology for determining payments to
22		hospitals for approved graduate medical education (GME)
23		programs for dates of service on and after July 1, 2018.
24		(1) As used in this subsection, "hospitals" means the
25		University of Illinois Hospital as defined in the
26		University of Illinois Hospital Act and a county hospital

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1		in a county of over 3,000,000 inhabitants.
2		(2) An amendment to the Illinois Title XIX State Plan
3		defining GME shall maximize reimbursement, shall not be
4		limited to the education programs or special patient care
5		payments allowed under Medicare, and shall include:
6		(A) inpatient days;
7		(B) outpatient days;
8		(C) direct costs;
9		(D) indirect costs;
10		(E) managed care days;
11		(F) all stages of medical training and education
12		including students, interns, residents, and fellows
13		with no caps on the number of persons who may qualify;
14		and
15		(G) patient care payments related to the
16		complexities of treating Medicaid enrollees including
17		clinical and social determinants of health.
18		(3) The Department shall make all GME payments
19		directly to hospitals including such costs in support of
20		clients enrolled in Medicaid managed care entities.
21		(4) The Department shall promptly take all actions
22		necessary for reimbursement to be effective for dates of
23		service on and after July 1, 2018 including publishing all
24		appropriate public notices, amendments to the Illinois
25		Title XIX State Plan, and adoption of administrative rules
26		if necessary.

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1		(5) As used in this subsection, "managed care days"
2		means costs associated with services rendered to enrollees
3		of Medicaid managed care entities. "Medicaid managed care
4		entities" means any entity which contracts with the
5		Department to provide services paid for on a capitated
6		basis. "Medicaid managed care entities" includes a managed
7		care organization and a managed care community network.
8		(6) All payments under this Section are contingent
9		upon federal approval of changes to the Illinois Title XIX
10		State Plan, if that approval is required.
11		(7) The Department may adopt rules necessary to
12		implement Public Act 100-581 through the use of emergency
13		rulemaking in accordance with subsection (aa) of Section
14		5-45 of the Illinois Administrative Procedure Act. For
15		purposes of that Act, the General Assembly finds that the
16		adoption of rules to implement Public Act 100-581 is
17		deemed an emergency and necessary for the public interest,
18		safety, and welfare.
19		(Source: P.A. 101-81, eff. 7-12-19; 102-682, eff. 12-10-21;
20		102-886, eff. 5-17-22.)
21		ARTICLE 85.
22		Section 85-5. The Illinois Act on the Aging is amended by
23		changing Section 4.02 as follows:

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1		(20 ILCS 105/4.02)
2		Sec. 4.02. Community Care Program. The Department shall
3		establish a program of services to prevent unnecessary
4		institutionalization of persons age 60 and older in need of
5		long term care or who are established as persons who suffer
6		from Alzheimer's disease or a related disorder under the
7		Alzheimer's Disease Assistance Act, thereby enabling them to
8		remain in their own homes or in other living arrangements.
9		Such preventive services, which may be coordinated with other
10		programs for the aged, may include, but are not limited to, any
11		or all of the following:
12		(a) (blank);
13		(b) (blank);
14		(c) home care aide services;
15		(d) personal assistant services;
16		(e) adult day services;
17		(f) home-delivered meals;
18		(g) education in self-care;
19		(h) personal care services;
20		(i) adult day health services;
21		(j) habilitation services;
22		(k) respite care;
23		(k-5) community reintegration services;
24		(k-6) flexible senior services;
25		(k-7) medication management;
26		(k-8) emergency home response;

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1		(l) other nonmedical social services that may enable
2		the person to become self-supporting; or
3		(m) (blank).
4		The Department shall establish eligibility standards for
5		such services. In determining the amount and nature of
6		services for which a person may qualify, consideration shall
7		not be given to the value of cash, property, or other assets
8		held in the name of the person's spouse pursuant to a written
9		agreement dividing marital property into equal but separate
10		shares or pursuant to a transfer of the person's interest in a
11		home to his spouse, provided that the spouse's share of the
12		marital property is not made available to the person seeking
13		such services.
14		The Department shall require as a condition of eligibility
15		that all new financially eligible applicants apply for and
16		enroll in medical assistance under Article V of the Illinois
17		Public Aid Code in accordance with rules promulgated by the
18		Department.
19		The Department shall, in conjunction with the Department
20		of Public Aid (now Department of Healthcare and Family
21		Services), seek appropriate amendments under Sections 1915 and
22		1924 of the Social Security Act. The purpose of the amendments
23		shall be to extend eligibility for home and community based
24		services under Sections 1915 and 1924 of the Social Security
25		Act to persons who transfer to or for the benefit of a spouse
26		those amounts of income and resources allowed under Section

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1		1924 of the Social Security Act. Subject to the approval of
2		such amendments, the Department shall extend the provisions of
3		Section 5-4 of the Illinois Public Aid Code to persons who, but
4		for the provision of home or community-based services, would
5		require the level of care provided in an institution, as is
6		provided for in federal law. Those persons no longer found to
7		be eligible for receiving noninstitutional services due to
8		changes in the eligibility criteria shall be given 45 days
9		notice prior to actual termination. Those persons receiving
10		notice of termination may contact the Department and request
11		the determination be appealed at any time during the 45 day
12		notice period. The target population identified for the
13		purposes of this Section are persons age 60 and older with an
14		identified service need. Priority shall be given to those who
15		are at imminent risk of institutionalization. The services
16		shall be provided to eligible persons age 60 and older to the
17		extent that the cost of the services together with the other
18		personal maintenance expenses of the persons are reasonably
19		related to the standards established for care in a group
20		facility appropriate to the person's condition. These
21		noninstitutional services, pilot projects, or experimental
22		facilities may be provided as part of or in addition to those
23		authorized by federal law or those funded and administered by
24		the Department of Human Services. The Departments of Human
25		Services, Healthcare and Family Services, Public Health,
26		Veterans' Affairs, and Commerce and Economic Opportunity and

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1		other appropriate agencies of State, federal, and local
2		governments shall cooperate with the Department on Aging in
3		the establishment and development of the noninstitutional
4		services. The Department shall require an annual audit from
5		all personal assistant and home care aide vendors contracting
6		with the Department under this Section. The annual audit shall
7		assure that each audited vendor's procedures are in compliance
8		with Department's financial reporting guidelines requiring an
9		administrative and employee wage and benefits cost split as
10		defined in administrative rules. The audit is a public record
11		under the Freedom of Information Act. The Department shall
12		execute, relative to the nursing home prescreening project,
13		written inter-agency agreements with the Department of Human
14		Services and the Department of Healthcare and Family Services,
15		to effect the following: (1) intake procedures and common
16		eligibility criteria for those persons who are receiving
17		noninstitutional services; and (2) the establishment and
18		development of noninstitutional services in areas of the State
19		where they are not currently available or are undeveloped. On
20		and after July 1, 1996, all nursing home prescreenings for
21		individuals 60 years of age or older shall be conducted by the
22		Department.
23		As part of the Department on Aging's routine training of
24		case managers and case manager supervisors, the Department may
25		include information on family futures planning for persons who
26		are age 60 or older and who are caregivers of their adult

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1		children with developmental disabilities. The content of the
2		training shall be at the Department's discretion.
3		The Department is authorized to establish a system of
4		recipient copayment for services provided under this Section,
5		such copayment to be based upon the recipient's ability to pay
6		but in no case to exceed the actual cost of the services
7		provided. Additionally, any portion of a person's income which
8		is equal to or less than the federal poverty standard shall not
9		be considered by the Department in determining the copayment.
10		The level of such copayment shall be adjusted whenever
11		necessary to reflect any change in the officially designated
12		federal poverty standard.
13		The Department, or the Department's authorized
14		representative, may recover the amount of moneys expended for
15		services provided to or in behalf of a person under this
16		Section by a claim against the person's estate or against the
17		estate of the person's surviving spouse, but no recovery may
18		be had until after the death of the surviving spouse, if any,
19		and then only at such time when there is no surviving child who
20		is under age 21 or blind or who has a permanent and total
21		disability. This paragraph, however, shall not bar recovery,
22		at the death of the person, of moneys for services provided to
23		the person or in behalf of the person under this Section to
24		which the person was not entitled; provided that such recovery
25		shall not be enforced against any real estate while it is
26		occupied as a homestead by the surviving spouse or other

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1		dependent, if no claims by other creditors have been filed
2		against the estate, or, if such claims have been filed, they
3		remain dormant for failure of prosecution or failure of the
4		claimant to compel administration of the estate for the
5		purpose of payment. This paragraph shall not bar recovery from
6		the estate of a spouse, under Sections 1915 and 1924 of the
7		Social Security Act and Section 5-4 of the Illinois Public Aid
8		Code, who precedes a person receiving services under this
9		Section in death. All moneys for services paid to or in behalf
10		of the person under this Section shall be claimed for recovery
11		from the deceased spouse's estate. "Homestead", as used in
12		this paragraph, means the dwelling house and contiguous real
13		estate occupied by a surviving spouse or relative, as defined
14		by the rules and regulations of the Department of Healthcare
15		and Family Services, regardless of the value of the property.
16		The Department shall increase the effectiveness of the
17		existing Community Care Program by:
18		(1) ensuring that in-home services included in the
19		care plan are available on evenings and weekends;
20		(2) ensuring that care plans contain the services that
21		eligible participants need based on the number of days in
22		a month, not limited to specific blocks of time, as
23		identified by the comprehensive assessment tool selected
24		by the Department for use statewide, not to exceed the
25		total monthly service cost maximum allowed for each
26		service; the Department shall develop administrative rules

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1		to implement this item (2);
2		(3) ensuring that the participants have the right to
3		choose the services contained in their care plan and to
4		direct how those services are provided, based on
5		administrative rules established by the Department;
6		(4)(blank);
7		(5) ensuring that homemakers can provide personal care
8		services that may or may not involve contact with clients,
9		including, but not limited to:
10		(A) bathing;
11		(B) grooming;
12		(C) toileting;
13		(D) nail care;
14		(E) transferring;
15		(F) respiratory services;
16		(G) exercise; or
17		(H) positioning;
18		(6) ensuring that homemaker program vendors are not
19		restricted from hiring homemakers who are family members
20		of clients or recommended by clients; the Department may
21		not, by rule or policy, require homemakers who are family
22		members of clients or recommended by clients to accept
23		assignments in homes other than the client;
24		(7) ensuring that the State may access maximum federal
25		matching funds by seeking approval for the Centers for
26		Medicare and Medicaid Services for modifications to the

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1		State's home and community based services waiver and
2		additional waiver opportunities, including applying for
3		enrollment in the Balance Incentive Payment Program by May
4		1, 2013, in order to maximize federal matching funds; this
5		shall include, but not be limited to, modification that
6		reflects all changes in the Community Care Program
7		services and all increases in the services cost maximum;
8		(8) ensuring that the determination of need tool
9		accurately reflects the service needs of individuals with
10		Alzheimer's disease and related dementia disorders;
11		(9) ensuring that services are authorized accurately
12		and consistently for the Community Care Program (CCP); the
13		Department shall implement a Service Authorization policy
14		directive; the purpose shall be to ensure that eligibility
15		and services are authorized accurately and consistently in
16		the CCP program; the policy directive shall clarify
17		service authorization guidelines to Care Coordination
18		Units and Community Care Program providers no later than
19		May 1, 2013;
20		(10) working in conjunction with Care Coordination
21		Units, the Department of Healthcare and Family Services,
22		the Department of Human Services, Community Care Program
23		providers, and other stakeholders to make improvements to
24		the Medicaid claiming processes and the Medicaid
25		enrollment procedures or requirements as needed,
26		including, but not limited to, specific policy changes or

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1		rules to improve the up-front enrollment of participants
2		in the Medicaid program and specific policy changes or
3		rules to ensure insure more prompt submission of bills to
4		the federal government to secure maximum federal matching
5		dollars as promptly as possible; the Department on Aging
6		shall have at least 3 meetings with stakeholders by
7		January 1, 2014 in order to address these improvements;
8		(11) requiring home care service providers to comply
9		with the rounding of hours worked provisions under the
10		federal Fair Labor Standards Act (FLSA) and as set forth
11		in 29 CFR 785.48(b) by May 1, 2013;
12		(12) implementing any necessary policy changes or
13		promulgating any rules, no later than January 1, 2014, to
14		assist the Department of Healthcare and Family Services in
15		moving as many participants as possible, consistent with
16		federal regulations, into coordinated care plans if a care
17		coordination plan that covers long term care is available
18		in the recipient's area; and
19		(13) (blank).
20		By January 1, 2009 or as soon after the end of the Cash and
21		Counseling Demonstration Project as is practicable, the
22		Department may, based on its evaluation of the demonstration
23		project, promulgate rules concerning personal assistant
24		services, to include, but need not be limited to,
25		qualifications, employment screening, rights under fair labor
26		standards, training, fiduciary agent, and supervision

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1		requirements. All applicants shall be subject to the
2		provisions of the Health Care Worker Background Check Act.
3		The Department shall develop procedures to enhance
4		availability of services on evenings, weekends, and on an
5		emergency basis to meet the respite needs of caregivers.
6		Procedures shall be developed to permit the utilization of
7		services in successive blocks of 24 hours up to the monthly
8		maximum established by the Department. Workers providing these
9		services shall be appropriately trained.
10		No person may perform chore/housekeeping and home care
11		aide services under a program authorized by this Section
12		unless that person has been issued a certificate of
13		pre-service to do so by his or her employing agency.
14		Information gathered to effect such certification shall
15		include (i) the person's name, (ii) the date the person was
16		hired by his or her current employer, and (iii) the training,
17		including dates and levels. Persons engaged in the program
18		authorized by this Section before the effective date of this
19		amendatory Act of 1991 shall be issued a certificate of all
20		pre-service and in-service training from his or her employer
21		upon submitting the necessary information. The employing
22		agency shall be required to retain records of all staff
23		pre-service and in-service training, and shall provide such
24		records to the Department upon request and upon termination of
25		the employer's contract with the Department. In addition, the
26		employing agency is responsible for the issuance of

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1		certifications of in-service training completed to its their
2		employees.
3		The Department is required to develop a system to ensure
4		that persons working as home care aides and personal
5		assistants receive increases in their wages when the federal
6		minimum wage is increased by requiring vendors to certify that
7		they are meeting the federal minimum wage statute for home
8		care aides and personal assistants. An employer that cannot
9		ensure that the minimum wage increase is being given to home
10		care aides and personal assistants shall be denied any
11		increase in reimbursement costs.
12		The Community Care Program Advisory Committee is created
13		in the Department on Aging. The Director shall appoint
14		individuals to serve in the Committee, who shall serve at
15		their own expense. Members of the Committee must abide by all
16		applicable ethics laws. The Committee shall advise the
17		Department on issues related to the Department's program of
18		services to prevent unnecessary institutionalization. The
19		Committee shall meet on a bi-monthly basis and shall serve to
20		identify and advise the Department on present and potential
21		issues affecting the service delivery network, the program's
22		clients, and the Department and to recommend solution
23		strategies. Persons appointed to the Committee shall be
24		appointed on, but not limited to, their own and their agency's
25		experience with the program, geographic representation, and
26		willingness to serve. The Director shall appoint members to

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1		the Committee to represent provider, advocacy, policy
2		research, and other constituencies committed to the delivery
3		of high quality home and community-based services to older
4		adults. Representatives shall be appointed to ensure
5		representation from community care providers, including, but
6		not limited to, adult day service providers, homemaker
7		providers, case coordination and case management units,
8		emergency home response providers, statewide trade or labor
9		unions that represent home care aides and direct care staff,
10		area agencies on aging, adults over age 60, membership
11		organizations representing older adults, and other
12		organizational entities, providers of care, or individuals
13		with demonstrated interest and expertise in the field of home
14		and community care as determined by the Director.
15		Nominations may be presented from any agency or State
16		association with interest in the program. The Director, or his
17		or her designee, shall serve as the permanent co-chair of the
18		advisory committee. One other co-chair shall be nominated and
19		approved by the members of the committee on an annual basis.
20		Committee members' terms of appointment shall be for 4 years
21		with one-quarter of the appointees' terms expiring each year.
22		A member shall continue to serve until his or her replacement
23		is named. The Department shall fill vacancies that have a
24		remaining term of over one year, and this replacement shall
25		occur through the annual replacement of expiring terms. The
26		Director shall designate Department staff to provide technical

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1		assistance and staff support to the committee. Department
2		representation shall not constitute membership of the
3		committee. All Committee papers, issues, recommendations,
4		reports, and meeting memoranda are advisory only. The
5		Director, or his or her designee, shall make a written report,
6		as requested by the Committee, regarding issues before the
7		Committee.
8		The Department on Aging and the Department of Human
9		Services shall cooperate in the development and submission of
10		an annual report on programs and services provided under this
11		Section. Such joint report shall be filed with the Governor
12		and the General Assembly on or before March 31 of the following
13		fiscal year.
14		The requirement for reporting to the General Assembly
15		shall be satisfied by filing copies of the report as required
16		by Section 3.1 of the General Assembly Organization Act and
17		filing such additional copies with the State Government Report
18		Distribution Center for the General Assembly as is required
19		under paragraph (t) of Section 7 of the State Library Act.
20		Those persons previously found eligible for receiving
21		noninstitutional services whose services were discontinued
22		under the Emergency Budget Act of Fiscal Year 1992, and who do
23		not meet the eligibility standards in effect on or after July
24		1, 1992, shall remain ineligible on and after July 1, 1992.
25		Those persons previously not required to cost-share and who
26		were required to cost-share effective March 1, 1992, shall

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1		continue to meet cost-share requirements on and after July 1,
2		1992. Beginning July 1, 1992, all clients will be required to
3		meet eligibility, cost-share, and other requirements and will
4		have services discontinued or altered when they fail to meet
5		these requirements.
6		For the purposes of this Section, "flexible senior
7		services" refers to services that require one-time or periodic
8		expenditures, including, but not limited to, respite care,
9		home modification, assistive technology, housing assistance,
10		and transportation.
11		The Department shall implement an electronic service
12		verification based on global positioning systems or other
13		cost-effective technology for the Community Care Program no
14		later than January 1, 2014.
15		The Department shall require, as a condition of
16		eligibility, application for the medical assistance program
17		under Article V of the Illinois Public Aid Code.
18		The Department may authorize Community Care Program
19		services until an applicant is determined eligible for medical
20		assistance under Article V of the Illinois Public Aid Code.
21		The Department shall continue to provide Community Care
22		Program reports as required by statute, which shall include an
23		annual report on Care Coordination Unit performance and
24		adherence to service guidelines and a 6-month supplemental
25		report.
26		In regard to community care providers, failure to comply

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1		with Department on Aging policies shall be cause for
2		disciplinary action, including, but not limited to,
3		disqualification from serving Community Care Program clients.
4		Each provider, upon submission of any bill or invoice to the
5		Department for payment for services rendered, shall include a
6		notarized statement, under penalty of perjury pursuant to
7		Section 1-109 of the Code of Civil Procedure, that the
8		provider has complied with all Department policies.
9		The Director of the Department on Aging shall make
10		information available to the State Board of Elections as may
11		be required by an agreement the State Board of Elections has
12		entered into with a multi-state voter registration list
13		maintenance system.
14		The Department shall pay an enhanced rate of at least
15		$1.77 per unit under the Community Care Program to those
16		in-home service provider agencies that offer health insurance
17		coverage as a benefit to their direct service worker employees
18		pursuant to rules adopted by the Department. The Department
19		shall review the enhanced rate as part of its process to rebase
20		in-home service provider reimbursement rates pursuant to
21		federal waiver requirements. Subject to federal approval,
22		beginning on January 1, 2024, rates for adult day services
23		shall be increased to $16.84 per hour and rates for each way
24		transportation services for adult day services shall be
25		increased to $12.44 per unit transportation.
26		Subject to federal approval, on and after January 1, 2024,

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1		rates for homemaker services shall be increased to $28.07 to
2		sustain a minimum wage of $17 per hour for direct service
3		workers. Rates in subsequent State fiscal years shall be no
4		lower than the rates put into effect upon federal approval.
5		Providers of in-home services shall be required to certify to
6		the Department that they remain in compliance with the
7		mandated wage increase for direct service workers. Fringe
8		benefits, including, but not limited to, paid time off and
9		payment for training, health insurance, travel, or
10		transportation, shall not be reduced in relation to the rate
11		increases described in this paragraph.
12		Subject to and upon federal approval, on and after January
13		1, 2025, rates for homemaker services shall be increased to
14		$29.63 to sustain a minimum wage of $18 per hour for direct
15		service workers. Rates in subsequent State fiscal years shall
16		be no lower than the rates put into effect upon federal
17		approval. Providers of in-home services shall be required to
18		certify to the Department that they remain in compliance with
19		the mandated wage increase for direct service workers. Fringe
20		benefits, including, but not limited to, paid time off and
21		payment for training, health insurance, travel, or
22		transportation, shall not be reduced in relation to the rate
23		increases described in this paragraph.
24		Subject to and upon federal approval, on and after January
25		1, 2026, rates for homemaker services shall be increased to
26		$30.80 to sustain a minimum wage of $18.75 per hour for direct

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1		service workers. Rates in subsequent State fiscal years shall
2		be no lower than the rates put into effect upon federal
3		approval. Providers of in-home services shall be required to
4		certify to the Department that they remain in compliance with
5		the mandated wage increase for direct service workers. Fringe
6		benefits, including, but not limited to, paid time off and
7		payment for training, health insurance, travel, or
8		transportation, shall not be reduced in relation to the rate
9		increases described in this paragraph.
10		Beginning January 1, 2027, subject to any necessary
11		federal approval, rates for adult day services shall be
12		increased to $17.84 per hour and rates for each way
13		transportation services for adult day services shall be
14		increased to $13.44 per unit transportation.
15		The General Assembly finds it necessary to authorize an
16		aggressive Medicaid enrollment initiative designed to maximize
17		federal Medicaid funding for the Community Care Program which
18		produces significant savings for the State of Illinois. The
19		Department on Aging shall establish and implement a Community
20		Care Program Medicaid Initiative. Under the Initiative, the
21		Department on Aging shall, at a minimum: (i) provide an
22		enhanced rate to adequately compensate care coordination units
23		to enroll eligible Community Care Program clients into
24		Medicaid; (ii) use recommendations from a stakeholder
25		committee on how best to implement the Initiative; and (iii)
26		establish requirements for State agencies to make enrollment

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1		in the State's Medical Assistance program easier for seniors.
2		The Community Care Program Medicaid Enrollment Oversight
3		Subcommittee is created as a subcommittee of the Older Adult
4		Services Advisory Committee established in Section 35 of the
5		Older Adult Services Act to make recommendations on how best
6		to increase the number of medical assistance recipients who
7		are enrolled in the Community Care Program. The Subcommittee
8		shall consist of all of the following persons who must be
9		appointed within 30 days after June 4, 2018 (the effective
10		date of Public Act 100-587):
11		(1) The Director of Aging, or his or her designee, who
12		shall serve as the chairperson of the Subcommittee.
13		(2) One representative of the Department of Healthcare
14		and Family Services, appointed by the Director of
15		Healthcare and Family Services.
16		(3) One representative of the Department of Human
17		Services, appointed by the Secretary of Human Services.
18		(4) One individual representing a care coordination
19		unit, appointed by the Director of Aging.
20		(5) One individual from a non-governmental statewide
21		organization that advocates for seniors, appointed by the
22		Director of Aging.
23		(6) One individual representing Area Agencies on
24		Aging, appointed by the Director of Aging.
25		(7) One individual from a statewide association
26		dedicated to Alzheimer's care, support, and research,

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1		appointed by the Director of Aging.
2		(8) One individual from an organization that employs
3		persons who provide services under the Community Care
4		Program, appointed by the Director of Aging.
5		(9) One member of a trade or labor union representing
6		persons who provide services under the Community Care
7		Program, appointed by the Director of Aging.
8		(10) One member of the Senate, who shall serve as
9		co-chairperson, appointed by the President of the Senate.
10		(11) One member of the Senate, who shall serve as
11		co-chairperson, appointed by the Minority Leader of the
12		Senate.
13		(12) One member of the House of Representatives, who
14		shall serve as co-chairperson, appointed by the Speaker of
15		the House of Representatives.
16		(13) One member of the House of Representatives, who
17		shall serve as co-chairperson, appointed by the Minority
18		Leader of the House of Representatives.
19		(14) One individual appointed by a labor organization
20		representing frontline employees at the Department of
21		Human Services.
22		The Subcommittee shall provide oversight to the Community
23		Care Program Medicaid Initiative and shall meet quarterly. At
24		each Subcommittee meeting the Department on Aging shall
25		provide the following data sets to the Subcommittee: (A) the
26		number of Illinois residents, categorized by planning and

SB3365 Enrolled - 208 - LRB104 18483 SSS 31925 b
1		service area, who are receiving services under the Community
2		Care Program and are enrolled in the State's Medical
3		Assistance Program; (B) the number of Illinois residents,
4		categorized by planning and service area, who are receiving
5		services under the Community Care Program, but are not
6		enrolled in the State's Medical Assistance Program; and (C)
7		the number of Illinois residents, categorized by planning and
8		service area, who are receiving services under the Community
9		Care Program and are eligible for benefits under the State's
10		Medical Assistance Program, but are not enrolled in the
11		State's Medical Assistance Program. In addition to this data,
12		the Department on Aging shall provide the Subcommittee with
13		plans on how the Department on Aging will reduce the number of
14		Illinois residents who are not enrolled in the State's Medical
15		Assistance Program but who are eligible for medical assistance
16		benefits. The Department on Aging shall enroll in the State's
17		Medical Assistance Program those Illinois residents who
18		receive services under the Community Care Program and are
19		eligible for medical assistance benefits but are not enrolled
20		in the State's Medical Medicaid Assistance Program. The data
21		provided to the Subcommittee shall be made available to the
22		public via the Department on Aging's website.
23		The Department on Aging, with the involvement of the
24		Subcommittee, shall collaborate with the Department of Human
25		Services and the Department of Healthcare and Family Services
26		on how best to achieve the responsibilities of the Community

SB3365 Enrolled - 209 - LRB104 18483 SSS 31925 b
1		Care Program Medicaid Initiative.
2		The Department on Aging, the Department of Human Services,
3		and the Department of Healthcare and Family Services shall
4		coordinate and implement a streamlined process for seniors to
5		access benefits under the State's Medical Assistance Program.
6		The Subcommittee shall collaborate with the Department of
7		Human Services on the adoption of a uniform application
8		submission process. The Department of Human Services and any
9		other State agency involved with processing the medical
10		assistance application of any person enrolled in the Community
11		Care Program shall include the appropriate care coordination
12		unit in all communications related to the determination or
13		status of the application.
14		The Community Care Program Medicaid Initiative shall
15		provide targeted funding to care coordination units to help
16		seniors complete their applications for medical assistance
17		benefits. On and after July 1, 2019, care coordination units
18		shall receive no less than $200 per completed application,
19		which rate may be included in a bundled rate for initial intake
20		services when Medicaid application assistance is provided in
21		conjunction with the initial intake process for new program
22		participants.
23		The Community Care Program Medicaid Initiative shall cease
24		operation 5 years after June 4, 2018 (the effective date of
25		Public Act 100-587), after which the Subcommittee shall
26		dissolve.

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1		Effective July 1, 2023, subject to federal approval, the
2		Department on Aging shall reimburse Care Coordination Units at
3		the following rates for case management services: $252.40 for
4		each initial assessment; $366.40 for each initial assessment
5		with translation; $229.68 for each redetermination assessment;
6		$313.68 for each redetermination assessment with translation;
7		$200.00 for each completed application for medical assistance
8		benefits; $132.26 for each face-to-face, choices-for-care
9		screening; $168.26 for each face-to-face, choices-for-care
10		screening with translation; $124.56 for each 6-month,
11		face-to-face visit; $132.00 for each MCO participant
12		eligibility determination; and $157.00 for each MCO
13		participant eligibility determination with translation.
14		(Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section
15		45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.
16		1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;
17		103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.
18		1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)
19		ARTICLE 145.
20		Section 145-5. The Illinois Public Aid Code is amended by
21		changing Section 14-12.5 as follows:
22		(305 ILCS 5/14-12.5)
23		Sec. 14-12.5. Hospital rate updates.

SB3365 Enrolled - 211 - LRB104 18483 SSS 31925 b
1		(a) Notwithstanding any other provision of this Code, the
2		hospital rates of reimbursement authorized under Sections
3		5-5.05, 14-12, and 14-13 of this Code shall be adjusted in
4		accordance with the provisions of this Section.
5		(b) Notwithstanding any other provision of this Code,
6		effective for dates of service on and after January 1, 2024,
7		subject to federal approval, hospital reimbursement rates
8		shall be revised as follows:
9		(1) For inpatient general acute care services, the
10		statewide-standardized amount and the per diem rates for
11		hospitals exempt from the APR-DRG reimbursement system, in
12		effect January 1, 2023, shall be increased by 10%.
13		(2) For inpatient psychiatric services:
14		(A) For safety-net hospitals, the hospital
15		specific per diem rate in effect January 1, 2023 and
16		the minimum per diem rate of $630, authorized in
17		subsection (b-5) of Section 5-5.05 of this Code, shall
18		be increased by 10%.
19		(B) For all general acute care hospitals that are
20		not safety-net hospitals, the inpatient psychiatric
21		care per diem rates in effect January 1, 2023 shall be
22		increased by 10%, except that all rates shall be at
23		least 90% of the minimum inpatient psychiatric care
24		per diem rate for safety-net hospitals as authorized
25		in subsection (b-5) of Section 5-5.05 of this Code
26		including the adjustments authorized in this Section.

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1		The statewide default per diem rate for a hospital
2		opening a new psychiatric distinct part unit, shall be
3		set at 90% of the minimum inpatient psychiatric care
4		per diem rate for safety-net hospitals as authorized
5		in subsection (b-5) of Section 5-5.05 of this Code,
6		including the adjustment authorized in this Section.
7		(C) For all psychiatric specialty hospitals, the
8		per diem rates in effect January 1, 2023, shall be
9		increased by 10%, except that all rates shall be at
10		least 90% of the minimum inpatient per diem rate for
11		safety-net hospitals as authorized in subsection (b-5)
12		of Section 5-5.05 of this Code, including the
13		adjustments authorized in this Section. The statewide
14		default per diem rate for a new psychiatric specialty
15		hospital shall be set at 90% of the minimum inpatient
16		psychiatric care per diem rate for safety-net
17		hospitals as authorized in subsection (b-5) of Section
18		5-5.05 of this Code, including the adjustment
19		authorized in this Section.
20		(3) For inpatient rehabilitative services, all
21		hospital specific per diem rates in effect January 1,
22		2023, shall be increased by 10%. The statewide default
23		inpatient rehabilitative services per diem rates, for
24		general acute care hospitals and for rehabilitation
25		specialty hospitals respectively, shall be increased by
26		10%.

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1		(4) The statewide-standardized amount for outpatient
2		general acute care services in effect January 1, 2023,
3		shall be increased by 10%.
4		(5) The statewide-standardized amount for outpatient
5		psychiatric care services in effect January 1, 2023, shall
6		be increased by 10%.
7		(6) The statewide-standardized amount for outpatient
8		rehabilitative care services in effect January 1, 2023,
9		shall be increased by 10%.
10		(7) The per diem rate in effect January 1, 2023, as
11		authorized in subsection (a) of Section 14-13 of this
12		Article shall be increased by 10%.
13		(8) For services provided on and after January 1, 2024
14		through June 30, 2024, and on and after January 1, 2029
15		2027, subject to federal approval, in addition to the
16		statewide standardized amount, an add-on payment of at
17		least $210 shall be paid for each inpatient General Acute
18		and Psychiatric day of care, excluding Medicare-Medicaid
19		dual eligible crossover days, for all safety-net hospitals
20		defined in Section 5-5e.1 of this Code.
21		(A) For Psychiatric days of care, the Department
22		may implement payment of this add-on by increasing the
23		hospital specific psychiatric per diem rate, adjusted
24		in accordance with subparagraph (A) of paragraph (2)
25		of subsection (b) by $210, or by a separate add-on
26		payment.

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1		(B) If the add-on adjustment is added to the
2		hospital specific psychiatric per diem rate to
3		operationalize payment, the Department shall provide a
4		rate sheet to each safety-net hospital, which
5		identifies the hospital psychiatric per diem rate
6		before and after the adjustment.
7		(C) The add-on adjustment shall not be considered
8		when setting the 90% minimum rate identified in
9		paragraph (2) of subsection (b).
10		(9) For services provided on and after July 1, 2024,
11		and on or before December 31, 2028 2026, subject to
12		federal approval, in addition to the statewide
13		standardized amount and any other payments authorized
14		under this Code, a safety-net hospital health care equity
15		add-on payment shall be paid for each inpatient General
16		Acute and Psychiatric day of care, excluding
17		Medicare-Medicaid dual eligible crossover days, for
18		safety-net hospitals defined in Section 5-5e.1 of this
19		Code, as follows:
20		(A) if the safety-net hospital's Medicaid
21		inpatient utilization rate, as calculated under
22		Section 5-5e.1 of this Code, is equal to or greater
23		than 70%, the add-on payment shall be $425;
24		(B) if the safety-net hospital's Medicaid
25		inpatient utilization rate, as calculated under
26		Section 5-5e.1 of this Code, is equal to or greater

SB3365 Enrolled - 215 - LRB104 18483 SSS 31925 b
1		than 50% and less than 70%, the add-on payment shall be
2		$300;
3		(C) if the safety-net hospital's Medicaid
4		inpatient utilization rate, as calculated under
5		Section 5-5e.1 of this Code, is equal to or greater
6		than 40% and less than 50%, the add-on payment shall be
7		$225; and
8		(D) if the safety-net hospital's Medicaid
9		inpatient utilization rate, as calculated under
10		Section 5-5e.1 of this Code, is less than 40%, the
11		add-on payment shall be $210.
12		Qualification for the safety-net hospital health care
13		equity add-on payment shall be updated January 1, 2026,
14		and each January 1 thereafter based on the MIUR
15		determination effective 3 months prior to the start of
16		each the January 1, 2026 calendar year, ending in 2028.
17		Rates described in subparagraphs (A) through (C) shall
18		be adjusted annually beginning January 1, 2026 by applying
19		a uniform factor to each rate to spend an approximate
20		amount of $50,000,000 annually per year using State fiscal
21		year 2024 days as a basis for calendar year 2026 rates.
22		The add-on adjustment under this paragraph shall not
23		be considered when setting the 90% minimum rate identified
24		in subparagraph (B) of paragraph (2).
25		(10) For services provided on and after July 1, 2024,
26		and on or before December 31, 2028 2026, subject to

SB3365 Enrolled - 216 - LRB104 18483 SSS 31925 b
1		federal approval, in addition to the statewide
2		standardized amount and any other payments authorized
3		under this Code, a safety-net hospital low volume add-on
4		payment of the lesser of $200 or the annually recalculated
5		amount described below shall be paid for each inpatient
6		General Acute and Psychiatric day of care, excluding
7		Medicare-Medicaid dual eligible crossover days, for any
8		safety-net hospital as defined in Section 5-5e.1 that
9		provided less than 11,000 Medicaid inpatient days of care,
10		excluding Medicare-Medicaid dual eligible crossover days,
11		in the base period. As used in this paragraph, "base
12		period" means State fiscal year 2022 admissions received
13		by the Department prior to October 1, 2023 for the payment
14		period July 1, 2024 through December 31, 2025, and
15		beginning in calendar year 2026, the State fiscal year
16		that ends 30 months before the applicable calendar year,
17		such as State fiscal year 2023 admissions received by the
18		Department prior to October 1, 2024, for calendar year
19		2026. The low volume add-on payment amount of $200 shall
20		be adjusted annually beginning January 1, 2027 if
21		projected overall payment exceeds $30,000,000 by setting a
22		rate to spend an approximate amount of $30,000,000
23		annually using the most recent complete State fiscal year
24		inpatient General Acute and Psychiatric day of care data,
25		excluding Medicare-Medicaid dual eligible crossover days
26		for qualifying hospitals. State Fiscal Year 2025 data

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1		shall be used as the basis for the Calendar Year 2027 rate,
2		and State Fiscal Year 2026 data shall be used as the basis
3		for the Calendar Year 2028 rate.
4		(c) The Department shall take all actions necessary to
5		ensure the changes authorized in Public Act 103-102 and this
6		amendatory Act of the 103rd General Assembly are in effect for
7		dates of service on and after the effective date of the changes
8		made to this Section by this amendatory Act of the 103rd
9		General Assembly, including publishing all appropriate public
10		notices, applying for federal approval of amendments to the
11		Illinois Title XIX State Plan, and adopting administrative
12		rules if necessary.
13		(d) The Department of Healthcare and Family Services may
14		adopt rules necessary to implement the changes made by Public
15		Act 103-102 and this amendatory Act of the 103rd General
16		Assembly through the use of emergency rulemaking in accordance
17		with Section 5-45 of the Illinois Administrative Procedure
18		Act. The 24-month limitation on the adoption of emergency
19		rules does not apply to rules adopted under this Section. The
20		General Assembly finds that the adoption of rules to implement
21		the changes made by Public Act 103-102 and this amendatory Act
22		of the 103rd General Assembly is deemed an emergency and
23		necessary for the public interest, safety, and welfare.
24		(e) The Department shall ensure that all necessary
25		adjustments to the managed care organization capitation base
26		rates necessitated by the adjustments in this Section are

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1		completed, published, and applied in accordance with Section
2		5-30.8 of this Code 90 days prior to the implementation date of
3		the changes required under Public Act 103-102 and this
4		amendatory Act of the 103rd General Assembly.
5		(f) The Department shall publish updated rate sheets or
6		add-on payment amounts, as applicable, for all hospitals 30
7		days prior to the effective date of the rate increase, or
8		within 30 days after federal approval by the Centers for
9		Medicare and Medicaid Services, whichever is later.
10		(Source: P.A. 103-102, eff. 6-16-23; 103-593, eff. 6-7-24.)
11		ARTICLE 175.
12		Section 175-5. The Illinois Public Aid Code is amended by
13		changing Section 5-30.1 as follows:
14		(305 ILCS 5/5-30.1)
15		Sec. 5-30.1. Managed care protections.
16		(a) As used in this Section:
17		"Managed care organization" or "MCO" means any entity
18		which contracts with the Department to provide services where
19		payment for medical services is made on a capitated basis.
20		"Emergency services" means health care items and services,
21		including inpatient and outpatient hospital services,
22		furnished or required to evaluate and stabilize an emergency
23		medical condition. "Emergency services" include inpatient

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1		stabilization services furnished during the inpatient
2		stabilization period. "Emergency services" do not include
3		post-stabilization medical services.
4		"Emergency medical condition" means a medical condition
5		manifesting itself by acute symptoms of sufficient severity,
6		regardless of the final diagnosis given, such that a prudent
7		layperson, who possesses an average knowledge of health and
8		medicine, could reasonably expect the absence of immediate
9		medical attention to result in:
10		(1) placing the health of the individual (or, with
11		respect to a pregnant woman, the health of the woman or her
12		unborn child) in serious jeopardy;
13		(2) serious impairment to bodily functions;
14		(3) serious dysfunction of any bodily organ or part;
15		(4) inadequately controlled pain; or
16		(5) with respect to a pregnant woman who is having
17		contractions:
18		(A) inadequate time to complete a safe transfer to
19		another hospital before delivery; or
20		(B) a transfer to another hospital may pose a
21		threat to the health or safety of the woman or unborn
22		child.
23		"Emergency medical screening examination" means a medical
24		screening examination and evaluation by a physician licensed
25		to practice medicine in all its branches or, to the extent
26		permitted by applicable laws, by other appropriately licensed

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1		personnel under the supervision of or in collaboration with a
2		physician licensed to practice medicine in all its branches to
3		determine whether the need for emergency services exists.
4		"Health care services" means mean any medical or
5		behavioral health services covered under the medical
6		assistance program that are subject to review under a service
7		authorization program.
8		"Inpatient stabilization period" means the initial 72
9		hours of inpatient stabilization services, beginning from the
10		date and time of the order for inpatient admission to the
11		hospital.
12		"Inpatient stabilization services" means mean emergency
13		services furnished in the inpatient setting at a hospital
14		pursuant to an order for inpatient admission by a physician or
15		other qualified practitioner who has admitting privileges at
16		the hospital, as permitted by State law, to stabilize an
17		emergency medical condition following an emergency medical
18		screening examination.
19		"Post-stabilization medical services" means health care
20		services provided to an enrollee that are furnished in a
21		hospital by a provider that is qualified to furnish such
22		services and determined to be medically necessary by the
23		provider and directly related to the emergency medical
24		condition following stabilization.
25		"Provider" means a facility or individual who is actively
26		enrolled in the medical assistance program and licensed or

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1		otherwise authorized to order, prescribe, refer, or render
2		health care services in this State.
3		"Service authorization determination" means a decision
4		made by a service authorization program in advance of,
5		concurrent to, or after the provision of a health care service
6		to approve, change the level of care, partially deny, deny, or
7		otherwise limit coverage and reimbursement for a health care
8		service upon review of a service authorization request.
9		"Service authorization program" means any utilization
10		review, utilization management, peer review, quality review,
11		or other medical management activity conducted by an MCO, or
12		its contracted utilization review organization, including, but
13		not limited to, prior authorization, prior approval,
14		pre-certification, concurrent review, retrospective review, or
15		certification of admission, of health care services provided
16		in the inpatient or outpatient hospital setting.
17		"Service authorization request" means a request by a
18		provider to a service authorization program to determine
19		whether a health care service meets the reimbursement
20		eligibility requirements for medically necessary, clinically
21		appropriate care, resulting in the issuance of a service
22		authorization determination.
23		"Utilization review organization" or "URO" means an MCO's
24		utilization review department or a peer review organization or
25		quality improvement organization that contracts with an MCO to
26		administer a service authorization program and make service

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1		authorization determinations.
2		(b) As provided by Section 5-16.12, managed care
3		organizations are subject to the provisions of the Managed
4		Care Reform and Patient Rights Act.
5		(c) An MCO shall pay any provider of emergency services,
6		including for inpatient stabilization services provided during
7		the inpatient stabilization period, that does not have in
8		effect a contract with the contracted Medicaid MCO. The
9		default rate of reimbursement shall be the rate paid under
10		Illinois Medicaid fee-for-service program methodology,
11		including all policy adjusters, including but not limited to
12		Medicaid High Volume Adjustments, Medicaid Percentage
13		Adjustments, Outpatient High Volume Adjustments, and all
14		outlier add-on adjustments to the extent such adjustments are
15		incorporated in the development of the applicable MCO
16		capitated rates.
17		(d) (Blank).
18		(e) Notwithstanding any other provision of law, the
19		following requirements apply to MCOs in determining payment
20		for all emergency services, including inpatient stabilization
21		services provided during the inpatient stabilization period:
22		(1) The MCO shall not impose any service authorization
23		program requirements for emergency services, including,
24		but not limited to, prior authorization, prior approval,
25		pre-certification, certification of admission, concurrent
26		review, or retrospective review.

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1		(A) Notification period: Hospitals shall notify
2		the enrollee's Medicaid MCO within 48 hours of the
3		date and time the order for inpatient admission is
4		written. Notification shall be limited to advising the
5		MCO that the patient has been admitted to a hospital
6		inpatient level of care.
7		(B) If the admitting hospital complies with the
8		notification provisions of subparagraph (A), the
9		Medicaid MCO may not initiate concurrent review before
10		the end of the inpatient stabilization period. If the
11		admitting hospital does not comply with the
12		notification requirements in subparagraph (A), the
13		Medicaid MCO may initiate concurrent review for the
14		continuation of the stay beginning at the end of the
15		48-hour notification period.
16		(C) Coverage for services provided during the
17		48-hour notification period may not be retrospectively
18		denied.
19		(2) The MCO shall cover emergency services provided to
20		enrollees who are temporarily away from their residence
21		and outside the contracting area to the extent that the
22		enrollees would be entitled to the emergency services if
23		they still were within the contracting area.
24		(3) The MCO shall have no obligation to cover
25		emergency services provided on an emergency basis that are
26		not covered services under the contract between the MCO

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1		and the Department.
2		(4) The MCO shall not condition coverage for emergency
3		services on the treating provider notifying the MCO of the
4		enrollee's emergency medical screening examination and
5		treatment within 10 days after presentation for emergency
6		services.
7		(5) The determination of the attending emergency
8		physician, or the practitioner responsible for the
9		enrollee's care at the hospital, of whether an enrollee
10		requires inpatient stabilization services, can be
11		stabilized in the outpatient setting, or is sufficiently
12		stabilized for discharge or transfer to another setting,
13		shall be binding on the MCO. The MCO shall cover and
14		reimburse providers for emergency services as billed by
15		the provider for all enrollees whether the emergency
16		services are provided by an affiliated or non-affiliated
17		provider, except in cases of fraud. The MCO shall
18		reimburse inpatient stabilization services provided during
19		the inpatient stabilization period and billed as inpatient
20		level of care based on the appropriate inpatient
21		reimbursement methodology.
22		(6) The MCO's financial responsibility for
23		post-stabilization medical services it has not
24		pre-approved ends when:
25		(A) a plan physician with privileges at the
26		treating hospital assumes responsibility for the

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1		enrollee's care;
2		(B) a plan physician assumes responsibility for
3		the enrollee's care through transfer;
4		(C) a contracting entity representative and the
5		treating physician reach an agreement concerning the
6		enrollee's care; or
7		(D) the enrollee is discharged.
8		(e-5) An MCO shall pay for all post-stabilization medical
9		services as a covered service in any of the following
10		situations:
11		(1) the MCO or its URO authorized such services;
12		(2) such services were administered to maintain the
13		enrollee's stabilized condition within one hour after a
14		request to the MCO for authorization of further
15		post-stabilization services;
16		(3) the MCO or its URO did not respond to a request to
17		authorize such services within one hour;
18		(4) the MCO or its URO could not be contacted; or
19		(5) the MCO or its URO and the treating provider, if
20		the treating provider is a non-affiliated provider, could
21		not reach an agreement concerning the enrollee's care and
22		an affiliated provider was unavailable for a consultation,
23		in which case the MCO must pay for such services rendered
24		by the treating non-affiliated provider until an
25		affiliated provider was reached and either concurred with
26		the treating non-affiliated provider's plan of care or

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1		assumed responsibility for the enrollee's care. Such
2		payment shall be made at the default rate of reimbursement
3		paid under the State's Medicaid fee-for-service program
4		methodology, including all policy adjusters, including,
5		but not limited to, Medicaid High Volume Adjustments,
6		Medicaid Percentage Adjustments, Outpatient High Volume
7		Adjustments, and all outlier add-on adjustments to the
8		extent that such adjustments are incorporated in the
9		development of the applicable MCO capitated rates.
10		(f) Network adequacy and transparency.
11		(1) The Department shall:
12		(A) ensure that an adequate provider network is in
13		place, taking into consideration health professional
14		shortage areas and medically underserved areas;
15		(B) publicly release an explanation of its process
16		for analyzing network adequacy;
17		(C) periodically ensure that an MCO continues to
18		have an adequate network in place;
19		(D) require MCOs, including Medicaid Managed Care
20		Entities as defined in Section 5-30.2, to meet
21		provider directory requirements under Section 5-30.3;
22		(E) require MCOs to ensure that any
23		Medicaid-certified provider under contract with an MCO
24		and previously submitted on a roster on the date of
25		service is paid for any medically necessary,
26		Medicaid-covered, and authorized service rendered to

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1		any of the MCO's enrollees, regardless of inclusion on
2		the MCO's published and publicly available directory
3		of available providers; and
4		(F) require MCOs, including Medicaid Managed Care
5		Entities as defined in Section 5-30.2, to meet each of
6		the requirements under subsection (d-5) of Section 10
7		of the Network Adequacy and Transparency Act; with
8		necessary exceptions to the MCO's network to ensure
9		that admission and treatment with a provider or at a
10		treatment facility in accordance with the network
11		adequacy standards in paragraph (3) of subsection
12		(d-5) of Section 10 of the Network Adequacy and
13		Transparency Act is limited to providers or facilities
14		that are Medicaid certified.
15		(2) Each MCO shall confirm its receipt of information
16		submitted specific to physician or dentist additions or
17		physician or dentist deletions from the MCO's provider
18		network within 3 days after receiving all required
19		information from contracted physicians or dentists, and
20		electronic physician and dental directories must be
21		updated consistent with current rules as published by the
22		Centers for Medicare and Medicaid Services or its
23		successor agency.
24		(g) Timely payment of claims.
25		(1) The MCO shall pay a claim within 30 days of
26		receiving a claim that contains all the essential

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1		information needed to adjudicate the claim.
2		(2) The MCO shall notify the billing party of its
3		inability to adjudicate a claim within 30 days of
4		receiving that claim.
5		(3) The MCO shall pay a penalty that is at least equal
6		to the timely payment interest penalty imposed under
7		Section 368a of the Illinois Insurance Code for any claims
8		not timely paid.
9		(A) When an MCO is required to pay a timely payment
10		interest penalty to a provider, the MCO must calculate
11		and pay the timely payment interest penalty that is
12		due to the provider within 30 days after the payment of
13		the claim. In no event shall a provider be required to
14		request or apply for payment of any owed timely
15		payment interest penalties.
16		(B) Such payments shall be reported separately
17		from the claim payment for services rendered to the
18		MCO's enrollee and clearly identified as interest
19		payments.
20		(4)(A) The Department shall require MCOs to expedite
21		payments to providers identified on the Department's
22		expedited provider list, determined in accordance with 89
23		Ill. Adm. Code 140.71(b), on a schedule at least as
24		frequently as the providers are paid under the
25		Department's fee-for-service expedited provider schedule.
26		(B) Compliance with the expedited provider requirement

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1		may be satisfied by an MCO through the use of a Periodic
2		Interim Payment (PIP) program that has been mutually
3		agreed to and documented between the MCO and the provider,
4		if the PIP program ensures that any expedited provider
5		receives regular and periodic payments based on prior
6		period payment experience from that MCO. Total payments
7		under the PIP program may be reconciled against future PIP
8		payments on a schedule mutually agreed to between the MCO
9		and the provider.
10		(C) The Department shall share at least monthly its
11		expedited provider list and the frequency with which it
12		pays providers on the expedited list.
13		(g-5) Recognizing that the rapid transformation of the
14		Illinois Medicaid program may have unintended operational
15		challenges for both payers and providers:
16		(1) in no instance shall a medically necessary covered
17		service rendered in good faith, based upon eligibility
18		information documented by the provider, be denied coverage
19		or diminished in payment amount if the eligibility or
20		coverage information available at the time the service was
21		rendered is later found to be inaccurate in the assignment
22		of coverage responsibility between MCOs or the
23		fee-for-service system, except for instances when an
24		individual is deemed to have not been eligible for
25		coverage under the Illinois Medicaid program; and
26		(2) the Department shall, by December 31, 2016, adopt

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1		rules establishing policies that shall be included in the
2		Medicaid managed care policy and procedures manual
3		addressing payment resolutions in situations in which a
4		provider renders services based upon information obtained
5		after verifying a patient's eligibility and coverage plan
6		through either the Department's current enrollment system
7		or a system operated by the coverage plan identified by
8		the patient presenting for services:
9		(A) such medically necessary covered services
10		shall be considered rendered in good faith;
11		(B) such policies and procedures shall be
12		developed in consultation with industry
13		representatives of the Medicaid managed care health
14		plans and representatives of provider associations
15		representing the majority of providers within the
16		identified provider industry; and
17		(C) such rules shall be published for a review and
18		comment period of no less than 30 days on the
19		Department's website with final rules remaining
20		available on the Department's website.
21		The rules on payment resolutions shall include, but
22		not be limited to:
23		(A) the extension of the timely filing period;
24		(B) retroactive prior authorizations; and
25		(C) guaranteed minimum payment rate of no less
26		than the current, as of the date of service,

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1		fee-for-service rate, plus all applicable add-ons,
2		when the resulting service relationship is out of
3		network.
4		The rules shall be applicable for both MCO coverage
5		and fee-for-service coverage.
6		If the fee-for-service system is ultimately determined to
7		have been responsible for coverage on the date of service, the
8		Department shall provide for an extended period for claims
9		submission outside the standard timely filing requirements.
10		(g-6) MCO Performance Metrics Report.
11		(1) The Department shall publish, on at least a
12		quarterly basis, each MCO's operational performance,
13		including, but not limited to, the following categories of
14		metrics:
15		(A) claims payment, including timeliness and
16		accuracy;
17		(B) prior authorizations;
18		(C) grievance and appeals;
19		(D) utilization statistics;
20		(E) provider disputes;
21		(F) provider credentialing; and
22		(G) member and provider customer service.
23		(2) The Department shall ensure that the metrics
24		report is accessible to providers online by January 1,
25		2017.
26		(3) The metrics shall be developed in consultation

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

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1		itself of the MCO's internal dispute resolution process.
2		Disputes that are submitted to the MCO internal dispute
3		resolution process may be submitted to the Department of
4		Healthcare and Family Services' complaint portal no sooner
5		than 30 days after submitting to the MCO's internal process
6		and not later than 30 days after the unsatisfactory resolution
7		of the internal MCO process or 60 days after submitting the
8		dispute to the MCO internal process. Multiple claim disputes
9		involving the same MCO may be submitted in one complaint,
10		regardless of whether the claims are for different enrollees,
11		when the specific reason for non-payment of the claims
12		involves a common question of fact or policy. Within 10
13		business days of receipt of a complaint, the Department shall
14		present such disputes to the appropriate MCO, which shall then
15		have 30 days to issue its written proposal to resolve the
16		dispute. The Department may grant one 30-day extension of this
17		time frame to one of the parties to resolve the dispute. If the
18		dispute remains unresolved at the end of this time frame or the
19		provider is not satisfied with the MCO's written proposal to
20		resolve the dispute, the provider may, within 30 days, request
21		the Department to review the dispute and make a final
22		determination. Within 30 days of the request for Department
23		review of the dispute, both the provider and the MCO shall
24		present all relevant information to the Department for
25		resolution and make individuals with knowledge of the issues
26		available to the Department for further inquiry if needed.

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1		Within 30 days of receiving the relevant information on the
2		dispute, or the lapse of the period for submitting such
3		information, the Department shall issue a written decision on
4		the dispute based on contractual terms between the provider
5		and the MCO, contractual terms between the MCO and the
6		Department of Healthcare and Family Services and applicable
7		Medicaid policy. The decision of the Department shall be
8		final. By January 1, 2020, the Department shall establish by
9		rule further details of this dispute resolution process.
10		Disputes between MCOs and providers presented to the
11		Department for resolution are not contested cases, as defined
12		in Section 1-30 of the Illinois Administrative Procedure Act,
13		conferring any right to an administrative hearing.
14		(g-9)(1) The Department shall publish annually on its
15		website a report on the calculation of each managed care
16		organization's medical loss ratio showing the following:
17		(A) Premium revenue, with appropriate adjustments.
18		(B) Benefit expense, setting forth the aggregate
19		amount spent for the following:
20		(i) Direct paid claims.
21		(ii) Subcapitation payments.
22		(iii) Other claim payments.
23		(iv) Direct reserves.
24		(v) Gross recoveries.
25		(vi) Expenses for activities that improve health
26		care quality as allowed by the Department.

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1		(2) The medical loss ratio shall be calculated consistent
2		with federal law and regulation following a claims runout
3		period determined by the Department.
4		(g-10)(1) "Liability effective date" means the date on
5		which an MCO becomes responsible for payment for medically
6		necessary and covered services rendered by a provider to one
7		of its enrollees in accordance with the contract terms between
8		the MCO and the provider. The liability effective date shall
9		be the later of:
10		(A) The execution date of a network participation
11		contract agreement.
12		(B) The date the provider or its representative
13		submits to the MCO the complete and accurate standardized
14		roster form for the provider in the format approved by the
15		Department.
16		(C) The provider effective date contained within the
17		Department's provider enrollment subsystem within the
18		Illinois Medicaid Program Advanced Cloud Technology
19		(IMPACT) System.
20		(2) The standardized roster form may be submitted to the
21		MCO at the same time that the provider submits an enrollment
22		application to the Department through IMPACT.
23		(3) By October 1, 2019, the Department shall require all
24		MCOs to update their provider directory with information for
25		new practitioners of existing contracted providers within 30
26		days of receipt of a complete and accurate standardized roster

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1		template in the format approved by the Department provided
2		that the provider is effective in the Department's provider
3		enrollment subsystem within the IMPACT system. Such provider
4		directory shall be readily accessible for purposes of
5		selecting an approved health care provider and comply with all
6		other federal and State requirements.
7		(g-11) The Department shall work with relevant
8		stakeholders on the development of operational guidelines to
9		enhance and improve operational performance of Illinois'
10		Medicaid managed care program, including, but not limited to,
11		improving provider billing practices, reducing claim
12		rejections and inappropriate payment denials, and
13		standardizing processes, procedures, definitions, and response
14		timelines, with the goal of reducing provider and MCO
15		administrative burdens and conflict. The Department shall
16		include a report on the progress of these program improvements
17		and other topics in its Fiscal Year 2020 annual report to the
18		General Assembly.
19		(g-12) Notwithstanding any other provision of law, if the
20		Department or an MCO requires submission of a claim for
21		payment in a non-electronic format, a provider shall always be
22		afforded a period of no less than 90 business days, as a
23		correction period, following any notification of rejection by
24		either the Department or the MCO to correct errors or
25		omissions in the original submission.
26		Under no circumstances, either by an MCO or under the

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1		State's fee-for-service system, shall a provider be denied
2		payment for failure to comply with any timely submission
3		requirements under this Code or under any existing contract,
4		unless the non-electronic format claim submission occurs after
5		the initial 180 days following the latest date of service on
6		the claim, or after the 90 business days correction period
7		following notification to the provider of rejection or denial
8		of payment.
9		(g-13) Utilization Review Standardization and
10		Transparency.
11		(1) To ensure greater standardization and transparency
12		related to service authorization determinations, for all
13		individuals covered under the medical assistance program
14		and enrolled in the managed care program , including both
15		the fee-for-service and managed care programs, the
16		Department shall, in consultation with the MCOs, a
17		statewide association representing the MCOs, a statewide
18		association representing the majority of Illinois
19		hospitals, a statewide association representing
20		physicians, or any other interested parties deemed
21		appropriate by the Department, adopt administrative rules
22		consistent with this subsection, in accordance with the
23		Illinois Administrative Procedure Act.
24		(2) No later than July 1, 2025, the Department shall
25		in accordance with the Illinois Administrative Procedure
26		Act file emergency rules, and adopt permanent rules no

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1		later than November 28, 2025 October 1, 2025, which govern
2		MCO practices for dates of services on and after July 1,
3		2025, as follows:
4		(A) guidelines related to the publication of MCO
5		service authorization policies;
6		(B) procedures listed on the Medicare Inpatient
7		Only list published on January 1, 2025 by the Centers
8		for Medicare and Medicaid Services in Addendum B to
9		CMS-1809-FC that, due to medical complexity, must be
10		reimbursed under the applicable inpatient methodology,
11		when provided in the inpatient setting and billed as
12		an inpatient service;
13		(C) standardization of administrative forms used
14		in the member appeal process;
15		(D) limitations on second or subsequent medical
16		necessity review of a health care service already
17		authorized by the MCO or URO under a service
18		authorization program;
19		(E) standardization of peer-to-peer processes and
20		timelines;
21		(F) defined criteria for urgent and standard
22		post-acute care and long-term acute care service
23		authorization requests; and
24		(G) standardized criteria for service
25		authorization programs for authorization of admission
26		to a long-term acute care hospital.

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1		(3) The Department shall expand the scope of the
2		quality and compliance audits conducted by its contracted
3		external quality review organization to include, but not
4		be limited to:
5		(A) an analysis of the Medicaid MCO's compliance
6		with nationally recognized clinical decision
7		guidelines for inpatient and outpatient hospital
8		services;
9		(B) an analysis that compares and contrasts the
10		Medicaid MCO's service authorization determination
11		outcomes for inpatient and outpatient hospital
12		services to the outcomes of each other MCO plan and the
13		State's fee-for-service program model to evaluate
14		whether service authorization determinations are being
15		made consistently by all Medicaid MCOs to ensure that
16		all individuals are being treated in accordance with
17		equitable standards of care;
18		(C) an analysis, for each Medicaid MCO, of the
19		number of service authorization requests, including
20		requests for concurrent review of inpatient hospital
21		admissions and certification of inpatient hospital
22		admissions, received, initially denied, overturned
23		through any post-denial process including, but not
24		limited to, enrollee or provider appeal, peer-to-peer
25		review, or the provider dispute resolution process,
26		denied but approved for a lower or different level of

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1		care, and the number denied on final determination;
2		and
3		(D) provide a written report to the General
4		Assembly, detailing the items listed in this
5		subsection and any other metrics deemed necessary by
6		the Department, by the second April, following June 7,
7		2025 2024 (the effective date of Public Act 103-593),
8		and each April thereafter. The Department shall make
9		this report available within 30 days of delivery to
10		the General Assembly, on its public facing website.
11		(h) The Department shall not expand mandatory MCO
12		enrollment into new counties beyond those counties already
13		designated by the Department as of June 1, 2014 for the
14		individuals whose eligibility for medical assistance is not
15		the seniors or people with disabilities population until the
16		Department provides an opportunity for accountable care
17		entities and MCOs to participate in such newly designated
18		counties.
19		(h-5) Leading indicator data sharing. By January 1, 2024,
20		the Department shall obtain input from the Department of Human
21		Services, the Department of Juvenile Justice, the Department
22		of Children and Family Services, the State Board of Education,
23		managed care organizations, providers, and clinical experts to
24		identify and analyze key indicators and data elements that can
25		be used in an analysis of lead indicators from assessments and
26		data sets available to the Department that can be shared with

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1		managed care organizations and similar care coordination
2		entities contracted with the Department as leading indicators
3		for elevated behavioral health crisis risk for children,
4		including data sets such as the Illinois Medicaid
5		Comprehensive Assessment of Needs and Strengths (IM-CANS),
6		calls made to the State's Crisis and Referral Entry Services
7		(CARES) hotline, health services information from Health and
8		Human Services Innovators, or other data sets that may include
9		key indicators. The workgroup shall complete its
10		recommendations for leading indicator data elements on or
11		before September 1, 2024. To the extent permitted by State and
12		federal law, the identified leading indicators shall be shared
13		with managed care organizations and similar care coordination
14		entities contracted with the Department on or before December
15		1, 2024 for the purpose of improving care coordination with
16		the early detection of elevated risk. Leading indicators shall
17		be reassessed annually with stakeholder input. The Department
18		shall implement guidance to managed care organizations and
19		similar care coordination entities contracted with the
20		Department, so that the managed care organizations and care
21		coordination entities respond to lead indicators with services
22		and interventions that are designed to help stabilize the
23		child.
24		(i) The requirements of this Section apply to contracts
25		with accountable care entities and MCOs entered into, amended,
26		or renewed after June 16, 2014 (the effective date of Public

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1		Act 98-651).
2		(j) Health care information released to managed care
3		organizations. A health care provider shall release to a
4		Medicaid managed care organization, upon request, and subject
5		to the Health Insurance Portability and Accountability Act of
6		1996 and any other law applicable to the release of health
7		information, the health care information of the MCO's
8		enrollee, if the enrollee has completed and signed a general
9		release form that grants to the health care provider
10		permission to release the recipient's health care information
11		to the recipient's insurance carrier.
12		(k) The Department of Healthcare and Family Services,
13		managed care organizations, a statewide organization
14		representing hospitals, and a statewide organization
15		representing safety-net hospitals shall explore ways to
16		support billing departments in safety-net hospitals.
17		(l) The requirements of this Section added by Public Act
18		102-4 shall apply to services provided on or after the first
19		day of the month that begins 60 days after April 27, 2021 (the
20		effective date of Public Act 102-4).
21		(m) Except where otherwise expressly specified, the
22		requirements of this Section added by Public Act 103-593 shall
23		apply to services provided on and after July 1, 2026.
24		(Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;
25		103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.
26		8-15-25.)

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1		ARTICLE 180.
2		Section 180-5. The Psychiatric Residential Treatment
3		Facilities (PRTF) Act is amended by changing Sections 10 and
4		15 as follows:
5		(405 ILCS 142/10)
6		Sec. 10. PRTF services.
7		(a) The Department shall establish an Illinois Psychiatric
8		Residential Treatment Facilities (PRTF) program that is
9		family-driven, youth-guided, and trauma-informed, and includes
10		youth and family involvement in all aspects of care planning.
11		The Illinois PRTF program design shall establish meaningful
12		opportunities for youth and families to be involved in the
13		design, monitoring, and oversight of PRTF services.
14		(b) By September 1, 2027 By January 1, 2026, the
15		Department shall submit a State Plan Amendment to the Centers
16		for Medicare and Medicaid Services to establish coverage of
17		federally authorized, medically necessary inpatient
18		psychiatric services delivered by a certified PRTF to medical
19		assistance beneficiaries under 21 years of age.
20		(c) The Department shall adopt rules to implement the
21		Illinois PRTF program. The rules may establish the services,
22		standards, and requirements for participation in the program
23		to comply with all applicable federal statutes, regulations,

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1		requirements, and policies. The rules proposed by the
2		Department may take into consideration the recommendations of
3		the PRTF Advisory Committee, as outlined in Section 20. At a
4		minimum, the rules shall include the following:
5		(1) Certification and participation requirements for
6		PRTF providers in compliance with all applicable federal
7		laws, regulations, requirements, and policies, including
8		those found at 42 CFR 441, Subpart D and 42 CFR 483,
9		Subpart G or any successor regulations.
10		(2) Monitoring and oversight of PRTF services,
11		including on-site review protocols that include scheduled
12		and unannounced on-site visits. Each provider seeking PRTF
13		certification shall minimally have an on-site review prior
14		to initiating services and all PRTFs shall have at least
15		one on-site review annually thereafter.
16		(3) Utilization management criteria to ensure that
17		PRTF services are provided as medically necessary and
18		emphasize clinically appropriate patient transitions back
19		to the community, including, but not limited to, service
20		authorization, documentation, and treatment plan
21		requirements for initial stay reviews and continued stay
22		reviews.
23		(4) A limit on allowable beds at any one PRTF, not to
24		exceed 40 total beds, unless waived in writing by the
25		Director of the Department.
26		(5) A limit on the number of new PRTF facilities to be

SB3365 Enrolled - 245 - LRB104 18483 SSS 31925 b
1		certified in any State fiscal year.
2		(6) A requirement that PRTFs are distinct, standalone
3		non-hospital entities not physically attached or adjacent
4		to any other type of facility engaged in providing
5		congregate care.
6		(7) A requirement that, in order to obtain PRTF
7		certification, providers must undergo a survey from the
8		State Survey Agency, the Department of Public Health, to
9		establish the provider's compliance with the Conditions of
10		Participation for PRTFs outlined in 42 CFR 483, Subpart G
11		and the Interpretive Guidelines issued by the Centers for
12		Medicare and Medicaid Services.
13		(8) A requirement that, in order to obtain PRTF
14		certification, providers be accredited from one of the
15		following organizations identified in 42 CFR 441.151, or
16		any successor regulations:
17		(i) Joint Commission on Accreditation of
18		Healthcare Organizations.
19		(ii) The Commission on Accreditation of
20		Rehabilitation Facilities.
21		(iii) The Council on Accreditation of Services for
22		Families and Children.
23		(iv) Any other accrediting organization with
24		comparable standards recognized by the Department.
25		(9) Requirements for the reporting of emergency safety
26		interventions and serious occurrences to the Department

SB3365 Enrolled - 246 - LRB104 18483 SSS 31925 b
1		and the State-designated Protection and Advocacy System no
2		later than the close of business the next business day
3		after the intervention or occurrence.
4		(Source: P.A. 104-147, eff. 8-1-25.)
5		(405 ILCS 142/15)
6		Sec. 15. PRTF capacity analysis.
7		(a) The Department shall establish, and update as needed,
8		a methodology for completing a statewide PRTF capacity
9		analysis for the purposes of identifying capacity needs for
10		PRTF services under the Illinois Medical Assistance Program.
11		The Department shall utilize the PRTF capacity analysis to
12		inform its certification and enrollment of PRTF providers. The
13		capacity analysis shall minimally include:
14		(1) An analysis of aggregate service utilization data
15		for Medicaid eligible individuals under the age of 21,
16		including community-based services, behavioral health
17		crisis services, and inpatient psychiatric hospitalization
18		services.
19		(2) Identification of locations across the State with
20		demonstrated need for PRTF services and locations with
21		demonstrated surplus of PRTF service capacity.
22		(3) Consideration of specialized treatment needs based
23		on increased utilization of out-of-state facilities to
24		address specialized treatment needs.
25		(4) Other factors of consideration identified by the

SB3365 Enrolled - 247 - LRB104 18483 SSS 31925 b
1		Department as necessary to support access to care,
2		compliance with the federal Medicaid program, and all
3		other applicable federal or State laws, regulations,
4		policies, requirements, and programs impacting Illinois'
5		children's behavioral health service delivery system.
6		(5) Recommendations to the Department and the PRTF
7		Advisory Committee on capacity needs within the Illinois
8		PRTF program. The recommendations shall seek to avoid the
9		concentration of PRTF facilities in any particular
10		community or area of the State to promote access for
11		families or guardians to visit patients when appropriate.
12		(b) The Department's methodology, completed analyses, and
13		outcomes shall be published on its website, with an initial
14		PRTF capacity analysis to be published by no later than April
15		1, 2027 January 1, 2026.
16		(c) The Department's PRTF capacity analysis shall be
17		updated at a minimum of every 5 years and shall be performed
18		consistent with the Department's published methodology.
19		(Source: P.A. 104-147, eff. 8-1-25.)
20		ARTICLE 185.
21		Section 185-5. The Illinois Public Aid Code is amended by
22		changing Section 1-8.5 as follows:
23		(305 ILCS 5/1-8.5)

SB3365 Enrolled - 248 - LRB104 18483 SSS 31925 b
1		Sec. 1-8.5. Eligibility for medical assistance during
2		periods of incarceration or detention.
3		(a) To the extent permitted by federal law and
4		notwithstanding any other provision of this Code, the
5		Department of Healthcare and Family Services shall not cancel
6		a person's eligibility for medical assistance, nor shall the
7		Department deny a person's application for medical assistance,
8		solely because that person has become or is an inmate of a
9		public institution, including, but not limited to, a county
10		jail, juvenile detention center, or State correctional
11		facility. The person may be and remain enrolled for medical
12		assistance as long as all other eligibility criteria are met.
13		(b) The Department may adopt rules to permit a person to
14		apply for medical assistance while he or she is an inmate of a
15		public institution as described in subsection (a). The rules
16		may limit applications to persons who would be likely to
17		qualify for medical assistance if they resided in the
18		community. Any such person who is not already enrolled for
19		medical assistance may apply for medical assistance prior to
20		the date of scheduled release or discharge from a penal
21		institution or county jail or similar status.
22		(c) Except as provided under Section 17 of the County Jail
23		Act, the Department shall not be responsible to provide
24		medical assistance under this Code for any medical care,
25		services, or supplies provided to a person while he or she is
26		an inmate of a public institution as described in subsection

SB3365 Enrolled - 249 - LRB104 18483 SSS 31925 b
1		(a). The responsibility for providing medical care shall
2		remain as otherwise provided by law with the Department of
3		Corrections, county, or other arresting authority. The
4		Department may seek federal financial participation, to the
5		extent that it is available and with the cooperation of the
6		Department of Juvenile Justice, the Department of Corrections,
7		or the relevant county, for the costs of those services.
8		(c-1) Notwithstanding subsection (c), the Department may
9		provide medical assistance under this Code for medical care,
10		services, and supplies provided to a person while he or she is
11		an inmate of a public institution as described in subsection
12		(a) only to the extent required by the federal Medicaid
13		program, the Children's Health Insurance Program, or otherwise
14		authorized under a federally approved 1115 Waiver, State Plan
15		Amendment, or other federal authority. The medical care,
16		services, and supplies covered, and any other standards,
17		limitations, or conditions for eligibility and coverage, shall
18		be established by rule by the Department in accordance with
19		the applicable federal requirement, waiver, State Plan
20		amendment, or other authority.
21		(d) To the extent permitted under State and federal law,
22		the Department shall develop procedures to expedite required
23		periodic reviews of continued eligibility for persons
24		described in subsection (a).
25		(e) Counties, the Department of Juvenile Justice, the
26		Department of Human Services, and the Department of

SB3365 Enrolled - 250 - LRB104 18483 SSS 31925 b
1		Corrections shall cooperate with the Department in
2		administering this Section. That cooperation shall include
3		managing eligibility processing and sharing information
4		sufficient to inform the Department, in a manner established
5		by the Department, that a person enrolled in the medical
6		assistance program has been detained or incarcerated.
7		(f) The Department shall resume responsibility for
8		providing medical assistance upon release of the person to the
9		community as long as all of the following apply:
10		(1) The person is enrolled for medical assistance at
11		the time of release.
12		(2) Neither a county, the Department of Juvenile
13		Justice, the Department of Corrections, nor any other
14		criminal justice authority continues to bear
15		responsibility for the person's medical care.
16		(3) The county, the Department of Juvenile Justice, or
17		the Department of Corrections provides timely notice of
18		the date of release in a manner established by the
19		Department.
20		(g) This Section applies on and after December 31, 2011.
21		(Source: P.A. 98-139, eff. 1-1-14; 99-415, eff. 8-20-15.)
22		ARTICLE 190.
23		Section 190-5. The Illinois Public Aid Code is amended by
24		changing Sections 5-30.1 and 5-30.18 as follows:

SB3365 Enrolled - 251 - LRB104 18483 SSS 31925 b
1		(305 ILCS 5/5-30.1)
2		Sec. 5-30.1. Managed care protections.
3		(a) As used in this Section:
4		"Managed care organization" or "MCO" means any entity
5		which contracts with the Department to provide services where
6		payment for medical services is made on a capitated basis.
7		"Emergency services" means health care items and services,
8		including inpatient and outpatient hospital services,
9		furnished or required to evaluate and stabilize an emergency
10		medical condition. "Emergency services" include inpatient
11		stabilization services furnished during the inpatient
12		stabilization period. "Emergency services" do not include
13		post-stabilization medical services.
14		"Emergency medical condition" means a medical condition
15		manifesting itself by acute symptoms of sufficient severity,
16		regardless of the final diagnosis given, such that a prudent
17		layperson, who possesses an average knowledge of health and
18		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;
24		(3) serious dysfunction of any bodily organ or part;
25		(4) inadequately controlled pain; or

SB3365 Enrolled - 252 - LRB104 18483 SSS 31925 b
1		(5) with respect to a pregnant woman who is having
2		contractions:
3		(A) inadequate time to complete a safe transfer to
4		another hospital before delivery; or
5		(B) a transfer to another hospital may pose a
6		threat to the health or safety of the woman or unborn
7		child.
8		"Emergency medical screening examination" means a medical
9		screening examination and evaluation by a physician licensed
10		to practice medicine in all its branches or, to the extent
11		permitted by applicable laws, by other appropriately licensed
12		personnel under the supervision of or in collaboration with a
13		physician licensed to practice medicine in all its branches to
14		determine whether the need for emergency services exists.
15		"Health care services" means mean any medical or
16		behavioral health services covered under the medical
17		assistance program that are subject to review under a service
18		authorization program.
19		"Inpatient stabilization period" means the initial 72
20		hours of inpatient stabilization services, beginning from the
21		date and time of the order for inpatient admission to the
22		hospital.
23		"Inpatient stabilization services" means mean emergency
24		services furnished in the inpatient setting at a hospital
25		pursuant to an order for inpatient admission by a physician or
26		other qualified practitioner who has admitting privileges at

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1		the hospital, as permitted by State law, to stabilize an
2		emergency medical condition following an emergency medical
3		screening examination.
4		"Post-stabilization medical services" means health care
5		services provided to an enrollee that are furnished in a
6		hospital by a provider that is qualified to furnish such
7		services and determined to be medically necessary by the
8		provider and directly related to the emergency medical
9		condition following stabilization.
10		"Provider" means a facility or individual who is actively
11		enrolled in the medical assistance program and licensed or
12		otherwise authorized to order, prescribe, refer, or render
13		health care services in this State.
14		"Service authorization determination" means a decision
15		made by a service authorization program in advance of,
16		concurrent to, or after the provision of a health care service
17		to approve, change the level of care, partially deny, deny, or
18		otherwise limit coverage and reimbursement for a health care
19		service upon review of a service authorization request.
20		"Service authorization program" means any utilization
21		review, utilization management, peer review, quality review,
22		or other medical management activity conducted by an MCO, or
23		its contracted utilization review organization, including, but
24		not limited to, prior authorization, prior approval,
25		pre-certification, concurrent review, retrospective review, or
26		certification of admission, of health care services provided

SB3365 Enrolled - 254 - LRB104 18483 SSS 31925 b
1		in the inpatient or outpatient hospital setting.
2		"Service authorization request" means a request by a
3		provider to a service authorization program to determine
4		whether a health care service meets the reimbursement
5		eligibility requirements for medically necessary, clinically
6		appropriate care, resulting in the issuance of a service
7		authorization determination.
8		"Utilization review organization" or "URO" means an MCO's
9		utilization review department or a peer review organization or
10		quality improvement organization that contracts with an MCO to
11		administer a service authorization program and make service
12		authorization determinations.
13		(b) As provided by Section 5-16.12, managed care
14		organizations are subject to the provisions of the Managed
15		Care Reform and Patient Rights Act.
16		(c) An MCO shall pay any provider of emergency services,
17		including for inpatient stabilization services provided during
18		the inpatient stabilization period, that does not have in
19		effect a contract with the contracted Medicaid MCO. The
20		default rate of reimbursement shall be the rate paid under
21		Illinois Medicaid fee-for-service program methodology,
22		including all policy adjusters, including but not limited to
23		Medicaid High Volume Adjustments, Medicaid Percentage
24		Adjustments, Outpatient High Volume Adjustments, and all
25		outlier add-on adjustments to the extent such adjustments are
26		incorporated in the development of the applicable MCO

SB3365 Enrolled - 255 - LRB104 18483 SSS 31925 b
1		capitated rates.
2		(d) (Blank).
3		(e) Notwithstanding any other provision of law, the
4		following requirements apply to MCOs in determining payment
5		for all emergency services, including inpatient stabilization
6		services provided during the inpatient stabilization period:
7		(1) The MCO shall not impose any service authorization
8		program requirements for emergency services, including,
9		but not limited to, prior authorization, prior approval,
10		pre-certification, certification of admission, concurrent
11		review, or retrospective review.
12		(A) Notification period: Hospitals shall notify
13		the enrollee's Medicaid MCO within 48 hours of the
14		date and time the order for inpatient admission is
15		written. Notification shall be limited to advising the
16		MCO that the patient has been admitted to a hospital
17		inpatient level of care.
18		(B) If the admitting hospital complies with the
19		notification provisions of subparagraph (A), the
20		Medicaid MCO may not initiate concurrent review before
21		the end of the inpatient stabilization period. If the
22		admitting hospital does not comply with the
23		notification requirements in subparagraph (A), the
24		Medicaid MCO may initiate concurrent review for the
25		continuation of the stay beginning at the end of the
26		48-hour notification period.

SB3365 Enrolled - 256 - LRB104 18483 SSS 31925 b
1		(C) Coverage for services provided during the
2		48-hour notification period may not be retrospectively
3		denied.
4		(2) The MCO shall cover emergency services provided to
5		enrollees who are temporarily away from their residence
6		and outside the contracting area to the extent that the
7		enrollees would be entitled to the emergency services if
8		they still were within the contracting area.
9		(3) The MCO shall have no obligation to cover
10		emergency services provided on an emergency basis that are
11		not covered services under the contract between the MCO
12		and the Department.
13		(4) The MCO shall not condition coverage for emergency
14		services on the treating provider notifying the MCO of the
15		enrollee's emergency medical screening examination and
16		treatment within 10 days after presentation for emergency
17		services.
18		(5) The determination of the attending emergency
19		physician, or the practitioner responsible for the
20		enrollee's care at the hospital, of whether an enrollee
21		requires inpatient stabilization services, can be
22		stabilized in the outpatient setting, or is sufficiently
23		stabilized for discharge or transfer to another setting,
24		shall be binding on the MCO. The MCO shall cover and
25		reimburse providers for emergency services as billed by
26		the provider for all enrollees whether the emergency

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1		services are provided by an affiliated or non-affiliated
2		provider, except in cases of fraud. The MCO shall
3		reimburse inpatient stabilization services provided during
4		the inpatient stabilization period and billed as inpatient
5		level of care based on the appropriate inpatient
6		reimbursement methodology.
7		(6) The MCO's financial responsibility for
8		post-stabilization medical services it has not
9		pre-approved ends when:
10		(A) a plan physician with privileges at the
11		treating hospital assumes responsibility for the
12		enrollee's care;
13		(B) a plan physician assumes responsibility for
14		the enrollee's care through transfer;
15		(C) a contracting entity representative and the
16		treating physician reach an agreement concerning the
17		enrollee's care; or
18		(D) the enrollee is discharged.
19		(e-5) An MCO shall pay for all post-stabilization medical
20		services as a covered service in any of the following
21		situations:
22		(1) the MCO or its URO authorized such services;
23		(2) such services were administered to maintain the
24		enrollee's stabilized condition within one hour after a
25		request to the MCO for authorization of further
26		post-stabilization services;

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1		(3) the MCO or its URO did not respond to a request to
2		authorize such services within one hour;
3		(4) the MCO or its URO could not be contacted; or
4		(5) the MCO or its URO and the treating provider, if
5		the treating provider is a non-affiliated provider, could
6		not reach an agreement concerning the enrollee's care and
7		an affiliated provider was unavailable for a consultation,
8		in which case the MCO must pay for such services rendered
9		by the treating non-affiliated provider until an
10		affiliated provider was reached and either concurred with
11		the treating non-affiliated provider's plan of care or
12		assumed responsibility for the enrollee's care. Such
13		payment shall be made at the default rate of reimbursement
14		paid under the State's Medicaid fee-for-service program
15		methodology, including all policy adjusters, including,
16		but not limited to, Medicaid High Volume Adjustments,
17		Medicaid Percentage Adjustments, Outpatient High Volume
18		Adjustments, and all outlier add-on adjustments to the
19		extent that such adjustments are incorporated in the
20		development of the applicable MCO capitated rates.
21		(f) Network adequacy and transparency.
22		(1) The Department shall:
23		(A) ensure that an adequate provider network is in
24		place, taking into consideration health professional
25		shortage areas and medically underserved areas;
26		(B) publicly release an explanation of its process

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1		for analyzing network adequacy;
2		(C) periodically ensure that an MCO continues to
3		have an adequate network in place;
4		(D) require MCOs, including Medicaid Managed Care
5		Entities as defined in Section 5-30.2, to meet
6		provider directory requirements under Section 5-30.3;
7		(E) require MCOs to ensure that any
8		Medicaid-certified provider under contract with an MCO
9		and previously submitted on a roster on the date of
10		service is paid for any medically necessary,
11		Medicaid-covered, and authorized service rendered to
12		any of the MCO's enrollees, regardless of inclusion on
13		the MCO's published and publicly available directory
14		of available providers; and
15		(F) require MCOs, including Medicaid Managed Care
16		Entities as defined in Section 5-30.2, to meet each of
17		the requirements under subsection (d-5) of Section 10
18		of the Network Adequacy and Transparency Act; with
19		necessary exceptions to the MCO's network to ensure
20		that admission and treatment with a provider or at a
21		treatment facility in accordance with the network
22		adequacy standards in paragraph (3) of subsection
23		(d-5) of Section 10 of the Network Adequacy and
24		Transparency Act is limited to providers or facilities
25		that are Medicaid certified.
26		(2) Each MCO shall confirm its receipt of information

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1		submitted specific to physician or dentist additions or
2		physician or dentist deletions from the MCO's provider
3		network within 3 days after receiving all required
4		information from contracted physicians or dentists, and
5		electronic physician and dental directories must be
6		updated consistent with current rules as published by the
7		Centers for Medicare and Medicaid Services or its
8		successor agency.
9		(g) Timely payment of claims.
10		(1) The MCO shall pay a claim within 30 days of
11		receiving a claim that contains all the essential
12		information needed to adjudicate the claim.
13		(2) The MCO shall notify the billing party of its
14		inability to adjudicate a claim within 30 days of
15		receiving that claim.
16		(3) The MCO shall pay a penalty that is at least equal
17		to the timely payment interest penalty imposed under
18		Section 368a of the Illinois Insurance Code for any claims
19		not timely paid.
20		(A) When an MCO is required to pay a timely payment
21		interest penalty to a provider, the MCO must calculate
22		and pay the timely payment interest penalty that is
23		due to the provider within 30 days after the payment of
24		the claim. In no event shall a provider be required to
25		request or apply for payment of any owed timely
26		payment interest penalties.

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1		(B) Such payments shall be reported separately
2		from the claim payment for services rendered to the
3		MCO's enrollee and clearly identified as interest
4		payments.
5		(4)(A) The Department shall require MCOs to expedite
6		payments to providers identified on the Department's
7		expedited provider list, determined in accordance with 89
8		Ill. Adm. Code 140.71(b), on a schedule at least as
9		frequently as the providers are paid under the
10		Department's fee-for-service expedited provider schedule.
11		(B) Compliance with the expedited provider requirement
12		may be satisfied by an MCO through the use of a Periodic
13		Interim Payment (PIP) program that has been mutually
14		agreed to and documented between the MCO and the provider,
15		if the PIP program ensures that any expedited provider
16		receives regular and periodic payments based on prior
17		period payment experience from that MCO. Total payments
18		under the PIP program may be reconciled against future PIP
19		payments on a schedule mutually agreed to between the MCO
20		and the provider.
21		(C) The Department shall share at least monthly its
22		expedited provider list and the frequency with which it
23		pays providers on the expedited list.
24		(g-5) Recognizing that the rapid transformation of the
25		Illinois Medicaid program may have unintended operational
26		challenges for both payers and providers:

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1		(1) in no instance shall a medically necessary covered
2		service rendered in good faith, based upon eligibility
3		information documented by the provider, be denied coverage
4		or diminished in payment amount if the eligibility or
5		coverage information available at the time the service was
6		rendered is later found to be inaccurate in the assignment
7		of coverage responsibility between MCOs or the
8		fee-for-service system, except for instances when an
9		individual is deemed to have not been eligible for
10		coverage under the Illinois Medicaid program; and
11		(2) the Department shall, by December 31, 2016, adopt
12		rules establishing policies that shall be included in the
13		Medicaid managed care policy and procedures manual
14		addressing payment resolutions in situations in which a
15		provider renders services based upon information obtained
16		after verifying a patient's eligibility and coverage plan
17		through either the Department's current enrollment system
18		or a system operated by the coverage plan identified by
19		the patient presenting for services:
20		(A) such medically necessary covered services
21		shall be considered rendered in good faith;
22		(B) such policies and procedures shall be
23		developed in consultation with industry
24		representatives of the Medicaid managed care health
25		plans and representatives of provider associations
26		representing the majority of providers within the

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1		identified provider industry; and
2		(C) such rules shall be published for a review and
3		comment period of no less than 30 days on the
4		Department's website with final rules remaining
5		available on the Department's website.
6		The rules on payment resolutions shall include, but
7		not be limited to:
8		(A) the extension of the timely filing period;
9		(B) retroactive prior authorizations; and
10		(C) guaranteed minimum payment rate of no less
11		than the current, as of the date of service,
12		fee-for-service rate, plus all applicable add-ons,
13		when the resulting service relationship is out of
14		network.
15		The rules shall be applicable for both MCO coverage
16		and fee-for-service coverage.
17		If the fee-for-service system is ultimately determined to
18		have been responsible for coverage on the date of service, the
19		Department shall provide for an extended period for claims
20		submission outside the standard timely filing requirements.
21		(g-6) MCO Performance Metrics Report.
22		(1) The Department shall publish, on at least a
23		quarterly basis, each MCO's operational performance,
24		including, but not limited to, the following categories of
25		metrics:
26		(A) claims payment, including timeliness and

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1		accuracy;
2		(B) prior authorizations;
3		(C) grievance and appeals;
4		(D) utilization statistics;
5		(E) provider disputes;
6		(F) provider credentialing; and
7		(G) member and provider customer service.
8		(2) The Department shall ensure that the metrics
9		report is accessible to providers online by January 1,
10		2017.
11		(3) The metrics shall be developed in consultation
12		with industry representatives of the Medicaid managed care
13		health plans and representatives of associations
14		representing the majority of providers within the
15		identified industry.
16		(4) Metrics shall be defined and incorporated into the
17		applicable Managed Care Policy Manual issued by the
18		Department.
19		(g-7) MCO claims processing and performance analysis. In
20		order to monitor MCO payments to hospital providers, pursuant
21		to Public Act 100-580, the Department shall post an analysis
22		of MCO claims processing and payment performance on its
23		website every 6 months. Such analysis shall include a review
24		and evaluation of a representative sample of hospital claims
25		that are rejected and denied for clean and unclean claims and
26		the top 5 reasons for such actions and timeliness of claims

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1		adjudication, which identifies the percentage of claims
2		adjudicated within 30, 60, 90, and over 90 days, and the dollar
3		amounts associated with those claims.
4		(g-8) Dispute resolution process. The Department shall
5		maintain a provider complaint portal through which a provider
6		can submit to the Department unresolved disputes with an MCO.
7		An unresolved dispute means an MCO's decision that denies in
8		whole or in part a claim for reimbursement to a provider for
9		health care services rendered by the provider to an enrollee
10		of the MCO with which the provider disagrees. Disputes shall
11		not be submitted to the portal until the provider has availed
12		itself of the MCO's internal dispute resolution process.
13		Disputes that are submitted to the MCO internal dispute
14		resolution process may be submitted to the Department of
15		Healthcare and Family Services' complaint portal no sooner
16		than 30 days after submitting to the MCO's internal process
17		and not later than 30 days after the unsatisfactory resolution
18		of the internal MCO process or 60 days after submitting the
19		dispute to the MCO internal process. Multiple claim disputes
20		involving the same MCO may be submitted in one complaint,
21		regardless of whether the claims are for different enrollees,
22		when the specific reason for non-payment of the claims
23		involves a common question of fact or policy. Within 10
24		business days of receipt of a complaint, the Department shall
25		present such disputes to the appropriate MCO, which shall then
26		have 30 days to issue its written proposal to resolve the

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1		dispute. The Department may grant one 30-day extension of this
2		time frame to one of the parties to resolve the dispute. If the
3		dispute remains unresolved at the end of this time frame or the
4		provider is not satisfied with the MCO's written proposal to
5		resolve the dispute, the provider may, within 30 days, request
6		the Department to review the dispute and make a final
7		determination. Within 30 days of the request for Department
8		review of the dispute, both the provider and the MCO shall
9		present all relevant information to the Department for
10		resolution and make individuals with knowledge of the issues
11		available to the Department for further inquiry if needed.
12		Within 30 days of receiving the relevant information on the
13		dispute, or the lapse of the period for submitting such
14		information, the Department shall issue a written decision on
15		the dispute based on contractual terms between the provider
16		and the MCO, contractual terms between the MCO and the
17		Department of Healthcare and Family Services and applicable
18		Medicaid policy. The decision of the Department shall be
19		final. By January 1, 2020, the Department shall establish by
20		rule further details of this dispute resolution process.
21		Disputes between MCOs and providers presented to the
22		Department for resolution are not contested cases, as defined
23		in Section 1-30 of the Illinois Administrative Procedure Act,
24		conferring any right to an administrative hearing.
25		(g-9)(1) The Department shall publish annually on its
26		website a report on the calculation of each managed care

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1		organization's medical loss ratio showing the following:
2		(A) Premium revenue, with appropriate adjustments.
3		(B) Benefit expense, setting forth the aggregate
4		amount spent for the following:
5		(i) Direct paid claims.
6		(ii) Subcapitation payments.
7		(iii) Other claim payments.
8		(iv) Direct reserves.
9		(v) Gross recoveries.
10		(vi) Expenses for activities that improve health
11		care quality as allowed by the Department.
12		(2) The medical loss ratio shall be calculated consistent
13		with federal law and regulation following a claims runout
14		period determined by the Department.
15		(g-10)(1) "Liability effective date" means the date on
16		which an MCO becomes responsible for payment for medically
17		necessary and covered services rendered by a provider to one
18		of its enrollees in accordance with the contract terms between
19		the MCO and the provider. The liability effective date shall
20		be the later of:
21		(A) The execution date of a network participation
22		contract agreement.
23		(B) The date the provider or its representative
24		submits to the MCO the complete and accurate standardized
25		roster form for the provider in the format approved by the
26		Department.

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1		(C) The provider effective date contained within the
2		Department's provider enrollment subsystem within the
3		Illinois Medicaid Program Advanced Cloud Technology
4		(IMPACT) System.
5		(2) The standardized roster form may be submitted to the
6		MCO at the same time that the provider submits an enrollment
7		application to the Department through IMPACT.
8		(3) By October 1, 2019, the Department shall require all
9		MCOs to update their provider directory with information for
10		new practitioners of existing contracted providers within 30
11		days of receipt of a complete and accurate standardized roster
12		template in the format approved by the Department provided
13		that the provider is effective in the Department's provider
14		enrollment subsystem within the IMPACT system. Such provider
15		directory shall be readily accessible for purposes of
16		selecting an approved health care provider and comply with all
17		other federal and State requirements.
18		(g-11) The Department shall work with relevant
19		stakeholders on the development of operational guidelines to
20		enhance and improve operational performance of Illinois'
21		Medicaid managed care program, including, but not limited to,
22		improving provider billing practices, reducing claim
23		rejections and inappropriate payment denials, and
24		standardizing processes, procedures, definitions, and response
25		timelines, with the goal of reducing provider and MCO
26		administrative burdens and conflict. The Department shall

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1		include a report on the progress of these program improvements
2		and other topics in its Fiscal Year 2020 annual report to the
3		General Assembly.
4		(g-12) Notwithstanding any other provision of law, if the
5		Department or an MCO requires submission of a claim for
6		payment in a non-electronic format, a provider shall always be
7		afforded a period of no less than 90 business days, as a
8		correction period, following any notification of rejection by
9		either the Department or the MCO to correct errors or
10		omissions in the original submission.
11		Under no circumstances, either by an MCO or under the
12		State's fee-for-service system, shall a provider be denied
13		payment for failure to comply with any timely submission
14		requirements under this Code or under any existing contract,
15		unless the non-electronic format claim submission occurs after
16		the initial 180 days following the latest date of service on
17		the claim, or after the 90 business days correction period
18		following notification to the provider of rejection or denial
19		of payment.
20		(g-13) Utilization Review Standardization and
21		Transparency.
22		(1) To ensure greater standardization and transparency
23		related to service authorization determinations, for all
24		individuals covered under the medical assistance program,
25		including both the fee-for-service and managed care
26		programs, the Department shall, in consultation with the

SB3365 Enrolled - 270 - LRB104 18483 SSS 31925 b
1		MCOs, a statewide association representing the MCOs, a
2		statewide association representing the majority of
3		Illinois hospitals, a statewide association representing
4		physicians, or any other interested parties deemed
5		appropriate by the Department, adopt administrative rules
6		consistent with this subsection, in accordance with the
7		Illinois Administrative Procedure Act.
8		(2) No later than July 1, 2025, the Department shall
9		in accordance with the Illinois Administrative Procedure
10		Act file emergency rules, and adopt permanent rules no
11		later than October 1, 2025, which govern MCO practices for
12		dates of services on and after July 1, 2025, as follows:
13		(A) guidelines related to the publication of MCO
14		authorization policies;
15		(B) procedures that, due to medical complexity,
16		must be reimbursed under the applicable inpatient
17		methodology, when provided in the inpatient setting
18		and billed as an inpatient service;
19		(C) standardization of administrative forms used
20		in the member appeal process;
21		(D) limitations on second or subsequent medical
22		necessity review of a health care service already
23		authorized by the MCO or URO under a service
24		authorization program;
25		(E) standardization of peer-to-peer processes and
26		timelines;

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1		(F) defined criteria for urgent and standard
2		post-acute care and long-term acute care service
3		authorization requests; and
4		(G) standardized criteria for service
5		authorization programs for authorization of admission
6		to a long-term acute care hospital.
7		(3) The Department shall expand the scope of the
8		quality and compliance audits conducted by its contracted
9		external quality review organization to include, but not
10		be limited to:
11		(A) an analysis of the Medicaid MCO's compliance
12		with nationally recognized clinical decision
13		guidelines;
14		(B) an analysis that compares and contrasts the
15		Medicaid MCO's service authorization determination
16		outcomes to the outcomes of each other MCO plan and the
17		State's fee-for-service program model to evaluate
18		whether service authorization determinations are being
19		made consistently by all Medicaid MCOs to ensure that
20		all individuals are being treated in accordance with
21		equitable standards of care;
22		(C) an analysis, for each Medicaid MCO, of the
23		number of service authorization requests, including
24		requests for concurrent review and certification of
25		admissions, received, initially denied, overturned
26		through any post-denial process including, but not

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1		limited to, enrollee or provider appeal, peer-to-peer
2		review, or the provider dispute resolution process,
3		denied but approved for a lower or different level of
4		care, and the number denied on final determination;
5		and
6		(D) provide a written report to the General
7		Assembly, detailing the items listed in this
8		subsection and any other metrics deemed necessary by
9		the Department, by the second April, following June 7,
10		2024 (the effective date of Public Act 103-593), and
11		each April thereafter. The Department shall make this
12		report available within 30 days of delivery to the
13		General Assembly, on its public facing website.
14		(h) The Department shall not expand mandatory MCO
15		enrollment into new counties beyond those counties already
16		designated by the Department as of June 1, 2014 for the
17		individuals whose eligibility for medical assistance is not
18		the seniors or people with disabilities population until the
19		Department provides an opportunity for accountable care
20		entities and MCOs to participate in such newly designated
21		counties.
22		(h-5) Leading indicator data sharing. By January 1, 2024,
23		the Department shall obtain input from the Department of Human
24		Services, the Department of Juvenile Justice, the Department
25		of Children and Family Services, the State Board of Education,
26		managed care organizations, providers, and clinical experts to

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1		identify and analyze key indicators and data elements that can
2		be used in an analysis of lead indicators from assessments and
3		data sets available to the Department that can be shared with
4		managed care organizations and similar care coordination
5		entities contracted with the Department as leading indicators
6		for elevated behavioral health crisis risk for children,
7		including data sets such as the Illinois Medicaid
8		Comprehensive Assessment of Needs and Strengths (IM-CANS),
9		calls made to the State's Crisis and Referral Entry Services
10		(CARES) hotline, health services information from Health and
11		Human Services Innovators, or other data sets that may include
12		key indicators. The workgroup shall complete its
13		recommendations for leading indicator data elements on or
14		before September 1, 2024. To the extent permitted by State and
15		federal law, the identified leading indicators shall be shared
16		with managed care organizations and similar care coordination
17		entities contracted with the Department on or before December
18		1, 2024 for the purpose of improving care coordination with
19		the early detection of elevated risk. Leading indicators shall
20		be reassessed annually with stakeholder input. The Department
21		shall implement guidance to managed care organizations and
22		similar care coordination entities contracted with the
23		Department, so that the managed care organizations and care
24		coordination entities respond to lead indicators with services
25		and interventions that are designed to help stabilize the
26		child.

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1		(i) The requirements of this Section apply to contracts
2		with accountable care entities and MCOs entered into, amended,
3		or renewed after June 16, 2014 (the effective date of Public
4		Act 98-651).
5		(j) Health care information released to managed care
6		organizations. A health care provider shall release to a
7		Medicaid managed care organization, upon request, and subject
8		to the Health Insurance Portability and Accountability Act of
9		1996 and any other law applicable to the release of health
10		information, the health care information of the MCO's
11		enrollee, if the enrollee has completed and signed a general
12		release form that grants to the health care provider
13		permission to release the recipient's health care information
14		to the recipient's insurance carrier.
15		(k) The Department of Healthcare and Family Services,
16		managed care organizations, a statewide organization
17		representing hospitals, and a statewide organization
18		representing safety-net hospitals shall explore ways to
19		support billing departments in safety-net hospitals.
20		(l) The requirements of this Section added by Public Act
21		102-4 shall apply to services provided on or after the first
22		day of the month that begins 60 days after April 27, 2021 (the
23		effective date of Public Act 102-4).
24		(m) Except where otherwise expressly specified, the
25		requirements of this Section added by Public Act 103-593 shall
26		apply to services provided on and after July 1, 2027 July 1,

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1		2026.
2		(Source: P.A. 103-546, eff. 8-11-23; 103-593, eff. 6-7-24;
3		103-885, eff. 8-9-24; 104-9, eff. 6-16-25; 104-417, eff.
4		8-15-25.)
5		(305 ILCS 5/5-30.18)
6		(Section scheduled to be repealed on December 31, 2030)
7		Sec. 5-30.18. Service authorization program performance.
8		(a) Definitions. As used in this Section:
9		"Gold Card provider" means a provider identified by each
10		Medicaid Managed Care Organization (MCO) as qualified under
11		the guidelines outlined by the Department in accordance with
12		subsection (c) and thereby granted a service authorization
13		exemption when ordering a health care service.
14		"Health care service" means any medical or behavioral
15		health service covered under the medical assistance program
16		that is rendered in the inpatient or outpatient hospital
17		setting, including hospital-based clinics, and subject to
18		review under a service authorization program.
19		"Provider" means an individual actively enrolled in the
20		medical assistance program and licensed or otherwise
21		authorized to order, prescribe, refer, or render health care
22		services in this State, and, as determined by the Department,
23		may also include hospitals that submit service authorization
24		requests.
25		"Service authorization exemption" means an exception

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1		granted by a Medicaid MCO to a provider under which all service
2		authorization requests for covered health care services,
3		excluding pharmacy services and durable medical equipment, are
4		automatically deemed to be medically necessary, clinically
5		appropriate, and approved for reimbursement as ordered.
6		"Service authorization program" means any utilization
7		review, utilization management, peer review, quality review,
8		or other medical management activity conducted in advance of,
9		concurrent to, or after the provision of a health care service
10		by a Medicaid MCO, either directly or through a contracted
11		utilization review organization (URO), including, but not
12		limited to, prior authorization, pre-certification,
13		certification of admission, concurrent review, and
14		retrospective review of health care services.
15		"Service authorization request" means a request by a
16		provider to a service authorization program to determine
17		whether a health care service that is otherwise covered under
18		the medical assistance program meets the reimbursement
19		requirements established by the Medicaid MCO, or its
20		contracted URO, for medically necessary, clinically
21		appropriate care and to issue a service authorization
22		determination.
23		"Utilization review organization" or "URO" means a managed
24		care organization or other entity that has established or
25		administers one or more service authorization programs.
26		(b) In consultation with the Medicaid MCOs, a statewide

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1		association representing managed care organizations, a
2		statewide association representing the majority of Illinois
3		hospitals, and a statewide association representing
4		physicians, the Department shall in accordance with the
5		Illinois Administrative Procedure Act, adopt administrative
6		rules no later than October July 1, 2026, consistent with this
7		Section, to require each Medicaid MCO to identify Gold Card
8		providers with such identification initially being effective
9		for health care services provided on and after January 1, 2027
10		July 1, 2026.
11		(c) The Department shall adopt rules, in accordance with
12		the Illinois Administrative Procedure Act, to implement this
13		Section that include, but are not limited to, the following
14		provisions:
15		(1) Require each Medicaid MCO to provide a service
16		authorization exemption to a provider if the provider has
17		submitted at least 50 service authorization requests to
18		its service authorization program in the preceding
19		calendar year and the service authorization program
20		approved at least 90% of all service authorization
21		requests, regardless of the type of health care services
22		requested.
23		(2) Require that service authorization exemptions be
24		limited to services provided in an inpatient or outpatient
25		hospital setting inclusive of hospital-based clinics.
26		Service authorization exemptions under this Section shall

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1		not pertain to pharmacy services and durable medical
2		equipment and supplies.
3		(3) The service authorization exemption shall be valid
4		for at least one year, shall be made by each Medicaid MCO
5		or its URO, and shall be binding on the Medicaid MCO and
6		its URO.
7		(4) The provider shall be required to continue to
8		document medically necessary, clinically appropriate care
9		and submit such documentation to the Medicaid MCO for the
10		purpose of continuous performance monitoring. If a
11		provider fails to maintain the 90% service authorization
12		standard, as determined on no more frequent a basis than
13		bi-annually, the provider's service authorization
14		exemption is subject to temporary or permanent suspension.
15		(5) Require that each Medicaid MCO publish on its
16		provider portal a list of all providers that have
17		qualified for a service authorization exemption or
18		indicate that a provider has qualified for a service
19		authorization exemption on its provider-facing provider
20		roster.
21		(6) Require that no later than June 1 of each calendar
22		year, each Medicaid MCO shall provide written notification
23		to all providers who qualify for a service authorization
24		exemption, for the subsequent State fiscal year.
25		(7) Require that each Medicaid MCO or its URO use the
26		policies and guidelines published by the Department to

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1		evaluate whether a provider meets the criteria to qualify
2		for a service authorization exemption and the conditions
3		under which a service authorization exemption may be
4		rescinded, including review of the provider's service
5		authorization determinations during the preceding calendar
6		year.
7		(8) Require each Medicaid MCO to provide the
8		Department a list of all providers who were denied a
9		service authorization exemption or had a previously
10		granted service authorization exemption suspended, with
11		such denials being subject to an annual audit conducted by
12		an independent third-party URO to ensure their
13		appropriateness.
14		(A) The independent third-party URO shall issue a
15		written report consistent with this paragraph.
16		(B) The independent third-party URO shall not be
17		owned by, affiliated with, or employed by any Medicaid
18		MCO or its contracted URO, nor shall it have any
19		financial interest in the Medicaid MCO's service
20		authorization exemption program.
21		(d) Each Medicaid MCO must have a standard method to
22		accept and process professional claims and facility claims, as
23		billed by the provider, for a health care service that is
24		rendered, prescribed, or ordered by a provider granted a
25		service authorization exemption, except in cases of fraud.
26		(e) A service authorization program shall not deny,

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1		partially deny, reduce the level of care, or otherwise limit
2		reimbursement to the rendering or supervising provider,
3		including the rendering facility, for health care services
4		ordered by a provider who qualifies for a service
5		authorization exemption, except in cases of fraud.
6		(f) This Section is repealed on December 31, 2030.
7		(Source: P.A. 103-593, eff. 6-7-24; 104-9, eff. 6-16-25.)
8		ARTICLE 195.
9		Section 195-5. The Illinois Insurance Code is amended by
10		changing Section 370c.1 as follows:
11		(215 ILCS 5/370c.1)
12		Sec. 370c.1. Mental, emotional, nervous, or substance use
13		disorder or condition parity.
14		(a) On and after July 23, 2021 (the effective date of
15		Public Act 102-135), every insurer that amends, delivers,
16		issues, or renews a group or individual policy of accident and
17		health insurance or a qualified health plan offered through
18		the Health Insurance Marketplace in this State providing
19		coverage for hospital or medical treatment and for the
20		treatment of mental, emotional, nervous, or substance use
21		disorders or conditions shall ensure prior to policy issuance
22		that:
23		(1) the financial requirements applicable to such

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1		mental, emotional, nervous, or substance use disorder or
2		condition benefits are no more restrictive than the
3		predominant financial requirements applied to
4		substantially all hospital and medical benefits covered by
5		the policy and that there are no separate cost-sharing
6		requirements that are applicable only with respect to
7		mental, emotional, nervous, or substance use disorder or
8		condition benefits; and
9		(2) the treatment limitations applicable to such
10		mental, emotional, nervous, or substance use disorder or
11		condition benefits are no more restrictive than the
12		predominant treatment limitations applied to substantially
13		all hospital and medical benefits covered by the policy
14		and that there are no separate treatment limitations that
15		are applicable only with respect to mental, emotional,
16		nervous, or substance use disorder or condition benefits.
17		(b) The following provisions shall apply concerning
18		aggregate lifetime limits:
19		(1) In the case of a group or individual policy of
20		accident and health insurance or a qualified health plan
21		offered through the Health Insurance Marketplace amended,
22		delivered, issued, or renewed in this State on or after
23		September 9, 2015 (the effective date of Public Act
24		99-480) that provides coverage for hospital or medical
25		treatment and for the treatment of mental, emotional,
26		nervous, or substance use disorders or conditions the

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1		following provisions shall apply:
2		(A) if the policy does not include an aggregate
3		lifetime limit on substantially all hospital and
4		medical benefits, then the policy may not impose any
5		aggregate lifetime limit on mental, emotional,
6		nervous, or substance use disorder or condition
7		benefits; or
8		(B) if the policy includes an aggregate lifetime
9		limit on substantially all hospital and medical
10		benefits (in this subsection referred to as the
11		"applicable lifetime limit"), then the policy shall
12		either:
13		(i) apply the applicable lifetime limit both
14		to the hospital and medical benefits to which it
15		otherwise would apply and to mental, emotional,
16		nervous, or substance use disorder or condition
17		benefits and not distinguish in the application of
18		the limit between the hospital and medical
19		benefits and mental, emotional, nervous, or
20		substance use disorder or condition benefits; or
21		(ii) not include any aggregate lifetime limit
22		on mental, emotional, nervous, or substance use
23		disorder or condition benefits that is less than
24		the applicable lifetime limit.
25		(2) In the case of a policy that is not described in
26		paragraph (1) of subsection (b) of this Section and that

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1		includes no or different aggregate lifetime limits on
2		different categories of hospital and medical benefits, the
3		Director shall establish rules under which subparagraph
4		(B) of paragraph (1) of subsection (b) of this Section is
5		applied to such policy with respect to mental, emotional,
6		nervous, or substance use disorder or condition benefits
7		by substituting for the applicable lifetime limit an
8		average aggregate lifetime limit that is computed taking
9		into account the weighted average of the aggregate
10		lifetime limits applicable to such categories.
11		(c) The following provisions shall apply concerning annual
12		limits:
13		(1) In the case of a group or individual policy of
14		accident and health insurance or a qualified health plan
15		offered through the Health Insurance Marketplace amended,
16		delivered, issued, or renewed in this State on or after
17		September 9, 2015 (the effective date of Public Act
18		99-480) that provides coverage for hospital or medical
19		treatment and for the treatment of mental, emotional,
20		nervous, or substance use disorders or conditions the
21		following provisions shall apply:
22		(A) if the policy does not include an annual limit
23		on substantially all hospital and medical benefits,
24		then the policy may not impose any annual limits on
25		mental, emotional, nervous, or substance use disorder
26		or condition benefits; or

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1		(B) if the policy includes an annual limit on
2		substantially all hospital and medical benefits (in
3		this subsection referred to as the "applicable annual
4		limit"), then the policy shall either:
5		(i) apply the applicable annual limit both to
6		the hospital and medical benefits to which it
7		otherwise would apply and to mental, emotional,
8		nervous, or substance use disorder or condition
9		benefits and not distinguish in the application of
10		the limit between the hospital and medical
11		benefits and mental, emotional, nervous, or
12		substance use disorder or condition benefits; or
13		(ii) not include any annual limit on mental,
14		emotional, nervous, or substance use disorder or
15		condition benefits that is less than the
16		applicable annual limit.
17		(2) In the case of a policy that is not described in
18		paragraph (1) of subsection (c) of this Section and that
19		includes no or different annual limits on different
20		categories of hospital and medical benefits, the Director
21		shall establish rules under which subparagraph (B) of
22		paragraph (1) of subsection (c) of this Section is applied
23		to such policy with respect to mental, emotional, nervous,
24		or substance use disorder or condition benefits by
25		substituting for the applicable annual limit an average
26		annual limit that is computed taking into account the

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1		weighted average of the annual limits applicable to such
2		categories.
3		(d) With respect to mental, emotional, nervous, or
4		substance use disorders or conditions, an insurer shall use
5		policies and procedures for the election and placement of
6		mental, emotional, nervous, or substance use disorder or
7		condition treatment drugs on its their formulary that are no
8		less favorable to the insured as those policies and procedures
9		the insurer uses for the selection and placement of drugs for
10		medical or surgical conditions and shall follow the expedited
11		coverage determination requirements for substance abuse
12		treatment drugs set forth in Section 45.2 of the Managed Care
13		Reform and Patient Rights Act.
14		(e) This Section shall be interpreted in a manner
15		consistent with all applicable federal parity regulations
16		including, but not limited to, the Paul Wellstone and Pete
17		Domenici Mental Health Parity and Addiction Equity Act of
18		2008, final regulations issued under the Paul Wellstone and
19		Pete Domenici Mental Health Parity and Addiction Equity Act of
20		2008 and final regulations applying the Paul Wellstone and
21		Pete Domenici Mental Health Parity and Addiction Equity Act of
22		2008 to Medicaid managed care organizations, the Children's
23		Health Insurance Program, and alternative benefit plans.
24		(f) The provisions of subsections (b) and (c) of this
25		Section shall not be interpreted to allow the use of lifetime
26		or annual limits otherwise prohibited by State or federal law.

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1		(g) As used in this Section:
2		"Financial requirement" includes deductibles, copayments,
3		coinsurance, and out-of-pocket maximums, but does not include
4		an aggregate lifetime limit or an annual limit subject to
5		subsections (b) and (c).
6		"Mental, emotional, nervous, or substance use disorder or
7		condition" means a condition or disorder that involves a
8		mental health condition or substance use disorder that falls
9		under any of the diagnostic categories listed in the mental
10		and behavioral disorders chapter of the current edition of the
11		International Classification of Disease or that is listed in
12		the most recent version of the Diagnostic and Statistical
13		Manual of Mental Disorders.
14		"Treatment limitation" includes limits on benefits based
15		on the frequency of treatment, number of visits, days of
16		coverage, days in a waiting period, or other similar limits on
17		the scope or duration of treatment. "Treatment limitation"
18		includes both quantitative treatment limitations, which are
19		expressed numerically (such as 50 outpatient visits per year),
20		and nonquantitative treatment limitations, which otherwise
21		limit the scope or duration of treatment. A permanent
22		exclusion of all benefits for a particular condition or
23		disorder shall not be considered a treatment limitation.
24		"Nonquantitative treatment limitations" means those
25		limitations as described under federal regulations (26 CFR
26		54.9812-1). "Nonquantitative treatment limitations" include,

SB3365 Enrolled - 287 - LRB104 18483 SSS 31925 b
1		but are not limited to, those limitations described under
2		federal regulations 26 CFR 54.9812-1, 29 CFR 2590.712, and 45
3		CFR 146.136.
4		(h) The Department of Insurance shall implement the
5		following education initiatives:
6		(1) By January 1, 2016, the Department shall develop a
7		plan for a Consumer Education Campaign on parity. The
8		Consumer Education Campaign shall focus its efforts
9		throughout the State and include trainings in the
10		northern, southern, and central regions of the State, as
11		defined by the Department, as well as each of the 5 managed
12		care regions of the State as identified by the Department
13		of Healthcare and Family Services. Under this Consumer
14		Education Campaign, the Department shall: (1) by January
15		1, 2017, provide at least one live training in each region
16		on parity for consumers and providers and one webinar
17		training to be posted on the Department website and (2)
18		establish a consumer hotline to assist consumers in
19		navigating the parity process by March 1, 2017. By January
20		1, 2018 the Department shall issue a report to the General
21		Assembly on the success of the Consumer Education
22		Campaign, which shall indicate whether additional training
23		is necessary or would be recommended.
24		(2) (Blank).
25		(3) Not later than March January 1 of each year,
26		beginning in calendar year 2027, the Department, in

SB3365 Enrolled - 288 - LRB104 18483 SSS 31925 b
1		conjunction with the Department of Healthcare and Family
2		Services, shall issue a joint report to the General
3		Assembly. The joint report shall be posted on each
4		respective department's website and provide an educational
5		presentation to the General Assembly. The report and
6		presentation shall:
7		(A) Cover the methodology the Departments use to
8		check for compliance with the federal Paul Wellstone
9		and Pete Domenici Mental Health Parity and Addiction
10		Equity Act of 2008, 42 U.S.C. 18031(j), and any
11		federal regulations or guidance relating to the
12		compliance and oversight of the federal Paul Wellstone
13		and Pete Domenici Mental Health Parity and Addiction
14		Equity Act of 2008 and 42 U.S.C. 18031(j).
15		(B) Cover the methodology the Departments use to
16		check for compliance with this Section and Sections
17		356z.23 and 370c of this Code.
18		(C) Identify market conduct examinations or, in
19		the case of the Department of Healthcare and Family
20		Services, audits conducted or completed during the
21		preceding 12-month period regarding compliance with
22		parity in mental, emotional, nervous, and substance
23		use disorder or condition benefits under State and
24		federal laws and summarize the results of such market
25		conduct examinations and audits. This shall include:
26		(i) the number of market conduct examinations

SB3365 Enrolled - 289 - LRB104 18483 SSS 31925 b
1		and audits initiated and completed;
2		(ii) the benefit classifications examined by
3		each market conduct examination and audit;
4		(iii) the subject matter of each market
5		conduct examination and audit, including
6		quantitative and nonquantitative treatment
7		limitations; and
8		(iv) a summary of the basis for the final
9		decision rendered in each market conduct
10		examination and audit.
11		Individually identifiable information shall be
12		excluded from the reports consistent with federal
13		privacy protections.
14		(D) Detail any educational or corrective actions
15		the Departments have taken to ensure compliance with
16		the federal Paul Wellstone and Pete Domenici Mental
17		Health Parity and Addiction Equity Act of 2008, 42
18		U.S.C. 18031(j), this Section, and Sections 356z.23
19		and 370c of this Code.
20		(E) The report must be written in non-technical,
21		readily understandable language and shall be made
22		available to the public by, among such other means as
23		the Departments find appropriate, posting the report
24		on the Departments' websites.
25		(i) The Parity Advancement Fund is created as a special
26		fund in the State treasury. Moneys from fines and penalties

SB3365 Enrolled - 290 - LRB104 18483 SSS 31925 b
1		collected from insurers for violations of this Section shall
2		be deposited into the Fund. Moneys deposited into the Fund for
3		appropriation by the General Assembly to the Department shall
4		be used for the purpose of providing financial support of the
5		Consumer Education Campaign, parity compliance advocacy, and
6		other initiatives that support parity implementation and
7		enforcement on behalf of consumers.
8		(j) (Blank).
9		(j-5) The Department of Insurance shall collect the
10		following information:
11		(1) The number of employment disability insurance
12		plans offered in this State, including, but not limited
13		to:
14		(A) individual short-term policies;
15		(B) individual long-term policies;
16		(C) group short-term policies; and
17		(D) group long-term policies.
18		(2) The number of policies referenced in paragraph (1)
19		of this subsection that limit mental health and substance
20		use disorder benefits.
21		(3) The average defined benefit period for the
22		policies referenced in paragraph (1) of this subsection,
23		both for those policies that limit and those policies that
24		have no limitation on mental health and substance use
25		disorder benefits.
26		(4) Whether the policies referenced in paragraph (1)

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1		of this subsection are purchased on a voluntary or
2		non-voluntary basis.
3		(5) The identities of the individuals, entities, or a
4		combination of the 2 that assume the cost associated with
5		covering the policies referenced in paragraph (1) of this
6		subsection.
7		(6) The average defined benefit period for plans that
8		cover physical disability and mental health and substance
9		abuse without limitation, including, but not limited to:
10		(A) individual short-term policies;
11		(B) individual long-term policies;
12		(C) group short-term policies; and
13		(D) group long-term policies.
14		(7) The average premiums for disability income
15		insurance issued in this State for:
16		(A) individual short-term policies that limit
17		mental health and substance use disorder benefits;
18		(B) individual long-term policies that limit
19		mental health and substance use disorder benefits;
20		(C) group short-term policies that limit mental
21		health and substance use disorder benefits;
22		(D) group long-term policies that limit mental
23		health and substance use disorder benefits;
24		(E) individual short-term policies that include
25		mental health and substance use disorder benefits
26		without limitation;

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1		(F) individual long-term policies that include
2		mental health and substance use disorder benefits
3		without limitation;
4		(G) group short-term policies that include mental
5		health and substance use disorder benefits without
6		limitation; and
7		(H) group long-term policies that include mental
8		health and substance use disorder benefits without
9		limitation.
10		The Department shall present its findings regarding
11		information collected under this subsection (j-5) to the
12		General Assembly no later than April 30, 2024. Information
13		regarding a specific insurance provider's contributions to the
14		Department's report shall be exempt from disclosure under
15		paragraph (t) of subsection (1) of Section 7 of the Freedom of
16		Information Act. The aggregated information gathered by the
17		Department shall not be exempt from disclosure under paragraph
18		(t) of subsection (1) of Section 7 of the Freedom of
19		Information Act.
20		(k) An insurer that amends, delivers, issues, or renews a
21		group or individual policy of accident and health insurance or
22		a qualified health plan offered through the health insurance
23		marketplace in this State providing coverage for hospital or
24		medical treatment and for the treatment of mental, emotional,
25		nervous, or substance use disorders or conditions shall submit
26		an annual report, the format and definitions for which will be

SB3365 Enrolled - 293 - LRB104 18483 SSS 31925 b
1		determined by the Department and the Department of Healthcare
2		and Family Services and posted on their respective websites,
3		starting on September 1, 2023 and annually thereafter, that
4		contains the following information separately for inpatient
5		in-network benefits, inpatient out-of-network benefits,
6		outpatient in-network benefits, outpatient out-of-network
7		benefits, emergency care benefits, and prescription drug
8		benefits in the case of accident and health insurance or
9		qualified health plans, or inpatient, outpatient, emergency
10		care, and prescription drug benefits in the case of medical
11		assistance:
12		(1) A summary of the plan's pharmacy management
13		processes for mental, emotional, nervous, or substance use
14		disorder or condition benefits compared to those for other
15		medical benefits.
16		(2) A summary of the internal processes of review for
17		experimental benefits and unproven technology for mental,
18		emotional, nervous, or substance use disorder or condition
19		benefits and those for other medical benefits.
20		(3) A summary of how the plan's policies and
21		procedures for utilization management for mental,
22		emotional, nervous, or substance use disorder or condition
23		benefits compare to those for other medical benefits.
24		(4) A description of the process used to develop or
25		select the medical necessity criteria for mental,
26		emotional, nervous, or substance use disorder or condition

SB3365 Enrolled - 294 - LRB104 18483 SSS 31925 b
1		benefits and the process used to develop or select the
2		medical necessity criteria for medical and surgical
3		benefits.
4		(5) Identification of all nonquantitative treatment
5		limitations that are applied to both mental, emotional,
6		nervous, or substance use disorder or condition benefits
7		and medical and surgical benefits within each
8		classification of benefits.
9		(6) The results of an analysis that demonstrates that
10		for the medical necessity criteria described in
11		subparagraph (A) and for each nonquantitative treatment
12		limitation identified in subparagraph (B), as written and
13		in operation, the processes, strategies, evidentiary
14		standards, or other factors used in applying the medical
15		necessity criteria and each nonquantitative treatment
16		limitation to mental, emotional, nervous, or substance use
17		disorder or condition benefits within each classification
18		of benefits are comparable to, and are applied no more
19		stringently than, the processes, strategies, evidentiary
20		standards, or other factors used in applying the medical
21		necessity criteria and each nonquantitative treatment
22		limitation to medical and surgical benefits within the
23		corresponding classification of benefits; at a minimum,
24		the results of the analysis shall:
25		(A) identify the factors used to determine that a
26		nonquantitative treatment limitation applies to a

SB3365 Enrolled - 295 - LRB104 18483 SSS 31925 b
1		benefit, including factors that were considered but
2		rejected;
3		(B) identify and define the specific evidentiary
4		standards used to define the factors and any other
5		evidence relied upon in designing each nonquantitative
6		treatment limitation;
7		(C) provide the comparative analyses, including
8		the results of the analyses, performed to determine
9		that the processes and strategies used to design each
10		nonquantitative treatment limitation, as written, for
11		mental, emotional, nervous, or substance use disorder
12		or condition benefits are comparable to, and are
13		applied no more stringently than, the processes and
14		strategies used to design each nonquantitative
15		treatment limitation, as written, for medical and
16		surgical benefits;
17		(D) provide the comparative analyses, including
18		the results of the analyses, performed to determine
19		that the processes and strategies used to apply each
20		nonquantitative treatment limitation, in operation,
21		for mental, emotional, nervous, or substance use
22		disorder or condition benefits are comparable to, and
23		applied no more stringently than, the processes or
24		strategies used to apply each nonquantitative
25		treatment limitation, in operation, for medical and
26		surgical benefits; and

SB3365 Enrolled - 296 - LRB104 18483 SSS 31925 b
1		(E) disclose the specific findings and conclusions
2		reached by the insurer that the results of the
3		analyses described in subparagraphs (C) and (D)
4		indicate that the insurer is in compliance with this
5		Section and the Mental Health Parity and Addiction
6		Equity Act of 2008 and its implementing regulations,
7		which include includes 42 CFR Parts 438, 440, and 457
8		and 45 CFR 146.136 and any other related federal
9		regulations found in the Code of Federal Regulations.
10		(7) Any other information necessary to clarify data
11		provided in accordance with this Section requested by the
12		Director, including information that may be proprietary or
13		have commercial value, under the requirements of Section
14		30 of the Viatical Settlements Act of 2009.
15		(l) An insurer that amends, delivers, issues, or renews a
16		group or individual policy of accident and health insurance or
17		a qualified health plan offered through the health insurance
18		marketplace in this State providing coverage for hospital or
19		medical treatment and for the treatment of mental, emotional,
20		nervous, or substance use disorders or conditions on or after
21		January 1, 2019 (the effective date of Public Act 100-1024)
22		shall, in advance of the plan year, make available to the
23		Department or, with respect to medical assistance, the
24		Department of Healthcare and Family Services and to all plan
25		participants and beneficiaries the information required in
26		subparagraphs (C) through (E) of paragraph (6) of subsection

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1		(k). For plan participants and medical assistance
2		beneficiaries, the information required in subparagraphs (C)
3		through (E) of paragraph (6) of subsection (k) shall be made
4		available on a publicly available website whose web address is
5		prominently displayed in plan and managed care organization
6		informational and marketing materials.
7		(m) In conjunction with its compliance examination program
8		conducted in accordance with the Illinois State Auditing Act,
9		the Auditor General shall undertake a review of compliance by
10		the Department and the Department of Healthcare and Family
11		Services with Section 370c and this Section. Any findings
12		resulting from the review conducted under this Section shall
13		be included in the applicable State agency's compliance
14		examination report. Each compliance examination report shall
15		be issued in accordance with Section 3-14 of the Illinois
16		State Auditing Act. A copy of each report shall also be
17		delivered to the head of the applicable State agency and
18		posted on the Auditor General's website.
19		(Source: P.A. 103-94, eff. 1-1-24; 103-105, eff. 6-27-23;
20		103-605, eff. 7-1-24; 104-334, eff. 8-15-25.)
21		ARTICLE 200.
22		Section 200-5. The Illinois Public Aid Code is amended by
23		changing Sections 5F-10, 5F-15, and 5F-35 as follows:

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1		(305 ILCS 5/5F-10)
2		Sec. 5F-10. Scope. This Article applies to policies and
3		contracts amended, delivered, issued, or renewed on or after
4		the effective date of this amendatory Act of the 98th General
5		Assembly for the nursing home component of the
6		Medicare-Medicaid Alignment Initiative and the Managed
7		Long-Term Services and Support Program, a fully integrated
8		dual eligible special needs plan, or any managed care plan for
9		persons who are dually eligible for Medicare and Medicaid.
10		This Article does not diminish a managed care organization's
11		duties and responsibilities under other federal or State laws
12		or rules adopted under those laws and the 3-way
13		Medicare-Medicaid Alignment Initiative contract and the
14		Managed Long-Term Services and Support Program contract.
15		(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
16		(305 ILCS 5/5F-15)
17		Sec. 5F-15. Definitions. As used in this Article:
18		"Appeal" means any of the procedures that deal with the
19		review of adverse organization determinations on the health
20		care services the enrollee believes he or she is entitled to
21		receive, including delay in providing, arranging for, or
22		approving the health care services, such that a delay would
23		adversely affect the health of the enrollee or on any amounts
24		the enrollee must pay for a service, as defined under 42 CFR
25		422.566(b). These procedures include reconsiderations by the

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1		managed care organization and, if necessary, an independent
2		review entity as provided by the Health Carrier External
3		Review Act, hearings before administrative law judges, review
4		by the Medicare Appeals Council, and judicial review.
5		"Demonstration Project" means the nursing home component
6		of the Medicare-Medicaid Alignment Initiative Demonstration
7		Project, a fully integrated dual eligible special needs plan,
8		or any managed care plan for persons who are dually eligible
9		for Medicare and Medicaid.
10		"Department" means the Department of Healthcare and Family
11		Services.
12		"Enrollee" means an individual who resides in a nursing
13		home or is qualified to be admitted to a nursing home and is
14		enrolled with a managed care organization participating in the
15		Demonstration Project.
16		"Health care services" means the diagnosis, treatment, and
17		prevention of disease and includes medication, primary care,
18		nursing or medical care, mental health treatment, psychiatric
19		rehabilitation, memory loss services, physical, occupational,
20		and speech rehabilitation, enhanced care, medical supplies and
21		equipment and the repair of such equipment, and assistance
22		with activities of daily living.
23		"Managed care organization" or "MCO" means an entity that
24		meets the definition of health maintenance organization as
25		defined in the Health Maintenance Organization Act, is
26		licensed, regulated and in good standing with the Department

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1		of Insurance, and is authorized to participate in the nursing
2		home component of the Medicare-Medicaid Alignment Initiative
3		Demonstration Project by a 3-way contract with the Department
4		of Healthcare and Family Services and the Centers for Medicare
5		and Medicaid Services.
6		"Medical professional" means a physician, physician
7		assistant, or nurse practitioner.
8		"Medically necessary" means health care services that a
9		medical professional, exercising prudent clinical judgment,
10		would provide to a patient for the purpose of preventing,
11		evaluating, diagnosing, or treating an illness, injury, or
12		disease or its symptoms, and that are: (i) in accordance with
13		the generally accepted standards of medical practice; (ii)
14		clinically appropriate, in terms of type, frequency, extent,
15		site, and duration, and considered effective for the patient's
16		illness, injury, or disease; and (iii) not primarily for the
17		convenience of the patient, a medical professional, other
18		health care provider, caregiver, family member, or other
19		interested party.
20		"Nursing home" means a facility licensed under the Nursing
21		Home Care Act.
22		"Nurse practitioner" means an individual properly licensed
23		as a nurse practitioner under the Nurse Practice Act.
24		"Physician" means an individual licensed to practice in
25		all branches of medicine under the Medical Practice Act of
26		1987.

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1		"Physician assistant" means an individual properly
2		licensed under the Physician Assistant Practice Act of 1987.
3		"Resident" means an enrollee who is receiving personal or
4		medical care, including, but not limited to, mental health
5		treatment, psychiatric rehabilitation, physical
6		rehabilitation, and assistance with activities of daily
7		living, from a nursing home.
8		"RAI Manual" means the most recent Resident Assessment
9		Instrument Manual, published by the Centers for Medicare and
10		Medicaid Services.
11		"Resident's representative" means a person designated in
12		writing by a resident to be the resident's representative or
13		the resident's guardian, as described by the Nursing Home Care
14		Act.
15		"SNFist" means a medical professional specializing in the
16		care of individuals residing in nursing homes employed by or
17		under contract with an a MCO.
18		"Transition period" means a period of time immediately
19		following enrollment into the Demonstration Project or an
20		enrollee's movement from one managed care organization to
21		another managed care organization or one care setting to
22		another care setting.
23		(Source: P.A. 98-651, eff. 6-16-14.)
24		(305 ILCS 5/5F-35)
25		Sec. 5F-35. Reimbursement. The Department shall provide

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1		each managed care organization with the quarterly
2		facility-specific RUG-IV nursing component per diem along with
3		any add-ons for enhanced care services, support component per
4		diem, and capital component per diem effective for each
5		nursing home under contract with the managed care
6		organization.
7		(Source: P.A. 98-651, eff. 6-16-14.)
8		ARTICLE 210.
9		Section 210-5. The Nursing Home Care Act is amended by
10		adding Article IIIB as follows:
11		(210 ILCS 45/Art. IIIB heading new)
12		ARTICLE IIIB. COTTAGE STYLE NURSING HOMES
13		(210 ILCS 45/3B-100 new)
14		Sec. 3B-100. Definitions. As used in this Article:
15		"Clinical support team" (CST) means non-universal team
16		members who provide support services throughout the campus.
17		The CST provides support to self-directed or self-managed work
18		teams. The CST includes, but is not limited to, the
19		Administrator, Director of Nursing, Assistant Director of
20		Nursing, and Minimum Data Set nurse.
21		"Cottage style" or "cottage style facilities" means small,
22		free-standing, self-contained homes that:

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1		(1) Surround or are adjacent to a central
2		administration unit.
3		(2) Provide up to 12 private residents' rooms that are
4		shared only at the request of a resident to accommodate a
5		spouse, partner, or family member. A spouse that does not
6		meet medical criteria for nursing facility placement may
7		reside in the room assigned to a spouse who is admitted to
8		the facility and who meets medical criteria for admission.
9		The facility may charge the spouse who does not meet
10		medical criteria for room and board, as well as other
11		services so long as the facility meets all requirements or
12		cost reporting.
13		(3) Have a full, accessible private bathroom for each
14		resident room that contains, at a minimum, a toilet, sink,
15		and shower.
16		(4) Have the appearance of a residential dwelling for
17		both the exterior and the interior.
18		(5) Have residents' rooms constructed around a
19		central, communal, family-style open space that includes a
20		hearth room, dining area, and residential-style kitchen.
21		The central communal area shall contain a living area
22		where residents and staff may socialize, dine, and prepare
23		food together that, at a minimum, provides a living room
24		seating area, a dining area large enough for a single
25		table serving all residents in the home plus 2 staff
26		members, and an open full kitchen. The communal area may

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1		include a gas fireplace with a fixed, "stay-cool" glass
2		screen.
3		(6) Have all residents' room entrances visible from
4		the central communal area.
5		(7) Each communal area may not exceed a ratio of one
6		communal area to 12 resident rooms.
7		(8) Two cottages may share a centralized kitchen and
8		laundry, but each may not exceed a ratio of one
9		kitchen/laundry to 24 resident rooms.
10		(9) Contains residential-style design approach, scale,
11		details, and materials throughout the home that are
12		similar to the typical residential designs and finishes in
13		the immediate surrounding community and does not contain
14		or utilize commercial and institutional elements and
15		products such as a nurse station, medication carts,
16		hospital or office type fluorescent lighting, acoustical
17		tile ceilings, institutional-style railings, room
18		numbering, and labeling and signage that would not
19		normally be found in a private home setting.
20		Where rules require specific institutional elements,
21		every effort shall be made to provide the institutional
22		elements in a manner consistent with what might be found
23		in a new private home in the community (such as
24		residential wall sconces used for required nurse call
25		lights).
26		(10) Have outdoor space that:

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1		(A) allows residents to ambulate, with or without
2		assistive devices such as wheelchairs or walkers;
3		(B) signals staff wirelessly when someone enters
4		the outdoor space from the cottage style home;
5		(C) is partially covered to protect from sun and
6		elements under the covered area; and
7		(D) provides for outdoor activities.
8		(11) Utilize a wireless alert or call system. The
9		system shall also include, for residents who have been
10		care planned to be at risk for wandering or elopement,
11		location bracelets that permit residents to signal for
12		assistance and enable staff to locate residents. Wired
13		call or alert systems and overhead paging are not
14		permitted.
15		(12) Utilize a wireless communication and notification
16		system for staff. The system shall provide a means for
17		notification of staff both in the home and in other homes
18		or other areas of the facility occupied by other staff.
19		(13) Contain ample natural light in each habitable
20		space provided through exterior windows and other means,
21		with window areas, exclusive of skylights and
22		clerestories, being a minimum of 10% of the area of the
23		room.
24		(14) Have built-in safety features (such as magnetic
25		locks on cabinets with chemicals or knives) to allow all
26		areas of the house, including the kitchen and any staff

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1		office, to be accessible to the residents during the
2		majority of the day and night.
3		(15) Provide self-directed care for residents through
4		the establishment of self-managed or self-directed work
5		teams consisting of certified nursing assistants.
6		(16) Prepare and cook at least 80% of resident meals
7		in the cottage style home. Nothing in this item (16)
8		prohibits the consumption of foods that are:
9		(A) prepared outside the cottage style home by
10		family, acquaintances, or social organizations such as
11		churches;
12		(B) grown in or on the grounds of the cottage style
13		home by residents or staff; or
14		(C) prepared by local retail eating establishments
15		that are licensed or inspected based on local, State,
16		or federal laws.
17		(17) Train all staff involved in the operation of the
18		project in the philosophy, operations, and skills required
19		to implement and maintain self-directed care,
20		self-directed or self-managed work teams, a
21		non-institutional approach to life and care in long-term
22		care, appropriate safety and emergency skills, and other
23		elements required for successful operations and outcomes
24		of the project.
25		(18) Are designed to be fully accessible for persons
26		with disabilities.

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1		(19) Have overhead lift tracks that run from the bed
2		into the bathroom in at least 30% of resident rooms.
3		(20) Have at least one lift motor for each cottage
4		style home.
5		(21) Have separate slings for each resident in the
6		facility who requires a lift.
7		(22) Are not connected to, or share, any area that
8		would not typically be connected or shared between private
9		homes in the surrounding community (such as a driveway).
10		(23) Provide the necessary care and services to attain
11		or maintain the highest practicable physical, mental, and
12		psychological well-being of the resident, in accordance
13		with each resident's comprehensive resident care plan.
14		(24) Maintain a staffing plan compliant with the
15		minimum direct care staffing ratios required by this Act,
16		the Illinois Administrative Code, and any other applicable
17		State or federal law.
18		(25) Maintain all professional licensure for staff and
19		employees in accordance with applicable State laws,
20		including, but not limited to, Department of Financial and
21		Professional Regulation requirements.
22		(26) Comply with any applicable State and federal
23		consent decrees.
24		(27) Obtain proof and documentation of federal
25		approval by the Centers for Medicare and Medicaid
26		Services.

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1		"Home" means each discrete cottage style unit housing up
2		to 12 private residents' rooms.
3		"Person-directed care" means a holistic model that takes
4		into consideration each resident's physical, mental, and
5		social needs in the development of a care and treatment plan
6		and the delivery of services that is driven to the greatest
7		extent possible by resident choice, as opposed to an
8		institutional medical model that is schedule and task driven.
9		"Self-managed or self-directed work team" means the
10		universal workers assigned to a specific cottage style home
11		and who determine, plan, and manage day-to-day activities in
12		the house with little or no direct supervision.
13		"Food safety" means a method of ensuring safe preparation
14		and delivery of food for and to residents.
15		"Family-style dining" means residential-style dining, in
16		which all food is placed in serving bowls, platters, and
17		similar residential serving dishes on the table, residents and
18		staff dine together, and residents are encouraged to serve
19		themselves or serve themselves with help from staff.
20		"Universal or flexible worker" means a certified nursing
21		assistant who has received additional training in the areas of
22		dietary, housekeeping, activities, and laundry and is a member
23		of the self-managed or self-directed work team.
24		(210 ILCS 45/3B-105 new)
25		Sec. 3B-105. Intent. This Article creates a framework that

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1		encourages the construction and operation of skilled nursing
2		facilities that are consistent with State and federal laws and
3		referred to as "cottage style". The cottage style model is a
4		facility model resulting in a residential-style physical plant
5		and specific principles of staff interaction. The cottage
6		style model utilizes small, free-standing, self-contained
7		homes. A single cottage consists of up to 12 private rooms,
8		each with full bathrooms. Two cottages may share a common
9		kitchen and laundry but the maximum ratio of 1 kitchen and
10		laundry per 24 rooms must be maintained. The residents' rooms
11		are constructed around a central, communal, family-style open
12		space that includes a hearth room and dining area. All
13		residents' room entrances are visible from the central
14		communal area. The maximum ratio of one communal area per 12
15		rooms must be maintained. Each home is built to blend
16		architecturally with neighboring homes.
17		(210 ILCS 45/3B-110 new)
18		Sec. 3B-110. Applicability. Nursing homes that meet the
19		requirements of this Article to be designated as a cottage
20		style nursing home are still subject to all requirements of
21		this Act, administrative rules, and applicable State or
22		federal laws. All requirements of this Article are additional
23		requirements necessary to be designated as cottage style as
24		defined in Section 3B-100.

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1		(210 ILCS 45/3B-115 new)
2		Sec. 3B-115. License designation. During the initial
3		licensure survey required under Section 3-109 of this Act, the
4		Department must also review compliance with this Article. The
5		Department must indicate, on licenses issued under this Act,
6		"cottage style" for nursing homes that meet the requirements
7		of this Article.
8		(210 ILCS 45/3B-120 new)
9		Sec. 3B-120. Staff Training.
10		(a) In addition to any State or federal training
11		requirements pertaining to long-term care facilities, each
12		certified nursing assistant (CNA) working in a cottage style
13		home shall complete the following 40 hours of training, to
14		include, but not be limited to:
15		(1) Cottage Style Model v. Traditional Model, a
16		minimum of 2 hours covering at least the following topics:
17		(A) Meaningful Engagement. Development of, and
18		appreciation for, activities designed to meet the
19		individual's personal preferences and needs.
20		(B) Organizational Culture Change.
21		(2) Universal or Flexible Worker, a minimum of 2 hours
22		covering at least the following topics:
23		(A) Concept.
24		(B) Responsibilities of the Worker.
25		(3) Person-Directed Care, a minimum of 2 hours

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1		covering at least the following topics:
2		(A) Concepts and Relationship Building.
3		(B) Execution. How elder preferences shape
4		workflow.
5		(4) Self-Managed or Self-Directed Work Team, a minimum
6		of 4 hours covering at least the following topics:
7		(A) Concept.
8		(B) Responsibilities.
9		(C) Conflict Resolution and Learning Circles.
10		(5) Food Safety, a minimum of 22 hours covering at
11		least the following topics:
12		(A) Safety.
13		(B) Contamination.
14		(C) Allergies.
15		(D) Therapeutic Diets.
16		(E) Thickening Agents.
17		(F) Food Preparation.
18		(G) Family Style Dining.
19		(H) Cottage Equipment Use. Appliance usage and
20		safety.
21		(6) Emergency Situations and Evacuation, a minimum of
22		2 hours covering at least the following topics:
23		(A) Fire Drills.
24		(B) Tornado Drills.
25		(C) Disaster Drills.
26		(D) Evacuation.

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1		(E) Environmental Policy.
2		(7) Cottage Orientation, a minimum of 2 hours covering
3		at least the following topics:
4		(A) Phone System.
5		(B) Call System.
6		(C) Cleaning Supply Storage.
7		(D) Cleaning Supply Usage.
8		(E) Workplace Organization.
9		(8) Communication, a minimum of 2 hours covering at
10		least the following topics:
11		(A) Communication Skills.
12		(B) Coaching Skills.
13		(C) Accountability.
14		(D) Support.
15		(9) Observation Skills, a minimum of 2 hours covering
16		at least the following topics:
17		(A) How to obtain a history from family.
18		(B) How to modify a care plan.
19		(C) How to identify a resident's change in
20		condition.
21		(b) Upon opening and for the first 90 days of continuous
22		operation of a cottage style home, all CNAs working in that
23		home shall complete all of the required training listed in
24		subsection (a) prior to providing services in the cottage
25		style home.
26		(c) After a cottage style home has been in continuous

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1		operation servicing residents for at least 90 days, each CNA
2		assigned to the cottage style home for the first time, and who
3		has not been trained in accordance with subsections (a) and
4		(b), shall complete the following 16-hour training schedule
5		before working with residents:
6		(1) Cottage Style Model v. Traditional Model, a
7		minimum of 1.5 hours.
8		(2) Universal or Flexible Worker, a minimum of 1.5
9		hours.
10		(3) Person-Directed Care, a minimum of 3 hours.
11		(4) Self-Managed or Self-Directed Work Team, a minimum
12		of 3 hours.
13		(5) Food Safety, a minimum of 3 hours.
14		(6) Family Style Dining, a minimum of one hour.
15		(7) Emergency Situations and Evacuations, a minimum of
16		one hour.
17		(8) Cottage Equipment Use, a minimum of one hour.
18		(9) Cottage Orientation, a minimum of one hour.
19		Following the 16-hour training the CNA shall complete the
20		remaining 24 hours of training listed in subsection (a) within
21		90 days.
22		(d) All shared common staff shall undergo the following
23		training within 45 days of the opening of the first cottage
24		style home:
25		(1) Cottage Style Model v. Traditional Model, a
26		minimum of 1.5 hours.

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1		(2) Clinical Support Team, a minimum of one hour.
2		(3) Universal or Flexible Worker, a minimum of one
3		hour.
4		(4) Self-Managed or Self-Directed Work Team, a minimum
5		of 3 hours.
6		(5) Person-Directed Care, a minimum of 3 hours.
7		(6) Team Communication, a minimum of one hour.
8		(7) Learning Circles, a minimum of one hour.
9		(8) Understanding Aging in the Elderly, a minimum of
10		one hour.
11		(9) Cottage Systems, a minimum of 2 hours.
12		(e) Each facility seeking designation as a cottage style
13		facility shall provide to the Department a syllabus, a list of
14		required reference and study materials, and a proposed
15		curriculum of training as required under this Section. As used
16		in this Section, "curriculum" means a detailed study guide
17		that states the learning objectives and provides information
18		or materials designed to impart to the student or trainee the
19		necessary skills, knowledge, or ability required under the
20		learning objectives.
21		(f) Facilities must keep all trainings current with all
22		changes in best practices and local, State, and federal laws,
23		rules, regulations, and guidance.
24		(210 ILCS 45/3B-125 new)
25		Sec. 3B-125. Implementation. The Department may adopt

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1		administrative rules to implement any part of this Article;
2		however, all provisions of this Article are fully effective
3		upon taking effect even if administrative rules have not been
4		adopted.
5		Section 210-10. The Illinois Public Aid Code is amended by
6		adding Section 5-5.2a as follows:
7		(305 ILCS 5/5-5.2a new)
8		Sec. 5-5.2a. Cottage style nursing home reimbursement
9		adjustment.
10		(a) As used in this Section, "cottage style nursing home"
11		means a nursing home meeting the requirements under Article
12		IIIB of the Nursing Home Care Act.
13		(b) Subject to any necessary federal approval, for dates
14		of service on and after July 1, 2027, the Department shall
15		reimburse cottage style nursing homes with a per diem add-on
16		of at least $50.
17		(c) This per diem add-on amount is in addition to all
18		amounts reimbursed to a nursing home under this Code. To
19		account for the unique person-directed care model in cottage
20		style nursing homes, the Department may increase the initial
21		default rates of a new cottage style nursing home until data
22		required to calculate those rates are available.
23		ARTICLE 215.

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1		Section 215-5. The Illinois Public Aid Code is amended by
2		changing Section 5-5e.1 as follows:
3		(305 ILCS 5/5-5e.1)
4		Sec. 5-5e.1. Safety-Net Hospitals.
5		(a) A Safety-Net Hospital is an Illinois hospital that:
6		(1) is licensed by the Department of Public Health as
7		a general acute care or pediatric hospital; and
8		(2) is a disproportionate share hospital, as described
9		in Section 1923 of the federal Social Security Act, as
10		determined by the Department; and
11		(3) meets one of the following:
12		(A) has a MIUR of at least 40% and a charity
13		percent of at least 4%; or
14		(B) has a MIUR of at least 50%.
15		(b) Definitions. As used in this Section:
16		(1) "Charity percent" means the ratio of (i) the
17		hospital's charity charges for services provided to
18		individuals without health insurance or another source of
19		third party coverage to (ii) the Illinois total hospital
20		charges, each as reported on the hospital's OBRA form.
21		(2) "MIUR" means Medicaid Inpatient Utilization Rate
22		and is defined as a fraction, the numerator of which is the
23		number of a hospital's inpatient days provided in the
24		hospital's fiscal year ending 3 years prior to the rate

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1		year, to patients who, for such days, were eligible for
2		Medicaid under Title XIX of the federal Social Security
3		Act, 42 USC 1396a et seq., excluding those persons
4		eligible for medical assistance pursuant to 42 U.S.C.
5		1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
6		Section 5-2 of this Article, and the denominator of which
7		is the total number of the hospital's inpatient days in
8		that same period, excluding those persons eligible for
9		medical assistance pursuant to 42 U.S.C.
10		1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of
11		Section 5-2 of this Article.
12		(3) "OBRA form" means form HFS-3834, OBRA '93 data
13		collection form, for the rate year.
14		(4) "Rate year" means the 12-month period beginning on
15		October 1.
16		(c) Beginning July 1, 2012 and ending on December 31, 2028
17		2026, a hospital that would have qualified for the rate year
18		beginning October 1, 2011 or October 1, 2012 shall be a
19		Safety-Net Hospital.
20		(c-5) Beginning July 1, 2020 and ending on December 31,
21		2028 2026, a hospital that would have qualified for the rate
22		year beginning October 1, 2020 and was designated a federal
23		rural referral center under 42 CFR 412.96 as of October 1, 2020
24		shall be a Safety-Net Hospital.
25		(d) No later than August 15 preceding the rate year, each
26		hospital shall submit the OBRA form to the Department. Prior

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1		to October 1, the Department shall notify each hospital
2		whether it has qualified as a Safety-Net Hospital.
3		(e) The Department may promulgate rules in order to
4		implement this Section.
5		(f) Nothing in this Section shall be construed as limiting
6		the ability of the Department to include the Safety-Net
7		Hospitals in the hospital rate reform mandated by Section
8		14-11 of this Code and implemented under Section 14-12 of this
9		Code and by administrative rulemaking.
10		(Source: P.A. 101-650, eff. 7-7-20; 101-669, eff. 4-2-21;
11		102-886, eff. 5-17-22.)
12		ARTICLE 220.
13		Section 220-5. The Illinois Administrative Procedure Act
14		is amended by adding Section 5-45.72 as follows:
15		(5 ILCS 100/5-45.72 new)
16		Sec. 5-45.72. Emergency rulemaking; Department of
17		Healthcare and Family Services. In order to provide for the
18		expeditious and timely implementation of the federal Medicaid
19		provisions contained in Public Law 119-21, including all
20		corresponding federal regulations and requirements issued by
21		the federal Centers for Medicare and Medicaid Services, the
22		Department of Healthcare and Family Services may adopt
23		emergency rules during fiscal year 2027. Emergency rulemaking

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1		authority will pertain to changes in Public Law 119-21 with
2		implementation dates on or before January 1, 2027, which are
3		addressed in this amendatory Act of the 104th General
4		Assembly. During the 12-month period in which this Section is
5		in effect, the 24-month limitation on the adoption of
6		emergency rules does not apply to the rules adopted under this
7		subsection if such an amendment is due to subsequent federal
8		guidance or other federal requirements pertaining to changes
9		in federal law or regulation. The adoption of emergency rules
10		authorized by this Section shall be deemed to be necessary for
11		the public interest, safety, and welfare.
12		This Section is repealed one year after the effective date
13		of this amendatory Act of the 104th General Assembly.
14		Section 220-10. The Illinois Public Aid Code is amended by
15		changing Sections 1-11, 5-2, 5-2.1d, 11-4, 11-5.1, and 11-5.4
16		as follows:
17		(305 ILCS 5/1-11)
18		Sec. 1-11. Citizenship. To the extent not otherwise
19		provided in this Code or federal law, all clients who receive
20		cash or medical assistance under Article III, IV, V, or VI of
21		this Code must meet the citizenship requirements as
22		established in this Section. To be eligible for assistance an
23		individual, who is otherwise eligible, must be either a United
24		States citizen or included in one of the following categories

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1		of non-citizens:
2		(1) United States veterans honorably discharged and
3		persons on active military duty, and the spouse and
4		unmarried dependent children of these persons;
5		(2) Refugees under Section 207 of the Immigration and
6		Nationality Act;
7		(3) Asylees under Section 208 of the Immigration and
8		Nationality Act;
9		(4) Persons for whom deportation has been withheld
10		under Section 243(h) of the Immigration and Nationality
11		Act;
12		(5) Persons granted conditional entry under Section
13		203(a)(7) of the Immigration and Nationality Act as in
14		effect prior to April 1, 1980;
15		(6) Persons lawfully admitted for permanent residence
16		under the Immigration and Nationality Act;
17		(7) Parolees, for at least one year, under Section
18		212(d)(5) of the Immigration and Nationality Act;
19		(8) Nationals of Cuba or Haiti admitted on or after
20		April 21, 1980;
21		(9) Amerasians from Vietnam, and their close family
22		members, admitted through the Orderly Departure Program
23		beginning on March 20, 1988;
24		(10) Persons identified by the federal Office of
25		Refugee Resettlement (ORR) as victims of trafficking;
26		(11) Persons legally residing in the United States who

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1		were members of a Hmong or Highland Laotian tribe when the
2		tribe helped United States personnel by taking part in a
3		military or rescue operation during the Vietnam era
4		(between August 5, 1965 and May 7, 1975); this also
5		includes the person's spouse, a widow or widower who has
6		not remarried, and unmarried dependent children;
7		(12) American Indians born in Canada under Section 289
8		of the Immigration and Nationality Act and members of an
9		Indian tribe as defined in Section 4e of the Indian
10		Self-Determination and Education Assistance Act;
11		(13) Persons who are a spouse, widow, or child of a
12		U.S. citizen or a spouse or child of a legal permanent
13		resident (LPR) who have been battered or subjected to
14		extreme cruelty by the U.S. citizen or LPR or a member of
15		that relative's family who lived with them, who no longer
16		live with the abuser or plan to live separately within one
17		month of receipt of assistance and whose need for
18		assistance is due, at least in part, to the abuse; and
19		(14) Persons who are foreign-born victims of
20		trafficking, torture, or other serious crimes as defined
21		in Section 2-19 of this Code.
22		Those persons who are in the categories set forth in
23		paragraphs subdivisions    (6) and (7) of this Section, who enter
24		the United States on or after August 22, 1996, shall not be
25		eligible for 5 years beginning on the date the person entered
26		the United States.

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1		The Illinois Department may, by rule, cover prenatal care
2		or emergency medical care for non-citizens who are not
3		otherwise eligible under this Section. Local governmental
4		units which do not receive State funds may impose their own
5		citizenship requirements and are authorized to provide any
6		benefits and impose any citizenship requirements as are
7		allowed under the Personal Responsibility and Work Opportunity
8		Reconciliation Act of 1996 (P.L. 104-193).
9		In order to implement the federal Medicaid provisions
10		contained in Public Law 119-21, and notwithstanding any other
11		provision of this Section, any category of non-citizens or
12		part thereof listed in paragraphs (1) through (14) of this
13		Section shall not be eligible for medical assistance under
14		Article V of this Code to the extent Public Law 119-21 and any
15		corresponding federal regulations or requirements issued by
16		the federal Centers for Medicare and Medicaid Services
17		excludes such category of non-citizens or part thereof from
18		eligibility, federal financial participation, or other federal
19		funding. This Section shall not require any category of
20		non-citizens or part thereof to be funded at state-only cost
21		under Article V of this Code, unless otherwise provided by
22		State law. The Department shall amend 89 Ill. Adm. Code
23		120.310 to conform to the provisions of this paragraph
24		effective October 1, 2026.
25		(Source: P.A. 99-870, eff. 8-22-16.)

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1		(305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
2		Sec. 5-2. Classes of persons eligible. Medical assistance
3		under this Article shall be available to any of the following
4		classes of persons in respect to whom a plan for coverage has
5		been submitted to the Governor by the Illinois Department and
6		approved by him. If changes made in this Section 5-2 require
7		federal approval, they shall not take effect until such
8		approval has been received:
9		1. Recipients of basic maintenance grants under
10		Articles III and IV.
11		2. Beginning January 1, 2014, persons otherwise
12		eligible for basic maintenance under Article III,
13		excluding any eligibility requirements that are
14		inconsistent with any federal law or federal regulation,
15		as interpreted by the U.S. Department of Health and Human
16		Services, but who fail to qualify thereunder on the basis
17		of need, and who have insufficient income and resources to
18		meet the costs of necessary medical care, including, but
19		not limited to, the following:
20		(a) All persons otherwise eligible for basic
21		maintenance under Article III but who fail to qualify
22		under that Article on the basis of need and who meet
23		either of the following requirements:
24		(i) their income, as determined by the
25		Illinois Department in accordance with any federal
26		requirements, is equal to or less than 100% of the

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1		federal poverty level; or
2		(ii) their income, after the deduction of
3		costs incurred for medical care and for other
4		types of remedial care, is equal to or less than
5		100% of the federal poverty level.
6		(b) (Blank).
7		3. (Blank).
8		4. Persons not eligible under any of the preceding
9		paragraphs who fall sick, are injured, or die, not having
10		sufficient money, property or other resources to meet the
11		costs of necessary medical care or funeral and burial
12		expenses.
13		5.(a) Beginning January 1, 2020, individuals during
14		pregnancy and during the 12-month period beginning on the
15		last day of the pregnancy, together with their infants,
16		whose income is at or below 200% of the federal poverty
17		level. Until September 30, 2019, or sooner if the
18		maintenance of effort requirements under the Patient
19		Protection and Affordable Care Act are eliminated or may
20		be waived before then, individuals during pregnancy and
21		during the 12-month period beginning on the last day of
22		the pregnancy, whose countable monthly income, after the
23		deduction of costs incurred for medical care and for other
24		types of remedial care as specified in administrative
25		rule, is equal to or less than the Medical Assistance-No
26		Grant(C) (MANG(C)) Income Standard in effect on April 1,

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1		2013 as set forth in administrative rule.
2		(b) The plan for coverage shall provide ambulatory
3		prenatal care to pregnant individuals during a presumptive
4		eligibility period and establish an income eligibility
5		standard that is equal to 200% of the federal poverty
6		level, provided that costs incurred for medical care are
7		not taken into account in determining such income
8		eligibility.
9		(c) The Illinois Department may conduct a
10		demonstration in at least one county that will provide
11		medical assistance to pregnant individuals together with
12		their infants and children up to one year of age, where the
13		income eligibility standard is set up to 185% of the
14		nonfarm income official poverty line, as defined by the
15		federal Office of Management and Budget. The Illinois
16		Department shall seek and obtain necessary authorization
17		provided under federal law to implement such a
18		demonstration. Such demonstration may establish resource
19		standards that are not more restrictive than those
20		established under Article IV of this Code.
21		6. (a) Subject to federal approval, children younger
22		than age 19 when countable income is at or below 313% of
23		the federal poverty level, as determined by the Department
24		and in accordance with all applicable federal
25		requirements. The Department is authorized to adopt
26		emergency rules to implement the changes made to this

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1		paragraph by Public Act 102-43. Until September 30, 2019,
2		or sooner if the maintenance of effort requirements under
3		the Patient Protection and Affordable Care Act are
4		eliminated or may be waived before then, children younger
5		than age 19 whose countable monthly income, after the
6		deduction of costs incurred for medical care and for other
7		types of remedial care as specified in administrative
8		rule, is equal to or less than the Medical Assistance-No
9		Grant(C) (MANG(C)) Income Standard in effect on April 1,
10		2013 as set forth in administrative rule.
11		(b) Children and youth who are under temporary custody
12		or guardianship of the Department of Children and Family
13		Services or who receive financial assistance in support of
14		an adoption or guardianship placement from the Department
15		of Children and Family Services.
16		7. (Blank).
17		8. As required under federal law, persons who are
18		eligible for Transitional Medical Assistance as a result
19		of an increase in earnings or child or spousal support
20		received. The plan for coverage for this class of persons
21		shall:
22		(a) extend the medical assistance coverage to the
23		extent required by federal law; and
24		(b) offer persons who have initially received 6
25		months of the coverage provided in paragraph (a)
26		above, the option of receiving an additional 6 months

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1		of coverage, subject to the following:
2		(i) such coverage shall be pursuant to
3		provisions of the federal Social Security Act;
4		(ii) such coverage shall include all services
5		covered under Illinois' State Medicaid Plan;
6		(iii) no premium shall be charged for such
7		coverage; and
8		(iv) such coverage shall be suspended in the
9		event of a person's failure without good cause to
10		file in a timely fashion reports required for this
11		coverage under the Social Security Act and
12		coverage shall be reinstated upon the filing of
13		such reports if the person remains otherwise
14		eligible.
15		9. Persons with acquired immunodeficiency syndrome
16		(AIDS) or with AIDS-related conditions with respect to
17		whom there has been a determination that but for home or
18		community-based services such individuals would require
19		the level of care provided in an inpatient hospital,
20		skilled nursing facility or intermediate care facility the
21		cost of which is reimbursed under this Article. Assistance
22		shall be provided to such persons to the maximum extent
23		permitted under Title XIX of the Federal Social Security
24		Act.
25		10. Participants in the long-term care insurance
26		partnership program established under the Illinois

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1		Long-Term Care Partnership Program Act who meet the
2		qualifications for protection of resources described in
3		Section 15 of that Act.
4		11. Persons with disabilities who are employed and
5		eligible for Medicaid, pursuant to Section
6		1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
7		subject to federal approval, persons with a medically
8		improved disability who are employed and eligible for
9		Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
10		the Social Security Act, as provided by the Illinois
11		Department by rule. In establishing eligibility standards
12		under this paragraph 11, the Department shall, subject to
13		federal approval:
14		(a) set the income eligibility standard at not
15		lower than 350% of the federal poverty level;
16		(b) exempt retirement accounts that the person
17		cannot access without penalty before the age of 59
18		1/2, and medical savings accounts established pursuant
19		to 26 U.S.C. 220;
20		(c) allow non-exempt assets up to $25,000 as to
21		those assets accumulated during periods of eligibility
22		under this paragraph 11; and
23		(d) continue to apply subparagraphs (b) and (c) in
24		determining the eligibility of the person under this
25		Article even if the person loses eligibility under
26		this paragraph 11.

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1		12. Subject to federal approval, persons who are
2		eligible for medical assistance coverage under applicable
3		provisions of the federal Social Security Act and the
4		federal Breast and Cervical Cancer Prevention and
5		Treatment Act of 2000. Those eligible persons are defined
6		to include, but not be limited to, the following persons:
7		(1) persons who have been screened for breast or
8		cervical cancer under the U.S. Centers for Disease
9		Control and Prevention Breast and Cervical Cancer
10		Program established under Title XV of the federal
11		Public Health Service Act in accordance with the
12		requirements of Section 1504 of that Act as
13		administered by the Illinois Department of Public
14		Health; and
15		(2) persons whose screenings under the above
16		program were funded in whole or in part by funds
17		appropriated to the Illinois Department of Public
18		Health for breast or cervical cancer screening.
19		"Medical assistance" under this paragraph 12 shall be
20		identical to the benefits provided under the State's
21		approved plan under Title XIX of the Social Security Act.
22		The Department must request federal approval of the
23		coverage under this paragraph 12 within 30 days after July
24		3, 2001 (the effective date of Public Act 92-47).
25		In addition to the persons who are eligible for
26		medical assistance pursuant to subparagraphs (1) and (2)

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1		of this paragraph 12, and to be paid from funds
2		appropriated to the Department for its medical programs,
3		any uninsured person as defined by the Department in rules
4		residing in Illinois who is younger than 65 years of age,
5		who has been screened for breast and cervical cancer in
6		accordance with standards and procedures adopted by the
7		Department of Public Health for screening, and who is
8		referred to the Department by the Department of Public
9		Health as being in need of treatment for breast or
10		cervical cancer is eligible for medical assistance
11		benefits that are consistent with the benefits provided to
12		those persons described in subparagraphs (1) and (2).
13		Medical assistance coverage for the persons who are
14		eligible under the preceding sentence is not dependent on
15		federal approval, but federal moneys may be used to pay
16		for services provided under that coverage upon federal
17		approval.
18		13. Subject to appropriation and to federal approval,
19		persons living with HIV/AIDS who are not otherwise
20		eligible under this Article and who qualify for services
21		covered under Section 5-5.04 as provided by the Illinois
22		Department by rule.
23		14. Subject to the availability of funds for this
24		purpose, the Department may provide coverage under this
25		Article to persons who
26		(a) reside in Illinois;

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1		(b) are not eligible under any of the preceding
2		paragraphs of this Section;
3		(c) meet the income guidelines of paragraph 2(a)
4		of this Section; and
5		(d) meet one of the following conditions:
6		(i) have filed an application for asylum
7		status under 8 U.S.C. 1158 that is pending with
8		the appropriate federal agency or have a pending
9		appeal of such an application before a court of
10		competent jurisdiction and are represented either
11		by counsel or by an advocate accredited by the
12		appropriate federal agency and employed by a
13		not-for-profit organization in regard to that
14		application or appeal;
15		(ii) are receiving services through a
16		federally funded torture treatment center;
17		(iii) have filed a pending application for T
18		nonimmigrant status pursuant to 8 U.S.C.
19		1101(a)(15)(T);
20		(iv) have filed a pending application for U
21		nonimmigrant status pursuant to 8 U.S.C.
22		1101(a)(15)(U); or
23		(v) have filed as a derivative family member
24		or are included in the application for item (i),
25		(iii), or (iv) as provided by Department rule.
26		Medical coverage under this paragraph 14 may be

SB3365 Enrolled - 332 - LRB104 18483 SSS 31925 b
1		provided for up to 24 continuous months from the initial
2		eligibility date so long as an individual continues to
3		satisfy the criteria of this paragraph 14. If an
4		individual has an application or appeal pending regarding
5		an application for asylum, T nonimmigrant status, or U
6		nonimmigrant status before the appropriate federal agency
7		for such applications or appeals, eligibility under this
8		paragraph 14 may be extended until a final decision is
9		rendered with respect to the application or appeal, except
10		that an individual who is approved for a U visa continues
11		to qualify for medical coverage under this paragraph 14 as
12		long as the individual meets all other eligibility
13		criteria. The Department shall adopt rules governing the
14		implementation of this paragraph 14.
15		15. Family Care Eligibility.
16		(a) On and after July 1, 2012, a parent or other
17		caretaker relative who is 19 years of age or older when
18		countable income is at or below 133% of the federal
19		poverty level. A person may not spend down to become
20		eligible under this paragraph 15.
21		(b) Eligibility shall be reviewed annually.
22		(c) (Blank).
23		(d) (Blank).
24		(e) (Blank).
25		(f) (Blank).
26		(g) (Blank).

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1		(h) (Blank).
2		(i) Following termination of an individual's
3		coverage under this paragraph 15, the individual must
4		be determined eligible before the person can be
5		re-enrolled.
6		16. Subject to appropriation, uninsured persons who
7		are not otherwise eligible under this Section who have
8		been certified and referred by the Department of Public
9		Health as having been screened and found to need
10		diagnostic evaluation or treatment, or both diagnostic
11		evaluation and treatment, for prostate or testicular
12		cancer. For the purposes of this paragraph 16, uninsured
13		persons are those who do not have creditable coverage, as
14		defined under the Health Insurance Portability and
15		Accountability Act, or have otherwise exhausted any
16		insurance benefits they may have had, for prostate or
17		testicular cancer diagnostic evaluation or treatment, or
18		both diagnostic evaluation and treatment. To be eligible,
19		a person must furnish a Social Security number. A person's
20		assets are exempt from consideration in determining
21		eligibility under this paragraph 16. Such persons shall be
22		eligible for medical assistance under this paragraph 16
23		for so long as they need treatment for the cancer. A person
24		shall be considered to need treatment if, in the opinion
25		of the person's treating physician, the person requires
26		therapy directed toward cure or palliation of prostate or

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1		testicular cancer, including recurrent metastatic cancer
2		that is a known or presumed complication of prostate or
3		testicular cancer and complications resulting from the
4		treatment modalities themselves. Persons who require only
5		routine monitoring services are not considered to need
6		treatment. "Medical assistance" under this paragraph 16
7		shall be identical to the benefits provided under the
8		State's approved plan under Title XIX of the Social
9		Security Act. Notwithstanding any other provision of law,
10		the Department (i) does not have a claim against the
11		estate of a deceased recipient of services under this
12		paragraph 16 and (ii) does not have a lien against any
13		homestead property or other legal or equitable real
14		property interest owned by a recipient of services under
15		this paragraph 16.
16		17. Persons who, pursuant to a waiver approved by the
17		Secretary of the U.S. Department of Health and Human
18		Services, are eligible for medical assistance under Title
19		XIX or XXI of the federal Social Security Act.
20		Notwithstanding any other provision of this Code and
21		consistent with the terms of the approved waiver, the
22		Illinois Department, may by rule:
23		(a) Limit the geographic areas in which the waiver
24		program operates.
25		(b) Determine the scope, quantity, duration, and
26		quality, and the rate and method of reimbursement, of

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1		the medical services to be provided, which may differ
2		from those for other classes of persons eligible for
3		assistance under this Article.
4		(c) Restrict the persons' freedom in choice of
5		providers.
6		18. Beginning January 1, 2014, persons aged 19 or
7		older, but younger than 65, who are not otherwise eligible
8		for medical assistance under this Section 5-2, who qualify
9		for medical assistance pursuant to 42 U.S.C.
10		1396a(a)(10)(A)(i)(VIII) to the extent permitted under
11		federal law and applicable federal regulations, and who
12		have income at or below 133% of the federal poverty level
13		plus 5% for the applicable family size as determined
14		pursuant to 42 U.S.C. 1396a(e)(14) and applicable federal
15		regulations. Persons eligible for medical assistance under
16		this paragraph 18 shall receive coverage for the Health
17		Benefits Service Package as that term is defined in
18		subsection (m) of Section 5-1.1 of this Code. If Illinois'
19		federal medical assistance percentage (FMAP) is reduced
20		below 90% for persons eligible for medical assistance
21		under this paragraph 18, eligibility under this paragraph
22		18 shall cease no later than the end of the third month
23		following the month in which the reduction in FMAP takes
24		effect.
25		19. Beginning January 1, 2014, as required under 42
26		U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18

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1		and younger than age 26 who are not otherwise eligible for
2		medical assistance under paragraphs (1) through (17) of
3		this Section who (i) were in foster care under the
4		responsibility of the State on the date of attaining age
5		18 or on the date of attaining age 21 when a court has
6		continued wardship for good cause as provided in Section
7		2-31 of the Juvenile Court Act of 1987 and (ii) received
8		medical assistance under the Illinois Title XIX State Plan
9		or waiver of such plan while in foster care.
10		20. (Blank).
11		21. Persons who are not otherwise eligible for medical
12		assistance under this Section who may qualify for medical
13		assistance pursuant to 42 U.S.C.
14		1396a(a)(10)(A)(ii)(XXIII) and 42 U.S.C. 1396(ss) for the
15		duration of any federal or State declared emergency due to
16		COVID-19. Medical assistance to persons eligible for
17		medical assistance solely pursuant to this paragraph 21
18		shall be limited to any in vitro diagnostic product (and
19		the administration of such product) described in 42 U.S.C.
20		1396d(a)(3)(B) on or after March 18, 2020, any visit
21		described in 42 U.S.C. 1396o(a)(2)(G), or any other
22		medical assistance that may be federally authorized for
23		this class of persons. The Department may also cover
24		treatment of COVID-19 for this class of persons, or any
25		similar category of uninsured individuals, to the extent
26		authorized under a federally approved 1115 Waiver or other

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1		federal authority. Notwithstanding the provisions of
2		Section 1-11 of this Code, due to the nature of the
3		COVID-19 public health emergency, the Department may cover
4		and provide the medical assistance described in this
5		paragraph 21 to noncitizens who would otherwise meet the
6		eligibility requirements for the class of persons
7		described in this paragraph 21 for the duration of the
8		State emergency period.
9		In implementing the provisions of Public Act 96-20, the
10		Department is authorized to adopt only those rules necessary,
11		including emergency rules. Nothing in Public Act 96-20 permits
12		the Department to adopt rules or issue a decision that expands
13		eligibility for the FamilyCare Program to a person whose
14		income exceeds 185% of the Federal Poverty Level as determined
15		from time to time by the U.S. Department of Health and Human
16		Services, unless the Department is provided with express
17		statutory authority.
18		The eligibility of any such person for medical assistance
19		under this Article is not affected by the payment of any grant
20		under the Senior Citizens and Persons with Disabilities
21		Property Tax Relief Act or any distributions or items of
22		income described under subparagraph (X) of paragraph (2) of
23		subsection (a) of Section 203 of the Illinois Income Tax Act.
24		The Department shall by rule establish the amounts of
25		assets to be disregarded in determining eligibility for
26		medical assistance, which shall at a minimum equal the amounts

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1		to be disregarded under the Federal Supplemental Security
2		Income Program. The amount of assets of a single person to be
3		disregarded shall not be less than $2,000, and the amount of
4		assets of a married couple to be disregarded shall not be less
5		than $3,000.
6		To the extent permitted under federal law, any person
7		found guilty of a second violation of Article VIIIA shall be
8		ineligible for medical assistance under this Article, as
9		provided in Section 8A-8.
10		The eligibility of any person for medical assistance under
11		this Article shall not be affected by the receipt by the person
12		of donations or benefits from fundraisers held for the person
13		in cases of serious illness, as long as neither the person nor
14		members of the person's family have actual control over the
15		donations or benefits or the disbursement of the donations or
16		benefits.
17		Notwithstanding any other provision of this Code, if the
18		United States Supreme Court holds Title II, Subtitle A,
19		Section 2001(a) of Public Law 111-148 to be unconstitutional,
20		or if a holding of Public Law 111-148 makes Medicaid
21		eligibility allowed under Section 2001(a) inoperable, the
22		State or a unit of local government shall be prohibited from
23		enrolling individuals in the Medical Assistance Program as the
24		result of federal approval of a State Medicaid waiver on or
25		after June 14, 2012 (the effective date of Public Act 97-687),
26		and any individuals enrolled in the Medical Assistance Program

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1		pursuant to eligibility permitted as a result of such a State
2		Medicaid waiver shall become immediately ineligible.
3		Notwithstanding any other provision of this Code, if an
4		Act of Congress that becomes a Public Law eliminates Section
5		2001(a) of Public Law 111-148, the State or a unit of local
6		government shall be prohibited from enrolling individuals in
7		the Medical Assistance Program as the result of federal
8		approval of a State Medicaid waiver on or after June 14, 2012
9		(the effective date of Public Act 97-687), and any individuals
10		enrolled in the Medical Assistance Program pursuant to
11		eligibility permitted as a result of such a State Medicaid
12		waiver shall become immediately ineligible.
13		Effective October 1, 2013, the determination of
14		eligibility of persons who qualify under paragraphs 5, 6, 8,
15		15, 17, and 18 of this Section shall comply with the
16		requirements of 42 U.S.C. 1396a(e)(14) and applicable federal
17		regulations.
18		The Department of Healthcare and Family Services, the
19		Department of Human Services, and the Illinois health
20		insurance marketplace shall work cooperatively to assist
21		persons who would otherwise lose health benefits as a result
22		of changes made under Public Act 98-104 to transition to other
23		health insurance coverage.
24		(Source: P.A. 104-9, eff. 1-1-26.)
25		(305 ILCS 5/5-2.1d)

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1		Sec. 5-2.1d. Retroactive eligibility. Subject to federal
2		approval and in accordance with applicable federal law and
3		requirements, an An applicant for medical assistance may be
4		eligible for up to 3 months prior to the date of application if
5		the person would have been eligible for medical assistance at
6		the time he or she received the services if he or she had
7		applied, regardless of whether the individual is alive when
8		the application for medical assistance is made. In determining
9		financial eligibility for medical assistance for retroactive
10		months, the Department shall consider the amount of income and
11		resources and exemptions available to a person as of the first
12		day of each of the backdated months for which eligibility is
13		sought. The Department shall, by rule, establish the duration
14		of retroactive eligibility, which shall at a minimum equal the
15		duration of eligibility for federal matching funds.
16		(Source: P.A. 97-689, eff. 6-14-12.)
17		(305 ILCS 5/11-4)  (from Ch. 23, par. 11-4)
18		Sec. 11-4. Applications; assistance in making
19		applications. An initial application for public assistance
20		shall be deemed an application for all such benefits to which
21		any person may be entitled except to the extent that the
22		applicant expressly declines in writing to apply for
23		particular benefits. A redetermination of eligibility shall
24		occur at least annually or for any other periodic time period
25		established by the Department by rule that is necessary to

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1		implement the federal Medicaid provisions contained in Public
2		Law 119-21 and any corresponding federal regulations or
3		requirements issued by the federal Centers for Medicare and
4		Medicaid Services. A redetermination The redetermination is an
5		annual redetermination of eligibility is for of current
6		benefits and is not an initial application. The Illinois
7		Department shall provide information in writing about all
8		benefits provided under this Code to any person seeking public
9		assistance. The Illinois Department shall also provide
10		information in writing and orally to all applicants about an
11		election to have financial aid deposited directly in a
12		recipient's savings account or checking account or in any
13		electronic benefits account or accounts as provided in Section
14		11-3.1, to the extent that those elections are actually
15		available, including information on any programs administered
16		by the State Treasurer to facilitate or encourage the
17		distribution of financial aid by direct deposit or electronic
18		benefits transfer. The Illinois Department shall determine the
19		applicant's eligibility for cash assistance, medical
20		assistance and food stamps unless the applicant expressly
21		declines in writing to apply for particular benefits. The
22		Illinois Department shall adopt policies and procedures to
23		facilitate timely changes between programs that result from
24		changes in categorical eligibility factors.
25		The County departments, local governmental units and the
26		Illinois Department shall assist applicants for public

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1		assistance to properly complete their applications. Such
2		assistance shall include, but not be limited to, assistance in
3		securing evidence in support of their eligibility.
4		(Source: P.A. 104-9, eff. 6-16-25.)
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
13		the Department receives written denial from the federal
14		government, this Section shall be implemented:
15		(a) The Department of Healthcare and Family Services or
16		its designees shall:
17		(1) By no later than July 1, 2011, require
18		verification of, at a minimum, one month's income from all
19		sources required for determining the eligibility of
20		applicants for medical assistance under this Code. Such
21		verification shall take the form of pay stubs, business or
22		income and expense records for self-employed persons,
23		letters from employers, and any other valid documentation
24		of income including data obtained electronically by the
25		Department or its designees from other sources as

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1		described in subsection (b) of this Section. A month's
2		income may be verified by a single pay stub with the
3		monthly income extrapolated from the time period covered
4		by the pay stub.
5		(2) By no later than October 1, 2011, require
6		verification of, at a minimum, one month's income from all
7		sources required for determining the continued eligibility
8		of recipients at their annual review of eligibility for
9		medical assistance under this Code. Information the
10		Department receives prior to the annual review, including
11		information available to the Department as a result of the
12		recipient's application for other non-Medicaid benefits,
13		that is sufficient to make a determination of continued
14		Medicaid eligibility may be reviewed and verified, and
15		subsequent action taken including client notification of
16		continued Medicaid eligibility. The date of client
17		notification establishes the date for subsequent annual
18		Medicaid eligibility reviews. Such verification shall take
19		the form of pay stubs, business or income and expense
20		records for self-employed persons, letters from employers,
21		and any other valid documentation of income including data
22		obtained electronically by the Department or its designees
23		from other sources as described in subsection (b) of this
24		Section. A month's income may be verified by a single pay
25		stub with the monthly income extrapolated from the time
26		period covered by the pay stub. The Department shall send

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1		a notice to recipients at least 60 days prior to the end of
2		their period of eligibility that informs them of the
3		requirements for continued eligibility. If a recipient
4		does not fulfill the requirements for continued
5		eligibility by the deadline established in the notice a
6		notice of cancellation shall be issued to the recipient
7		and coverage shall end no later than the last day of the
8		month following the last day of the eligibility period. A
9		recipient's eligibility may be reinstated without
10		requiring a new application if the recipient fulfills the
11		requirements for continued eligibility prior to the end of
12		the third month following the last date of coverage (or
13		longer period if required by federal regulations). Nothing
14		in this Section shall prevent an individual whose coverage
15		has been cancelled from reapplying for health benefits at
16		any time.
17		(3) By no later than July 1, 2011, require
18		verification of Illinois residency.
19		The Department, with federal approval, may choose to adopt
20		continuous financial eligibility for a full 12 months for
21		adults on Medicaid.
22		(b) The Department shall establish or continue cooperative
23		arrangements with the Social Security Administration, the
24		Illinois Secretary of State, the Department of Human Services,
25		the Department of Revenue, the Department of Employment
26		Security, and any other appropriate entity to gain electronic

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1		access, to the extent allowed by law, to information available
2		to those entities that may be appropriate for electronically
3		verifying any factor of eligibility for benefits under the
4		Program. Data relevant to eligibility shall be provided for no
5		other purpose than to verify the eligibility of new applicants
6		or current recipients of health benefits under the Program.
7		Data shall be requested or provided for any new applicant or
8		current recipient only insofar as that individual's
9		circumstances are relevant to that individual's or another
10		individual's eligibility.
11		(c) Within 90 days of the effective date of this
12		amendatory Act of the 96th General Assembly, the Department of
13		Healthcare and Family Services shall send notice to current
14		recipients informing them of the changes regarding their
15		eligibility verification.
16		(d) As soon as practical if the data is reasonably
17		available, but no later than January 1, 2017, the Department
18		shall compile on a monthly basis data on eligibility
19		redeterminations of beneficiaries of medical assistance
20		provided under Article V of this Code. In addition to the other
21		data required under this subsection, the Department shall
22		compile on a monthly basis data on the percentage of
23		beneficiaries whose eligibility is renewed through ex parte
24		redeterminations as described in subsection (b) of Section
25		5-1.6 of this Code, subject to federal approval of the changes
26		made in subsection (b) of Section 5-1.6 by this amendatory Act

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1		of the 102nd General Assembly. This data shall be posted on the
2		Department's website, and data from prior months shall be
3		retained and available on the Department's website. The data
4		compiled and reported shall include the following:
5		(1) The total number of redetermination decisions made
6		in a month and, of that total number, the number of
7		decisions to continue or change benefits and the number of
8		decisions to cancel benefits.
9		(2) A breakdown of enrollee language preference for
10		the total number of redetermination decisions made in a
11		month and, of that total number, a breakdown of enrollee
12		language preference for the number of decisions to
13		continue or change benefits, and a breakdown of enrollee
14		language preference for the number of decisions to cancel
15		benefits. The language breakdown shall include, at a
16		minimum, English, Spanish, and the next 4 most commonly
17		used languages.
18		(3) The percentage of cancellation decisions made in a
19		month due to each of the following:
20		(A) The beneficiary's ineligibility due to excess
21		income.
22		(B) The beneficiary's ineligibility due to not
23		being an Illinois resident.
24		(C) The beneficiary's ineligibility due to being
25		deceased.
26		(D) The beneficiary's request to cancel benefits.

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1		(E) The beneficiary's lack of response after
2		notices mailed to the beneficiary are returned to the
3		Department as undeliverable by the United States
4		Postal Service.
5		(F) The beneficiary's lack of response to a
6		request for additional information when reliable
7		information in the beneficiary's account, or other
8		more current information, is unavailable to the
9		Department to make a decision on whether to continue
10		benefits.
11		(G) Other reasons tracked by the Department for
12		the purpose of ensuring program integrity.
13		(4) If a vendor is utilized to provide services in
14		support of the Department's redetermination decision
15		process, the total number of redetermination decisions
16		made in a month and, of that total number, the number of
17		decisions to continue or change benefits, and the number
18		of decisions to cancel benefits (i) with the involvement
19		of the vendor and (ii) without the involvement of the
20		vendor.
21		(5) Of the total number of benefit cancellations in a
22		month, the number of beneficiaries who return from
23		cancellation within one month, the number of beneficiaries
24		who return from cancellation within 2 months, and the
25		number of beneficiaries who return from cancellation
26		within 3 months. Of the number of beneficiaries who return

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1		from cancellation within 3 months, the percentage of those
2		cancellations due to each of the reasons listed under
3		paragraph (3) of this subsection.
4		(e) The Department shall conduct a complete review of the
5		Medicaid redetermination process in order to identify changes
6		that can increase the use of ex parte redetermination
7		processing. This review shall be completed within 90 days
8		after the effective date of this amendatory Act of the 101st
9		General Assembly. Within 90 days of completion of the review,
10		the Department shall seek written federal approval of policy
11		changes the review recommended and implement once approved.
12		The review shall specifically include, but not be limited to,
13		use of ex parte redeterminations of the following populations:
14		(1) Recipients of developmental disabilities services.
15		(2) Recipients of benefits under the State's Aid to
16		the Aged, Blind, or Disabled program.
17		(3) Recipients of Medicaid long-term care services and
18		supports, including waiver services.
19		(4) All Modified Adjusted Gross Income (MAGI)
20		populations.
21		(5) Populations with no verifiable income.
22		(6) Self-employed people.
23		The report shall also outline populations and
24		circumstances in which an ex parte redetermination is not a
25		recommended option.
26		(f) The Department shall explore and implement, as

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1		practical and technologically possible, roles that
2		stakeholders outside State agencies can play to assist in
3		expediting eligibility determinations and redeterminations
4		within 24 months after the effective date of this amendatory
5		Act of the 101st General Assembly. Such practical roles to be
6		explored to expedite the eligibility determination processes
7		shall include the implementation of hospital presumptive
8		eligibility, as authorized by the Patient Protection and
9		Affordable Care Act.
10		(g) The Department or its designee shall seek federal
11		approval to enhance the reasonable compatibility standard from
12		5% to 10%.
13		(h) Reporting. The Department of Healthcare and Family
14		Services and the Department of Human Services shall publish
15		quarterly reports on their progress in implementing policies
16		and practices pursuant to this Section as modified by this
17		amendatory Act of the 101st General Assembly.
18		(1) The reports shall include, but not be limited to,
19		the following:
20		(A) Medical application processing, including a
21		breakdown of the number of MAGI, non-MAGI, long-term
22		care, and other medical cases pending for various
23		incremental time frames between 0 to 181 or more days.
24		(B) Medical redeterminations completed, including:
25		(i) a breakdown of the number of households that were
26		redetermined ex parte and those that were not; (ii)

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1		the reasons households were not redetermined ex parte;
2		and (iii) the relative percentages of these reasons.
3		(C) A narrative discussion on issues identified in
4		the functioning of the State's Integrated Eligibility
5		System and progress on addressing those issues, as
6		well as progress on implementing strategies to address
7		eligibility backlogs, including expanding ex parte
8		determinations to ensure timely eligibility
9		determinations and renewals.
10		(2) Initial reports shall be issued within 90 days
11		after the effective date of this amendatory Act of the
12		101st General Assembly.
13		(3) All reports shall be published on the Department's
14		website.
15		(i) It is the determination of the General Assembly that
16		the Department must include seniors and persons with
17		disabilities in ex parte renewals. It is the determination of
18		the General Assembly that the Department must use its asset
19		verification system to assist in the determination of whether
20		an individual's coverage can be renewed using the ex parte
21		process. If a State Plan amendment is required, the Department
22		shall pursue such State Plan amendment by July 1, 2022. Within
23		60 days after receiving federal approval or guidance, the
24		Department of Healthcare and Family Services and the
25		Department of Human Services shall make necessary technical
26		and rule changes to implement these changes to the

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1		redetermination process.
2		(Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20;
3		102-1037, eff. 6-2-22.)
4		(305 ILCS 5/11-5.4)
5		Sec. 11-5.4. Expedited long-term care eligibility
6		determination and enrollment.
7		(a) Establishment of the expedited long-term care
8		eligibility determination and enrollment system shall be a
9		joint venture of the Departments of Human Services and
10		Healthcare and Family Services and the Department on Aging.
11		(b) Streamlined application enrollment process; expedited
12		eligibility process. The streamlined application and
13		enrollment process must include, but need not be limited to,
14		the following:
15		(1) On or before July 1, 2019, a streamlined
16		application and enrollment process shall be put in place
17		which must include, but need not be limited to, the
18		following:
19		(A) Minimize the burden on applicants by
20		collecting only the data necessary to determine
21		eligibility for medical services, long-term care
22		services, and spousal impoverishment offset.
23		(B) Integrate online data sources to simplify the
24		application process by reducing the amount of
25		information needed to be entered and to expedite

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1		eligibility verification.
2		(C) Provide online prompts to alert the applicant
3		that information is missing or not complete.
4		(D) Provide training and step-by-step written
5		instructions for caseworkers, applicants, and
6		providers.
7		(2) The State must expedite the eligibility process
8		for applicants meeting specified guidelines, regardless of
9		the age of the application. The guidelines, subject to
10		federal approval, must include, but need not be limited
11		to, the following individually or collectively:
12		(A) Full Medicaid benefits in the community for a
13		specified period of time.
14		(B) No transfer of assets or resources during the
15		federally prescribed look-back period, as specified in
16		federal law.
17		(C) Receives Supplemental Security Income payments
18		or was receiving such payments at the time of
19		admission to a nursing facility.
20		(D) For applicants or recipients with verified
21		income at or below 100% of the federal poverty level
22		when the declared value of their countable resources
23		is no greater than the allowable amounts pursuant to
24		Section 5-2 of this Code for classes of eligible
25		persons for whom a resource limit applies. Such
26		simplified verification policies shall apply to

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1		community cases as well as long-term care cases.
2		(3) Subject to federal approval, the Department of
3		Healthcare and Family Services must implement an ex parte
4		renewal process for Medicaid-eligible individuals residing
5		in long-term care facilities. "Renewal" has the same
6		meaning as "redetermination" in State policies,
7		administrative rule, and federal Medicaid law. The ex
8		parte renewal process must be fully operational on or
9		before January 1, 2019. If an individual has transferred
10		to another long-term care facility, any annual notice
11		concerning redetermination of eligibility must be sent to
12		the long-term care facility where the individual resides
13		as well as to the individual.
14		(4) The Department of Human Services must use the
15		standards and distribution requirements described in this
16		subsection and in Section 11-6 for notification of missing
17		supporting documents and information during all phases of
18		the application process: initial, renewal, and appeal.
19		(c) The Department of Human Services must adopt policies
20		and procedures to improve communication between long-term care
21		benefits central office personnel, applicants and their
22		representatives, and facilities in which the applicants
23		reside. Such policies and procedures must at a minimum permit
24		applicants and their representatives and the facility in which
25		the applicants reside to speak directly to an individual
26		trained to take telephone inquiries and provide appropriate

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1		responses.
2		(d) Effective 30 days after the completion of 3 regionally
3		based trainings, nursing facilities shall submit all
4		applications for medical assistance online via the Application
5		for Benefits Eligibility (ABE) website. This requirement shall
6		extend to scanning and uploading with the online application
7		any required additional forms such as the Long Term Care
8		Facility Notification and the Additional Financial Information
9		for Long Term Care Applicants as well as scanned copies of any
10		supporting documentation. Long-term care facility admission
11		documents must be submitted as required in Section 5-5 of this
12		Code. No local Department of Human Services office shall
13		refuse to accept an electronically filed application. No
14		Department of Human Services office shall request submission
15		of any document in hard copy.
16		(e) Notwithstanding any other provision of this Code, the
17		Department of Human Services and the Department of Healthcare
18		and Family Services' Office of the Inspector General shall,
19		upon request, allow an applicant additional time to submit
20		information and documents needed as part of a review of
21		available resources or resources transferred during the
22		look-back period. The initial extension shall not exceed 30
23		days. A second extension of 30 days may be granted upon
24		request. Any request for information issued by the State to an
25		applicant shall include the following: an explanation of the
26		information required and the date by which the information

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1		must be submitted; a statement that failure to respond in a
2		timely manner can result in denial of the application; a
3		statement that the applicant or the facility in the name of the
4		applicant may seek an extension; and the name and contact
5		information of a caseworker in case of questions. Any such
6		request for information shall also be sent to the facility. In
7		deciding whether to grant an extension, the Department of
8		Human Services or the Department of Healthcare and Family
9		Services' Office of the Inspector General shall take into
10		account what is in the best interest of the applicant. The time
11		limits for processing an application shall be tolled during
12		the period of any extension granted under this subsection.
13		(f) The Department of Human Services and the Department of
14		Healthcare and Family Services must jointly compile data on
15		pending applications, denials, appeals, and redeterminations
16		into a monthly report, which shall be posted on each
17		Department's website for the purposes of monitoring long-term
18		care eligibility processing. The report must specify the
19		number of applications and redeterminations pending long-term
20		care eligibility determination and admission and the number of
21		appeals of denials in the following categories:
22		(A) Length of time applications, redeterminations, and
23		appeals are pending - 0 to 45 days, 46 days to 90 days, 91
24		days to 180 days, 181 days to 12 months, over 12 months to
25		18 months, over 18 months to 24 months, and over 24 months.
26		(B) Percentage of applications and redeterminations

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1		pending in the Department of Human Services' Family
2		Community Resource Centers, in the Department of Human
3		Services' long-term care hubs, with the Department of
4		Healthcare and Family Services' Office of Inspector
5		General, and those applications which are being tolled due
6		to requests for extension of time for additional
7		information.
8		(C) Status of pending applications, denials, appeals,
9		and redeterminations.
10		(g) Beginning on July 1, 2017, the Auditor General shall
11		report every 3 years to the General Assembly on the
12		performance and compliance of the Department of Healthcare and
13		Family Services, the Department of Human Services, and the
14		Department on Aging in meeting the requirements of this
15		Section and the federal requirements concerning eligibility
16		determinations for Medicaid long-term care services and
17		supports, and shall report any issues or deficiencies and make
18		recommendations. The Auditor General shall, at a minimum,
19		review, consider, and evaluate the following:
20		(1) compliance with federal regulations on furnishing
21		services as related to Medicaid long-term care services
22		and supports as provided under 42 CFR 435.930;
23		(2) compliance with federal regulations on the timely
24		determination of eligibility as provided under 42 CFR
25		435.912;
26		(3) the accuracy and completeness of the report

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1		required under paragraph (9) of subsection (e);
2		(4) the efficacy and efficiency of the task-based
3		process used for making eligibility determinations in the
4		centralized offices of the Department of Human Services
5		for long-term care services, including the role of the
6		State's integrated eligibility system, as opposed to the
7		traditional caseworker-specific process from which these
8		central offices have converted; and
9		(5) any issues affecting eligibility determinations
10		related to the Department of Human Services' staff
11		completing Medicaid eligibility determinations instead of
12		the designated single-state Medicaid agency in Illinois,
13		the Department of Healthcare and Family Services.
14		The Auditor General's report shall include any and all
15		other areas or issues which are identified through an annual
16		review. Paragraphs (1) through (5) of this subsection shall
17		not be construed to limit the scope of the annual review and
18		the Auditor General's authority to thoroughly and completely
19		evaluate any and all processes, policies, and procedures
20		concerning compliance with federal and State law requirements
21		on eligibility determinations for Medicaid long-term care
22		services and supports.
23		(h) The Department of Healthcare and Family Services shall
24		adopt any rules necessary to administer and enforce any
25		provision of this Section. Rulemaking shall not delay the full
26		implementation of this Section.

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1		(i) Beginning on June 29, 2018, provisional eligibility
2		for medical assistance under Article V of this Code, in the
3		form of a recipient identification number and any other
4		necessary credentials to permit an applicant to receive
5		covered services under Article V, must be issued to any
6		applicant who has not received a determination on his or her
7		application for Medicaid and Medicaid long-term care services
8		filed simultaneously or, if already Medicaid enrolled,
9		application for Medicaid long-term care services under Article
10		V of this Code within the federally prescribed timeliness
11		requirements for determinations on such applications. The
12		Department of Healthcare and Family Services must maintain the
13		applicant's provisional eligibility status until a
14		determination is made on the individual's application for
15		long-term care services. The Department of Healthcare and
16		Family Services or the managed care organization, if
17		applicable, must reimburse providers for services rendered
18		during an applicant's provisional eligibility period.
19		(1) Claims for services rendered to an applicant with
20		provisional eligibility status must be submitted and
21		processed in the same manner as those submitted on behalf
22		of beneficiaries determined to qualify for benefits.
23		(2) An applicant with provisional eligibility status
24		must have his or her long-term care benefits paid for
25		under the State's fee-for-service system during the period
26		of provisional eligibility. If an individual otherwise

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1		eligible for medical assistance under Article V of this
2		Code is enrolled with a managed care organization for
3		community benefits at the time the individual's
4		provisional eligibility for long-term care services is
5		issued, the managed care organization is only responsible
6		for paying benefits covered under the capitation payment
7		received by the managed care organization for the
8		individual.
9		(3) The Department of Healthcare and Family Services,
10		within 10 business days of issuing provisional eligibility
11		to an applicant, must submit to the Office of the
12		Comptroller for payment a voucher for all retroactive
13		reimbursement due. The Department of Healthcare and Family
14		Services must clearly identify such vouchers as
15		provisional eligibility vouchers.
16		(Source: P.A. 101-101, eff. 1-1-20; 101-209, eff. 8-5-19;
17		101-265, eff. 8-9-19; 101-559, eff. 8-23-19; 102-558, eff.
18		8-20-21.)
19		ARTICLE 225.
20		Section 225-5. The Illinois Act on the Aging is amended by
21		changing Section 4.02 as follows:
22		(20 ILCS 105/4.02)
23		Sec. 4.02. Community Care Program. The Department shall

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1		establish a program of services to prevent unnecessary
2		institutionalization of persons age 60 and older in need of
3		long term care or who are established as persons who suffer
4		from Alzheimer's disease or a related disorder under the
5		Alzheimer's Disease Assistance Act, thereby enabling them to
6		remain in their own homes or in other living arrangements.
7		Such preventive services, which may be coordinated with other
8		programs for the aged, may include, but are not limited to, any
9		or all of the following:
10		(a) (blank);
11		(b) (blank);
12		(c) home care aide services;
13		(d) personal assistant services;
14		(e) adult day services;
15		(f) home-delivered meals;
16		(g) education in self-care;
17		(h) personal care services;
18		(i) adult day health services;
19		(j) habilitation services;
20		(k) respite care;
21		(k-5) community reintegration services;
22		(k-6) flexible senior services;
23		(k-7) medication management;
24		(k-8) emergency home response;
25		(l) other nonmedical social services that may enable
26		the person to become self-supporting; or

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1		(m) (blank).
2		The Department shall establish eligibility standards for
3		such services. In determining the amount and nature of
4		services for which a person may qualify, consideration shall
5		not be given to the value of cash, property, or other assets
6		held in the name of the person's spouse pursuant to a written
7		agreement dividing marital property into equal but separate
8		shares or pursuant to a transfer of the person's interest in a
9		home to his spouse, provided that the spouse's share of the
10		marital property is not made available to the person seeking
11		such services.
12		The Department shall require as a condition of eligibility
13		that all new financially eligible applicants apply for and
14		enroll in medical assistance under Article V of the Illinois
15		Public Aid Code in accordance with rules promulgated by the
16		Department.
17		The Department shall, in conjunction with the Department
18		of Public Aid (now Department of Healthcare and Family
19		Services), seek appropriate amendments under Sections 1915 and
20		1924 of the Social Security Act. The purpose of the amendments
21		shall be to extend eligibility for home and community based
22		services under Sections 1915 and 1924 of the Social Security
23		Act to persons who transfer to or for the benefit of a spouse
24		those amounts of income and resources allowed under Section
25		1924 of the Social Security Act. Subject to the approval of
26		such amendments, the Department shall extend the provisions of

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1		Section 5-4 of the Illinois Public Aid Code to persons who, but
2		for the provision of home or community-based services, would
3		require the level of care provided in an institution, as is
4		provided for in federal law. Those persons no longer found to
5		be eligible for receiving noninstitutional services due to
6		changes in the eligibility criteria shall be given 45 days
7		notice prior to actual termination. Those persons receiving
8		notice of termination may contact the Department and request
9		the determination be appealed at any time during the 45 day
10		notice period. The target population identified for the
11		purposes of this Section are persons age 60 and older with an
12		identified service need. Priority shall be given to those who
13		are at imminent risk of institutionalization. The services
14		shall be provided to eligible persons age 60 and older to the
15		extent that the cost of the services together with the other
16		personal maintenance expenses of the persons are reasonably
17		related to the standards established for care in a group
18		facility appropriate to the person's condition. These
19		noninstitutional services, pilot projects, or experimental
20		facilities may be provided as part of or in addition to those
21		authorized by federal law or those funded and administered by
22		the Department of Human Services. The Departments of Human
23		Services, Healthcare and Family Services, Public Health,
24		Veterans' Affairs, and Commerce and Economic Opportunity and
25		other appropriate agencies of State, federal, and local
26		governments shall cooperate with the Department on Aging in

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1		the establishment and development of the noninstitutional
2		services. The Department shall require an annual audit from
3		all personal assistant and home care aide vendors contracting
4		with the Department under this Section. The annual audit shall
5		assure that each audited vendor's procedures are in compliance
6		with Department's financial reporting guidelines requiring an
7		administrative and employee wage and benefits cost split as
8		defined in administrative rules. The audit is a public record
9		under the Freedom of Information Act. The Department shall
10		execute, relative to the nursing home prescreening project,
11		written inter-agency agreements with the Department of Human
12		Services and the Department of Healthcare and Family Services,
13		to effect the following: (1) intake procedures and common
14		eligibility criteria for those persons who are receiving
15		noninstitutional services; and (2) the establishment and
16		development of noninstitutional services in areas of the State
17		where they are not currently available or are undeveloped. On
18		and after July 1, 1996, all nursing home prescreenings for
19		individuals 60 years of age or older shall be conducted by the
20		Department.
21		As part of the Department on Aging's routine training of
22		case managers and case manager supervisors, the Department may
23		include information on family futures planning for persons who
24		are age 60 or older and who are caregivers of their adult
25		children with developmental disabilities. The content of the
26		training shall be at the Department's discretion.

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1		The Department is authorized to establish a system of
2		recipient copayment for services provided under this Section,
3		such copayment to be based upon the recipient's ability to pay
4		but in no case to exceed the actual cost of the services
5		provided. Additionally, any portion of a person's income which
6		is equal to or less than the federal poverty standard shall not
7		be considered by the Department in determining the copayment.
8		The level of such copayment shall be adjusted whenever
9		necessary to reflect any change in the officially designated
10		federal poverty standard.
11		The Department, or the Department's authorized
12		representative, may recover the amount of moneys expended for
13		services provided to or in behalf of a person under this
14		Section by a claim against the person's estate or against the
15		estate of the person's surviving spouse, but no recovery may
16		be had until after the death of the surviving spouse, if any,
17		and then only at such time when there is no surviving child who
18		is under age 21 or blind or who has a permanent and total
19		disability. This paragraph, however, shall not bar recovery,
20		at the death of the person, of moneys for services provided to
21		the person or in behalf of the person under this Section to
22		which the person was not entitled; provided that such recovery
23		shall not be enforced against any real estate while it is
24		occupied as a homestead by the surviving spouse or other
25		dependent, if no claims by other creditors have been filed
26		against the estate, or, if such claims have been filed, they

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1		remain dormant for failure of prosecution or failure of the
2		claimant to compel administration of the estate for the
3		purpose of payment. This paragraph shall not bar recovery from
4		the estate of a spouse, under Sections 1915 and 1924 of the
5		Social Security Act and Section 5-4 of the Illinois Public Aid
6		Code, who precedes a person receiving services under this
7		Section in death. All moneys for services paid to or in behalf
8		of the person under this Section shall be claimed for recovery
9		from the deceased spouse's estate. "Homestead", as used in
10		this paragraph, means the dwelling house and contiguous real
11		estate occupied by a surviving spouse or relative, as defined
12		by the rules and regulations of the Department of Healthcare
13		and Family Services, regardless of the value of the property.
14		The Department shall increase the effectiveness of the
15		existing Community Care Program by:
16		(1) ensuring that in-home services included in the
17		care plan are available on evenings and weekends;
18		(2) ensuring that care plans contain the services that
19		eligible participants need based on the number of days in
20		a month, not limited to specific blocks of time, as
21		identified by the comprehensive assessment tool selected
22		by the Department for use statewide, not to exceed the
23		total monthly service cost maximum allowed for each
24		service; the Department shall develop administrative rules
25		to implement this item (2);
26		(3) ensuring that the participants have the right to

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1		choose the services contained in their care plan and to
2		direct how those services are provided, based on
3		administrative rules established by the Department;
4		(4)(blank);
5		(5) ensuring that homemakers can provide personal care
6		services that may or may not involve contact with clients,
7		including, but not limited to:
8		(A) bathing;
9		(B) grooming;
10		(C) toileting;
11		(D) nail care;
12		(E) transferring;
13		(F) respiratory services;
14		(G) exercise; or
15		(H) positioning;
16		(6) ensuring that homemaker program vendors are not
17		restricted from hiring homemakers who are family members
18		of clients or recommended by clients; the Department may
19		not, by rule or policy, require homemakers who are family
20		members of clients or recommended by clients to accept
21		assignments in homes other than the client;
22		(7) ensuring that the State may access maximum federal
23		matching funds by seeking approval for the Centers for
24		Medicare and Medicaid Services for modifications to the
25		State's home and community based services waiver and
26		additional waiver opportunities, including applying for

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1		enrollment in the Balance Incentive Payment Program by May
2		1, 2013, in order to maximize federal matching funds; this
3		shall include, but not be limited to, modification that
4		reflects all changes in the Community Care Program
5		services and all increases in the services cost maximum;
6		(8) ensuring that the determination of need tool
7		accurately reflects the service needs of individuals with
8		Alzheimer's disease and related dementia disorders;
9		(9) ensuring that services are authorized accurately
10		and consistently for the Community Care Program (CCP); the
11		Department shall implement a Service Authorization policy
12		directive; the purpose shall be to ensure that eligibility
13		and services are authorized accurately and consistently in
14		the CCP program; the policy directive shall clarify
15		service authorization guidelines to Care Coordination
16		Units and Community Care Program providers no later than
17		May 1, 2013;
18		(10) working in conjunction with Care Coordination
19		Units, the Department of Healthcare and Family Services,
20		the Department of Human Services, Community Care Program
21		providers, and other stakeholders to make improvements to
22		the Medicaid claiming processes and the Medicaid
23		enrollment procedures or requirements as needed,
24		including, but not limited to, specific policy changes or
25		rules to improve the up-front enrollment of participants
26		in the Medicaid program and specific policy changes or

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1		rules to ensure insure more prompt submission of bills to
2		the federal government to secure maximum federal matching
3		dollars as promptly as possible; the Department on Aging
4		shall have at least 3 meetings with stakeholders by
5		January 1, 2014 in order to address these improvements;
6		(11) requiring home care service providers to comply
7		with the rounding of hours worked provisions under the
8		federal Fair Labor Standards Act (FLSA) and as set forth
9		in 29 CFR 785.48(b) by May 1, 2013;
10		(12) implementing any necessary policy changes or
11		promulgating any rules, no later than January 1, 2014, to
12		assist the Department of Healthcare and Family Services in
13		moving as many participants as possible, consistent with
14		federal regulations, into coordinated care plans if a care
15		coordination plan that covers long term care is available
16		in the recipient's area; and
17		(13) (blank).
18		By January 1, 2009 or as soon after the end of the Cash and
19		Counseling Demonstration Project as is practicable, the
20		Department may, based on its evaluation of the demonstration
21		project, promulgate rules concerning personal assistant
22		services, to include, but need not be limited to,
23		qualifications, employment screening, rights under fair labor
24		standards, training, fiduciary agent, and supervision
25		requirements. All applicants shall be subject to the
26		provisions of the Health Care Worker Background Check Act.

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1		The Department shall develop procedures to enhance
2		availability of services on evenings, weekends, and on an
3		emergency basis to meet the respite needs of caregivers.
4		Procedures shall be developed to permit the utilization of
5		services in successive blocks of 24 hours up to the monthly
6		maximum established by the Department. Workers providing these
7		services shall be appropriately trained.
8		No person may perform chore/housekeeping and home care
9		aide services under a program authorized by this Section
10		unless that person has been issued a certificate of
11		pre-service to do so by his or her employing agency.
12		Information gathered to effect such certification shall
13		include (i) the person's name, (ii) the date the person was
14		hired by his or her current employer, and (iii) the training,
15		including dates and levels. Persons engaged in the program
16		authorized by this Section before the effective date of this
17		amendatory Act of 1991 shall be issued a certificate of all
18		pre-service and in-service training from his or her employer
19		upon submitting the necessary information. The employing
20		agency shall be required to retain records of all staff
21		pre-service and in-service training, and shall provide such
22		records to the Department upon request and upon termination of
23		the employer's contract with the Department. In addition, the
24		employing agency is responsible for the issuance of
25		certifications of in-service training completed to their
26		employees.

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1		The Department is required to develop a system to ensure
2		that persons working as home care aides and personal
3		assistants receive increases in their wages when the federal
4		minimum wage is increased by requiring vendors to certify that
5		they are meeting the federal minimum wage statute for home
6		care aides and personal assistants. An employer that cannot
7		ensure that the minimum wage increase is being given to home
8		care aides and personal assistants shall be denied any
9		increase in reimbursement costs.
10		The Community Care Program Advisory Committee is created
11		in the Department on Aging. The Director shall appoint
12		individuals to serve in the Committee, who shall serve at
13		their own expense. Members of the Committee must abide by all
14		applicable ethics laws. The Committee shall advise the
15		Department on issues related to the Department's program of
16		services to prevent unnecessary institutionalization. The
17		Committee shall meet on a bi-monthly basis and shall serve to
18		identify and advise the Department on present and potential
19		issues affecting the service delivery network, the program's
20		clients, and the Department and to recommend solution
21		strategies. Persons appointed to the Committee shall be
22		appointed on, but not limited to, their own and their agency's
23		experience with the program, geographic representation, and
24		willingness to serve. The Director shall appoint members to
25		the Committee to represent provider, advocacy, policy
26		research, and other constituencies committed to the delivery

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1		of high quality home and community-based services to older
2		adults. Representatives shall be appointed to ensure
3		representation from community care providers, including, but
4		not limited to, adult day service providers, homemaker
5		providers, case coordination and case management units,
6		emergency home response providers, statewide trade or labor
7		unions that represent home care aides and direct care staff,
8		area agencies on aging, adults over age 60, membership
9		organizations representing older adults, and other
10		organizational entities, providers of care, or individuals
11		with demonstrated interest and expertise in the field of home
12		and community care as determined by the Director.
13		Nominations may be presented from any agency or State
14		association with interest in the program. The Director, or his
15		or her designee, shall serve as the permanent co-chair of the
16		advisory committee. One other co-chair shall be nominated and
17		approved by the members of the committee on an annual basis.
18		Committee members' terms of appointment shall be for 4 years
19		with one-quarter of the appointees' terms expiring each year.
20		A member shall continue to serve until his or her replacement
21		is named. The Department shall fill vacancies that have a
22		remaining term of over one year, and this replacement shall
23		occur through the annual replacement of expiring terms. The
24		Director shall designate Department staff to provide technical
25		assistance and staff support to the committee. Department
26		representation shall not constitute membership of the

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1		committee. All Committee papers, issues, recommendations,
2		reports, and meeting memoranda are advisory only. The
3		Director, or his or her designee, shall make a written report,
4		as requested by the Committee, regarding issues before the
5		Committee.
6		The Department on Aging and the Department of Human
7		Services shall cooperate in the development and submission of
8		an annual report on programs and services provided under this
9		Section. Such joint report shall be filed with the Governor
10		and the General Assembly on or before March 31 of the following
11		fiscal year.
12		The requirement for reporting to the General Assembly
13		shall be satisfied by filing copies of the report as required
14		by Section 3.1 of the General Assembly Organization Act and
15		filing such additional copies with the State Government Report
16		Distribution Center for the General Assembly as is required
17		under paragraph (t) of Section 7 of the State Library Act.
18		Those persons previously found eligible for receiving
19		noninstitutional services whose services were discontinued
20		under the Emergency Budget Act of Fiscal Year 1992, and who do
21		not meet the eligibility standards in effect on or after July
22		1, 1992, shall remain ineligible on and after July 1, 1992.
23		Those persons previously not required to cost-share and who
24		were required to cost-share effective March 1, 1992, shall
25		continue to meet cost-share requirements on and after July 1,
26		1992. Beginning July 1, 1992, all clients will be required to

SB3365 Enrolled - 373 - LRB104 18483 SSS 31925 b
1		meet eligibility, cost-share, and other requirements and will
2		have services discontinued or altered when they fail to meet
3		these requirements.
4		For the purposes of this Section, "flexible senior
5		services" refers to services that require one-time or periodic
6		expenditures, including, but not limited to, respite care,
7		home modification, assistive technology, housing assistance,
8		and transportation.
9		The Department shall implement an electronic service
10		verification based on global positioning systems or other
11		cost-effective technology for the Community Care Program no
12		later than January 1, 2014.
13		The Department shall require, as a condition of
14		eligibility, application for the medical assistance program
15		under Article V of the Illinois Public Aid Code.
16		The Department may authorize Community Care Program
17		services until an applicant is determined eligible for medical
18		assistance under Article V of the Illinois Public Aid Code.
19		The Department shall continue to provide Community Care
20		Program reports as required by statute, which shall include an
21		annual report on Care Coordination Unit performance and
22		adherence to service guidelines and a 6-month supplemental
23		report.
24		In regard to community care providers, failure to comply
25		with Department on Aging policies shall be cause for
26		disciplinary action, including, but not limited to,

SB3365 Enrolled - 374 - LRB104 18483 SSS 31925 b
1		disqualification from serving Community Care Program clients.
2		Each provider, upon submission of any bill or invoice to the
3		Department for payment for services rendered, shall include a
4		notarized statement, under penalty of perjury pursuant to
5		Section 1-109 of the Code of Civil Procedure, that the
6		provider has complied with all Department policies.
7		The Director of the Department on Aging shall make
8		information available to the State Board of Elections as may
9		be required by an agreement the State Board of Elections has
10		entered into with a multi-state voter registration list
11		maintenance system.
12		The Department shall pay an enhanced rate of at least
13		$1.77 per unit under the Community Care Program to those
14		in-home service provider agencies that offer health insurance
15		coverage as a benefit to their direct service worker employees
16		pursuant to rules adopted by the Department. The Department
17		shall review the enhanced rate as part of its process to rebase
18		in-home service provider reimbursement rates pursuant to
19		federal waiver requirements. Subject to federal approval,
20		beginning on January 1, 2024, rates for adult day services
21		shall be increased to $16.84 per hour and rates for each way
22		transportation services for adult day services shall be
23		increased to $12.44 per unit transportation.
24		Subject to federal approval, on and after January 1, 2024,
25		rates for homemaker services shall be increased to $28.07 to
26		sustain a minimum wage of $17 per hour for direct service

SB3365 Enrolled - 375 - LRB104 18483 SSS 31925 b
1		workers. Rates in subsequent State fiscal years shall be no
2		lower than the rates put into effect upon federal approval.
3		Providers of in-home services shall be required to certify to
4		the Department that they remain in compliance with the
5		mandated wage increase for direct service workers. Fringe
6		benefits, including, but not limited to, paid time off and
7		payment for training, health insurance, travel, or
8		transportation, shall not be reduced in relation to the rate
9		increases described in this paragraph.
10		Subject to and upon federal approval, on and after January
11		1, 2025, rates for homemaker services shall be increased to
12		$29.63 to sustain a minimum wage of $18 per hour for direct
13		service workers. Rates in subsequent State fiscal years shall
14		be no lower than the rates put into effect upon federal
15		approval. Providers of in-home services shall be required to
16		certify to the Department that they remain in compliance with
17		the mandated wage increase for direct service workers. Fringe
18		benefits, including, but not limited to, paid time off and
19		payment for training, health insurance, travel, or
20		transportation, shall not be reduced in relation to the rate
21		increases described in this paragraph.
22		Subject to and upon federal approval, on and after January
23		1, 2026, rates for homemaker services shall be increased to
24		$30.80 to sustain a minimum wage of $18.75 per hour for direct
25		service workers. Rates in subsequent State fiscal years shall
26		be no lower than the rates put into effect upon federal

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1		approval. Providers of in-home services shall be required to
2		certify to the Department that they remain in compliance with
3		the mandated wage increase for direct service workers. Fringe
4		benefits, including, but not limited to, paid time off and
5		payment for training, health insurance, travel, or
6		transportation, shall not be reduced in relation to the rate
7		increases described in this paragraph.
8		The General Assembly finds it necessary to authorize an
9		aggressive Medicaid enrollment initiative designed to maximize
10		federal Medicaid funding for the Community Care Program which
11		produces significant savings for the State of Illinois. The
12		Department on Aging shall establish and implement a Community
13		Care Program Medicaid Initiative. Under the Initiative, the
14		Department on Aging shall, at a minimum: (i) provide an
15		enhanced rate to adequately compensate care coordination units
16		to enroll eligible Community Care Program clients into
17		Medicaid; (ii) use recommendations from a stakeholder
18		committee on how best to implement the Initiative; and (iii)
19		establish requirements for State agencies to make enrollment
20		in the State's Medical Assistance program easier for seniors.
21		The Community Care Program Medicaid Enrollment Oversight
22		Subcommittee is created as a subcommittee of the Older Adult
23		Services Advisory Committee established in Section 35 of the
24		Older Adult Services Act to make recommendations on how best
25		to increase the number of medical assistance recipients who
26		are enrolled in the Community Care Program. The Subcommittee

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1		shall consist of all of the following persons who must be
2		appointed within 30 days after June 4, 2018 (the effective
3		date of Public Act 100-587):
4		(1) The Director of Aging, or his or her designee, who
5		shall serve as the chairperson of the Subcommittee.
6		(2) One representative of the Department of Healthcare
7		and Family Services, appointed by the Director of
8		Healthcare and Family Services.
9		(3) One representative of the Department of Human
10		Services, appointed by the Secretary of Human Services.
11		(4) One individual representing a care coordination
12		unit, appointed by the Director of Aging.
13		(5) One individual from a non-governmental statewide
14		organization that advocates for seniors, appointed by the
15		Director of Aging.
16		(6) One individual representing Area Agencies on
17		Aging, appointed by the Director of Aging.
18		(7) One individual from a statewide association
19		dedicated to Alzheimer's care, support, and research,
20		appointed by the Director of Aging.
21		(8) One individual from an organization that employs
22		persons who provide services under the Community Care
23		Program, appointed by the Director of Aging.
24		(9) One member of a trade or labor union representing
25		persons who provide services under the Community Care
26		Program, appointed by the Director of Aging.

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1		(10) One member of the Senate, who shall serve as
2		co-chairperson, appointed by the President of the Senate.
3		(11) One member of the Senate, who shall serve as
4		co-chairperson, appointed by the Minority Leader of the
5		Senate.
6		(12) One member of the House of Representatives, who
7		shall serve as co-chairperson, appointed by the Speaker of
8		the House of Representatives.
9		(13) One member of the House of Representatives, who
10		shall serve as co-chairperson, appointed by the Minority
11		Leader of the House of Representatives.
12		(14) One individual appointed by a labor organization
13		representing frontline employees at the Department of
14		Human Services.
15		The Subcommittee shall provide oversight to the Community
16		Care Program Medicaid Initiative and shall meet quarterly. At
17		each Subcommittee meeting the Department on Aging shall
18		provide the following data sets to the Subcommittee: (A) the
19		number of Illinois residents, categorized by planning and
20		service area, who are receiving services under the Community
21		Care Program and are enrolled in the State's Medical
22		Assistance Program; (B) the number of Illinois residents,
23		categorized by planning and service area, who are receiving
24		services under the Community Care Program, but are not
25		enrolled in the State's Medical Assistance Program; and (C)
26		the number of Illinois residents, categorized by planning and

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1		service area, who are receiving services under the Community
2		Care Program and are eligible for benefits under the State's
3		Medical Assistance Program, but are not enrolled in the
4		State's Medical Assistance Program. In addition to this data,
5		the Department on Aging shall provide the Subcommittee with
6		plans on how the Department on Aging will reduce the number of
7		Illinois residents who are not enrolled in the State's Medical
8		Assistance Program but who are eligible for medical assistance
9		benefits. The Department on Aging shall enroll in the State's
10		Medical Assistance Program those Illinois residents who
11		receive services under the Community Care Program and are
12		eligible for medical assistance benefits but are not enrolled
13		in the State's Medicaid Assistance Program. The data provided
14		to the Subcommittee shall be made available to the public via
15		the Department on Aging's website.
16		The Department on Aging, with the involvement of the
17		Subcommittee, shall collaborate with the Department of Human
18		Services and the Department of Healthcare and Family Services
19		on how best to achieve the responsibilities of the Community
20		Care Program Medicaid Initiative.
21		The Department on Aging, the Department of Human Services,
22		and the Department of Healthcare and Family Services shall
23		coordinate and implement a streamlined process for seniors to
24		access benefits under the State's Medical Assistance Program.
25		The Subcommittee shall collaborate with the Department of
26		Human Services on the adoption of a uniform application

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1		submission process. The Department of Human Services and any
2		other State agency involved with processing the medical
3		assistance application of any person enrolled in the Community
4		Care Program shall include the appropriate care coordination
5		unit in all communications related to the determination or
6		status of the application.
7		The Community Care Program Medicaid Initiative shall
8		provide targeted funding to care coordination units to help
9		seniors complete their applications for medical assistance
10		benefits. On and after July 1, 2019, care coordination units
11		shall receive no less than $200 per completed application,
12		which rate may be included in a bundled rate for initial intake
13		services when Medicaid application assistance is provided in
14		conjunction with the initial intake process for new program
15		participants.
16		The Community Care Program Medicaid Initiative shall cease
17		operation 5 years after June 4, 2018 (the effective date of
18		Public Act 100-587), after which the Subcommittee shall
19		dissolve.
20		Effective July 1, 2023 through June 30, 2026, subject to
21		federal approval, the Department on Aging shall reimburse Care
22		Coordination Units at the following rates for case management
23		services: $252.40 for each initial assessment; $366.40 for
24		each initial assessment with translation; $229.68 for each
25		redetermination assessment; $313.68 for each redetermination
26		assessment with translation; $200.00 for each completed

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1		application for medical assistance benefits; $132.26 for each
2		face-to-face, choices-for-care screening; $168.26 for each
3		face-to-face, choices-for-care screening with translation;
4		$124.56 for each 6-month, face-to-face visit; $132.00 for each
5		MCO participant eligibility determination; and $157.00 for
6		each MCO participant eligibility determination with
7		translation.
8		Effective July 1, 2026, subject to federal approval, the
9		Department on Aging shall reimburse Care Coordination Units at
10		the following rates for case management services: $252.40 for
11		each initial assessment; $366.40 for each initial assessment
12		with translation; $229.68 for each redetermination assessment;
13		$313.68 for each redetermination assessment with translation;
14		$200.00 for each completed application for medical assistance
15		benefits; $132.26 for each face-to-face, choices-for-care
16		screening; $168.26 for each face-to-face, choices-for-care
17		screening with translation; $124.56 for each 6-month,
18		face-to-face visit; $172 for each managed care participant
19		eligibility determination; $197.00 for each managed care
20		participant eligibility determination with translation; and
21		$90 for each administration of a participant transfer from
22		non-managed care CCP to managed care CCP or from managed care
23		CCP to non-managed care CCP.
24		(Source: P.A. 103-8, eff. 6-7-23; 103-102, Article 45, Section
25		45-5, eff. 1-1-24; 103-102, Article 85, Section 85-5, eff.
26		1-1-24; 103-102, Article 90, Section 90-5, eff. 1-1-24;

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1		103-588, eff. 6-5-24; 103-605, eff. 7-1-24; 103-670, eff.
2		1-1-25; 104-2, eff. 6-16-25; 104-417, eff. 8-15-25.)
3		ARTICLE 230.
4		Section 230-5. The Specialized Mental Health
5		Rehabilitation Act of 2013 is amended by changing Sections
6		5-107 and 5-113 and by adding Section 5-114 as follows:
7		(210 ILCS 49/5-107)
8		Sec. 5-107. Quality of life enhancement. Beginning on July
9		1, 2019, for improving the quality of life and the quality of
10		care, an additional payment shall be awarded to a facility for
11		their single occupancy rooms. This payment shall be in
12		addition to the rate for recovery and rehabilitation. The
13		additional rate for single room occupancy shall be no less
14		than $10 per day, per single room occupancy. The Department of
15		Healthcare and Family Services shall adjust payment to
16		Medicaid managed care entities to cover these costs. Beginning
17		July 1, 2022, for improving the quality of life and the quality
18		of care, a payment of no less than $5 per day, per single room
19		occupancy shall be added to the existing $10 additional per
20		day, per single room occupancy rate for a total of at least $15
21		per day, per single room occupancy. For improving the quality
22		of life and the quality of care, on January 1, 2024, a payment
23		of no less than $10.50 per day, per single room occupancy shall

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1		be added to the existing $15 additional per day, per single
2		room occupancy rate for a total of at least $25.50 per day, per
3		single room occupancy. For improving the quality of life and
4		the quality of care, beginning on January 1, 2025, a payment of
5		no less than $10 per day, per single room occupancy shall be
6		added to the existing $25.50 additional per day, per single
7		room occupancy rate for a total of at least $35.50 per day, per
8		single room occupancy. For improving the quality of life and
9		the quality of care, beginning on July 1, 2026, a payment of no
10		less than $8 per day, per single room occupancy shall be added
11		to the existing $35.50 additional per day, per single room
12		occupancy rate for a total of at least $43.50 per day, per
13		single room occupancy. Beginning July 1, 2022, for improving
14		the quality of life and the quality of care, an additional
15		payment shall be awarded to a facility for its dual-occupancy
16		rooms. This payment shall be in addition to the rate for
17		recovery and rehabilitation. The additional rate for
18		dual-occupancy rooms shall be no less than $10 per day, per
19		Medicaid-occupied bed, in each dual-occupancy room. Beginning
20		January 1, 2024, for improving the quality of life and the
21		quality of care, a payment of no less than $4.50 per day, per
22		dual-occupancy room shall be added to the existing $10
23		additional per day, per dual-occupancy room rate for a total
24		of at least $14.50, per Medicaid-occupied bed, in each
25		dual-occupancy room. Beginning January 1, 2025, for improving
26		the quality of life and the quality of care, a payment of no

SB3365 Enrolled - 384 - LRB104 18483 SSS 31925 b
1		less than $8.75 per day, per dual-occupancy room shall be
2		added to the existing $14.50 additional per day, per
3		dual-occupancy room rate for a total of at least $23.25, per
4		Medicaid-occupied bed, in each dual-occupancy room. The
5		Department of Healthcare and Family Services shall adjust
6		payment to Medicaid managed care entities to cover these
7		costs. Beginning July 1, 2026, for improving the quality of
8		life and the quality of care, a payment of no less than $2.50
9		per day, per dual-occupancy room shall be added to the
10		existing $23.25 additional per day, per dual-occupancy room
11		rate for a total of at least $25.75, per Medicaid-occupied
12		bed, in each dual-occupancy room. The Department of Healthcare
13		and Family Services shall adjust payment to Medicaid managed
14		care entities to cover these costs. As used in this Section,
15		"dual-occupancy room" means a room that contains 2 resident
16		beds.
17		(Source: P.A. 102-699, eff. 4-19-22; 103-102, eff. 1-1-24;
18		103-593, eff. 6-7-24.)
19		(210 ILCS 49/5-113)
20		Sec. 5-113. Specialized mental health rehabilitation
21		facility; one payment. Notwithstanding any other provision of
22		this Act to the contrary, beginning January 1, 2025, there
23		shall be a separate per diem add-on paid solely and
24		exclusively to facilities licensed under this Act that are
25		licensed for only single occupancy rooms and have reduced

SB3365 Enrolled - 385 - LRB104 18483 SSS 31925 b
1		their licensed capacity. No facility licensed under this Act
2		shall be eligible for these payments if the facility contains
3		any rooms that house more than a single occupant and has have
4		failed to reduce the facility's facilities' licensed capacity.
5		The payment shall be a per diem add-on payment. For
6		facilities with less than 100 licensed beds, the add-on
7		payment shall result in a rate not less than $240 per day. For
8		facilities with 100 licensed beds to 130 licensed beds, the
9		add-on payment shall result in a rate not less than $230 per
10		day. For facilities with more than 130 licensed beds, the
11		add-on payment shall result in a rate of not less than $220 per
12		day. All add-on rates shall be based upon the new licensed
13		capacity.
14		Any additional payments in effect after January 1, 2025
15		under Section 5-107 shall be paid in addition to the amounts
16		listed in this Section. Facilities receiving payments under
17		this Section shall receive payment as prescribed under Section
18		5-101.
19		Beginning July 1, 2026, for facilities with less than 100
20		licensed beds, the payment shall result in a rate not less than
21		$247.50 per day. Beginning July 1, 2026, for facilities with
22		100 licensed beds to 130 licensed beds, the payment shall
23		result in a rate not less than $237.50 per day. For facilities
24		with more than 130 beds, the payment shall result in a rate of
25		no less than $225 per day.
26		(Source: P.A. 103-593, eff. 6-7-24.)

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1		(210 ILCS 49/5-114 new)
2		Sec. 5-114. Forensic add-on payment. Notwithstanding any
3		other provisions to the contrary, any facility that provides
4		services to a resident found not guilty by reason of insanity
5		and is thereby deemed unable to stand trial shall receive an
6		additional payment of $15 per bed, per day for any resident
7		found not guilty by reason of insanity and is thereby deemed
8		unable to stand trial.
9		ARTICLE 235.
10		Section 235-5. The Department of Human Services Act is
11		amended by adding Section 10-13 as follows:
12		(20 ILCS 1305/10-13 new)
13		Sec. 10-13. Pilot programs with local government entities,
14		nonprofits, or privately funded programs. The Department of
15		Human Services may, subject to appropriation, establish pilot
16		programs through which financial and other support, provided
17		by local governments, nonprofits, or privately funded
18		programs, may be provided to Illinois residents through
19		current or future distribution methods utilized and
20		administered by the Department of Human Services.
21		ARTICLE 240.

SB3365 Enrolled - 387 - LRB104 18483 SSS 31925 b
1		Section 240-5. The Illinois Public Aid Code is amended by
2		adding Section 5-54 as follows:
3		(305 ILCS 5/5-54 new)
4		Sec. 5-54. Coverage for proteomic blood tests.
5		(a) The medical assistance program shall provide coverage
6		and reimbursement for a prescribed proteomic blood test, with
7		clinical trial proof of improved infant outcomes published in
8		peer-reviewed journals, that identifies and quantifies the
9		risk of preterm birth for an individual pregnancy.
10		(b) The medical assistance program shall provide coverage
11		and reimbursement for remote patient management services,
12		including telecare management and remote physiologic
13		monitoring, that address maternity and postpartum care access
14		challenges for individualized care delivery by licensed
15		providers. Only remote patient management services with
16		evidence of improved patient care shall be covered and
17		reimbursed under this subsection.
18		ARTICLE 245.
19		Section 245-5. The Illinois Public Aid Code is amended by
20		adding Section 5-30.19 as follows:
21		(305 ILCS 5/5-30.19 new)

SB3365 Enrolled - 388 - LRB104 18483 SSS 31925 b
1		Sec. 5-30.19. MCO behavioral health post-payment reviews.
2		(a) In this Section:
3		"Extrapolated" shall be used as "extrapolation" is used in
4		89 Ill. Adm. Code 140.30(b) or any successor rule.
5		"Managed care organization" or "MCO" has the meaning given
6		to that term in Section 5-30.1 of this Code.
7		"Post-payment review" means an examination that occurs
8		after payment is made by an MCO for a selected claim to
9		determine whether the initial determination for payment was
10		appropriate.
11		"Provider" means a community mental health center,
12		behavioral health clinic, certified community behavioral
13		health clinic, or substance use treatment and recovery center
14		that is enrolled in the medical assistance program and
15		contracted with or reimbursed by an MCO.
16		(b) Beginning July 1, 2027, when conducting post-payment
17		reviews of providers, MCOs must establish guidelines that
18		follow the Department's guidance. The Department's guidance
19		shall mandate that MCOs:
20		(1) Clearly define the documentation and the response
21		time frames ensuring that all requests are directly tied
22		to the review objectives. Documentation and response time
23		frames do not apply to methods necessary for fraud, waste,
24		and abuse post-payment reviews, including, but not limited
25		to, unscheduled or unannounced site visits and database
26		checks.

SB3365 Enrolled - 389 - LRB104 18483 SSS 31925 b
1		(2) Identify regulatory, statutory, or contractual
2		authority and standards for conducting the post-payment
3		review.
4		(3) Clearly define evaluation criteria and provide
5		documentation checklists.
6		(4) Establish a process to dispute MCO record requests
7		not made in conformance with this Section.
8		(5) Establish a process and clarify the instances that
9		allow for entry and exit communications with providers to
10		clearly convey the review scope, expectations, preliminary
11		findings, compliance status, and next steps, ensuring
12		consistent messaging throughout the review process.
13		(6) Establish qualifications of reviewers with
14		relevant knowledge, experience, and training.
15		(7) Provide the data on how the provider varies
16		significantly from other providers in the same provider
17		type, service specialty, jurisdiction, or locality, if the
18		basis for selection of a provider for review is
19		comparative data except where fraud, waste, and abuse
20		processes and procedures prevent disclosure.
21		(8) Clearly outline communication protocols, including
22		advance written notice, delivered electronically, by MCOs
23		to providers of documentation requests with an allowance
24		for reasonable response times and except for instances
25		where fraud, waste, and abuse processes and procedures
26		prevent advance notice, including, but not limited to,

SB3365 Enrolled - 390 - LRB104 18483 SSS 31925 b
1		unscheduled or unannounced site visits.
2		(9) Upon completion of the review, issue a formal
3		written notice of compliance or closure to the provider.
4		The final review findings shall include clear references
5		to applicable regulatory or contractual citations, an
6		explanation of the rationale for each finding, guidance on
7		required next steps or corrective actions, and information
8		regarding the process and timelines for appealing the
9		findings.
10		(10) Use the least burdensome and lowest-cost method
11		of record submission, including secure electronic methods,
12		when available. The date on which documentation is
13		received in the electronic communication shall be the
14		official date of receipt. All communication protocols
15		shall be compliant with privacy and security laws.
16		(11) Issue findings and related written communications
17		in a clear, consistent, and non-contradictory manner to
18		prevent confusion or conflicting conclusions.
19		(12) Disclose the methodology supporting any
20		extrapolated finding.
21		(c) The MCO shall post the guidelines and any updates on
22		its publicly available website.
23		(d) Providers must not be subject to any adverse action,
24		payment delay, sanctions, or contract termination solely for
25		exercising the right to dispute a records request in
26		accordance with this Section, except for matters involving

SB3365 Enrolled - 391 - LRB104 18483 SSS 31925 b
1		allegations of fraud, waste, or abuse.
2		(e) Nothing in this Section shall be construed to conflict
3		with State or federal program integrity law, regulations,
4		guidance, processes, or procedures.
5		ARTICLE 250.
6		Section 250-5. The Illinois Public Aid Code is amended by
7		adding Section 5-70 as follows:
8		(305 ILCS 5/5-70 new)
9		Sec. 5-70. Virtual intensive outpatient program services.
10		For dates of service on and after January 1, 2027, subject to
11		any necessary federal approval, the medical assistance program
12		shall provide coverage for virtual intensive outpatient
13		program services when clinically appropriate, delivered in
14		line with generally accepted standards of care, and only at
15		the request of or with the consent of the patient. The
16		Department shall establish provider qualifications for
17		intensive outpatient program services offering a virtual
18		service delivery option. The Department may establish
19		utilization controls and any appropriate guidelines for
20		coverage of the virtual intensive outpatient program to
21		protect the well-being of persons eligible and enrolled in the
22		medical assistance program. The Department may adopt rules
23		necessary to implement this Section.

SB3365 Enrolled - 392 - LRB104 18483 SSS 31925 b
1		ARTICLE 255.
2		Section 255-5. The Illinois Public Aid Code is amended by
3		changing Section 5-5.01a as follows:
4		(305 ILCS 5/5-5.01a)
5		Sec. 5-5.01a. Supportive living facilities program.
6		(a) The Department shall establish and provide oversight
7		for a program of supportive living facilities that seek to
8		promote resident independence, dignity, respect, and
9		well-being in the most cost-effective manner.
10		A supportive living facility is (i) a free-standing
11		facility or (ii) a distinct physical and operational entity
12		within a mixed-use building that meets the criteria
13		established in subsection (d). A supportive living facility
14		integrates housing with health, personal care, and supportive
15		services and is a designated setting that offers residents
16		their own separate, private, and distinct living units.
17		Sites for the operation of the program shall be selected
18		by the Department based upon criteria that may include the
19		need for services in a geographic area, the availability of
20		funding, and the site's ability to meet the standards.
21		(b) Beginning July 1, 2014, subject to federal approval,
22		the Medicaid rates for supportive living facilities shall be
23		equal to the supportive living facility Medicaid rate

SB3365 Enrolled - 393 - LRB104 18483 SSS 31925 b
1		effective on June 30, 2014 increased by 8.85%. Once the
2		assessment imposed at Article V-G of this Code is determined
3		to be a permissible tax under Title XIX of the Social Security
4		Act, the Department shall increase the Medicaid rates for
5		supportive living facilities effective on July 1, 2014 by
6		9.09%. The Department shall apply this increase retroactively
7		to coincide with the imposition of the assessment in Article
8		V-G of this Code in accordance with the approval for federal
9		financial participation by the Centers for Medicare and
10		Medicaid Services.
11		The Medicaid rates for supportive living facilities
12		effective on July 1, 2017 must be equal to the rates in effect
13		for supportive living facilities on June 30, 2017 increased by
14		2.8%.
15		The Medicaid rates for supportive living facilities
16		effective on July 1, 2018 must be equal to the rates in effect
17		for supportive living facilities on June 30, 2018.
18		Subject to federal approval, the Medicaid rates for
19		supportive living services on and after July 1, 2019 must be at
20		least 54.3% of the average total nursing facility services per
21		diem for the geographic areas defined by the Department while
22		maintaining the rate differential for dementia care and must
23		be updated whenever the total nursing facility service per
24		diems are updated. Beginning July 1, 2022, upon the
25		implementation of the Patient Driven Payment Model, Medicaid
26		rates for supportive living services must be at least 54.3% of

SB3365 Enrolled - 394 - LRB104 18483 SSS 31925 b
1		the average total nursing services per diem rate for the
2		geographic areas. For purposes of this provision, the average
3		total nursing services per diem rate shall include all add-ons
4		for nursing facilities for the geographic area provided for in
5		Section 5-5.2. The rate differential for dementia care must be
6		maintained in these rates and the rates shall be updated
7		whenever nursing facility per diem rates are updated.
8		Subject to federal approval, beginning January 1, 2024,
9		the dementia care rate for supportive living services must be
10		no less than the non-dementia care supportive living services
11		rate multiplied by 1.5.
12		(b-5) Subject to federal approval, beginning January 1,
13		2025, Medicaid rates for supportive living services must be at
14		least 54.75% of the average total nursing facility per diem
15		rate for the geographic areas defined by the Department and
16		shall include all add-ons for nursing facilities for the
17		geographic area provided for in Section 5-5.2.
18		(c) The Department may adopt rules to implement this
19		Section. Rules that establish or modify the services,
20		standards, and conditions for participation in the program
21		shall be adopted by the Department in consultation with the
22		Department on Aging, the Department of Rehabilitation
23		Services, and the Department of Mental Health and
24		Developmental Disabilities (or their successor agencies).
25		(d) Subject to federal approval by the Centers for
26		Medicare and Medicaid Services, the Department shall accept

SB3365 Enrolled - 395 - LRB104 18483 SSS 31925 b
1		for consideration of certification under the program any
2		application for a site or building where distinct parts of the
3		site or building are designated for purposes other than the
4		provision of supportive living services, but only if:
5		(1) those distinct parts of the site or building are
6		not designated for the purpose of providing assisted
7		living services as required under the Assisted Living and
8		Shared Housing Act;
9		(2) those distinct parts of the site or building are
10		completely separate from the part of the building used for
11		the provision of supportive living program services,
12		including separate entrances;
13		(3) those distinct parts of the site or building do
14		not share any common spaces with the part of the building
15		used for the provision of supportive living program
16		services; and
17		(4) those distinct parts of the site or building do
18		not share staffing with the part of the building used for
19		the provision of supportive living program services.
20		(e) 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
24		Health Facilities Planning Act.
25		(f) Section 9817 of the American Rescue Plan Act of 2021
26		(Public Law 117-2) authorizes a 10% enhanced federal medical

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1		assistance percentage for supportive living services for a
2		12-month period from April 1, 2021 through March 31, 2022.
3		Subject to federal approval, including the approval of any
4		necessary waiver amendments or other federally required
5		documents or assurances, for a 12-month period the Department
6		must pay a supplemental $26 per diem rate to all supportive
7		living facilities with the additional federal financial
8		participation funds that result from the enhanced federal
9		medical assistance percentage from April 1, 2021 through March
10		31, 2022. The Department may issue parameters around how the
11		supplemental payment should be spent, including quality
12		improvement activities. The Department may alter the form,
13		methods, or timeframes concerning the supplemental per diem
14		rate to comply with any subsequent changes to federal law,
15		changes made by guidance issued by the federal Centers for
16		Medicare and Medicaid Services, or other changes necessary to
17		receive the enhanced federal medical assistance percentage.
18		(g) All applications for the expansion of supportive
19		living dementia care settings involving sites not approved by
20		the Department by January 1, 2024 may allow new elderly
21		non-dementia units in addition to new dementia care units. The
22		Department may approve such applications only if the
23		application has: (1) no more than one non-dementia care unit
24		for each dementia care unit and (2) the site is not located
25		within 4 miles of an existing supportive living program site
26		in Cook County (including the City of Chicago), not located

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1		within 12 miles of an existing supportive living program site
2		in Alexander, Bond, Boone, Calhoun, Champaign, Clinton,
3		DeKalb, DuPage, Fulton, Grundy, Henry, Jackson, Jersey,
4		Johnson, Kane, Kankakee, Kendall, Lake, Macon, Macoupin,
5		Madison, Marshall, McHenry, McLean, Menard, Mercer, Monroe,
6		Peoria, Piatt, Rock Island, Sangamon, Stark, St. Clair,
7		Tazewell, Vermilion, Will, Williamson, Winnebago, or Woodford
8		counties, or not located within 25 miles of an existing
9		supportive living program site in any other county.
10		(g-5) Subject to federal approval, beginning January 1,
11		2027, any individual age 44 to 64 who is diagnosed as having
12		Alzheimer's disease or a related dementia and is determined to
13		be a person with a disability by the Social Security
14		Administration shall be eligible for services in a supportive
15		living dementia care setting if the individual meets all other
16		eligibility requirements to receive services in a supportive
17		living dementia care setting under 89 Ill. Adm. Code 146
18		Subpart B and E. The Department shall apply for any federal
19		waiver necessary to implement this subsection.
20		(h) Beginning January 1, 2025, subject to federal
21		approval, for a person who is a resident of a supportive living
22		facility under this Section, the monthly personal needs
23		allowance shall be $120 per month.
24		(i) As stated in the supportive living program home and
25		community-based service waiver approved by the federal Centers
26		for Medicare and Medicaid Services, and beginning July 1,

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1		2025, the Department must maintain the rate add-on implemented
2		on January 1, 2023 for the provision of 2 meals per day at no
3		less than $6.15 per day.
4		(j) Subject to federal approval, the Department shall
5		allow a certified medication aide to administer medication in
6		a supportive living facility. For purposes of this subsection,
7		"certified medication aide" means a person who has met the
8		qualifications for certification under Section 79 of the
9		Assisted Living and Shared Housing Act and assists with
10		medication administration while under the supervision of a
11		registered professional nurse as authorized by Section 50-75
12		of the Nurse Practice Act. The Department may adopt rules to
13		implement this subsection.
14		(Source: P.A. 103-102, Article 20, Section 20-5, eff. 1-1-24;
15		103-102, Article 100, Section 100-5, eff. 1-1-24; 103-593,
16		Article 15, Section 15-5, eff. 6-7-24; 103-593, Article 100,
17		Section 100-5, eff. 6-7-24; 103-593, Article 165, Section
18		165-5, eff. 6-7-24; 103-605, eff. 7-1-24; 103-886, eff.
19		8-9-24; 104-9, eff. 6-16-25; 104-417, eff. 8-15-25; revised
20		9-12-25.)
21		ARTICLE 257.
22		Section 257-3. The Department of Public Health Powers and
23		Duties Law is amended by adding Section 2310-716 as follows:

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1		(20 ILCS 2310/2310-716 new)
2		Sec. 2310-716. Report on patient access and care. With a
3		health care landscape shifting dramatically from inpatient,
4		volume-drive care to more outpatient, community-faced care and
5		further exacerbated by HR1 changes that disinvests billions of
6		dollars from the health care system and increase uninsured
7		populations, the Department of Public Health, in partnership
8		with relevant State agencies and with the advice of
9		stakeholders and experts in the field, shall develop a
10		comprehensive report that identifies how the resources of the
11		State and other health care payers may be optimized to protect
12		communities' and patients' access and care and to improve
13		Illinois' population health outcomes.
14		The Department may engage a third-party experienced and
15		expert research entity to develop this report. The report
16		shall include analysis, findings, and recommendations to
17		reform and strengthen the health care system in Illinois. The
18		report will have emphasis on the needs and vulnerabilities
19		experienced by individuals living in communities with limited
20		access to critical health care services.
21		The report will include epidemiological analyses and
22		recommendations on policy and resource strategies to protect
23		and improve population health outcomes and health care access
24		including but not limited to:
25		(1) Patient experience that includes social needs
26		integration, reduced administrative burden, and enhanced

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1		digital tools.
2		(2) Care model transformation that emphasizes
3		continuous, community-based care built to address health
4		access gaps and needs.
5		(3) Workforce resilience and optimization that
6		highlights partnership and care-delivery opportunities
7		across institutions.
8		(4) System agility to absorb and recover from
9		unforeseen public health crises and other external
10		factors.
11		The Department shall have access to all the necessary data
12		from State agencies as well as health care facilities as
13		required to inform on these recommendations, within the bounds
14		of relevance to their mission. Health care facilities will
15		hereby be directed to provide the necessary data to the
16		Department.
17		The Department shall issue recommendations to the General
18		Assembly and the Governor no later than January 31, 2027,
19		including proposed statutory or administrative changes
20		necessary to strengthen health care access, quality, and
21		effectiveness.
22		(20 ILCS 2310/2310-715 rep.)
23		Section 257-5. The Department of Public Health Powers and
24		Duties Law of the Civil Administrative Code of Illinois is
25		amended by repealing Section 2310-715.

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1		Section 257-10. The Illinois Public Aid Code is amended by
2		changing Sections 5A-2, 5A-7, 5A-8, and 12-4.25 as follows:
3		(305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
4		Sec. 5A-2. Assessment.
5		(a)(1) Subject to Sections 5A-3 and 5A-10, for State
6		fiscal years 2009 through 2018, or as long as continued under
7		Section 5A-16, an annual assessment on inpatient services is
8		imposed on each hospital provider in an amount equal to
9		$218.38 multiplied by the difference of the hospital's
10		occupied bed days less the hospital's Medicare bed days,
11		provided, however, that the amount of $218.38 shall be
12		increased by a uniform percentage to generate an amount equal
13		to 75% of the State share of the payments authorized under
14		Section 5A-12.5, with such increase only taking effect upon
15		the date that a State share for such payments is required under
16		federal law. For the period of April through June 2015, the
17		amount of $218.38 used to calculate the assessment under this
18		paragraph shall, by emergency rule under subsection (s) of
19		Section 5-45 of the Illinois Administrative Procedure Act, be
20		increased by a uniform percentage to generate $20,250,000 in
21		the aggregate for that period from all hospitals subject to
22		the annual assessment under this paragraph.
23		(2) In addition to any other assessments imposed under
24		this Article, effective July 1, 2016 and semi-annually

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1		thereafter through June 2018, or as provided in Section 5A-16,
2		in addition to any federally required State share as
3		authorized under paragraph (1), the amount of $218.38 shall be
4		increased by a uniform percentage to generate an amount equal
5		to 75% of the ACA Assessment Adjustment, as defined in
6		subsection (b-6) of this Section.
7		For State fiscal years 2009 through 2018, or as provided
8		in Section 5A-16, a hospital's occupied bed days and Medicare
9		bed days shall be determined using the most recent data
10		available from each hospital's 2005 Medicare cost report as
11		contained in the Healthcare Cost Report Information System
12		file, for the quarter ending on December 31, 2006, without
13		regard to any subsequent adjustments or changes to such data.
14		If a hospital's 2005 Medicare cost report is not contained in
15		the Healthcare Cost Report Information System, then the
16		Illinois Department may obtain the hospital provider's
17		occupied bed days and Medicare bed days from any source
18		available, including, but not limited to, records maintained
19		by the hospital provider, which may be inspected at all times
20		during business hours of the day by the Illinois Department or
21		its duly authorized agents and employees.
22		(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
23		fiscal years 2019 and 2020, an annual assessment on inpatient
24		services is imposed on each hospital provider in an amount
25		equal to $197.19 multiplied by the difference of the
26		hospital's occupied bed days less the hospital's Medicare bed

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1		days. For State fiscal years 2019 and 2020, a hospital's
2		occupied bed days and Medicare bed days shall be determined
3		using the most recent data available from each hospital's 2015
4		Medicare cost report as contained in the Healthcare Cost
5		Report Information System file, for the quarter ending on
6		March 31, 2017, without regard to any subsequent adjustments
7		or changes to such data. If a hospital's 2015 Medicare cost
8		report is not contained in the Healthcare Cost Report
9		Information System, then the Illinois Department may obtain
10		the hospital provider's occupied bed days and Medicare bed
11		days from any source available, including, but not limited to,
12		records maintained by the hospital provider, which may be
13		inspected at all times during business hours of the day by the
14		Illinois Department or its duly authorized agents and
15		employees. Notwithstanding any other provision in this
16		Article, for a hospital provider that did not have a 2015
17		Medicare cost report, but paid an assessment in State fiscal
18		year 2018 on the basis of hypothetical data, that assessment
19		amount shall be used for State fiscal years 2019 and 2020.
20		(4) Subject to Sections 5A-3 and 5A-10 and to subsection
21		(b-8), for the period of July 1, 2020 through December 31, 2020
22		and calendar years 2021 through 2024, an annual assessment on
23		inpatient services is imposed on each hospital provider in an
24		amount equal to $221.50 multiplied by the difference of the
25		hospital's occupied bed days less the hospital's Medicare bed
26		days, provided however: for the period of July 1, 2020 through

SB3365 Enrolled - 404 - LRB104 18483 SSS 31925 b
1		December 31, 2020, (i) the assessment shall be equal to 50% of
2		the annual amount; and (ii) the amount of $221.50 shall be
3		retroactively adjusted by a uniform percentage to generate an
4		amount equal to 50% of the Assessment Adjustment, as defined
5		in subsection (b-7). For the period of July 1, 2020 through
6		December 31, 2020 and calendar years 2021 through 2024, a
7		hospital's occupied bed days and Medicare bed days shall be
8		determined using the most recent data available from each
9		hospital's 2015 Medicare cost report as contained in the
10		Healthcare Cost Report Information System file, for the
11		quarter ending on March 31, 2017, without regard to any
12		subsequent adjustments or changes to such data. If a
13		hospital's 2015 Medicare cost report is not contained in the
14		Healthcare Cost Report Information System, then the Illinois
15		Department may obtain the hospital provider's occupied bed
16		days and Medicare bed days from any source available,
17		including, but not limited to, records maintained by the
18		hospital provider, which may be inspected at all times during
19		business hours of the day by the Illinois Department or its
20		duly authorized agents and employees. Should the change in the
21		assessment methodology for fiscal years 2021 through December
22		31, 2022 not be approved on or before June 30, 2020, the
23		assessment and payments under this Article in effect for
24		fiscal year 2020 shall remain in place until the new
25		assessment is approved. If the assessment methodology for July
26		1, 2020 through December 31, 2022, is approved on or after July

SB3365 Enrolled - 405 - LRB104 18483 SSS 31925 b
1		1, 2020, it shall be retroactive to July 1, 2020, subject to
2		federal approval and provided that the payments authorized
3		under Section 5A-12.7 have the same effective date as the new
4		assessment methodology. In giving retroactive effect to the
5		assessment approved after June 30, 2020, credit toward the new
6		assessment shall be given for any payments of the previous
7		assessment for periods after June 30, 2020. Notwithstanding
8		any other provision of this Article, for a hospital provider
9		that did not have a 2015 Medicare cost report, but paid an
10		assessment in State Fiscal Year 2020 on the basis of
11		hypothetical data, the data that was the basis for the 2020
12		assessment shall be used to calculate the assessment under
13		this paragraph until December 31, 2023. Beginning July 1, 2022
14		and through December 31, 2024, a safety-net hospital that had
15		a change of ownership in calendar year 2021, and whose
16		inpatient utilization had decreased by 90% from the prior year
17		and prior to the change of ownership, may be eligible to pay a
18		tax based on hypothetical data based on a determination of
19		financial distress by the Department. Subject to federal
20		approval, the Department may, by January 1, 2024, develop a
21		hypothetical tax for a specialty cancer hospital which had a
22		structural change of ownership during calendar year 2022 from
23		a for-profit entity to a non-profit entity, and which has
24		experienced a decline of 60% or greater in inpatient days of
25		care as compared to the prior owners 2015 Medicare cost
26		report. This change of ownership may make the hospital

SB3365 Enrolled - 406 - LRB104 18483 SSS 31925 b
1		eligible for a hypothetical tax under the new hospital
2		provision of the assessment defined in this Section. This new
3		hypothetical tax may be applicable from January 1, 2024
4		through December 31, 2026.
5		(5) Subject to Sections 5A-3 and 5A-10, beginning January
6		1, 2025, an annual assessment on inpatient services is imposed
7		on each hospital provider in an amount equal to $362, or any
8		reduction thereof in accordance with this subsection,
9		multiplied by the difference of the hospital's occupied bed
10		days less the hospital's Medicare bed days; however, the rate
11		shall be $221.50 until the Department receives federal
12		approval and implements the reimbursement rates in subsection
13		(r) of Section 5A-12.7. The Department may bill for the
14		difference between the assessment rate of $362, or any
15		reduction thereof in accordance with this subsection, and
16		$221.50 no earlier than 17 calendar days after implementing
17		the reimbursement rates in subsection (r) of Section 5A-12.7.
18		(A) Upon receiving federal approval for the
19		reimbursement rates in subsection (r) of Section 5A-12.7,
20		the Department shall bill the hospital for the incremental
21		difference in total tax due resulting from the increase
22		provided in this subsection for the number of months from
23		January 1, 2025 through the date of federal approval. The
24		amount shall be due and payable no later than December 31,
25		2025 and no earlier than 17 calendar days after
26		implementing the reimbursement rates in subsection (r) of

SB3365 Enrolled - 407 - LRB104 18483 SSS 31925 b
1		Section 5A-12.7. The Department shall bill hospitals in
2		the same proportional rate as the Department has
3		implemented the inpatient reimbursement rates in
4		subsection (r) of Section 5A-12.7.
5		(B) Beginning January 1, 2025, a hospital's occupied
6		bed days and Medicare bed days shall be determined using
7		the most recent data available from each hospital's 2015
8		Medicare cost report as contained in the Healthcare Cost
9		Report Information System file, for the quarter ending on
10		March 31, 2017, without regard to any subsequent
11		adjustments or changes to such data. If a hospital's 2015
12		Medicare cost report is not contained in the Healthcare
13		Cost Report Information System, then the Department may
14		obtain the hospital provider's occupied bed days and
15		Medicare bed days from any source available, including,
16		but not limited to, records maintained by the hospital
17		provider, which may be inspected at all times during
18		business hours of the day by the Department or its duly
19		authorized agents and employees. If the reimbursement
20		rates in subsection (r) of Section 5A-12.7 require
21		reduction to comply with federal spending limits, then the
22		tax rate of $362 shall be reduced, in accordance with
23		subsection (s) of Section 5A-12.7, by the same percentage
24		reduction to payments required to comply with federal
25		spending limits.
26		(6) For calendar year 2026, and for each year thereafter

SB3365 Enrolled - 408 - LRB104 18483 SSS 31925 b
1		in which a tax is imposed under this Section, the Department
2		may seek to obtain a waiver from the federal Centers for
3		Medicare and Medicaid Services of the uniformity requirements
4		in place for the tax imposed under this Section, provided that
5		such waiver request does not risk the assessment imposed or
6		payments authorized under this Section from continuing. Such
7		uniformity requirements shall only be waived for
8		not-for-profit hospitals operating as a freestanding cancer
9		hospital that have contracted to provide services to members
10		served by at least 50% of the managed care organizations
11		contracted with the Department. Such tax rates imposed on a
12		hospital shall be no more than 50% and no less than 25% of the
13		tax imposed on all other hospitals in this State unless
14		different rates are necessary to meet federal statistical
15		tests necessary for continued federal financial participation.
16		Upon federal approval of such a waiver, other tax rates
17		imposed under this Article shall be adjusted to ensure budget
18		neutrality.
19		(b) (Blank).
20		(b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
21		portion of State fiscal year 2012, beginning June 10, 2012
22		through June 30, 2012, and for State fiscal years 2013 through
23		2018, or as provided in Section 5A-16, an annual assessment on
24		outpatient services is imposed on each hospital provider in an
25		amount equal to .008766 multiplied by the hospital's
26		outpatient gross revenue, provided, however, that the amount

SB3365 Enrolled - 409 - LRB104 18483 SSS 31925 b
1		of .008766 shall be increased by a uniform percentage to
2		generate an amount equal to 25% of the State share of the
3		payments authorized under Section 5A-12.5, with such increase
4		only taking effect upon the date that a State share for such
5		payments is required under federal law. For the period
6		beginning June 10, 2012 through June 30, 2012, the annual
7		assessment on outpatient services shall be prorated by
8		multiplying the assessment amount by a fraction, the numerator
9		of which is 21 days and the denominator of which is 365 days.
10		For the period of April through June 2015, the amount of
11		.008766 used to calculate the assessment under this paragraph
12		shall, by emergency rule under subsection (s) of Section 5-45
13		of the Illinois Administrative Procedure Act, be increased by
14		a uniform percentage to generate $6,750,000 in the aggregate
15		for that period from all hospitals subject to the annual
16		assessment under this paragraph.
17		(2) In addition to any other assessments imposed under
18		this Article, effective July 1, 2016 and semi-annually
19		thereafter through June 2018, in addition to any federally
20		required State share as authorized under paragraph (1), the
21		amount of .008766 shall be increased by a uniform percentage
22		to generate an amount equal to 25% of the ACA Assessment
23		Adjustment, as defined in subsection (b-6) of this Section.
24		For the portion of State fiscal year 2012, beginning June
25		10, 2012 through June 30, 2012, and State fiscal years 2013
26		through 2018, or as provided in Section 5A-16, a hospital's

SB3365 Enrolled - 410 - LRB104 18483 SSS 31925 b
1		outpatient gross revenue shall be determined using the most
2		recent data available from each hospital's 2009 Medicare cost
3		report as contained in the Healthcare Cost Report Information
4		System file, for the quarter ending on June 30, 2011, without
5		regard to any subsequent adjustments or changes to such data.
6		If a hospital's 2009 Medicare cost report is not contained in
7		the Healthcare Cost Report Information System, then the
8		Department may obtain the hospital provider's outpatient gross
9		revenue from any source available, including, but not limited
10		to, records maintained by the hospital provider, which may be
11		inspected at all times during business hours of the day by the
12		Department or its duly authorized agents and employees.
13		(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
14		fiscal years 2019 and 2020, an annual assessment on outpatient
15		services is imposed on each hospital provider in an amount
16		equal to .01358 multiplied by the hospital's outpatient gross
17		revenue. For State fiscal years 2019 and 2020, a hospital's
18		outpatient gross revenue shall be determined using the most
19		recent data available from each hospital's 2015 Medicare cost
20		report as contained in the Healthcare Cost Report Information
21		System file, for the quarter ending on March 31, 2017, without
22		regard to any subsequent adjustments or changes to such data.
23		If a hospital's 2015 Medicare cost report is not contained in
24		the Healthcare Cost Report Information System, then the
25		Department may obtain the hospital provider's outpatient gross
26		revenue from any source available, including, but not limited

SB3365 Enrolled - 411 - LRB104 18483 SSS 31925 b
1		to, records maintained by the hospital provider, which may be
2		inspected at all times during business hours of the day by the
3		Department or its duly authorized agents and employees.
4		Notwithstanding any other provision in this Article, for a
5		hospital provider that did not have a 2015 Medicare cost
6		report, but paid an assessment in State fiscal year 2018 on the
7		basis of hypothetical data, that assessment amount shall be
8		used for State fiscal years 2019 and 2020.
9		(4) Subject to Sections 5A-3 and 5A-10 and to subsection
10		(b-8), for the period of July 1, 2020 through December 31, 2020
11		and calendar years 2021 through 2024, an annual assessment on
12		outpatient services is imposed on each hospital provider in an
13		amount equal to .01525 multiplied by the hospital's outpatient
14		gross revenue, provided however: (i) for the period of July 1,
15		2020 through December 31, 2020, the assessment shall be equal
16		to 50% of the annual amount; and (ii) the amount of .01525
17		shall be retroactively adjusted by a uniform percentage to
18		generate an amount equal to 50% of the Assessment Adjustment,
19		as defined in subsection (b-7). For the period of July 1, 2020
20		through December 31, 2020 and calendar years 2021 through
21		2024, a hospital's outpatient gross revenue shall be
22		determined using the most recent data available from each
23		hospital's 2015 Medicare cost report as contained in the
24		Healthcare Cost Report Information System file, for the
25		quarter ending on March 31, 2017, without regard to any
26		subsequent adjustments or changes to such data. If a

SB3365 Enrolled - 412 - LRB104 18483 SSS 31925 b
1		hospital's 2015 Medicare cost report is not contained in the
2		Healthcare Cost Report Information System, then the Illinois
3		Department may obtain the hospital provider's outpatient
4		revenue data from any source available, including, but not
5		limited to, records maintained by the hospital provider, which
6		may be inspected at all times during business hours of the day
7		by the Illinois Department or its duly authorized agents and
8		employees. Should the change in the assessment methodology
9		above for fiscal years 2021 through calendar year 2022 not be
10		approved prior to July 1, 2020, the assessment and payments
11		under this Article in effect for fiscal year 2020 shall remain
12		in place until the new assessment is approved. If the change in
13		the assessment methodology above for July 1, 2020 through
14		December 31, 2022, is approved after June 30, 2020, it shall
15		have a retroactive effective date of July 1, 2020, subject to
16		federal approval and provided that the payments authorized
17		under Section 12A-7 have the same effective date as the new
18		assessment methodology. In giving retroactive effect to the
19		assessment approved after June 30, 2020, credit toward the new
20		assessment shall be given for any payments of the previous
21		assessment for periods after June 30, 2020. Notwithstanding
22		any other provision of this Article, for a hospital provider
23		that did not have a 2015 Medicare cost report, but paid an
24		assessment in State Fiscal Year 2020 on the basis of
25		hypothetical data, the data that was the basis for the 2020
26		assessment shall be used to calculate the assessment under

SB3365 Enrolled - 413 - LRB104 18483 SSS 31925 b
1		this paragraph until December 31, 2023. Beginning July 1, 2022
2		and through December 31, 2024, a safety-net hospital that had
3		a change of ownership in calendar year 2021, and whose
4		inpatient utilization had decreased by 90% from the prior year
5		and prior to the change of ownership, may be eligible to pay a
6		tax based on hypothetical data based on a determination of
7		financial distress by the Department.
8		(5) Subject to Sections 5A-3 and 5A-10, beginning January
9		1, 2025, an annual assessment on outpatient services is
10		imposed on each hospital provider in an amount equal to
11		.03273, or any reduction thereof in accordance with this
12		subsection, multiplied by the hospital's outpatient gross
13		revenue; however the rate shall remain .01525, until the
14		Department receives federal approval and implements the
15		reimbursement rates of payment in subsection (r) of Section
16		5A-12.7. The Department may bill for the difference between
17		the assessment multiplier of .03273 and .01525 no earlier than
18		17 calendar days after the first payment based on the
19		reimbursement rates in subsection (r) of Section 5A-12.7.
20		(A) Upon receiving federal approval for the
21		reimbursement rates in subsection (r) of Section 5A-12.7,
22		the Department shall bill the hospital for the incremental
23		difference in total tax due resulting from the increase
24		provided in this subsection for the number of months from
25		January 1, 2025 through the date of federal approval. The
26		amount shall be due and payable no later than December 31,

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1		2025 and no earlier than 17 calendar days after
2		implementing the reimbursement rates in subsection (r) of
3		Section 5A-12.7. The Department shall bill hospitals in
4		the same proportional rate as the Department has
5		implemented the outpatient reimbursement rates in
6		subsection (r) of Section 5A-12.7.
7		(B) Beginning January 1, 2025, a hospital's outpatient
8		gross revenue shall be determined using the most recent
9		data available from each hospital's 2015 Medicare cost
10		report as contained in the Healthcare Cost Report
11		Information System file, for the quarter ending on March
12		31, 2017, without regard to any subsequent adjustments or
13		changes to such data. If a hospital's 2015 Medicare cost
14		report is not contained in the Healthcare Cost Report
15		Information System, then the Department may obtain the
16		hospital provider's outpatient revenue data from any
17		source available, including, but not limited to, records
18		maintained by the hospital provider, which may be
19		inspected at all times during business hours of the day by
20		the Department or its duly authorized agents and
21		employees. If the reimbursement rates in subsection (r) of
22		Section 5A-12.7 require reduction to comply with federal
23		spending limits, then the tax rate of .03273 shall be
24		reduced, in accordance with subsection (s) of Section
25		5A-12.7, by the same percentage reduction to payments
26		required to comply with federal spending limits.

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1		(6) For calendar year 2026, and for each year thereafter
2		in which a tax is imposed under this Section, the Department
3		may seek to obtain a waiver from the federal Centers for
4		Medicare and Medicaid Services of the uniformity requirements
5		in place for the tax imposed under this Section, provided that
6		such waiver request does not risk the assessment imposed or
7		payments authorized under this Section from continuing. Such
8		uniformity requirements shall only be waived for
9		not-for-profit hospitals operating as a freestanding cancer
10		hospital that have contracted to provide services to members
11		served by at least 50% of the managed care organizations
12		contracted with the Department. Such tax rates imposed on a
13		hospital shall be no more than 50% and no less than 25% of the
14		tax imposed on all other hospitals in this State unless
15		different rates are necessary to meet federal statistical
16		tests necessary for continued federal financial participation.
17		Upon federal approval of such a waiver, other tax rates
18		imposed under this Article shall be adjusted to ensure budget
19		neutrality.
20		(b-6)(1) As used in this Section, "ACA Assessment
21		Adjustment" means:
22		(A) For the period of July 1, 2016 through December
23		31, 2016, the product of .19125 multiplied by the sum of
24		the fee-for-service payments to hospitals as authorized
25		under Section 5A-12.5 and the adjustments authorized under
26		subsection (t) of Section 5A-12.2 to managed care

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1		organizations for hospital services due and payable in the
2		month of April 2016 multiplied by 6.
3		(B) For the period of January 1, 2017 through June 30,
4		2017, the product of .19125 multiplied by the sum of the
5		fee-for-service payments to hospitals as authorized under
6		Section 5A-12.5 and the adjustments authorized under
7		subsection (t) of Section 5A-12.2 to managed care
8		organizations for hospital services due and payable in the
9		month of October 2016 multiplied by 6, except that the
10		amount calculated under this subparagraph (B) shall be
11		adjusted, either positively or negatively, to account for
12		the difference between the actual payments issued under
13		Section 5A-12.5 for the period beginning July 1, 2016
14		through December 31, 2016 and the estimated payments due
15		and payable in the month of April 2016 multiplied by 6 as
16		described in subparagraph (A).
17		(C) For the period of July 1, 2017 through December
18		31, 2017, the product of .19125 multiplied by the sum of
19		the fee-for-service payments to hospitals as authorized
20		under Section 5A-12.5 and the adjustments authorized under
21		subsection (t) of Section 5A-12.2 to managed care
22		organizations for hospital services due and payable in the
23		month of April 2017 multiplied by 6, except that the
24		amount calculated under this subparagraph (C) shall be
25		adjusted, either positively or negatively, to account for
26		the difference between the actual payments issued under

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1		Section 5A-12.5 for the period beginning January 1, 2017
2		through June 30, 2017 and the estimated payments due and
3		payable in the month of October 2016 multiplied by 6 as
4		described in subparagraph (B).
5		(D) For the period of January 1, 2018 through June 30,
6		2018, the product of .19125 multiplied by the sum of the
7		fee-for-service payments to hospitals as authorized under
8		Section 5A-12.5 and the adjustments authorized under
9		subsection (t) of Section 5A-12.2 to managed care
10		organizations for hospital services due and payable in the
11		month of October 2017 multiplied by 6, except that:
12		(i) the amount calculated under this subparagraph
13		(D) shall be adjusted, either positively or
14		negatively, to account for the difference between the
15		actual payments issued under Section 5A-12.5 for the
16		period of July 1, 2017 through December 31, 2017 and
17		the estimated payments due and payable in the month of
18		April 2017 multiplied by 6 as described in
19		subparagraph (C); and
20		(ii) the amount calculated under this subparagraph
21		(D) shall be adjusted to include the product of .19125
22		multiplied by the sum of the fee-for-service payments,
23		if any, estimated to be paid to hospitals under
24		subsection (b) of Section 5A-12.5.
25		(2) The Department shall complete and apply a final
26		reconciliation of the ACA Assessment Adjustment prior to June

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1		30, 2018 to account for:
2		(A) any differences between the actual payments issued
3		or scheduled to be issued prior to June 30, 2018 as
4		authorized in Section 5A-12.5 for the period of January 1,
5		2018 through June 30, 2018 and the estimated payments due
6		and payable in the month of October 2017 multiplied by 6 as
7		described in subparagraph (D); and
8		(B) any difference between the estimated
9		fee-for-service payments under subsection (b) of Section
10		5A-12.5 and the amount of such payments that are actually
11		scheduled to be paid.
12		The Department shall notify hospitals of any additional
13		amounts owed or reduction credits to be applied to the June
14		2018 ACA Assessment Adjustment. This is to be considered the
15		final reconciliation for the ACA Assessment Adjustment.
16		(3) Notwithstanding any other provision of this Section,
17		if for any reason the scheduled payments under subsection (b)
18		of Section 5A-12.5 are not issued in full by the final day of
19		the period authorized under subsection (b) of Section 5A-12.5,
20		funds collected from each hospital pursuant to subparagraph
21		(D) of paragraph (1) and pursuant to paragraph (2),
22		attributable to the scheduled payments authorized under
23		subsection (b) of Section 5A-12.5 that are not issued in full
24		by the final day of the period attributable to each payment
25		authorized under subsection (b) of Section 5A-12.5, shall be
26		refunded.

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1		(4) The increases authorized under paragraph (2) of
2		subsection (a) and paragraph (2) of subsection (b-5) shall be
3		limited to the federally required State share of the total
4		payments authorized under Section 5A-12.5 if the sum of such
5		payments yields an annualized amount equal to or less than
6		$450,000,000, or if the adjustments authorized under
7		subsection (t) of Section 5A-12.2 are found not to be
8		actuarially sound; however, this limitation shall not apply to
9		the fee-for-service payments described in subsection (b) of
10		Section 5A-12.5.
11		(b-7)(1) As used in this Section, "Assessment Adjustment"
12		means:
13		(A) For the period of July 1, 2020 through December
14		31, 2020, the product of .3853 multiplied by the total of
15		the actual payments made under subsections (c) through (k)
16		of Section 5A-12.7 attributable to the period, less the
17		total of the assessment imposed under subsections (a) and
18		(b-5) of this Section for the period.
19		(B) For each calendar quarter beginning January 1,
20		2021 through December 31, 2022, the product of .3853
21		multiplied by the total of the actual payments made under
22		subsections (c) through (k) of Section 5A-12.7
23		attributable to the period, less the total of the
24		assessment imposed under subsections (a) and (b-5) of this
25		Section for the period.
26		(C) Beginning on January 1, 2023, and each subsequent

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1		July 1 and January 1, the product of .3853 multiplied by
2		the total of the actual payments made under subsections
3		(c) through (j) and subsection (r) of Section 5A-12.7
4		attributable to the 6-month period immediately preceding
5		the period to which the adjustment applies, less the total
6		of the assessment imposed under subsections (a) and (b-5)
7		of this Section for the 6-month period immediately
8		preceding the period to which the adjustment applies.
9		(D) For the 6-month tax adjustment period beginning
10		July 1, 2026, the Assessment Adjustment defined in
11		subparagraph (C) of this paragraph (1) shall be half of
12		the amount calculated under subparagraph (C) of this
13		paragraph (1).
14		(2) The Department shall calculate and notify each
15		hospital of the total Assessment Adjustment and any additional
16		assessment owed by the hospital or refund owed to the hospital
17		on either a semi-annual or annual basis. Such notice shall be
18		issued at least 30 days prior to any period in which the
19		assessment will be adjusted. Any additional assessment owed by
20		the hospital or refund owed to the hospital shall be uniformly
21		applied to the assessment owed by the hospital in monthly
22		installments for the subsequent semi-annual period or calendar
23		year. If no assessment is owed in the subsequent year, any
24		amount owed by the hospital or refund due to the hospital,
25		shall be paid in a lump sum. If the calculation that is
26		computed under this Section could result in a decrease in the

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1		Department's federal financial participation percentage for
2		payments authorized under Section 5A-12.7, then the Department
3		shall instead apply a uniform percentage reduction to the
4		payment rates outlined in subsection (r) of Section 5A-12.7
5		for all classes as defined in subsections (g) and (h) of
6		Section 5A-12.7 by an amount no more than necessary to
7		maximize federal reimbursement.
8		(3) The Department shall publish all details of the
9		Assessment Adjustment calculation performed each year on its
10		website within 30 days of completing the calculation, and also
11		submit the details of the Assessment Adjustment calculation as
12		part of the Department's annual report to the General
13		Assembly.
14		(b-8) Notwithstanding any other provision of this Article,
15		the Department shall reduce the assessments imposed on each
16		hospital under subsections (a) and (b-5) by the uniform
17		percentage necessary to reduce the total assessment imposed on
18		all hospitals by an aggregate amount of $240,000,000, with
19		such reduction being applied by June 30, 2022. The assessment
20		reduction required for each hospital under this subsection
21		shall be forever waived, forgiven, and released by the
22		Department.
23		(c) (Blank).
24		(d) Notwithstanding any of the other provisions of this
25		Section, the Department is authorized to adopt rules to reduce
26		the rate of any annual assessment imposed under this Section,

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1		as authorized by Section 5-46.2 of the Illinois Administrative
2		Procedure Act.
3		(e) Notwithstanding any other provision of this Section,
4		any plan providing for an assessment on a hospital provider as
5		a permissible tax under Title XIX of the federal Social
6		Security Act and Medicaid-eligible payments to hospital
7		providers from the revenues derived from that assessment shall
8		be reviewed by the Illinois Department of Healthcare and
9		Family Services, as the Single State Medicaid Agency required
10		by federal law, to determine whether those assessments and
11		hospital provider payments meet federal Medicaid standards. If
12		the Department determines that the elements of the plan may
13		meet federal Medicaid standards and a related State Medicaid
14		Plan Amendment is prepared in a manner and form suitable for
15		submission, that State Plan Amendment shall be submitted in a
16		timely manner for review by the Centers for Medicare and
17		Medicaid Services of the United States Department of Health
18		and Human Services and subject to approval by the Centers for
19		Medicare and Medicaid Services of the United States Department
20		of Health and Human Services. No such plan shall become
21		effective without approval by the Illinois General Assembly by
22		the enactment into law of related legislation. Notwithstanding
23		any other provision of this Section, the Department is
24		authorized to adopt rules to reduce the rate of any annual
25		assessment imposed under this Section. Any such rules may be
26		adopted by the Department under Section 5-50 of the Illinois

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1		Administrative Procedure Act.
2		(f) To provide for the expeditious and timely
3		implementation of the changes made to this Section by Public
4		Act 104-7 this amendatory Act of the 104th General Assembly,
5		the Department may adopt emergency rules as authorized by
6		Section 5-45 of the Illinois Administrative Procedure Act. The
7		adoption of emergency rules is deemed to be necessary for the
8		public interest, safety, and welfare.
9		(Source: P.A. 103-102, eff. 1-1-24; 104-7, eff. 6-16-25;
10		104-9, eff. 6-16-25; revised 8-5-25.)
11		(305 ILCS 5/5A-7)  (from Ch. 23, par. 5A-7)
12		Sec. 5A-7. Administration; enforcement provisions.
13		(a) The Illinois Department shall establish and maintain a
14		listing of all hospital providers appearing in the licensing
15		records of the Illinois Department of Public Health, which
16		shall show each provider's name and principal place of
17		business and the name and address of each hospital operated,
18		conducted, or maintained by the provider in this State. The
19		listing shall also include the monthly assessment amounts owed
20		for each hospital and any unpaid assessment liability greater
21		than 90 days delinquent. The Illinois Department shall
22		administer and enforce this Article and collect the
23		assessments and penalty assessments imposed under this Article
24		using procedures employed in its administration of this Code
25		generally. The Illinois Department, its Director, and every

SB3365 Enrolled - 424 - LRB104 18483 SSS 31925 b
1		hospital provider subject to assessment under this Article
2		shall have the following powers, duties, and rights:
3		(1) The Illinois Department may initiate either
4		administrative or judicial proceedings, or both, to
5		enforce provisions of this Article. Administrative
6		enforcement proceedings initiated hereunder shall be
7		governed by the Illinois Department's administrative
8		rules. Judicial enforcement proceedings initiated
9		hereunder shall be governed by the rules of procedure
10		applicable in the courts of this State.
11		(2) (Blank).
12		(3) Any unpaid assessment under this Article shall
13		become a lien upon the assets of the hospital upon which it
14		was assessed. If any hospital provider, outside the usual
15		course of its business, sells or transfers the major part
16		of any one or more of (A) the real property and
17		improvements, (B) the machinery and equipment, or (C) the
18		furniture or fixtures, of any hospital that is subject to
19		the provisions of this Article, the seller or transferor
20		shall pay the Illinois Department the amount of any
21		assessment, assessment penalty, and interest (if any) due
22		from it under this Article up to the date of the sale or
23		transfer. The Illinois Department may, in its discretion,
24		foreclose on such a lien, but shall do so in a manner that
25		is consistent with Section 5e of the Retailers' Occupation
26		Tax Act. If the seller or transferor fails to pay any

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1		assessment, assessment penalty, and interest (if any) due,
2		the purchaser or transferee of such asset shall be liable
3		for the amount of the assessment, penalties, and interest
4		(if any) up to the amount of the reasonable value of the
5		property acquired by the purchaser or transferee. The
6		purchaser or transferee shall continue to be liable until
7		the purchaser or transferee pays the full amount of the
8		assessment, penalties, and interest (if any) up to the
9		amount of the reasonable value of the property acquired by
10		the purchaser or transferee or until the purchaser or
11		transferee receives from the Illinois Department a
12		certificate showing that such assessment, penalty, and
13		interest have been paid or a certificate from the Illinois
14		Department showing that no assessment, penalty, or
15		interest is due from the seller or transferor under this
16		Article.
17		(4) Payments under this Article are not subject to the
18		Illinois Prompt Payment Act. Credits or refunds shall not
19		bear interest.
20		(b) In addition to any other remedy provided for and
21		without sending a notice of assessment liability, the Illinois
22		Department shall collect an unpaid assessment by withholding,
23		as payment of the assessment, reimbursements or other amounts
24		otherwise payable by the Illinois Department to the hospital
25		provider, including, but not limited to, payment amounts
26		otherwise payable from a managed care organization performing

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1		duties under contract with the Illinois Department. To the
2		extent not prohibited by federal or State law, the Department
3		may collect an unpaid assessment by offsetting or recouping,
4		as payment of the assessment obligation, amounts otherwise
5		payable by any State agency to the hospital provider,
6		including, but not limited to, State grants and grant
7		appropriations.
8		(1) The requirements of this subsection may be waived
9		in instances when a disaster proclamation has been
10		declared by the Governor. In such circumstances, a
11		hospital must demonstrate temporary financial distress and
12		establish an agreement with the Illinois Department
13		specifying when repayment in full of all taxes owed will
14		occur.
15		(2) The requirements of this subsection may be waived
16		by the Illinois Department in instances when a hospital
17		has entered into and remains in compliance with a
18		repayment plan or a tax deferral plan. A repayment plan or
19		tax deferral plan must be entered into no later than 30
20		days after notice of an unpaid assessment payment.
21		Beginning July 1, 2026, the Illinois Department shall not
22		enter into any new tax deferral plan with a hospital. A
23		hospital may enter into a repayment plan with the
24		Department that includes terms for repayment of the total
25		amount owed over 72 months or less, repaid in equal
26		payment increments. Payments shall begin within 30 days of

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1		the signed agreement date. Hospitals with existing
2		repayment agreements that were negotiated and remain in
3		effect prior to June 1, 2026 may either adhere to the terms
4		of their existing agreements or, alternatively, seek to
5		amend the existing agreement's repayment period to 72
6		months or less from the date the new agreement is entered
7		into. Renegotiated repayment plans shall include equal
8		payment increments for the total amount owed over the
9		period of the renegotiated agreement. Such renegotiated
10		repayment agreements may only include amendments to (a)
11		the length of the repayment period and (b) the payment
12		increments, provided that the total amount to be repaid
13		does not change from what remained unpaid under the
14		original repayment agreement and any additional amounts
15		owed. An existing repayment or tax deferral agreement
16		cannot be amended more than once unless otherwise agreed
17		upon by the Department. No repayment plan may exceed a
18		period of 36 months. No tax deferral plan may exceed a
19		period of 6 months, and repayment after the end of a tax
20		deferral plan shall not exceed 36 months. Failure to
21		remain in compliance with a repayment plan or tax deferral
22		plan shall cause immediate termination of such plan unless
23		there is prior written consent from the Illinois
24		Department for a period of non-compliance.
25		(3) Beginning September 1, 2025, the Illinois
26		Department shall immediately collect all overdue unpaid

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1		assessments and penalties through the collection methods
2		authorized under this Section, unless a repayment plan or
3		tax deferral plan has already been agreed to by September
4		1, 2025.
5		(4) For any unpaid assessments and penalties that are
6		overdue as of the effective date of this amendatory Act of
7		the 104th General Assembly of House Bill 2771 of the 104th
8		General Assembly, upon receipt of payment the Department
9		may, at its discretion, transfer funds from the Hospital
10		Provider Fund to the Healthcare Provider Relief Fund,
11		provided that, at the time of each transfer, there are no
12		outstanding assessment-related payments owed to hospitals
13		that cannot be paid from resources remaining in the
14		Hospital Provider Fund after the transfer.
15		(c) To provide for the expeditious and timely
16		implementation of the changes made to this Section by this
17		amendatory Act of the 104th General Assembly, the Department
18		may adopt emergency rules as authorized by Section 5-45 of the
19		Illinois Administrative Procedure Act. The adoption of
20		emergency rules is deemed to be necessary for the public
21		interest, safety, and welfare.
22		(Source: P.A. 104-2, eff. 6-16-25; 104-7, eff. 6-16-25.)
23		(305 ILCS 5/12-4.25)  (from Ch. 23, par. 12-4.25)
24		Sec. 12-4.25. Medical assistance program; vendor
25		participation.

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1		(A) The Illinois Department may deny, suspend, or
2		terminate the eligibility of any person, firm, corporation,
3		association, agency, institution or other legal entity to
4		participate as a vendor of goods or services to recipients
5		under the medical assistance program under Article V, or may
6		exclude any such person or entity from participation as such a
7		vendor, and may deny, suspend, or recover payments, if after
8		reasonable notice and opportunity for a hearing the Illinois
9		Department finds:
10		(a) Such vendor is not complying with the Department's
11		policy or rules and regulations, or with the terms and
12		conditions prescribed by the Illinois Department in its
13		vendor agreement, which document shall be developed by the
14		Department as a result of negotiations with each vendor
15		category, including physicians, hospitals, long term care
16		facilities, pharmacists, optometrists, podiatric
17		physicians, and dentists setting forth the terms and
18		conditions applicable to the participation of each vendor
19		group in the program; or
20		(b) Such vendor has failed to keep or make available
21		for inspection, audit or copying, after receiving a
22		written request from the Illinois Department, such records
23		regarding payments claimed for providing services. This
24		section does not require vendors to make available patient
25		records of patients for whom services are not reimbursed
26		under this Code; or

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1		(c) Such vendor has failed to furnish any information
2		requested by the Department regarding payments for
3		providing goods or services; or
4		(d) Such vendor has knowingly made, or caused to be
5		made, any false statement or representation of a material
6		fact in connection with the administration of the medical
7		assistance program; or
8		(e) Such vendor has furnished goods or services to a
9		recipient which are (1) in excess of need, (2) harmful, or
10		(3) of grossly inferior quality, all of such
11		determinations to be based upon competent medical judgment
12		and evaluations; or
13		(f) The vendor; a person with management
14		responsibility for a vendor; an officer or person owning,
15		either directly or indirectly, 5% or more of the shares of
16		stock or other evidences of ownership in a corporate
17		vendor; an owner of a sole proprietorship which is a
18		vendor; or a partner in a partnership which is a vendor,
19		either:
20		(1) was previously terminated, suspended, or
21		excluded from participation in the Illinois medical
22		assistance program, or was terminated, suspended, or
23		excluded from participation in another state or
24		federal medical assistance or health care program; or
25		(2) was a person with management responsibility
26		for a vendor previously terminated, suspended, or

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1		excluded from participation in the Illinois medical
2		assistance program, or terminated, suspended, or
3		excluded from participation in another state or
4		federal medical assistance or health care program
5		during the time of conduct which was the basis for that
6		vendor's termination, suspension, or exclusion; or
7		(3) was an officer, or person owning, either
8		directly or indirectly, 5% or more of the shares of
9		stock or other evidences of ownership in a corporate
10		or limited liability company vendor previously
11		terminated, suspended, or excluded from participation
12		in the Illinois medical assistance program, or
13		terminated, suspended, or excluded from participation
14		in a state or federal medical assistance or health
15		care program during the time of conduct which was the
16		basis for that vendor's termination, suspension, or
17		exclusion; or
18		(4) was an owner of a sole proprietorship or
19		partner of a partnership previously terminated,
20		suspended, or excluded from participation in the
21		Illinois medical assistance program, or terminated,
22		suspended, or excluded from participation in a state
23		or federal medical assistance or health care program
24		during the time of conduct which was the basis for that
25		vendor's termination, suspension, or exclusion; or
26		(f-1) Such vendor has a delinquent debt owed to the

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1		Illinois Department; or
2		(g) The vendor; a person with management
3		responsibility for a vendor; an officer or person owning,
4		either directly or indirectly, 5% or more of the shares of
5		stock or other evidences of ownership in a corporate or
6		limited liability company vendor; an owner of a sole
7		proprietorship which is a vendor; or a partner in a
8		partnership which is a vendor, either:
9		(1) has engaged in practices prohibited by
10		applicable federal or State law or regulation; or
11		(2) was a person with management responsibility
12		for a vendor at the time that such vendor engaged in
13		practices prohibited by applicable federal or State
14		law or regulation; or
15		(3) was an officer, or person owning, either
16		directly or indirectly, 5% or more of the shares of
17		stock or other evidences of ownership in a vendor at
18		the time such vendor engaged in practices prohibited
19		by applicable federal or State law or regulation; or
20		(4) was an owner of a sole proprietorship or
21		partner of a partnership which was a vendor at the time
22		such vendor engaged in practices prohibited by
23		applicable federal or State law or regulation; or
24		(h) The direct or indirect ownership of the vendor
25		(including the ownership of a vendor that is a sole
26		proprietorship, a partner's interest in a vendor that is a

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1		partnership, or ownership of 5% or more of the shares of
2		stock or other evidences of ownership in a corporate
3		vendor) has been transferred by an individual who is
4		terminated, suspended, or excluded or barred from
5		participating as a vendor to the individual's spouse,
6		child, brother, sister, parent, grandparent, grandchild,
7		uncle, aunt, niece, nephew, cousin, or relative by
8		marriage.
9		(A-5) The Illinois Department may deny, suspend, or
10		terminate the eligibility of any person, firm, corporation,
11		association, agency, institution, or other legal entity to
12		participate as a vendor of goods or services to recipients
13		under the medical assistance program under Article V, or may
14		exclude any such person or entity from participation as such a
15		vendor, if, after reasonable notice and opportunity for a
16		hearing, the Illinois Department finds that the vendor; a
17		person with management responsibility for a vendor; an officer
18		or person owning, either directly or indirectly, 5% or more of
19		the shares of stock or other evidences of ownership in a
20		corporate vendor; an owner of a sole proprietorship that is a
21		vendor; or a partner in a partnership that is a vendor has been
22		convicted of an offense based on fraud or willful
23		misrepresentation related to any of the following:
24		(1) The medical assistance program under Article V of
25		this Code.
26		(2) A medical assistance or health care program in

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1		another state.
2		(3) The Medicare program under Title XVIII of the
3		Social Security Act.
4		(4) The provision of health care services.
5		(5) A violation of this Code, as provided in Article
6		VIIIA, or another state or federal medical assistance
7		program or health care program.
8		(A-10) The Illinois Department may deny, suspend, or
9		terminate the eligibility of any person, firm, corporation,
10		association, agency, institution, or other legal entity to
11		participate as a vendor of goods or services to recipients
12		under the medical assistance program under Article V, or may
13		exclude any such person or entity from participation as such a
14		vendor, if, after reasonable notice and opportunity for a
15		hearing, the Illinois Department finds that (i) the vendor,
16		(ii) a person with management responsibility for a vendor,
17		(iii) an officer or person owning, either directly or
18		indirectly, 5% or more of the shares of stock or other
19		evidences of ownership in a corporate vendor, (iv) an owner of
20		a sole proprietorship that is a vendor, or (v) a partner in a
21		partnership that is a vendor has been convicted of an offense
22		related to any of the following:
23		(1) Murder.
24		(2) A Class X felony under the Criminal Code of 1961 or
25		the Criminal Code of 2012.
26		(3) Sexual misconduct that may subject recipients to

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1		an undue risk of harm.
2		(4) A criminal offense that may subject recipients to
3		an undue risk of harm.
4		(5) A crime of fraud or dishonesty.
5		(6) A crime involving a controlled substance.
6		(7) A misdemeanor relating to fraud, theft,
7		embezzlement, breach of fiduciary responsibility, or other
8		financial misconduct related to a health care program.
9		(A-15) The Illinois Department may deny the eligibility of
10		any person, firm, corporation, association, agency,
11		institution, or other legal entity to participate as a vendor
12		of goods or services to recipients under the medical
13		assistance program under Article V if, after reasonable notice
14		and opportunity for a hearing, the Illinois Department finds:
15		(1) The applicant or any person with management
16		responsibility for the applicant; an officer or member of
17		the board of directors of an applicant; an entity owning
18		(directly or indirectly) 5% or more of the shares of stock
19		or other evidences of ownership in a corporate vendor
20		applicant; an owner of a sole proprietorship applicant; a
21		partner in a partnership applicant; or a technical or
22		other advisor to an applicant has a debt owed to the
23		Illinois Department, and no payment arrangements
24		acceptable to the Illinois Department have been made by
25		the applicant.
26		(2) The applicant or any person with management

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1		responsibility for the applicant; an officer or member of
2		the board of directors of an applicant; an entity owning
3		(directly or indirectly) 5% or more of the shares of stock
4		or other evidences of ownership in a corporate vendor
5		applicant; an owner of a sole proprietorship applicant; a
6		partner in a partnership vendor applicant; or a technical
7		or other advisor to an applicant was (i) a person with
8		management responsibility, (ii) an officer or member of
9		the board of directors of an applicant, (iii) an entity
10		owning (directly or indirectly) 5% or more of the shares
11		of stock or other evidences of ownership in a corporate
12		vendor, (iv) an owner of a sole proprietorship, (v) a
13		partner in a partnership vendor, (vi) a technical or other
14		advisor to a vendor, during a period of time where the
15		conduct of that vendor resulted in a debt owed to the
16		Illinois Department, and no payment arrangements
17		acceptable to the Illinois Department have been made by
18		that vendor.
19		(3) There is a credible allegation of the use,
20		transfer, or lease of assets of any kind to an applicant
21		from a current or prior vendor who has a debt owed to the
22		Illinois Department, no payment arrangements acceptable to
23		the Illinois Department have been made by that vendor or
24		the vendor's alternate payee, and the applicant knows or
25		should have known of such debt.
26		(4) There is a credible allegation of a transfer of

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1		management responsibilities, or direct or indirect
2		ownership, to an applicant from a current or prior vendor
3		who has a debt owed to the Illinois Department, and no
4		payment arrangements acceptable to the Illinois Department
5		have been made by that vendor or the vendor's alternate
6		payee, and the applicant knows or should have known of
7		such debt.
8		(5) There is a credible allegation of the use,
9		transfer, or lease of assets of any kind to an applicant
10		who is a spouse, child, brother, sister, parent,
11		grandparent, grandchild, uncle, aunt, niece, relative by
12		marriage, nephew, cousin, or relative of a current or
13		prior vendor who has a debt owed to the Illinois
14		Department and no payment arrangements acceptable to the
15		Illinois Department have been made.
16		(6) There is a credible allegation that the
17		applicant's previous affiliations with a provider of
18		medical services that has an uncollected debt, a provider
19		that has been or is subject to a payment suspension under a
20		federal health care program, or a provider that has been
21		previously excluded from participation in the medical
22		assistance program, poses a risk of fraud, waste, or abuse
23		to the Illinois Department.
24		As used in this subsection, "credible allegation" is
25		defined to include an allegation from any source, including,
26		but not limited to, fraud hotline complaints, claims data

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1		mining, patterns identified through provider audits, civil
2		actions filed under the Illinois False Claims Act, and law
3		enforcement investigations. An allegation is considered to be
4		credible when it has indicia of reliability.
5		(B) The Illinois Department shall deny, suspend or
6		terminate the eligibility of any person, firm, corporation,
7		association, agency, institution or other legal entity to
8		participate as a vendor of goods or services to recipients
9		under the medical assistance program under Article V, or may
10		exclude any such person or entity from participation as such a
11		vendor:
12		(1) immediately, if such vendor is not properly
13		licensed, certified, or authorized;
14		(2) within 30 days of the date when such vendor's
15		professional license, certification or other authorization
16		has been refused renewal, restricted, revoked, suspended,
17		or otherwise terminated; or
18		(3) if such vendor has been convicted of a violation
19		of this Code, as provided in Article VIIIA.
20		(C) Upon termination, suspension, or exclusion of a vendor
21		of goods or services from participation in the medical
22		assistance program authorized by this Article, a person with
23		management responsibility for such vendor during the time of
24		any conduct which served as the basis for that vendor's
25		termination, suspension, or exclusion is barred from
26		participation in the medical assistance program.

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1		Upon termination, suspension, or exclusion of a corporate
2		vendor, the officers and persons owning, directly or
3		indirectly, 5% or more of the shares of stock or other
4		evidences of ownership in the vendor during the time of any
5		conduct which served as the basis for that vendor's
6		termination, suspension, or exclusion are barred from
7		participation in the medical assistance program. A person who
8		owns, directly or indirectly, 5% or more of the shares of stock
9		or other evidences of ownership in a terminated, suspended, or
10		excluded vendor may not transfer his or her ownership interest
11		in that vendor to his or her spouse, child, brother, sister,
12		parent, grandparent, grandchild, uncle, aunt, niece, nephew,
13		cousin, or relative by marriage.
14		Upon termination, suspension, or exclusion of a sole
15		proprietorship or partnership, the owner or partners during
16		the time of any conduct which served as the basis for that
17		vendor's termination, suspension, or exclusion are barred from
18		participation in the medical assistance program. The owner of
19		a terminated, suspended, or excluded vendor that is a sole
20		proprietorship, and a partner in a terminated, suspended, or
21		excluded vendor that is a partnership, may not transfer his or
22		her ownership or partnership interest in that vendor to his or
23		her spouse, child, brother, sister, parent, grandparent,
24		grandchild, uncle, aunt, niece, nephew, cousin, or relative by
25		marriage.
26		A person who owns, directly or indirectly, 5% or more of

SB3365 Enrolled - 440 - LRB104 18483 SSS 31925 b
1		the shares of stock or other evidences of ownership in a
2		corporate or limited liability company vendor who owes a debt
3		to the Department, if that vendor has not made payment
4		arrangements acceptable to the Department, shall not transfer
5		his or her ownership interest in that vendor, or vendor assets
6		of any kind, to his or her spouse, child, brother, sister,
7		parent, grandparent, grandchild, uncle, aunt, niece, nephew,
8		cousin, or relative by marriage.
9		Rules adopted by the Illinois Department to implement
10		these provisions shall specifically include a definition of
11		the term "management responsibility" as used in this Section.
12		Such definition shall include, but not be limited to, typical
13		job titles, and duties and descriptions which will be
14		considered as within the definition of individuals with
15		management responsibility for a provider.
16		A vendor or a prior vendor who has been terminated,
17		excluded, or suspended from the medical assistance program, or
18		from another state or federal medical assistance or health
19		care program, and any individual currently or previously
20		barred from the medical assistance program, or from another
21		state or federal medical assistance or health care program, as
22		a result of being an officer or a person owning, directly or
23		indirectly, 5% or more of the shares of stock or other
24		evidences of ownership in a corporate or limited liability
25		company vendor during the time of any conduct which served as
26		the basis for that vendor's termination, suspension, or

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1		exclusion, may be required to post a surety bond as part of a
2		condition of enrollment or participation in the medical
3		assistance program. The Illinois Department shall establish,
4		by rule, the criteria and requirements for determining when a
5		surety bond must be posted and the value of the bond.
6		A vendor or a prior vendor who has a debt owed to the
7		Illinois Department and any individual currently or previously
8		barred from the medical assistance program, or from another
9		state or federal medical assistance or health care program, as
10		a result of being an officer or a person owning, directly or
11		indirectly, 5% or more of the shares of stock or other
12		evidences of ownership in that corporate or limited liability
13		company vendor during the time of any conduct which served as
14		the basis for the debt, may be required to post a surety bond
15		as part of a condition of enrollment or participation in the
16		medical assistance program. The Illinois Department shall
17		establish, by rule, the criteria and requirements for
18		determining when a surety bond must be posted and the value of
19		the bond.
20		(D) If a vendor has been suspended from the medical
21		assistance program under Article V of the Code, the Director
22		may require that such vendor correct any deficiencies which
23		served as the basis for the suspension. The Director shall
24		specify in the suspension order a specific period of time,
25		which shall not exceed one year from the date of the order,
26		during which a suspended vendor shall not be eligible to

SB3365 Enrolled - 442 - LRB104 18483 SSS 31925 b
1		participate. At the conclusion of the period of suspension the
2		Director shall reinstate such vendor, unless he finds that
3		such vendor has not corrected deficiencies upon which the
4		suspension was based.
5		If a vendor has been terminated, suspended, or excluded
6		from the medical assistance program under Article V, such
7		vendor shall be barred from participation for at least one
8		year, except that if a vendor has been terminated, suspended,
9		or excluded based on a conviction of a violation of Article
10		VIIIA or a conviction of a felony based on fraud or a willful
11		misrepresentation related to (i) the medical assistance
12		program under Article V, (ii) a federal or another state's
13		medical assistance or health care program, or (iii) the
14		provision of health care services, then the vendor shall be
15		barred from participation for 5 years or for the length of the
16		vendor's sentence for that conviction, whichever is longer. At
17		the end of one year a vendor who has been terminated,
18		suspended, or excluded may apply for reinstatement to the
19		program. Upon proper application to be reinstated such vendor
20		may be deemed eligible by the Director providing that such
21		vendor meets the requirements for eligibility under this Code.
22		If such vendor is deemed not eligible for reinstatement, he
23		shall be barred from again applying for reinstatement for one
24		year from the date his application for reinstatement is
25		denied.
26		A vendor whose termination, suspension, or exclusion from

SB3365 Enrolled - 443 - LRB104 18483 SSS 31925 b
1		participation in the Illinois medical assistance program under
2		Article V was based solely on an action by a governmental
3		entity other than the Illinois Department may, upon
4		reinstatement by that governmental entity or upon reversal of
5		the termination, suspension, or exclusion, apply for
6		rescission of the termination, suspension, or exclusion from
7		participation in the Illinois medical assistance program. Upon
8		proper application for rescission, the vendor may be deemed
9		eligible by the Director if the vendor meets the requirements
10		for eligibility under this Code.
11		If a vendor has been terminated, suspended, or excluded
12		and reinstated to the medical assistance program under Article
13		V and the vendor is terminated, suspended, or excluded a
14		second or subsequent time from the medical assistance program,
15		the vendor shall be barred from participation for at least 2
16		years, except that if a vendor has been terminated, suspended,
17		or excluded a second time based on a conviction of a violation
18		of Article VIIIA or a conviction of a felony based on fraud or
19		a willful misrepresentation related to (i) the medical
20		assistance program under Article V, (ii) a federal or another
21		state's medical assistance or health care program, or (iii)
22		the provision of health care services, then the vendor shall
23		be barred from participation for life. At the end of 2 years, a
24		vendor who has been terminated, suspended, or excluded may
25		apply for reinstatement to the program. Upon application to be
26		reinstated, the vendor may be deemed eligible if the vendor

SB3365 Enrolled - 444 - LRB104 18483 SSS 31925 b
1		meets the requirements for eligibility under this Code. If the
2		vendor is deemed not eligible for reinstatement, the vendor
3		shall be barred from again applying for reinstatement for 2
4		years from the date the vendor's application for reinstatement
5		is denied.
6		(E) The Illinois Department may recover money improperly
7		or erroneously paid, or overpayments, either by setoff,
8		crediting against future billings or by requiring direct
9		repayment to the Illinois Department. The Illinois Department
10		may suspend or deny payment, in whole or in part, if such
11		payment would be improper or erroneous or would otherwise
12		result in overpayment.
13		(1) Payments may be suspended, denied, or recovered
14		from a vendor or alternate payee: (i) for services
15		rendered in violation of the Illinois Department's
16		provider notices, statutes, rules, and regulations; (ii)
17		for services rendered in violation of the terms and
18		conditions prescribed by the Illinois Department in its
19		vendor agreement; (iii) for any vendor who fails to grant
20		the Office of Inspector General timely access to full and
21		complete records, including, but not limited to, records
22		relating to recipients under the medical assistance
23		program for the most recent 6 years, in accordance with
24		Section 140.28 of Title 89 of the Illinois Administrative
25		Code, and other information for the purpose of audits,
26		investigations, or other program integrity functions,

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1		after reasonable written request by the Inspector General;
2		this subsection (E) does not require vendors to make
3		available the medical records of patients for whom
4		services are not reimbursed under this Code or to provide
5		access to medical records more than 6 years old; (iv) when
6		the vendor has knowingly made, or caused to be made, any
7		false statement or representation of a material fact in
8		connection with the administration of the medical
9		assistance program; or (v) when the vendor previously
10		rendered services while terminated, suspended, or excluded
11		from participation in the medical assistance program or
12		while terminated or excluded from participation in another
13		state or federal medical assistance or health care
14		program.
15		(2) Notwithstanding any other provision of law, if a
16		vendor has the same taxpayer identification number
17		(assigned under Section 6109 of the Internal Revenue Code
18		of 1986) as is assigned to a vendor with past-due
19		financial obligations to the Illinois Department, the
20		Illinois Department may make any necessary adjustments to
21		payments to that vendor in order to satisfy any past-due
22		obligations, regardless of whether the vendor is assigned
23		a different billing number under the medical assistance
24		program.
25		(E-5) Civil monetary penalties.
26		(1) As used in this subsection (E-5):

SB3365 Enrolled - 446 - LRB104 18483 SSS 31925 b
1		(a) "Knowingly" means that a person, with respect
2		to information: (i) has actual knowledge of the
3		information; (ii) acts in deliberate ignorance of the
4		truth or falsity of the information; or (iii) acts in
5		reckless disregard of the truth or falsity of the
6		information. No proof of specific intent to defraud is
7		required.
8		(b) "Overpayment" means any funds that a person
9		receives or retains from the medical assistance
10		program to which the person, after applicable
11		reconciliation, is not entitled under this Code.
12		(c) "Remuneration" means the offer or transfer of
13		items or services for free or for other than fair
14		market value by a person; however, remuneration does
15		not include items or services of a nominal value of no
16		more than $10 per item or service, or $50 in the
17		aggregate on an annual basis, or any other offer or
18		transfer of items or services as determined by the
19		Department.
20		(d) "Should know" means that a person, with
21		respect to information: (i) acts in deliberate
22		ignorance of the truth or falsity of the information;
23		or (ii) acts in reckless disregard of the truth or
24		falsity of the information. No proof of specific
25		intent to defraud is required.
26		(2) Any person (including a vendor, provider,

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1		organization, agency, or other entity, or an alternate
2		payee thereof, but excluding a recipient) who:
3		(a) knowingly presents or causes to be presented
4		to an officer, employee, or agent of the State, a claim
5		that the Department determines:
6		(i) is for a medical or other item or service
7		that the person knows or should know was not
8		provided as claimed, including any person who
9		engages in a pattern or practice of presenting or
10		causing to be presented a claim for an item or
11		service that is based on a code that the person
12		knows or should know will result in a greater
13		payment to the person than the code the person
14		knows or should know is applicable to the item or
15		service actually provided;
16		(ii) is for a medical or other item or service
17		and the person knows or should know that the claim
18		is false or fraudulent;
19		(iii) is presented for a vendor physician's
20		service, or an item or service incident to a
21		vendor physician's service, by a person who knows
22		or should know that the individual who furnished,
23		or supervised the furnishing of, the service:
24		(AA) was not licensed as a physician;
25		(BB) was licensed as a physician but such
26		license had been obtained through a

SB3365 Enrolled - 448 - LRB104 18483 SSS 31925 b
1		misrepresentation of material fact (including
2		cheating on an examination required for
3		licensing); or
4		(CC) represented to the patient at the
5		time the service was furnished that the
6		physician was certified in a medical specialty
7		by a medical specialty board, when the
8		individual was not so certified;
9		(iv) is for a medical or other item or service
10		furnished during a period in which the person was
11		excluded from the medical assistance program or a
12		federal or state health care program under which
13		the claim was made pursuant to applicable law; or
14		(v) is for a pattern of medical or other items
15		or services that a person knows or should know are
16		not medically necessary;
17		(b) knowingly presents or causes to be presented
18		to any person a request for payment which is in
19		violation of the conditions for receipt of vendor
20		payments under the medical assistance program under
21		Section 11-13 of this Code;
22		(c) knowingly gives or causes to be given to any
23		person, with respect to medical assistance program
24		coverage of inpatient hospital services, information
25		that he or she knows or should know is false or
26		misleading, and that could reasonably be expected to

SB3365 Enrolled - 449 - LRB104 18483 SSS 31925 b
1		influence the decision when to discharge such person
2		or other individual from the hospital;
3		(d) in the case of a person who is not an
4		organization, agency, or other entity, is excluded
5		from participating in the medical assistance program
6		or a federal or state health care program and who, at
7		the time of a violation of this subsection (E-5):
8		(i) retains a direct or indirect ownership or
9		control interest in an entity that is
10		participating in the medical assistance program or
11		a federal or state health care program, and who
12		knows or should know of the action constituting
13		the basis for the exclusion; or
14		(ii) is an officer or managing employee of
15		such an entity;
16		(e) offers or transfers remuneration to any
17		individual eligible for benefits under the medical
18		assistance program that such person knows or should
19		know is likely to influence such individual to order
20		or receive from a particular vendor, provider,
21		practitioner, or supplier any item or service for
22		which payment may be made, in whole or in part, under
23		the medical assistance program;
24		(f) arranges or contracts (by employment or
25		otherwise) with an individual or entity that the
26		person knows or should know is excluded from

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1		participation in the medical assistance program or a
2		federal or state health care program, for the
3		provision of items or services for which payment may
4		be made under such a program;
5		(g) commits an act described in subsection (b) or
6		(c) of Section 8A-3;
7		(h) knowingly makes, uses, or causes to be made or
8		used, a false record or statement material to a false
9		or fraudulent claim for payment for items and services
10		furnished under the medical assistance program;
11		(i) fails to grant timely access, upon reasonable
12		request (as defined by the Department by rule), to the
13		Inspector General, for the purpose of audits,
14		investigations, evaluations, or other statutory
15		functions of the Inspector General of the Department;
16		(j) orders or prescribes a medical or other item
17		or service during a period in which the person was
18		excluded from the medical assistance program or a
19		federal or state health care program, in the case
20		where the person knows or should know that a claim for
21		such medical or other item or service will be made
22		under such a program;
23		(k) knowingly makes or causes to be made any false
24		statement, omission, or misrepresentation of a
25		material fact in any application, bid, or contract to
26		participate or enroll as a vendor or provider of

SB3365 Enrolled - 451 - LRB104 18483 SSS 31925 b
1		services or a supplier under the medical assistance
2		program;
3		(l) knows of an overpayment and does not report
4		and return the overpayment to the Department in
5		accordance with paragraph (6);
6		shall be subject, in addition to any other penalties that
7		may be prescribed by law, to a civil money penalty of not
8		more than $10,000 for each item or service (or, in cases
9		under subparagraph (c), $15,000 for each individual with
10		respect to whom false or misleading information was given;
11		in cases under subparagraph (d), $10,000 for each day the
12		prohibited relationship occurs; in cases under
13		subparagraph (g), $50,000 for each such act; in cases
14		under subparagraph (h), $50,000 for each false record or
15		statement; in cases under subparagraph (i), $15,000 for
16		each day of the failure described in such subparagraph; or
17		in cases under subparagraph (k), $50,000 for each false
18		statement, omission, or misrepresentation of a material
19		fact). In addition, such a person shall be subject to an
20		assessment of not more than 3 times the amount claimed for
21		each such item or service in lieu of damages sustained by
22		the State because of such claim (or, in cases under
23		subparagraph (g), damages of not more than 3 times the
24		total amount of remuneration offered, paid, solicited, or
25		received, without regard to whether a portion of such
26		remuneration was offered, paid, solicited, or received for

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1		a lawful purpose; or in cases under subparagraph (k), an
2		assessment of not more than 3 times the total amount
3		claimed for each item or service for which payment was
4		made based upon the application, bid, or contract
5		containing the false statement, omission, or
6		misrepresentation of a material fact).
7		(3) In addition, the Director or his or her designee
8		may make a determination in the same proceeding to
9		exclude, terminate, suspend, or bar the person from
10		participation in the medical assistance program.
11		(4) The Illinois Department may seek the civil
12		monetary penalties and exclusion, termination, suspension,
13		or barment identified in this subsection (E-5). Prior to
14		the imposition of any penalties or sanctions, the affected
15		person shall be afforded an opportunity for a hearing
16		after reasonable notice. The Department shall establish
17		hearing procedures by rule.
18		(5) Any final order, decision, or other determination
19		made, issued, or executed by the Director under the
20		provisions of this subsection (E-5), whereby a person is
21		aggrieved, shall be subject to review in accordance with
22		the provisions of the Administrative Review Law, and the
23		rules adopted pursuant thereto, which shall apply to and
24		govern all proceedings for the judicial review of final
25		administrative decisions of the Director.
26		(6)(a) If a person has received an overpayment, the

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1		person shall:
2		(i) report and return the overpayment to the
3		Department at the correct address; and
4		(ii) notify the Department in writing of the
5		reason for the overpayment.
6		(b) An overpayment must be reported and returned under
7		subparagraph (a) by the later of:
8		(i) the date which is 60 days after the date on
9		which the overpayment was identified; or
10		(ii) the date any corresponding cost report is
11		due, if applicable.
12		(E-10) A vendor who disputes an overpayment identified as
13		part of a Department audit shall utilize the Department's
14		self-referral disclosure protocol as set forth under this Code
15		to identify, investigate, and return to the Department any
16		undisputed audit overpayment amount. Unless the disputed
17		overpayment amount is subject to a fraud payment suspension,
18		or involves a termination sanction, the Department shall defer
19		the recovery of the disputed overpayment amount up to one year
20		after the date of the Department's final audit determination,
21		or earlier, or as required by State or federal law. If the
22		administrative hearing extends beyond one year, and such delay
23		was not caused by the request of the vendor, then the
24		Department shall not recover the disputed overpayment amount
25		until the date of the final administrative decision. If a
26		final administrative decision establishes that the disputed

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1		overpayment amount is owed to the Department, then the amount
2		shall be immediately due to the Department. The Department
3		shall be entitled to recover interest from the vendor on the
4		overpayment amount from the date of the overpayment through
5		the date the vendor returns the overpayment to the Department
6		at a rate not to exceed the Wall Street Journal Prime Rate, as
7		published from time to time, but not to exceed 5%. Any interest
8		billed by the Department shall be due immediately upon receipt
9		of the Department's billing statement.
10		(F) The Illinois Department may withhold payments to any
11		vendor or alternate payee prior to or during the pendency of
12		any audit or proceeding under this Section, and through the
13		pendency of any administrative appeal or administrative review
14		by any court proceeding. The Illinois Department shall state
15		by rule with as much specificity as practicable the conditions
16		under which payments will not be withheld under this Section.
17		Payments may be denied for bills submitted with service dates
18		occurring during the pendency of a proceeding, after a final
19		decision has been rendered, or after the conclusion of any
20		administrative appeal, where the final administrative decision
21		is to terminate, exclude, or suspend eligibility to
22		participate in the medical assistance program. The Illinois
23		Department shall state by rule with as much specificity as
24		practicable the conditions under which payments will not be
25		denied for such bills. The Illinois Department shall state by
26		rule a process and criteria by which a vendor or alternate

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1		payee may request full or partial release of payments withheld
2		under this subsection. The Department must complete a
3		proceeding under this Section in a timely manner.
4		Notwithstanding recovery allowed under subsection (E) or
5		this subsection (F), the Illinois Department may withhold
6		payments to any vendor or alternate payee who is not properly
7		licensed, certified, or in compliance with State or federal
8		agency regulations. Payments may be denied for bills submitted
9		with service dates occurring during the period of time that a
10		vendor is not properly licensed, certified, or in compliance
11		with State or federal regulations. Facilities licensed under
12		the Nursing Home Care Act shall have payments denied or
13		withheld pursuant to subsection (I) of this Section.
14		(F-5) The Illinois Department may temporarily withhold
15		payments to a vendor or alternate payee if any of the following
16		individuals have been indicted or otherwise charged under a
17		law of the United States or this or any other state with an
18		offense that is based on alleged fraud or willful
19		misrepresentation on the part of the individual related to (i)
20		the medical assistance program under Article V of this Code,
21		(ii) a federal or another state's medical assistance or health
22		care program, or (iii) the provision of health care services:
23		(1) If the vendor or alternate payee is a corporation:
24		an officer of the corporation or an individual who owns,
25		either directly or indirectly, 5% or more of the shares of
26		stock or other evidence of ownership of the corporation.

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1		(2) If the vendor is a sole proprietorship: the owner
2		of the sole proprietorship.
3		(3) If the vendor or alternate payee is a partnership:
4		a partner in the partnership.
5		(4) If the vendor or alternate payee is any other
6		business entity authorized by law to transact business in
7		this State: an officer of the entity or an individual who
8		owns, either directly or indirectly, 5% or more of the
9		evidences of ownership of the entity.
10		If the Illinois Department withholds payments to a vendor
11		or alternate payee under this subsection, the Department shall
12		not release those payments to the vendor or alternate payee
13		while any criminal proceeding related to the indictment or
14		charge is pending unless the Department determines that there
15		is good cause to release the payments before completion of the
16		proceeding. If the indictment or charge results in the
17		individual's conviction, the Illinois Department shall retain
18		all withheld payments, which shall be considered forfeited to
19		the Department. If the indictment or charge does not result in
20		the individual's conviction, the Illinois Department shall
21		release to the vendor or alternate payee all withheld
22		payments.
23		(F-10) If the Illinois Department establishes that the
24		vendor or alternate payee owes a debt to the Illinois
25		Department, and the vendor or alternate payee subsequently
26		fails to pay or make satisfactory payment arrangements with

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1		the Illinois Department for the debt owed, the Illinois
2		Department may seek all remedies available under the law of
3		this State to recover the debt, including, but not limited to,
4		wage garnishment or the filing of claims or liens against the
5		vendor or alternate payee.
6		(F-15) Enforcement of judgment.
7		(1) Any fine, recovery amount, other sanction, or
8		costs imposed, or part of any fine, recovery amount, other
9		sanction, or cost imposed, remaining unpaid after the
10		exhaustion of or the failure to exhaust judicial review
11		procedures under the Illinois Administrative Review Law is
12		a debt due and owing the State and may be collected using
13		all remedies available under the law.
14		(2) After expiration of the period in which judicial
15		review under the Illinois Administrative Review Law may be
16		sought for a final administrative decision, unless stayed
17		by a court of competent jurisdiction, the findings,
18		decision, and order of the Director may be enforced in the
19		same manner as a judgment entered by a court of competent
20		jurisdiction.
21		(3) In any case in which any person or entity has
22		failed to comply with a judgment ordering or imposing any
23		fine or other sanction, any expenses incurred by the
24		Illinois Department to enforce the judgment, including,
25		but not limited to, attorney's fees, court costs, and
26		costs related to property demolition or foreclosure, after

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1		they are fixed by a court of competent jurisdiction or the
2		Director, shall be a debt due and owing the State and may
3		be collected in accordance with applicable law. Prior to
4		any expenses being fixed by a final administrative
5		decision pursuant to this subsection (F-15), the Illinois
6		Department shall provide notice to the individual or
7		entity that states that the individual or entity shall
8		appear at a hearing before the administrative hearing
9		officer to determine whether the individual or entity has
10		failed to comply with the judgment. The notice shall set
11		the date for such a hearing, which shall not be less than 7
12		days from the date that notice is served. If notice is
13		served by mail, the 7-day period shall begin to run on the
14		date that the notice was deposited in the mail.
15		(4) Upon being recorded in the manner required by
16		Article XII of the Code of Civil Procedure or by the
17		Uniform Commercial Code, a lien shall be imposed on the
18		real estate or personal estate, or both, of the individual
19		or entity in the amount of any debt due and owing the State
20		under this Section. The lien may be enforced in the same
21		manner as a judgment of a court of competent jurisdiction.
22		A lien shall attach to all property and assets of such
23		person, firm, corporation, association, agency,
24		institution, or other legal entity until the judgment is
25		satisfied.
26		(5) The Director may set aside any judgment entered by

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1		default and set a new hearing date upon a petition filed at
2		any time (i) if the petitioner's failure to appear at the
3		hearing was for good cause, or (ii) if the petitioner
4		established that the Department did not provide proper
5		service of process. If any judgment is set aside pursuant
6		to this paragraph (5), the hearing officer shall have
7		authority to enter an order extinguishing any lien which
8		has been recorded for any debt due and owing the Illinois
9		Department as a result of the vacated default judgment.
10		(G) The provisions of the Administrative Review Law, as
11		now or hereafter amended, and the rules adopted pursuant
12		thereto, shall apply to and govern all proceedings for the
13		judicial review of final administrative decisions of the
14		Illinois Department under this Section. The term
15		"administrative decision" is defined as in Section 3-101 of
16		the Code of Civil Procedure.
17		(G-5) Vendors who pose a risk of fraud, waste, abuse, or
18		harm.
19		(1) Notwithstanding any other provision in this
20		Section, the Department may terminate, suspend, or exclude
21		vendors who pose a risk of fraud, waste, abuse, or harm
22		from participation in the medical assistance program prior
23		to an evidentiary hearing but after reasonable notice and
24		opportunity to respond as established by the Department by
25		rule.
26		(2) Vendors who pose a risk of fraud, waste, abuse, or

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1		harm shall submit to a fingerprint-based criminal
2		background check on current and future information
3		available in the State system and current information
4		available through the Federal Bureau of Investigation's
5		system by submitting all necessary fees and information in
6		the form and manner prescribed by the Illinois State
7		Police. The following individuals shall be subject to the
8		check:
9		(A) In the case of a vendor that is a corporation,
10		every shareholder who owns, directly or indirectly, 5%
11		or more of the outstanding shares of the corporation.
12		(B) In the case of a vendor that is a partnership,
13		every partner.
14		(C) In the case of a vendor that is a sole
15		proprietorship, the sole proprietor.
16		(D) Each officer or manager of the vendor.
17		Each such vendor shall be responsible for payment of
18		the cost of the criminal background check.
19		(3) Vendors who pose a risk of fraud, waste, abuse, or
20		harm may be required to post a surety bond. The Department
21		shall establish, by rule, the criteria and requirements
22		for determining when a surety bond must be posted and the
23		value of the bond.
24		(4) The Department, or its agents, may refuse to
25		accept requests for authorization from specific vendors
26		who pose a risk of fraud, waste, abuse, or harm, including

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1		prior-approval and post-approval requests, if:
2		(A) the Department has initiated a notice of
3		termination, suspension, or exclusion of the vendor
4		from participation in the medical assistance program;
5		or
6		(B) the Department has issued notification of its
7		withholding of payments pursuant to subsection (F-5)
8		of this Section; or
9		(C) the Department has issued a notification of
10		its withholding of payments due to reliable evidence
11		of fraud or willful misrepresentation pending
12		investigation.
13		(5) As used in this subsection, the following terms
14		are defined as follows:
15		(A) "Fraud" means an intentional deception or
16		misrepresentation made by a person with the knowledge
17		that the deception could result in some unauthorized
18		benefit to himself or herself or some other person. It
19		includes any act that constitutes fraud under
20		applicable federal or State law.
21		(B) "Abuse" means provider practices that are
22		inconsistent with sound fiscal, business, or medical
23		practices and that result in an unnecessary cost to
24		the medical assistance program or in reimbursement for
25		services that are not medically necessary or that fail
26		to meet professionally recognized standards for health

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1		care. It also includes recipient practices that result
2		in unnecessary cost to the medical assistance program.
3		Abuse does not include diagnostic or therapeutic
4		measures conducted primarily as a safeguard against
5		possible vendor liability.
6		(C) "Waste" means the unintentional misuse of
7		medical assistance resources, resulting in unnecessary
8		cost to the medical assistance program. Waste does not
9		include diagnostic or therapeutic measures conducted
10		primarily as a safeguard against possible vendor
11		liability.
12		(D) "Harm" means physical, mental, or monetary
13		damage to recipients or to the medical assistance
14		program.
15		(G-6) The Illinois Department, upon making a determination
16		based upon information in the possession of the Illinois
17		Department that continuation of participation in the medical
18		assistance program by a vendor would constitute an immediate
19		danger to the public, may immediately suspend such vendor's
20		participation in the medical assistance program without a
21		hearing. In instances in which the Illinois Department
22		immediately suspends the medical assistance program
23		participation of a vendor under this Section, a hearing upon
24		the vendor's participation must be convened by the Illinois
25		Department within 15 days after such suspension and completed
26		without appreciable delay. Such hearing shall be held to

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1		determine whether to recommend to the Director that the
2		vendor's medical assistance program participation be denied,
3		terminated, suspended, placed on provisional status, or
4		reinstated. In the hearing, any evidence relevant to the
5		vendor constituting an immediate danger to the public may be
6		introduced against such vendor; provided, however, that the
7		vendor, or his or her counsel, shall have the opportunity to
8		discredit, impeach, and submit evidence rebutting such
9		evidence.
10		(H) Nothing contained in this Code shall in any way limit
11		or otherwise impair the authority or power of any State agency
12		responsible for licensing of vendors.
13		(I) Based on a finding of noncompliance on the part of a
14		nursing home with any requirement for certification under
15		Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
16		1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
17		Department may impose one or more of the following remedies
18		after notice to the facility:
19		(1) Termination of the provider agreement.
20		(2) Temporary management.
21		(3) Denial of payment for new admissions.
22		(4) Civil money penalties.
23		(5) Closure of the facility in emergency situations or
24		transfer of residents, or both.
25		(6) State monitoring.
26		(7) Denial of all payments when the U.S. Department of

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1		Health and Human Services has imposed this sanction.
2		The Illinois Department shall by rule establish criteria
3		governing continued payments to a nursing facility subsequent
4		to termination of the facility's provider agreement if, in the
5		sole discretion of the Illinois Department, circumstances
6		affecting the health, safety, and welfare of the facility's
7		residents require those continued payments. The Illinois
8		Department may condition those continued payments on the
9		appointment of temporary management, sale of the facility to
10		new owners or operators, or other arrangements that the
11		Illinois Department determines best serve the needs of the
12		facility's residents.
13		Except in the case of a facility that has a right to a
14		hearing on the finding of noncompliance before an agency of
15		the federal government, a facility may request a hearing
16		before a State agency on any finding of noncompliance within
17		60 days after the notice of the intent to impose a remedy.
18		Except in the case of civil money penalties, a request for a
19		hearing shall not delay imposition of the penalty. The choice
20		of remedies is not appealable at a hearing. The level of
21		noncompliance may be challenged only in the case of a civil
22		money penalty. The Illinois Department shall provide by rule
23		for the State agency that will conduct the evidentiary
24		hearings.
25		The Illinois Department may collect interest on unpaid
26		civil money penalties.

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1		The Illinois Department may adopt all rules necessary to
2		implement this subsection (I).
3		(J) The Illinois Department, by rule, may permit
4		individual practitioners to designate that Department payments
5		that may be due the practitioner be made to an alternate payee
6		or alternate payees.
7		(a) Such alternate payee or alternate payees shall be
8		required to register as an alternate payee in the Medical
9		Assistance Program with the Illinois Department.
10		(b) If a practitioner designates an alternate payee,
11		the alternate payee and practitioner shall be jointly and
12		severally liable to the Department for payments made to
13		the alternate payee. Pursuant to subsection (E) of this
14		Section, any Department action to suspend or deny payment
15		or recover money or overpayments from an alternate payee
16		shall be subject to an administrative hearing.
17		(c) Registration as an alternate payee or alternate
18		payees in the Illinois Medical Assistance Program shall be
19		conditional. At any time, the Illinois Department may deny
20		or cancel any alternate payee's registration in the
21		Illinois Medical Assistance Program without cause. Any
22		such denial or cancellation is not subject to an
23		administrative hearing.
24		(d) The Illinois Department may seek a revocation of
25		any alternate payee, and all owners, officers, and
26		individuals with management responsibility for such

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1		alternate payee shall be permanently prohibited from
2		participating as an owner, an officer, or an individual
3		with management responsibility with an alternate payee in
4		the Illinois Medical Assistance Program, if after
5		reasonable notice and opportunity for a hearing the
6		Illinois Department finds that:
7		(1) the alternate payee is not complying with the
8		Department's policy or rules and regulations, or with
9		the terms and conditions prescribed by the Illinois
10		Department in its alternate payee registration
11		agreement; or
12		(2) the alternate payee has failed to keep or make
13		available for inspection, audit, or copying, after
14		receiving a written request from the Illinois
15		Department, such records regarding payments claimed as
16		an alternate payee; or
17		(3) the alternate payee has failed to furnish any
18		information requested by the Illinois Department
19		regarding payments claimed as an alternate payee; or
20		(4) the alternate payee has knowingly made, or
21		caused to be made, any false statement or
22		representation of a material fact in connection with
23		the administration of the Illinois Medical Assistance
24		Program; or
25		(5) the alternate payee, a person with management
26		responsibility for an alternate payee, an officer or

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1		person owning, either directly or indirectly, 5% or
2		more of the shares of stock or other evidences of
3		ownership in a corporate alternate payee, or a partner
4		in a partnership which is an alternate payee:
5		(a) was previously terminated, suspended, or
6		excluded from participation as a vendor in the
7		Illinois Medical Assistance Program, or was
8		previously revoked as an alternate payee in the
9		Illinois Medical Assistance Program, or was
10		terminated, suspended, or excluded from
11		participation as a vendor in a medical assistance
12		program in another state that is of the same kind
13		as the program of medical assistance provided
14		under Article V of this Code; or
15		(b) was a person with management
16		responsibility for a vendor previously terminated,
17		suspended, or excluded from participation as a
18		vendor in the Illinois Medical Assistance Program,
19		or was previously revoked as an alternate payee in
20		the Illinois Medical Assistance Program, or was
21		terminated, suspended, or excluded from
22		participation as a vendor in a medical assistance
23		program in another state that is of the same kind
24		as the program of medical assistance provided
25		under Article V of this Code, during the time of
26		conduct which was the basis for that vendor's

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1		termination, suspension, or exclusion or alternate
2		payee's revocation; or
3		(c) was an officer, or person owning, either
4		directly or indirectly, 5% or more of the shares
5		of stock or other evidences of ownership in a
6		corporate vendor previously terminated, suspended,
7		or excluded from participation as a vendor in the
8		Illinois Medical Assistance Program, or was
9		previously revoked as an alternate payee in the
10		Illinois Medical Assistance Program, or was
11		terminated, suspended, or excluded from
12		participation as a vendor in a medical assistance
13		program in another state that is of the same kind
14		as the program of medical assistance provided
15		under Article V of this Code, during the time of
16		conduct which was the basis for that vendor's
17		termination, suspension, or exclusion; or
18		(d) was an owner of a sole proprietorship or
19		partner in a partnership previously terminated,
20		suspended, or excluded from participation as a
21		vendor in the Illinois Medical Assistance Program,
22		or was previously revoked as an alternate payee in
23		the Illinois Medical Assistance Program, or was
24		terminated, suspended, or excluded from
25		participation as a vendor in a medical assistance
26		program in another state that is of the same kind

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1		as the program of medical assistance provided
2		under Article V of this Code, during the time of
3		conduct which was the basis for that vendor's
4		termination, suspension, or exclusion or alternate
5		payee's revocation; or
6		(6) the alternate payee, a person with management
7		responsibility for an alternate payee, an officer or
8		person owning, either directly or indirectly, 5% or
9		more of the shares of stock or other evidences of
10		ownership in a corporate alternate payee, or a partner
11		in a partnership which is an alternate payee:
12		(a) has engaged in conduct prohibited by
13		applicable federal or State law or regulation
14		relating to the Illinois Medical Assistance
15		Program; or
16		(b) was a person with management
17		responsibility for a vendor or alternate payee at
18		the time that the vendor or alternate payee
19		engaged in practices prohibited by applicable
20		federal or State law or regulation relating to the
21		Illinois Medical Assistance Program; or
22		(c) was an officer, or person owning, either
23		directly or indirectly, 5% or more of the shares
24		of stock or other evidences of ownership in a
25		vendor or alternate payee at the time such vendor
26		or alternate payee engaged in practices prohibited

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1		by applicable federal or State law or regulation
2		relating to the Illinois Medical Assistance
3		Program; or
4		(d) was an owner of a sole proprietorship or
5		partner in a partnership which was a vendor or
6		alternate payee at the time such vendor or
7		alternate payee engaged in practices prohibited by
8		applicable federal or State law or regulation
9		relating to the Illinois Medical Assistance
10		Program; or
11		(7) the direct or indirect ownership of the vendor
12		or alternate payee (including the ownership of a
13		vendor or alternate payee that is a partner's interest
14		in a vendor or alternate payee, or ownership of 5% or
15		more of the shares of stock or other evidences of
16		ownership in a corporate vendor or alternate payee)
17		has been transferred by an individual who is
18		terminated, suspended, or excluded or barred from
19		participating as a vendor or is prohibited or revoked
20		as an alternate payee to the individual's spouse,
21		child, brother, sister, parent, grandparent,
22		grandchild, uncle, aunt, niece, nephew, cousin, or
23		relative by marriage.
24		(K) The Illinois Department of Healthcare and Family
25		Services may withhold payments, in whole or in part, to a
26		provider or alternate payee where there is credible evidence,

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1		received from State or federal law enforcement or federal
2		oversight agencies or from the results of a preliminary
3		Department audit, that the circumstances giving rise to the
4		need for a withholding of payments may involve fraud or
5		willful misrepresentation under the Illinois Medical
6		Assistance program. The Department shall by rule define what
7		constitutes "credible" evidence for purposes of this
8		subsection. The Department may withhold payments without first
9		notifying the provider or alternate payee of its intention to
10		withhold such payments. A provider or alternate payee may
11		request a reconsideration of payment withholding, and the
12		Department must grant such a request. The Department shall
13		state by rule a process and criteria by which a provider or
14		alternate payee may request full or partial release of
15		payments withheld under this subsection. This request may be
16		made at any time after the Department first withholds such
17		payments.
18		(a) The Illinois Department must send notice of its
19		withholding of program payments within 5 days of taking
20		such action. The notice must set forth the general
21		allegations as to the nature of the withholding action,
22		but need not disclose any specific information concerning
23		its ongoing investigation. The notice must do all of the
24		following:
25		(1) State that payments are being withheld in
26		accordance with this subsection.

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1		(2) State that the withholding is for a temporary
2		period, as stated in paragraph (b) of this subsection,
3		and cite the circumstances under which withholding
4		will be terminated.
5		(3) Specify, when appropriate, which type or types
6		of Medicaid claims withholding is effective.
7		(4) Inform the provider or alternate payee of the
8		right to submit written evidence for reconsideration
9		of the withholding by the Illinois Department.
10		(5) Inform the provider or alternate payee that a
11		written request may be made to the Illinois Department
12		for full or partial release of withheld payments and
13		that such requests may be made at any time after the
14		Department first withholds such payments.
15		(b) All withholding-of-payment actions under this
16		subsection shall be temporary and shall not continue after
17		any of the following:
18		(1) The Illinois Department or the prosecuting
19		authorities determine that there is insufficient
20		evidence of fraud or willful misrepresentation by the
21		provider or alternate payee.
22		(2) Legal proceedings related to the provider's or
23		alternate payee's alleged fraud, willful
24		misrepresentation, violations of this Act, or
25		violations of the Illinois Department's administrative
26		rules are completed.

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1		(3) The withholding of payments for a period of 3
2		years.
3		(c) The Illinois Department may adopt all rules
4		necessary to implement this subsection (K).
5		(K-5) The Illinois Department may withhold payments, in
6		whole or in part, to a provider or alternate payee upon
7		initiation of an audit, quality of care review, investigation
8		when there is a credible allegation of fraud, or the provider
9		or alternate payee demonstrating a clear failure to cooperate
10		with the Illinois Department such that the circumstances give
11		rise to the need for a withholding of payments. As used in this
12		subsection, "credible allegation" is defined to include an
13		allegation from any source, including, but not limited to,
14		fraud hotline complaints, claims data mining, patterns
15		identified through provider audits, civil actions filed under
16		the Illinois False Claims Act, and law enforcement
17		investigations. An allegation is considered to be credible
18		when it has indicia of reliability. The Illinois Department
19		may withhold payments without first notifying the provider or
20		alternate payee of its intention to withhold such payments. A
21		provider or alternate payee may request a hearing or a
22		reconsideration of payment withholding, and the Illinois
23		Department must grant such a request. The Illinois Department
24		shall state by rule a process and criteria by which a provider
25		or alternate payee may request a hearing or a reconsideration
26		for the full or partial release of payments withheld under

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1		this subsection. This request may be made at any time after the
2		Illinois Department first withholds such payments.
3		(a) The Illinois Department must send notice of its
4		withholding of program payments within 5 days of taking
5		such action. The notice must set forth the general
6		allegations as to the nature of the withholding action but
7		need not disclose any specific information concerning its
8		ongoing investigation. The notice must do all of the
9		following:
10		(1) State that payments are being withheld in
11		accordance with this subsection.
12		(2) State that the withholding is for a temporary
13		period, as stated in paragraph (b) of this subsection,
14		and cite the circumstances under which withholding
15		will be terminated.
16		(3) Specify, when appropriate, which type or types
17		of claims are withheld.
18		(4) Inform the provider or alternate payee of the
19		right to request a hearing or a reconsideration of the
20		withholding by the Illinois Department, including the
21		ability to submit written evidence.
22		(5) Inform the provider or alternate payee that a
23		written request may be made to the Illinois Department
24		for a hearing or a reconsideration for the full or
25		partial release of withheld payments and that such
26		requests may be made at any time after the Illinois

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1		Department first withholds such payments.
2		(b) All withholding of payment actions under this
3		subsection shall be temporary and shall not continue after
4		any of the following:
5		(1) The Illinois Department determines that there
6		is insufficient evidence of fraud, or the provider or
7		alternate payee demonstrates clear cooperation with
8		the Illinois Department, as determined by the Illinois
9		Department, such that the circumstances do not give
10		rise to the need for withholding of payments; or
11		(2) The withholding of payments has lasted for a
12		period in excess of 3 years.
13		(c) The Illinois Department may adopt all rules
14		necessary to implement this subsection (K-5).
15		(L) The Illinois Department shall establish a protocol to
16		enable health care providers to disclose an actual or
17		potential violation of this Section pursuant to a
18		self-referral disclosure protocol, referred to in this
19		subsection as "the protocol". The protocol shall include
20		direction for health care providers on a specific person,
21		official, or office to whom such disclosures shall be made.
22		The Illinois Department shall post information on the protocol
23		on the Illinois Department's public website. The Illinois
24		Department may adopt rules necessary to implement this
25		subsection (L). In addition to other factors that the Illinois
26		Department finds appropriate, the Illinois Department may

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1		consider a health care provider's timely use or failure to use
2		the protocol in considering the provider's failure to comply
3		with this Code.
4		(M) Notwithstanding any other provision of this Code, the
5		Illinois Department, at its discretion, may exempt an entity
6		licensed under the Nursing Home Care Act, the ID/DD Community
7		Care Act, or the MC/DD Act from the provisions of subsections
8		(A-15), (B), and (C) of this Section if the licensed entity is
9		in receivership.
10		(N) Enforcement of advance payment agreements. To the
11		extent not prohibited by federal or State law, and
12		notwithstanding any other provision of this Code, if a
13		provider fails to comply with the terms of an advance payment
14		agreement, the Department is authorized to collect any unpaid
15		advance balance through one or more of the following methods:
16		(1) Direct withholding of Department reimbursements.
17		The Department may withhold reimbursement or other amounts
18		otherwise payable by the Department to the provider,
19		including, but not limited to, fee-for-service claims
20		payments, supplemental payments, and any other amounts the
21		Department is obligated to pay the provider under the
22		medical assistance program, and apply such withheld
23		amounts as repayment of the unpaid advance.
24		(2) Managed care organizations remittance. If a
25		provider participates in a managed care program
26		administered by the Department, the Department may direct

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1		the managed care organization to remit to the Department
2		amounts otherwise payable by the managed care organization
3		to the provider, and apply such remitted amounts as
4		repayment of the unpaid advance.
5		(3) Interagency recoupment. The Department may recoup
6		amounts otherwise payable by any State agency to the
7		provider, including, but not limited to, State grants and
8		grant appropriations, and apply such amounts as repayment
9		of the unpaid advance.
10		(4) Other collection methods. The Department may
11		pursue any other collection remedy available at law.
12		The Department shall adopt rules establishing procedures
13		for collection under this subsection (N). For purposes of this
14		subsection (N), "provider" includes, but is not limited to, a
15		long-term care facility as defined under the Nursing Home Care
16		Act and a hospital provider as defined under Article V-A of
17		this Code.
18		(Source: P.A. 102-538, eff. 8-20-21.)
19		ARTICLE 260.
20		Section 260-5. The Illinois Administrative Procedure Act
21		is amended by adding Section 5-45.73 as follows:
22		(5 ILCS 100/5-45.73 new)
23		Sec. 5-45.73. Emergency rulemaking; nursing home staffing

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1		ratios. To provide for the expeditious and timely
2		implementation of Section 3-202.05 of the Nursing Home Care
3		Act and changes made by this amendatory Act of the 104th
4		General Assembly to Section 3-202.05 of the Nursing Home Care
5		Act, emergency rules implementing Section 3-202.05 of the
6		Nursing Home Care Act and changes made by this amendatory Act
7		of the 104th General Assembly to Section 3-202.05 of the
8		Nursing Home Care Act may be adopted in accordance with
9		Section 5-45 by the Department of Public Health. The adoption
10		of emergency rules authorized by Section 5-45 and this Section
11		is deemed to be necessary for the public interest, safety, and
12		welfare.
13		This Section is repealed one year after the effective date
14		of this amendatory Act of the 104th General Assembly.
15		Section 260-10. The Nursing Home Care Act is amended by
16		changing Section 3-202.05 and by adding Section 3-130 as
17		follows:
18		(210 ILCS 45/3-130 new)
19		Sec. 3-130. Annual training for facility staff. A facility
20		must provide its staff with annual training based on the most
21		recurrent citations as specified by the Department. The annual
22		training requirements will be defined by the Department
23		annually based on the most frequent and recurrent findings or
24		citations during surveys or complaint investigations. The

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1		facility must provide proof or documentation of the annual
2		training performed for the recurrent violations. Failure to
3		provide such proof or documentation may result in
4		administrative fines and penalties under this Act. The
5		Department may adopt any rules necessary to implement this
6		Section.
7		The provisions of this Section are declarative of existing
8		law.
9		(210 ILCS 45/3-202.05)
10		Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
11		thereafter.
12		(a) For the purpose of computing staff to resident ratios,
13		direct care staff shall include:
14		(1) registered nurses;
15		(2) licensed practical nurses;
16		(3) certified nurse assistants;
17		(4) psychiatric services rehabilitation aides;
18		(5) rehabilitation and therapy aides;
19		(6) psychiatric services rehabilitation coordinators;
20		(7) assistant directors of nursing;
21		(8) 50% of the Director of Nurses' time; and
22		(9) 30% of the Social Services Directors' time.
23		The Department shall, by rule, allow certain facilities
24		subject to 77 Ill. Adm. Code 300.4000 and following (Subpart
25		S) to utilize specialized clinical staff, as defined in rules,

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1		to count towards the staffing ratios.
2		Within 120 days of June 14, 2012 (the effective date of
3		Public Act 97-689), the Department shall promulgate rules
4		specific to the staffing requirements for facilities federally
5		defined as Institutions for Mental Disease. These rules shall
6		recognize the unique nature of individuals with chronic mental
7		health conditions, shall include minimum requirements for
8		specialized clinical staff, including clinical social workers,
9		psychiatrists, psychologists, and direct care staff set forth
10		in paragraphs (4) through (6) and any other specialized staff
11		which may be utilized and deemed necessary to count toward
12		staffing ratios.
13		Within 120 days of June 14, 2012 (the effective date of
14		Public Act 97-689), the Department shall promulgate rules
15		specific to the staffing requirements for facilities licensed
16		under the Specialized Mental Health Rehabilitation Act of
17		2013. These rules shall recognize the unique nature of
18		individuals with chronic mental health conditions, shall
19		include minimum requirements for specialized clinical staff,
20		including clinical social workers, psychiatrists,
21		psychologists, and direct care staff set forth in paragraphs
22		(4) through (6) and any other specialized staff which may be
23		utilized and deemed necessary to count toward staffing ratios.
24		(a-5) The Centers for Medicare and Medicaid Services'
25		payroll-based journal job title codes, which correspond to the
26		staff used for the staffing ratios in subsection (a), are as

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1		follows:
2		(1) Registered Nurse Director of Nursing, job title
3		code 5.
4		(2) Registered Nurse with Administrative Duties, job
5		title code 6.
6		(3) Registered Nurse, job title code 7.
7		(4) Licensed Practical/Vocational Nurse with
8		Administrative Duties, job title code 8.
9		(5) Licensed Practical/Vocational Nurse, job title
10		code 9.
11		(6) Certified Nurse Aide, job title code 10.
12		(7) Nurse Aide in Training, job title code 11.
13		(8) Medication Aide/Technician, job title code 12.
14		(9) Nurse Practitioner, job title code 13.
15		(10) Clinical Nurse Specialist, job title code 14.
16		(11) Occupational Therapist, job title code 18.
17		(12) Occupational Therapy Assistant, job title code
18		19.
19		(13) Occupational Therapy Aide, job title code 20.
20		(14) Physical Therapist, job title code 21.
21		(15) Physical Therapy Assistant, job title code 22.
22		(16) Physical Therapy Assistant, job title code 23.
23		(17) Respiratory Therapist, job title code 24.
24		(18) Respiratory Therapy Technician, job title code
25		25.
26		(19) Speech/Language Pathologist, job title code 26.

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1		(20) Qualified Activities Professional, job title code
2		28.
3		(21) Other Activities Staff, job title code 29.
4		(22) Qualified Social Worker, job title code 30.
5		(23) Other Social Worker, job title code 31.
6		(24) Mental Health Service Worker, job title code 34.
7		For all job title codes in this subsection, 100% of the
8		hours worked by the staff must be counted toward the
9		staff-to-resident ratio, except job code title 5, which is
10		limited to 50%, and job title codes 28, 30, and 31, which are
11		limited to 30%.
12		(b) (Blank).
13		(b-5) For purposes of the minimum staffing ratios in this
14		Section, all residents shall be classified as requiring either
15		skilled care or intermediate care.
16		As used in this subsection:
17		"Intermediate care" means basic nursing care and other
18		restorative services under periodic medical direction.
19		"Skilled care" means skilled nursing care, continuous
20		skilled nursing observations, restorative nursing, and other
21		services under professional direction with frequent medical
22		supervision.
23		(c) Facilities shall notify the Department within 60 days
24		after July 29, 2010 (the effective date of Public Act
25		96-1372), in a form and manner prescribed by the Department,
26		of the staffing ratios in effect on July 29, 2010 (the

SB3365 Enrolled - 483 - LRB104 18483 SSS 31925 b
1		effective date of Public Act 96-1372) for both intermediate
2		and skilled care and the number of residents receiving each
3		level of care.
4		(d)(1) (Blank).
5		(2) (Blank).
6		(3) (Blank).
7		(4) (Blank).
8		(5) Effective January 1, 2014, the minimum staffing ratios
9		shall be increased to 3.8 hours of nursing and personal care
10		each day for a resident needing skilled care and 2.5 hours of
11		nursing and personal care each day for a resident needing
12		intermediate care.
13		(e) Ninety days after June 14, 2012 (the effective date of
14		Public Act 97-689), a minimum of 25% of nursing and personal
15		care time shall be provided by licensed nurses, with at least
16		10% of nursing and personal care time provided by registered
17		nurses. These minimum requirements shall remain in effect
18		until an acuity based registered nurse requirement is
19		promulgated by rule concurrent with the adoption of the
20		Resource Utilization Group classification-based payment
21		methodology, as provided in Section 5-5.2 of the Illinois
22		Public Aid Code. Registered nurses and licensed practical
23		nurses employed by a facility in excess of these requirements
24		may be used to satisfy the remaining 75% of the nursing and
25		personal care time requirements. Notwithstanding this
26		subsection, no staffing requirement in statute in effect on

SB3365 Enrolled - 484 - LRB104 18483 SSS 31925 b
1		June 14, 2012 (the effective date of Public Act 97-689) shall
2		be reduced on account of this subsection.
3		(f) The Department shall propose rules as are necessary to
4		implement the provisions of this Section and consistent with
5		this amendatory Act of the 104th General Assembly within 60
6		days after the effective date of this amendatory Act of the
7		104th General Assembly. submit proposed rules for adoption by
8		January 1, 2020 establishing a system for determining
9		compliance with minimum staffing set forth in this Section and
10		the requirements of 77 Ill. Adm. Code 300.1230 adjusted for
11		any waivers granted under Section 3-303.1. Compliance with
12		minimum staffing as required by this Section shall be
13		determined on a quarterly basis. The Department shall
14		determine compliance by comparing the number of hours provided
15		per resident per day using the Centers for Medicare and
16		Medicaid Services' payroll-based journal and the facility's
17		daily census, broken down by intermediate and skilled care as
18		self-reported by the facility to the Department on a quarterly
19		basis. As used in this subsection, "quarterly basis" means the
20		Centers for Medicare and Medicaid Services' quarterly
21		reporting periods for the federal fiscal year. The Department
22		shall use the quarterly payroll-based journal and the
23		self-reported census to calculate the number of hours provided
24		per resident per day and compare this ratio to the minimum
25		staffing standards required under this Section, as impacted by
26		any waivers granted under Section 3-303.1. Discrepancies

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1		between job titles contained in this Section and the
2		payroll-based journal shall be addressed by rule. The manner
3		in which the Department requests payroll-based journal
4		information to be submitted shall align with the federal
5		Centers for Medicare and Medicaid Services' requirements that
6		allow providers to submit the quarterly data in an aggregate
7		manner.
8		(g) Monetary penalties for non-compliance. The Department
9		shall propose rules that are necessary to implement the
10		provisions of this Section, consistent with the changes made
11		by this amendatory Act of the 104th General Assembly, within
12		60 days after the effective date of this amendatory Act of the
13		104th General Assembly. submit proposed rules for adoption by
14		January 1, 2020 establishing monetary penalties for facilities
15		not in compliance with minimum staffing standards under this
16		Section. Facilities shall be required to comply with the
17		provisions of this subsection beginning January 1, 2025. No
18		monetary penalty may be issued for noncompliance prior to the
19		revised implementation date, which shall be January 1, 2025.
20		If a facility is found to be noncompliant prior to the revised
21		implementation date, the Department shall provide a written
22		notice identifying the staffing deficiencies and require the
23		facility to provide a sufficiently detailed correction plan
24		that describes proposed and completed actions the facility
25		will take or has taken, including hiring actions, to address
26		the facility's failure to meet the statutory minimum staffing

SB3365 Enrolled - 486 - LRB104 18483 SSS 31925 b
1		levels. Monetary penalties shall be imposed beginning no later
2		than July 1, 2025, based on data for the quarter beginning July
3		1, 2026 through September 30, 2026 January 1, 2025 through
4		March 31, 2025 and quarterly thereafter. Monetary penalties
5		shall be assessed on a quarterly basis and established based
6		on a formula that calculates on a daily basis the cost of wages
7		and benefits for the missing staffing hours. All notices of
8		noncompliance shall include the computations used to determine
9		noncompliance and establishing the variance between minimum
10		staffing ratios and the Department's computations. The penalty
11		for the first offense shall be 125% of the cost of wages and
12		benefits for the missing staffing hours. The penalty shall
13		increase to 150% of the cost of wages and benefits for the
14		missing staffing hours for the second offense and 200% the
15		cost of wages and benefits for the missing staffing hours for
16		the third and all subsequent offenses. The penalty shall be
17		imposed regardless of whether the facility has committed other
18		violations of this Act during the same period that the
19		staffing offense occurred. The penalty may not be waived,
20		except where there is no more than a 10% deviation from the
21		staffing requirements, in which case the facility shall not
22		receive a violation or penalty. The Department shall:
23		(1) when calculating whether there is no more than a
24		10% deviation from the staffing requirements, determine
25		the deviation based only on days of the quarter where a
26		facility failed to meet the minimum staffing requirements;

SB3365 Enrolled - 487 - LRB104 18483 SSS 31925 b
1		and
2		(2) only assess penalties against categories of
3		payroll-based journal job titles that deviate from the
4		staffing requirements by more than 10%. Categories include
5		registered nurses, licensed practical nurses, and other
6		payroll-based journal job titles, as determined by the
7		required staffing levels in subsection (e) of this Section
8		and as listed in subsections (a) and (a-5) of this
9		Section. Penalties shall not be assessed against
10		categories of payroll-based journal job titles that have
11		no more than a 10% deviation from staffing requirements.
12		The Department is granted discretion to waive the
13		violation and penalty when unforeseen circumstances have
14		occurred that resulted in call-offs of scheduled staff. This
15		provision shall be applied no more than 6 times per quarter.
16		Nothing in this Section diminishes a facility's right to
17		appeal the imposition of a monetary penalty. No facility may
18		appeal a notice of noncompliance issued during the revised
19		implementation period. The changes made to this subsection by
20		this amendatory Act of the 104th General Assembly in regard to
21		nursing home staffing fines shall apply to the July 1, 2025
22		fines based on data for the quarter beginning July 1, 2026
23		through September 30, 2026, January 1, 2025 through March 31,
24		2025 and quarterly thereafter.
25		(Source: P.A. 104-9, eff. 6-16-25.)

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1		Section 260-15. The Illinois Public Aid Code is amended by
2		changing Sections 5-5.2 and 12-4.25 as follows:
3		(305 ILCS 5/5-5.2)
4		Sec. 5-5.2. Payment.
5		(a) All nursing facilities that are grouped pursuant to
6		Section 5-5.1 of this Act shall receive the same rate of
7		payment for similar services.
8		(b) It shall be a matter of State policy that the Illinois
9		Department shall utilize a uniform billing cycle throughout
10		the State for the long-term care providers.
11		(c) (Blank).
12		(c-1) Notwithstanding any other provisions of this Code,
13		the methodologies for reimbursement of nursing services as
14		provided under this Article shall no longer be applicable for
15		bills payable for nursing services rendered on or after a new
16		reimbursement system based on the Patient Driven Payment Model
17		(PDPM) has been fully operationalized, which shall take effect
18		for services provided on or after the implementation of the
19		PDPM reimbursement system begins. For the purposes of Public
20		Act 102-1035, the implementation date of the PDPM
21		reimbursement system and all related provisions shall be July
22		1, 2022 if the following conditions are met: (i) the Centers
23		for Medicare and Medicaid Services has approved corresponding
24		changes in the reimbursement system and bed assessment; and
25		(ii) the Department has filed rules to implement these changes

SB3365 Enrolled - 489 - LRB104 18483 SSS 31925 b
1		no later than June 1, 2022. Failure of the Department to file
2		rules to implement the changes provided in Public Act 102-1035
3		no later than June 1, 2022 shall result in the implementation
4		date being delayed to October 1, 2022.
5		(d) The new nursing services reimbursement methodology
6		utilizing the Patient Driven Payment Model, which shall be
7		referred to as the PDPM reimbursement system, taking effect
8		July 1, 2022, upon federal approval by the Centers for
9		Medicare and Medicaid Services, shall be based on the
10		following:
11		(1) The methodology shall be resident-centered,
12		facility-specific, cost-based, and based on guidance from
13		the Centers for Medicare and Medicaid Services.
14		(2) Costs shall be annually rebased and case mix index
15		quarterly updated. The nursing services methodology will
16		be assigned to the Medicaid enrolled residents on record
17		as of 30 days prior to the beginning of the rate period in
18		the Department's Medicaid Management Information System
19		(MMIS) as present on the last day of the second quarter
20		preceding the rate period based upon the Assessment
21		Reference Date of the Minimum Data Set (MDS).
22		(3) Regional wage adjustors based on the Health
23		Service Areas (HSA) groupings and adjusters in effect on
24		April 30, 2012 shall be included, except no adjuster shall
25		be lower than 1.06.
26		(4) PDPM nursing case mix indices in effect on March

SB3365 Enrolled - 490 - LRB104 18483 SSS 31925 b
1		1, 2022 shall be assigned to each resident class at no less
2		than 0.7858 of the Centers for Medicare and Medicaid
3		Services PDPM unadjusted case mix values, in effect on
4		March 1, 2022.
5		(5) The pool of funds available for distribution by
6		case mix and the base facility rate shall be determined
7		using the formula contained in subsection (d-1).
8		(6) The Department shall establish a variable per diem
9		staffing add-on in accordance with the most recent
10		available federal staffing report, currently the Payroll
11		Based Journal, for the same period of time, and if
12		applicable adjusted for acuity using the same quarter's
13		MDS. The Department shall rely on Payroll Based Journals
14		provided to the Department of Public Health to make a
15		determination of non-submission. If the Department is
16		notified by a facility of missing or inaccurate Payroll
17		Based Journal data or an incorrect calculation of
18		staffing, the Department must make a correction as soon as
19		the error is verified for the applicable quarter.
20		Beginning October 1, 2024, the staffing percentage
21		used in the calculation of the per diem staffing add-on
22		shall be its PDPM STRIVE Staffing Ratio which equals: its
23		Reported Total Nurse Staffing Hours Per Resident Per Day
24		as published in the most recent federal staffing report
25		(the Provider Information File), divided by the facility's
26		PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE

SB3365 Enrolled - 491 - LRB104 18483 SSS 31925 b
1		Staffing Target is equal to .82 times the facility's
2		Illinois Adjusted Facility Case-Mix Hours Per Resident Per
3		Day. A facility's Illinois Adjusted Facility Case Mix
4		Hours Per Resident Per Day is equal to its Case-Mix Total
5		Nurse Staffing Hours Per Resident Per Day (as published in
6		the most recent federal Provider Information file) times
7		3.662 (which reflects the national resident days-weighted
8		mean Reported Total Nurse Staffing Hours Per Resident Per
9		Day as calculated using the January 2024 federal Provider
10		Information Files), divided by the national resident
11		days-weighted mean Reported Total Nurse Staffing Hours Per
12		Resident Per Day calculated using the most recent State US
13		Averages file.
14		Beginning January 1, 2025, the staffing percentage
15		used in the calculation of the per diem staffing add-on
16		shall be its PDPM STRIVE Staffing Ratio which equals: its
17		Reported Total Nurse Staffing Hours Per Resident Per Day
18		as published in the most recent federal staffing report
19		(the Provider Information File), divided by the facility's
20		PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
21		Staffing Target is equal to .7122 times the facility's
22		Illinois Adjusted Facility Case-Mix Hours Per Resident Per
23		Day. A facility's Illinois Adjusted Facility Case Mix
24		Hours Per Resident Per Day is equal to its Case-Mix Total
25		Nurse Staffing Hours Per Resident Per Day (as published in
26		the most recent federal staffing report Provider

SB3365 Enrolled - 492 - LRB104 18483 SSS 31925 b
1		Information file) times 3.79 (which is the Reported Total
2		Nurse Staffing Hours Per Resident Per Day for the Nation
3		as reported the January 2024 State US Averages file),
4		divided by the Reported Total Nurse Staffing Hours Per
5		Resident Per Day for the Nation as reported in the most
6		recent State US Averages file.
7		(6.5) Beginning July 1, 2024, the paid per diem
8		staffing add-on shall be the paid per diem staffing add-on
9		in effect April 1, 2024. For dates beginning October 1,
10		2024 and through September 30, 2025, the denominator for
11		the staffing percentage shall be the lesser of the
12		facility's PDPM STRIVE Staffing Target and:
13		(A) For the quarter beginning October 1, 2024, the
14		sum of 20% of the facility's PDPM STRIVE Staffing
15		Target and 80% of the facility's Case-Mix Total Nurse
16		Staffing Hours Per Resident Per Day (as published in
17		the January 2024 federal staffing report).
18		(B) For the quarter beginning January 1, 2025, the
19		sum of 40% of the facility's PDPM STRIVE Staffing
20		Target and 60% of the facility's Case-Mix Total Nurse
21		Staffing Hours Per Resident Per Day (as published in
22		the January 2024 federal staffing report).
23		(C) For the quarter beginning March 1, 2025, the
24		sum of 60% of the facility's PDPM STRIVE Staffing
25		Target and 40% of the facility's Case-Mix Total Nurse
26		Staffing Hours Per Resident Per Day (as published in

SB3365 Enrolled - 493 - LRB104 18483 SSS 31925 b
1		the January 2024 federal staffing report).
2		(D) For the quarter beginning July 1, 2025, the
3		sum of 80% of the facility's PDPM STRIVE Staffing
4		Target and 20% of the facility's Case-Mix Total Nurse
5		Staffing Hours Per Resident Per Day (as published in
6		the January 2024 federal staffing report).
7		Facilities with at least 70% of the staffing
8		indicated by the STRIVE study shall be paid a per diem
9		add-on of $9, increasing by equivalent steps for each
10		whole percentage point until the facilities reach a per
11		diem of $16.52. Facilities with at least 80% of the
12		staffing indicated by the STRIVE study shall be paid a per
13		diem add-on of $16.52, increasing by equivalent steps for
14		each whole percentage point until the facilities reach a
15		per diem add-on of $25.77. Facilities with at least 92% of
16		the staffing indicated by the STRIVE study shall be paid a
17		per diem add-on of $25.77, increasing by equivalent steps
18		for each whole percentage point until the facilities reach
19		a per diem add-on of $30.98. Facilities with at least 100%
20		of the staffing indicated by the STRIVE study shall be
21		paid a per diem add-on of $30.98, increasing by equivalent
22		steps for each whole percentage point until the facilities
23		reach a per diem add-on of $36.44. Facilities with at
24		least 110% of the staffing indicated by the STRIVE study
25		shall be paid a per diem add-on of $36.44, increasing by
26		equivalent steps for each whole percentage point until the

SB3365 Enrolled - 494 - LRB104 18483 SSS 31925 b
1		facilities reach a per diem add-on of $38.68. Facilities
2		with at least 125% or higher of the staffing indicated by
3		the STRIVE study shall be paid a per diem add-on of $38.68.
4		No nursing facility's variable staffing per diem add-on
5		shall be reduced by more than 5% in 2 consecutive
6		quarters. For the quarters beginning July 1, 2022 and
7		October 1, 2022, no facility's variable per diem staffing
8		add-on shall be calculated at a rate lower than 85% of the
9		staffing indicated by the STRIVE study. No facility below
10		70% of the staffing indicated by the STRIVE study shall
11		receive a variable per diem staffing add-on after December
12		31, 2022.
13		Beginning January 1, 2027, a $2.25 rate increase shall
14		be added to each STRIVE staffing per diem add-on under
15		subparagraph (D) of this paragraph (6.5) for facilities
16		with at least 80% of the staffing indicated by the STRIVE
17		study.
18		(7) For dates of services beginning July 1, 2022, the
19		PDPM nursing component per diem for each nursing facility
20		shall be the product of the facility's (i) statewide PDPM
21		nursing base per diem rate, $92.25, adjusted for the
22		facility average PDPM case mix index calculated quarterly
23		and (ii) the regional wage adjuster, and then add the
24		Medicaid access adjustment as defined in (e-3) of this
25		Section. Transition rates for services provided between
26		July 1, 2022 and October 1, 2023 shall be the greater of

SB3365 Enrolled - 495 - LRB104 18483 SSS 31925 b
1		the PDPM nursing component per diem or:
2		(A) for the quarter beginning July 1, 2022, the
3		RUG-IV nursing component per diem;
4		(B) for the quarter beginning October 1, 2022, the
5		sum of the RUG-IV nursing component per diem
6		multiplied by 0.80 and the PDPM nursing component per
7		diem multiplied by 0.20;
8		(C) for the quarter beginning January 1, 2023, the
9		sum of the RUG-IV nursing component per diem
10		multiplied by 0.60 and the PDPM nursing component per
11		diem multiplied by 0.40;
12		(D) for the quarter beginning April 1, 2023, the
13		sum of the RUG-IV nursing component per diem
14		multiplied by 0.40 and the PDPM nursing component per
15		diem multiplied by 0.60;
16		(E) for the quarter beginning July 1, 2023, the
17		sum of the RUG-IV nursing component per diem
18		multiplied by 0.20 and the PDPM nursing component per
19		diem multiplied by 0.80; or
20		(F) for the quarter beginning October 1, 2023 and
21		each subsequent quarter, the transition rate shall end
22		and a nursing facility shall be paid 100% of the PDPM
23		nursing component per diem.
24		(d-1) Calculation of base year Statewide RUG-IV nursing
25		base per diem rate.
26		(1) Base rate spending pool shall be:

SB3365 Enrolled - 496 - LRB104 18483 SSS 31925 b
1		(A) The base year resident days which are
2		calculated by multiplying the number of Medicaid
3		residents in each nursing home as indicated in the MDS
4		data defined in paragraph (4) by 365.
5		(B) Each facility's nursing component per diem in
6		effect on July 1, 2012 shall be multiplied by
7		subsection (A).
8		(C) Thirteen million is added to the product of
9		subparagraph (A) and subparagraph (B) to adjust for
10		the exclusion of nursing homes defined in paragraph
11		(5).
12		(2) For each nursing home with Medicaid residents as
13		indicated by the MDS data defined in paragraph (4),
14		weighted days adjusted for case mix and regional wage
15		adjustment shall be calculated. For each home this
16		calculation is the product of:
17		(A) Base year resident days as calculated in
18		subparagraph (A) of paragraph (1).
19		(B) The nursing home's regional wage adjustor
20		based on the Health Service Areas (HSA) groupings and
21		adjustors in effect on April 30, 2012.
22		(C) Facility weighted case mix which is the number
23		of Medicaid residents as indicated by the MDS data
24		defined in paragraph (4) multiplied by the associated
25		case weight for the RUG-IV 48 grouper model using
26		standard RUG-IV procedures for index maximization.

SB3365 Enrolled - 497 - LRB104 18483 SSS 31925 b
1		(D) The sum of the products calculated for each
2		nursing home in subparagraphs (A) through (C) above
3		shall be the base year case mix, rate adjusted
4		weighted days.
5		(3) The Statewide RUG-IV nursing base per diem rate:
6		(A) on January 1, 2014 shall be the quotient of the
7		paragraph (1) divided by the sum calculated under
8		subparagraph (D) of paragraph (2);
9		(B) on and after July 1, 2014 and until July 1,
10		2022, shall be the amount calculated under
11		subparagraph (A) of this paragraph (3) plus $1.76; and
12		(C) beginning July 1, 2022 and thereafter, $7
13		shall be added to the amount calculated under
14		subparagraph (B) of this paragraph (3) of this
15		Section.
16		(4) Minimum Data Set (MDS) comprehensive assessments
17		for Medicaid residents on the last day of the quarter used
18		to establish the base rate.
19		(5) Nursing facilities designated as of July 1, 2012
20		by the Department as "Institutions for Mental Disease"
21		shall be excluded from all calculations under this
22		subsection. The data from these facilities shall not be
23		used in the computations described in paragraphs (1)
24		through (4) above to establish the base rate.
25		(e) Beginning July 1, 2014, the Department shall allocate
26		funding in the amount up to $10,000,000 for per diem add-ons to

SB3365 Enrolled - 498 - LRB104 18483 SSS 31925 b
1		the RUGS methodology for dates of service on and after July 1,
2		2014:
3		(1) $0.63 for each resident who scores in I4200
4		Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
5		(2) $2.67 for each resident who scores either a "1" or
6		"2" in any items S1200A through S1200I and also scores in
7		RUG groups PA1, PA2, BA1, or BA2.
8		(e-1) (Blank).
9		(e-2) For dates of services beginning January 1, 2014 and
10		ending September 30, 2023, the RUG-IV nursing component per
11		diem for a nursing home shall be the product of the statewide
12		RUG-IV nursing base per diem rate, the facility average case
13		mix index, and the regional wage adjustor. For dates of
14		service beginning July 1, 2022 and ending September 30, 2023,
15		the Medicaid access adjustment described in subsection (e-3)
16		shall be added to the product.
17		(e-3) A Medicaid Access Adjustment of $4 adjusted for the
18		facility average PDPM case mix index calculated quarterly
19		shall be added to the statewide PDPM nursing per diem for all
20		facilities with annual Medicaid bed days of at least 70% of all
21		occupied bed days adjusted quarterly. For each new calendar
22		year and for the 6-month period beginning July 1, 2022, the
23		percentage of a facility's occupied bed days comprised of
24		Medicaid bed days shall be determined by the Department
25		quarterly. For dates of service beginning January 1, 2023, the
26		Medicaid Access Adjustment shall be increased to $4.75. This

SB3365 Enrolled - 499 - LRB104 18483 SSS 31925 b
1		subsection shall be inoperative on and after December 31, 2029
2		January 1, 2028.
3		(e-3.5) For dates of service beginning January 1, 2027,
4		the Medicaid Access Adjustment shall be increased by $5.55 to
5		$10.30 per diem for those facilities with at least 70% of the
6		staffing indicated by the STRIVE study as described in
7		subparagraph (D) of paragraph (6.5) of subsection (d). A
8		facility shall be eligible for Medicaid Access Adjustment
9		described in this subsection (e-3.5) only if the facility
10		demonstrates compliance with the training requirements for
11		staff outlined in Section 3-130 of the Nursing Home Care Act.
12		This subsection (e-3.5) shall be inoperative on and after
13		December 31, 2029.
14		(e-3.6) For dates of service beginning January 1, 2027,
15		facilities located outside of Rate Areas 6, 7, and 8 that have
16		Medicaid bed days of at least 65% of all occupied bed days
17		adjusted quarterly shall qualify for the Medicaid Access
18		Adjustment described in subsections (e-3) and (e-3.5).
19		Facilities located inside Rate Areas 6, 7, and 8 shall have
20		their threshold remain at 70% for all qualifying facilities
21		described in subsections (e-3) and (e-3.5). This subsection
22		(e-3.6) shall be inoperative on and after December 31, 2029.
23		(e-4) Subject to federal approval, on and after January 1,
24		2024, the Department shall increase the rate add-on at
25		paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
26		for ventilator services from $208 per day to $481 per day.

SB3365 Enrolled - 500 - LRB104 18483 SSS 31925 b
1		Payment is subject to the criteria and requirements under 89
2		Ill. Adm. Code 147.335.
3		(f) (Blank).
4		(g) Notwithstanding any other provision of this Code, on
5		and after July 1, 2012, for facilities not designated by the
6		Department of Healthcare and Family Services as "Institutions
7		for Mental Disease", rates effective May 1, 2011 shall be
8		adjusted as follows:
9		(1) (Blank);
10		(2) (Blank);
11		(3) Facility rates for the capital and support
12		components shall be reduced by 1.7%.
13		(h) Notwithstanding any other provision of this Code, on
14		and after July 1, 2012, nursing facilities designated by the
15		Department of Healthcare and Family Services as "Institutions
16		for Mental Disease" and "Institutions for Mental Disease" that
17		are facilities licensed under the Specialized Mental Health
18		Rehabilitation Act of 2013 shall have the nursing,
19		socio-developmental, capital, and support components of their
20		reimbursement rate effective May 1, 2011 reduced in total by
21		2.7%.
22		(i) On and after July 1, 2014, the reimbursement rates for
23		the support component of the nursing facility rate for
24		facilities licensed under the Nursing Home Care Act as skilled
25		or intermediate care facilities shall be the rate in effect on
26		June 30, 2014 increased by 8.17%.

SB3365 Enrolled - 501 - LRB104 18483 SSS 31925 b
1		(i-1) Subject to federal approval, on and after January 1,
2		2024, the reimbursement rates for the support component of the
3		nursing facility rate for facilities licensed under the
4		Nursing Home Care Act as skilled or intermediate care
5		facilities shall be the rate in effect on June 30, 2023
6		increased by 12%.
7		(j) Notwithstanding any other provision of law, subject to
8		federal approval, effective July 1, 2019, sufficient funds
9		shall be allocated for changes to rates for facilities
10		licensed under the Nursing Home Care Act as skilled nursing
11		facilities or intermediate care facilities for dates of
12		services on and after July 1, 2019: (i) to establish, through
13		June 30, 2022 a per diem add-on to the direct care per diem
14		rate not to exceed $70,000,000 annually in the aggregate
15		taking into account federal matching funds for the purpose of
16		addressing the facility's unique staffing needs, adjusted
17		quarterly and distributed by a weighted formula based on
18		Medicaid bed days on the last day of the second quarter
19		preceding the quarter for which the rate is being adjusted.
20		Beginning July 1, 2022, the annual $70,000,000 described in
21		the preceding sentence shall be dedicated to the variable per
22		diem add-on for staffing under paragraph (6) of subsection
23		(d); and (ii) in an amount not to exceed $170,000,000 annually
24		in the aggregate taking into account federal matching funds to
25		permit the support component of the nursing facility rate to
26		be updated as follows:

SB3365 Enrolled - 502 - LRB104 18483 SSS 31925 b
1		(1) 80%, or $136,000,000, of the funds shall be used
2		to update each facility's rate in effect on June 30, 2019
3		using the most recent cost reports on file, which have had
4		a limited review conducted by the Department of Healthcare
5		and Family Services and will not hold up enacting the rate
6		increase, with the Department of Healthcare and Family
7		Services.
8		(2) After completing the calculation in paragraph (1),
9		any facility whose rate is less than the rate in effect on
10		June 30, 2019 shall have its rate restored to the rate in
11		effect on June 30, 2019 from the 20% of the funds set
12		aside.
13		(3) The remainder of the 20%, or $34,000,000, shall be
14		used to increase each facility's rate by an equal
15		percentage.
16		(k) During the first quarter of State Fiscal Year 2020,
17		the Department of Healthcare of Family Services must convene a
18		technical advisory group consisting of members of all trade
19		associations representing Illinois skilled nursing providers
20		to discuss changes necessary with federal implementation of
21		Medicare's Patient-Driven Payment Model. Implementation of
22		Medicare's Patient-Driven Payment Model shall, by September 1,
23		2020, end the collection of the MDS data that is necessary to
24		maintain the current RUG-IV Medicaid payment methodology. The
25		technical advisory group must consider a revised reimbursement
26		methodology that takes into account transparency,

SB3365 Enrolled - 503 - LRB104 18483 SSS 31925 b
1		accountability, actual staffing as reported under the
2		federally required Payroll Based Journal system, changes to
3		the minimum wage, adequacy in coverage of the cost of care, and
4		a quality component that rewards quality improvements.
5		(l) The Department shall establish per diem add-on
6		payments to improve the quality of care delivered by
7		facilities, including:
8		(1) Incentive payments determined by facility
9		performance on specified quality measures in an initial
10		amount of $70,000,000. Nothing in this subsection shall be
11		construed to limit the quality of care payments in the
12		aggregate statewide to $70,000,000, and, if quality of
13		care has improved across nursing facilities, the
14		Department shall adjust those add-on payments accordingly.
15		The quality payment methodology described in this
16		subsection must be used for at least State Fiscal Year
17		2023. Beginning with the quarter starting July 1, 2023,
18		the Department may add, remove, or change quality metrics
19		and make associated changes to the quality payment
20		methodology as outlined in subparagraph (E). Facilities
21		designated by the Centers for Medicare and Medicaid
22		Services as a special focus facility or a hospital-based
23		nursing home do not qualify for quality payments.
24		(A) Each quality pool must be distributed by
25		assigning a quality weighted score for each nursing
26		home which is calculated by multiplying the nursing

SB3365 Enrolled - 504 - LRB104 18483 SSS 31925 b
1		home's quality base period Medicaid days by the
2		nursing home's star rating weight in that period.
3		(B) Star rating weights are assigned based on the
4		nursing home's star rating for the LTS quality star
5		rating. As used in this subparagraph, "LTS quality
6		star rating" means the long-term stay quality rating
7		for each nursing facility, as assigned by the Centers
8		for Medicare and Medicaid Services under the Five-Star
9		Quality Rating System. The rating is a number ranging
10		from 0 (lowest) to 5 (highest).
11		(i) Zero-star or one-star rating has a weight
12		of 0.
13		(ii) Two-star rating has a weight of 0.75.
14		(iii) Three-star rating has a weight of 1.5.
15		(iv) Four-star rating has a weight of 2.5.
16		(v) Five-star rating has a weight of 3.5.
17		(C) Each nursing home's quality weight score is
18		divided by the sum of all quality weight scores for
19		qualifying nursing homes to determine the proportion
20		of the quality pool to be paid to the nursing home.
21		(D) The quality pool is no less than $70,000,000
22		annually or $17,500,000 per quarter. The Department
23		shall publish on its website the estimated payments
24		and the associated weights for each facility 45 days
25		prior to when the initial payments for the quarter are
26		to be paid. The Department shall assign each facility

SB3365 Enrolled - 505 - LRB104 18483 SSS 31925 b
1		the most recent and applicable quarter's STAR value
2		unless the facility notifies the Department within 15
3		days of an issue and the facility provides reasonable
4		evidence demonstrating its timely compliance with
5		federal data submission requirements for the quarter
6		of record. If such evidence cannot be provided to the
7		Department, the STAR rating assigned to the facility
8		shall be reduced by one from the prior quarter.
9		(E) The Department shall review quality metrics
10		used for payment of the quality pool and make
11		recommendations for any associated changes to the
12		methodology for distributing quality pool payments in
13		consultation with associations representing long-term
14		care providers, consumer advocates, organizations
15		representing workers of long-term care facilities, and
16		payors. The Department may establish, by rule, changes
17		to the methodology for distributing quality pool
18		payments.
19		(F) The Department shall disburse quality pool
20		payments from the Long-Term Care Provider Fund on a
21		monthly basis in amounts proportional to the total
22		quality pool payment determined for the quarter.
23		(G) The Department shall publish any changes in
24		the methodology for distributing quality pool payments
25		prior to the beginning of the measurement period or
26		quality base period for any metric added to the

SB3365 Enrolled - 506 - LRB104 18483 SSS 31925 b
1		distribution's methodology.
2		(2) Payments based on CNA tenure, promotion, and CNA
3		training for the purpose of increasing CNA compensation.
4		It is the intent of this subsection that payments made in
5		accordance with this paragraph be directly incorporated
6		into increased compensation for CNAs. As used in this
7		paragraph, "CNA" means a certified nursing assistant as
8		that term is described in Section 3-206 of the Nursing
9		Home Care Act, Section 3-206 of the ID/DD Community Care
10		Act, and Section 3-206 of the MC/DD Act. The Department
11		shall establish, by rule, payments to nursing facilities
12		equal to Medicaid's share of the tenure wage increments
13		specified in this paragraph for all reported CNA employee
14		hours compensated according to a posted schedule
15		consisting of increments at least as large as those
16		specified in this paragraph. The increments are as
17		follows: an additional $1.50 per hour for CNAs with at
18		least one and less than 2 years' experience plus another
19		$1 per hour for each additional year of experience up to a
20		maximum of $6.50 for CNAs with at least 6 years of
21		experience. For purposes of this paragraph, Medicaid's
22		share shall be the ratio determined by paid Medicaid bed
23		days divided by total bed days for the applicable time
24		period used in the calculation. In addition, and additive
25		to any tenure increments paid as specified in this
26		paragraph, the Department shall establish, by rule,

SB3365 Enrolled - 507 - LRB104 18483 SSS 31925 b
1		payments supporting Medicaid's share of the
2		promotion-based wage increments for CNA employee hours
3		compensated for that promotion with at least a $1.50
4		hourly increase. Medicaid's share shall be established as
5		it is for the tenure increments described in this
6		paragraph. Qualifying promotions shall be defined by the
7		Department in rules for an expected 10-15% subset of CNAs
8		assigned intermediate, specialized, or added roles such as
9		CNA trainers, CNA scheduling "captains", and CNA
10		specialists for resident conditions like dementia or
11		memory care or behavioral health.
12		(m) The Department shall work with nursing facility
13		industry representatives to design policies and procedures to
14		permit facilities to address the integrity of data from
15		federal reporting sites used by the Department in setting
16		facility rates.
17		(Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
18		102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
19		Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
20		Section 50-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff.
21		7-1-24; 103-1075, eff. 3-21-25.)
22		(305 ILCS 5/12-4.25)  (from Ch. 23, par. 12-4.25)
23		Sec. 12-4.25. Medical assistance program; vendor
24		participation.
25		(A) The Illinois Department may deny, suspend, or

SB3365 Enrolled - 508 - LRB104 18483 SSS 31925 b
1		terminate the eligibility of any person, firm, corporation,
2		association, agency, institution or other legal entity to
3		participate as a vendor of goods or services to recipients
4		under the medical assistance program under Article V, or may
5		exclude any such person or entity from participation as such a
6		vendor, and may deny, suspend, or recover payments, if after
7		reasonable notice and opportunity for a hearing the Illinois
8		Department finds:
9		(a) Such vendor is not complying with the Department's
10		policy or rules and regulations, or with the terms and
11		conditions prescribed by the Illinois Department in its
12		vendor agreement, which document shall be developed by the
13		Department as a result of negotiations with each vendor
14		category, including physicians, hospitals, long term care
15		facilities, pharmacists, optometrists, podiatric
16		physicians, and dentists setting forth the terms and
17		conditions applicable to the participation of each vendor
18		group in the program; or
19		(b) Such vendor has failed to keep or make available
20		for inspection, audit or copying, after receiving a
21		written request from the Illinois Department, such records
22		regarding payments claimed for providing services. This
23		section does not require vendors to make available patient
24		records of patients for whom services are not reimbursed
25		under this Code; or
26		(c) Such vendor has failed to furnish any information

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1		requested by the Department regarding payments for
2		providing goods or services; or
3		(d) Such vendor has knowingly made, or caused to be
4		made, any false statement or representation of a material
5		fact in connection with the administration of the medical
6		assistance program; or
7		(e) Such vendor has furnished goods or services to a
8		recipient which are (1) in excess of need, (2) harmful, or
9		(3) of grossly inferior quality, all of such
10		determinations to be based upon competent medical judgment
11		and evaluations; or
12		(f) The vendor; a person with management
13		responsibility for a vendor; an officer or person owning,
14		either directly or indirectly, 5% or more of the shares of
15		stock or other evidences of ownership in a corporate
16		vendor; an owner of a sole proprietorship which is a
17		vendor; or a partner in a partnership which is a vendor,
18		either:
19		(1) was previously terminated, suspended, or
20		excluded from participation in the Illinois medical
21		assistance program, or was terminated, suspended, or
22		excluded from participation in another state or
23		federal medical assistance or health care program; or
24		(2) was a person with management responsibility
25		for a vendor previously terminated, suspended, or
26		excluded from participation in the Illinois medical

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1		assistance program, or terminated, suspended, or
2		excluded from participation in another state or
3		federal medical assistance or health care program
4		during the time of conduct which was the basis for that
5		vendor's termination, suspension, or exclusion; or
6		(3) was an officer, or person owning, either
7		directly or indirectly, 5% or more of the shares of
8		stock or other evidences of ownership in a corporate
9		or limited liability company vendor previously
10		terminated, suspended, or excluded from participation
11		in the Illinois medical assistance program, or
12		terminated, suspended, or excluded from participation
13		in a state or federal medical assistance or health
14		care program during the time of conduct which was the
15		basis for that vendor's termination, suspension, or
16		exclusion; or
17		(4) was an owner of a sole proprietorship or
18		partner of a partnership previously terminated,
19		suspended, or excluded from participation in the
20		Illinois medical assistance program, or terminated,
21		suspended, or excluded from participation in a state
22		or federal medical assistance or health care program
23		during the time of conduct which was the basis for that
24		vendor's termination, suspension, or exclusion; or
25		(f-1) Such vendor has a delinquent debt owed to the
26		Illinois Department; or

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1		(g) The vendor; a person with management
2		responsibility for a vendor; an officer or person owning,
3		either directly or indirectly, 5% or more of the shares of
4		stock or other evidences of ownership in a corporate or
5		limited liability company vendor; an owner of a sole
6		proprietorship which is a vendor; or a partner in a
7		partnership which is a vendor, either:
8		(1) has engaged in practices prohibited by
9		applicable federal or State law or regulation; or
10		(2) was a person with management responsibility
11		for a vendor at the time that such vendor engaged in
12		practices prohibited by applicable federal or State
13		law or regulation; or
14		(3) was an officer, or person owning, either
15		directly or indirectly, 5% or more of the shares of
16		stock or other evidences of ownership in a vendor at
17		the time such vendor engaged in practices prohibited
18		by applicable federal or State law or regulation; or
19		(4) was an owner of a sole proprietorship or
20		partner of a partnership which was a vendor at the time
21		such vendor engaged in practices prohibited by
22		applicable federal or State law or regulation; or
23		(h) The direct or indirect ownership of the vendor
24		(including the ownership of a vendor that is a sole
25		proprietorship, a partner's interest in a vendor that is a
26		partnership, or ownership of 5% or more of the shares of

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1		stock or other evidences of ownership in a corporate
2		vendor) has been transferred by an individual who is
3		terminated, suspended, or excluded or barred from
4		participating as a vendor to the individual's spouse,
5		child, brother, sister, parent, grandparent, grandchild,
6		uncle, aunt, niece, nephew, cousin, or relative by
7		marriage.
8		(A-5) The Illinois Department may deny, suspend, or
9		terminate the eligibility of any person, firm, corporation,
10		association, agency, institution, or other legal entity to
11		participate as a vendor of goods or services to recipients
12		under the medical assistance program under Article V, or may
13		exclude any such person or entity from participation as such a
14		vendor, if, after reasonable notice and opportunity for a
15		hearing, the Illinois Department finds that the vendor; a
16		person with management responsibility for a vendor; an officer
17		or person owning, either directly or indirectly, 5% or more of
18		the shares of stock or other evidences of ownership in a
19		corporate vendor; an owner of a sole proprietorship that is a
20		vendor; or a partner in a partnership that is a vendor has been
21		convicted of an offense based on fraud or willful
22		misrepresentation related to any of the following:
23		(1) The medical assistance program under Article V of
24		this Code.
25		(2) A medical assistance or health care program in
26		another state.

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1		(3) The Medicare program under Title XVIII of the
2		Social Security Act.
3		(4) The provision of health care services.
4		(5) A violation of this Code, as provided in Article
5		VIIIA, or another state or federal medical assistance
6		program or health care program.
7		(A-10) The Illinois Department may deny, suspend, or
8		terminate the eligibility of any person, firm, corporation,
9		association, agency, institution, or other legal entity to
10		participate as a vendor of goods or services to recipients
11		under the medical assistance program under Article V, or may
12		exclude any such person or entity from participation as such a
13		vendor, if, after reasonable notice and opportunity for a
14		hearing, the Illinois Department finds that (i) the vendor,
15		(ii) a person with management responsibility for a vendor,
16		(iii) an officer or person owning, either directly or
17		indirectly, 5% or more of the shares of stock or other
18		evidences of ownership in a corporate vendor, (iv) an owner of
19		a sole proprietorship that is a vendor, or (v) a partner in a
20		partnership that is a vendor has been convicted of an offense
21		related to any of the following:
22		(1) Murder.
23		(2) A Class X felony under the Criminal Code of 1961 or
24		the Criminal Code of 2012.
25		(3) Sexual misconduct that may subject recipients to
26		an undue risk of harm.

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1		(4) A criminal offense that may subject recipients to
2		an undue risk of harm.
3		(5) A crime of fraud or dishonesty.
4		(6) A crime involving a controlled substance.
5		(7) A misdemeanor relating to fraud, theft,
6		embezzlement, breach of fiduciary responsibility, or other
7		financial misconduct related to a health care program.
8		(A-15) The Illinois Department may deny the eligibility of
9		any person, firm, corporation, association, agency,
10		institution, or other legal entity to participate as a vendor
11		of goods or services to recipients under the medical
12		assistance program under Article V if, after reasonable notice
13		and opportunity for a hearing, the Illinois Department finds:
14		(1) The applicant or any person with management
15		responsibility for the applicant; an officer or member of
16		the board of directors of an applicant; an entity owning
17		(directly or indirectly) 5% or more of the shares of stock
18		or other evidences of ownership in a corporate vendor
19		applicant; an owner of a sole proprietorship applicant; a
20		partner in a partnership applicant; or a technical or
21		other advisor to an applicant has a debt owed to the
22		Illinois Department, and no payment arrangements
23		acceptable to the Illinois Department have been made by
24		the applicant.
25		(2) The applicant or any person with management
26		responsibility for the applicant; an officer or member of

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1		the board of directors of an applicant; an entity owning
2		(directly or indirectly) 5% or more of the shares of stock
3		or other evidences of ownership in a corporate vendor
4		applicant; an owner of a sole proprietorship applicant; a
5		partner in a partnership vendor applicant; or a technical
6		or other advisor to an applicant was (i) a person with
7		management responsibility, (ii) an officer or member of
8		the board of directors of an applicant, (iii) an entity
9		owning (directly or indirectly) 5% or more of the shares
10		of stock or other evidences of ownership in a corporate
11		vendor, (iv) an owner of a sole proprietorship, (v) a
12		partner in a partnership vendor, (vi) a technical or other
13		advisor to a vendor, during a period of time where the
14		conduct of that vendor resulted in a debt owed to the
15		Illinois Department, and no payment arrangements
16		acceptable to the Illinois Department have been made by
17		that vendor.
18		(3) There is a credible allegation of the use,
19		transfer, or lease of assets of any kind to an applicant
20		from a current or prior vendor who has a debt owed to the
21		Illinois Department, no payment arrangements acceptable to
22		the Illinois Department have been made by that vendor or
23		the vendor's alternate payee, and the applicant knows or
24		should have known of such debt.
25		(4) There is a credible allegation of a transfer of
26		management responsibilities, or direct or indirect

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1		ownership, to an applicant from a current or prior vendor
2		who has a debt owed to the Illinois Department, and no
3		payment arrangements acceptable to the Illinois Department
4		have been made by that vendor or the vendor's alternate
5		payee, and the applicant knows or should have known of
6		such debt.
7		(5) There is a credible allegation of the use,
8		transfer, or lease of assets of any kind to an applicant
9		who is a spouse, child, brother, sister, parent,
10		grandparent, grandchild, uncle, aunt, niece, relative by
11		marriage, nephew, cousin, or relative of a current or
12		prior vendor who has a debt owed to the Illinois
13		Department and no payment arrangements acceptable to the
14		Illinois Department have been made.
15		(6) There is a credible allegation that the
16		applicant's previous affiliations with a provider of
17		medical services that has an uncollected debt, a provider
18		that has been or is subject to a payment suspension under a
19		federal health care program, or a provider that has been
20		previously excluded from participation in the medical
21		assistance program, poses a risk of fraud, waste, or abuse
22		to the Illinois Department.
23		As used in this subsection, "credible allegation" is
24		defined to include an allegation from any source, including,
25		but not limited to, fraud hotline complaints, claims data
26		mining, patterns identified through provider audits, civil

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1		actions filed under the Illinois False Claims Act, and law
2		enforcement investigations. An allegation is considered to be
3		credible when it has indicia of reliability.
4		(B) The Illinois Department shall deny, suspend or
5		terminate the eligibility of any person, firm, corporation,
6		association, agency, institution or other legal entity to
7		participate as a vendor of goods or services to recipients
8		under the medical assistance program under Article V, or may
9		exclude any such person or entity from participation as such a
10		vendor:
11		(1) immediately, if such vendor is not properly
12		licensed, certified, or authorized;
13		(2) within 30 days of the date when such vendor's
14		professional license, certification or other authorization
15		has been refused renewal, restricted, revoked, suspended,
16		or otherwise terminated; or
17		(3) if such vendor has been convicted of a violation
18		of this Code, as provided in Article VIIIA.
19		(C) Upon termination, suspension, or exclusion of a vendor
20		of goods or services from participation in the medical
21		assistance program authorized by this Article, a person with
22		management responsibility for such vendor during the time of
23		any conduct which served as the basis for that vendor's
24		termination, suspension, or exclusion is barred from
25		participation in the medical assistance program.
26		Upon termination, suspension, or exclusion of a corporate

SB3365 Enrolled - 518 - LRB104 18483 SSS 31925 b
1		vendor, the officers and persons owning, directly or
2		indirectly, 5% or more of the shares of stock or other
3		evidences of ownership in the vendor during the time of any
4		conduct which served as the basis for that vendor's
5		termination, suspension, or exclusion are barred from
6		participation in the medical assistance program. A person who
7		owns, directly or indirectly, 5% or more of the shares of stock
8		or other evidences of ownership in a terminated, suspended, or
9		excluded vendor may not transfer his or her ownership interest
10		in that vendor to his or her spouse, child, brother, sister,
11		parent, grandparent, grandchild, uncle, aunt, niece, nephew,
12		cousin, or relative by marriage.
13		Upon termination, suspension, or exclusion of a sole
14		proprietorship or partnership, the owner or partners during
15		the time of any conduct which served as the basis for that
16		vendor's termination, suspension, or exclusion are barred from
17		participation in the medical assistance program. The owner of
18		a terminated, suspended, or excluded vendor that is a sole
19		proprietorship, and a partner in a terminated, suspended, or
20		excluded vendor that is a partnership, may not transfer his or
21		her ownership or partnership interest in that vendor to his or
22		her spouse, child, brother, sister, parent, grandparent,
23		grandchild, uncle, aunt, niece, nephew, cousin, or relative by
24		marriage.
25		A person who owns, directly or indirectly, 5% or more of
26		the shares of stock or other evidences of ownership in a

SB3365 Enrolled - 519 - LRB104 18483 SSS 31925 b
1		corporate or limited liability company vendor who owes a debt
2		to the Department, if that vendor has not made payment
3		arrangements acceptable to the Department, shall not transfer
4		his or her ownership interest in that vendor, or vendor assets
5		of any kind, to his or her spouse, child, brother, sister,
6		parent, grandparent, grandchild, uncle, aunt, niece, nephew,
7		cousin, or relative by marriage.
8		Rules adopted by the Illinois Department to implement
9		these provisions shall specifically include a definition of
10		the term "management responsibility" as used in this Section.
11		Such definition shall include, but not be limited to, typical
12		job titles, and duties and descriptions which will be
13		considered as within the definition of individuals with
14		management responsibility for a provider.
15		A vendor or a prior vendor who has been terminated,
16		excluded, or suspended from the medical assistance program, or
17		from another state or federal medical assistance or health
18		care program, and any individual currently or previously
19		barred from the medical assistance program, or from another
20		state or federal medical assistance or health care program, as
21		a result of being an officer or a person owning, directly or
22		indirectly, 5% or more of the shares of stock or other
23		evidences of ownership in a corporate or limited liability
24		company vendor during the time of any conduct which served as
25		the basis for that vendor's termination, suspension, or
26		exclusion, may be required to post a surety bond as part of a

SB3365 Enrolled - 520 - LRB104 18483 SSS 31925 b
1		condition of enrollment or participation in the medical
2		assistance program. The Illinois Department shall establish,
3		by rule, the criteria and requirements for determining when a
4		surety bond must be posted and the value of the bond.
5		A vendor or a prior vendor who has a debt owed to the
6		Illinois Department and any individual currently or previously
7		barred from the medical assistance program, or from another
8		state or federal medical assistance or health care program, as
9		a result of being an officer or a person owning, directly or
10		indirectly, 5% or more of the shares of stock or other
11		evidences of ownership in that corporate or limited liability
12		company vendor during the time of any conduct which served as
13		the basis for the debt, may be required to post a surety bond
14		as part of a condition of enrollment or participation in the
15		medical assistance program. The Illinois Department shall
16		establish, by rule, the criteria and requirements for
17		determining when a surety bond must be posted and the value of
18		the bond.
19		(D) If a vendor has been suspended from the medical
20		assistance program under Article V of the Code, the Director
21		may require that such vendor correct any deficiencies which
22		served as the basis for the suspension. The Director shall
23		specify in the suspension order a specific period of time,
24		which shall not exceed one year from the date of the order,
25		during which a suspended vendor shall not be eligible to
26		participate. At the conclusion of the period of suspension the

SB3365 Enrolled - 521 - LRB104 18483 SSS 31925 b
1		Director shall reinstate such vendor, unless he finds that
2		such vendor has not corrected deficiencies upon which the
3		suspension was based.
4		If a vendor has been terminated, suspended, or excluded
5		from the medical assistance program under Article V, such
6		vendor shall be barred from participation for at least one
7		year, except that if a vendor has been terminated, suspended,
8		or excluded based on a conviction of a violation of Article
9		VIIIA or a conviction of a felony based on fraud or a willful
10		misrepresentation related to (i) the medical assistance
11		program under Article V, (ii) a federal or another state's
12		medical assistance or health care program, or (iii) the
13		provision of health care services, then the vendor shall be
14		barred from participation for 5 years or for the length of the
15		vendor's sentence for that conviction, whichever is longer. At
16		the end of one year a vendor who has been terminated,
17		suspended, or excluded may apply for reinstatement to the
18		program. Upon proper application to be reinstated such vendor
19		may be deemed eligible by the Director providing that such
20		vendor meets the requirements for eligibility under this Code.
21		If such vendor is deemed not eligible for reinstatement, he
22		shall be barred from again applying for reinstatement for one
23		year from the date his application for reinstatement is
24		denied.
25		A vendor whose termination, suspension, or exclusion from
26		participation in the Illinois medical assistance program under

SB3365 Enrolled - 522 - LRB104 18483 SSS 31925 b
1		Article V was based solely on an action by a governmental
2		entity other than the Illinois Department may, upon
3		reinstatement by that governmental entity or upon reversal of
4		the termination, suspension, or exclusion, apply for
5		rescission of the termination, suspension, or exclusion from
6		participation in the Illinois medical assistance program. Upon
7		proper application for rescission, the vendor may be deemed
8		eligible by the Director if the vendor meets the requirements
9		for eligibility under this Code.
10		If a vendor has been terminated, suspended, or excluded
11		and reinstated to the medical assistance program under Article
12		V and the vendor is terminated, suspended, or excluded a
13		second or subsequent time from the medical assistance program,
14		the vendor shall be barred from participation for at least 2
15		years, except that if a vendor has been terminated, suspended,
16		or excluded a second time based on a conviction of a violation
17		of Article VIIIA or a conviction of a felony based on fraud or
18		a willful misrepresentation related to (i) the medical
19		assistance program under Article V, (ii) a federal or another
20		state's medical assistance or health care program, or (iii)
21		the provision of health care services, then the vendor shall
22		be barred from participation for life. At the end of 2 years, a
23		vendor who has been terminated, suspended, or excluded may
24		apply for reinstatement to the program. Upon application to be
25		reinstated, the vendor may be deemed eligible if the vendor
26		meets the requirements for eligibility under this Code. If the

SB3365 Enrolled - 523 - LRB104 18483 SSS 31925 b
1		vendor is deemed not eligible for reinstatement, the vendor
2		shall be barred from again applying for reinstatement for 2
3		years from the date the vendor's application for reinstatement
4		is denied.
5		(E) The Illinois Department may recover money improperly
6		or erroneously paid, or overpayments, either by setoff,
7		crediting against future billings or by requiring direct
8		repayment to the Illinois Department. The Illinois Department
9		may suspend or deny payment, in whole or in part, if such
10		payment would be improper or erroneous or would otherwise
11		result in overpayment.
12		(1) Payments may be suspended, denied, or recovered
13		from a vendor or alternate payee: (i) for services
14		rendered in violation of the Illinois Department's
15		provider notices, statutes, rules, and regulations; (ii)
16		for services rendered in violation of the terms and
17		conditions prescribed by the Illinois Department in its
18		vendor agreement; (iii) for any vendor who fails to grant
19		the Office of Inspector General timely access to full and
20		complete records, including, but not limited to, records
21		relating to recipients under the medical assistance
22		program for the most recent 6 years, in accordance with
23		Section 140.28 of Title 89 of the Illinois Administrative
24		Code, and other information for the purpose of audits,
25		investigations, or other program integrity functions,
26		after reasonable written request by the Inspector General;

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1		this subsection (E) does not require vendors to make
2		available the medical records of patients for whom
3		services are not reimbursed under this Code or to provide
4		access to medical records more than 6 years old; (iv) when
5		the vendor has knowingly made, or caused to be made, any
6		false statement or representation of a material fact in
7		connection with the administration of the medical
8		assistance program; or (v) when the vendor previously
9		rendered services while terminated, suspended, or excluded
10		from participation in the medical assistance program or
11		while terminated or excluded from participation in another
12		state or federal medical assistance or health care
13		program.
14		(2) Notwithstanding any other provision of law, if a
15		vendor has the same taxpayer identification number
16		(assigned under Section 6109 of the Internal Revenue Code
17		of 1986) as is assigned to a vendor with past-due
18		financial obligations to the Illinois Department, the
19		Illinois Department may make any necessary adjustments to
20		payments to that vendor in order to satisfy any past-due
21		obligations, regardless of whether the vendor is assigned
22		a different billing number under the medical assistance
23		program.
24		(E-5) Civil monetary penalties.
25		(1) As used in this subsection (E-5):
26		(a) "Knowingly" means that a person, with respect

SB3365 Enrolled - 525 - LRB104 18483 SSS 31925 b
1		to information: (i) has actual knowledge of the
2		information; (ii) acts in deliberate ignorance of the
3		truth or falsity of the information; or (iii) acts in
4		reckless disregard of the truth or falsity of the
5		information. No proof of specific intent to defraud is
6		required.
7		(b) "Overpayment" means any funds that a person
8		receives or retains from the medical assistance
9		program to which the person, after applicable
10		reconciliation, is not entitled under this Code.
11		(c) "Remuneration" means the offer or transfer of
12		items or services for free or for other than fair
13		market value by a person; however, remuneration does
14		not include items or services of a nominal value of no
15		more than $10 per item or service, or $50 in the
16		aggregate on an annual basis, or any other offer or
17		transfer of items or services as determined by the
18		Department.
19		(d) "Should know" means that a person, with
20		respect to information: (i) acts in deliberate
21		ignorance of the truth or falsity of the information;
22		or (ii) acts in reckless disregard of the truth or
23		falsity of the information. No proof of specific
24		intent to defraud is required.
25		(2) Any person (including a vendor, provider,
26		organization, agency, or other entity, or an alternate

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1		payee thereof, but excluding a recipient) who:
2		(a) knowingly presents or causes to be presented
3		to an officer, employee, or agent of the State, a claim
4		that the Department determines:
5		(i) is for a medical or other item or service
6		that the person knows or should know was not
7		provided as claimed, including any person who
8		engages in a pattern or practice of presenting or
9		causing to be presented a claim for an item or
10		service that is based on a code that the person
11		knows or should know will result in a greater
12		payment to the person than the code the person
13		knows or should know is applicable to the item or
14		service actually provided;
15		(ii) is for a medical or other item or service
16		and the person knows or should know that the claim
17		is false or fraudulent;
18		(iii) is presented for a vendor physician's
19		service, or an item or service incident to a
20		vendor physician's service, by a person who knows
21		or should know that the individual who furnished,
22		or supervised the furnishing of, the service:
23		(AA) was not licensed as a physician;
24		(BB) was licensed as a physician but such
25		license had been obtained through a
26		misrepresentation of material fact (including

SB3365 Enrolled - 527 - LRB104 18483 SSS 31925 b
1		cheating on an examination required for
2		licensing); or
3		(CC) represented to the patient at the
4		time the service was furnished that the
5		physician was certified in a medical specialty
6		by a medical specialty board, when the
7		individual was not so certified;
8		(iv) is for a medical or other item or service
9		furnished during a period in which the person was
10		excluded from the medical assistance program or a
11		federal or state health care program under which
12		the claim was made pursuant to applicable law; or
13		(v) is for a pattern of medical or other items
14		or services that a person knows or should know are
15		not medically necessary;
16		(b) knowingly presents or causes to be presented
17		to any person a request for payment which is in
18		violation of the conditions for receipt of vendor
19		payments under the medical assistance program under
20		Section 11-13 of this Code;
21		(c) knowingly gives or causes to be given to any
22		person, with respect to medical assistance program
23		coverage of inpatient hospital services, information
24		that he or she knows or should know is false or
25		misleading, and that could reasonably be expected to
26		influence the decision when to discharge such person

SB3365 Enrolled - 528 - LRB104 18483 SSS 31925 b
1		or other individual from the hospital;
2		(d) in the case of a person who is not an
3		organization, agency, or other entity, is excluded
4		from participating in the medical assistance program
5		or a federal or state health care program and who, at
6		the time of a violation of this subsection (E-5):
7		(i) retains a direct or indirect ownership or
8		control interest in an entity that is
9		participating in the medical assistance program or
10		a federal or state health care program, and who
11		knows or should know of the action constituting
12		the basis for the exclusion; or
13		(ii) is an officer or managing employee of
14		such an entity;
15		(e) offers or transfers remuneration to any
16		individual eligible for benefits under the medical
17		assistance program that such person knows or should
18		know is likely to influence such individual to order
19		or receive from a particular vendor, provider,
20		practitioner, or supplier any item or service for
21		which payment may be made, in whole or in part, under
22		the medical assistance program;
23		(f) arranges or contracts (by employment or
24		otherwise) with an individual or entity that the
25		person knows or should know is excluded from
26		participation in the medical assistance program or a

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1		federal or state health care program, for the
2		provision of items or services for which payment may
3		be made under such a program;
4		(g) commits an act described in subsection (b) or
5		(c) of Section 8A-3;
6		(h) knowingly makes, uses, or causes to be made or
7		used, a false record or statement material to a false
8		or fraudulent claim for payment for items and services
9		furnished under the medical assistance program;
10		(i) fails to grant timely access, upon reasonable
11		request (as defined by the Department by rule), to the
12		Inspector General, for the purpose of audits,
13		investigations, evaluations, or other statutory
14		functions of the Inspector General of the Department;
15		(j) orders or prescribes a medical or other item
16		or service during a period in which the person was
17		excluded from the medical assistance program or a
18		federal or state health care program, in the case
19		where the person knows or should know that a claim for
20		such medical or other item or service will be made
21		under such a program;
22		(k) knowingly makes or causes to be made any false
23		statement, omission, or misrepresentation of a
24		material fact in any application, bid, or contract to
25		participate or enroll as a vendor or provider of
26		services or a supplier under the medical assistance

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1		program;
2		(l) knows of an overpayment and does not report
3		and return the overpayment to the Department in
4		accordance with paragraph (6);
5		shall be subject, in addition to any other penalties that
6		may be prescribed by law, to a civil money penalty of not
7		more than $10,000 for each item or service (or, in cases
8		under subparagraph (c), $15,000 for each individual with
9		respect to whom false or misleading information was given;
10		in cases under subparagraph (d), $10,000 for each day the
11		prohibited relationship occurs; in cases under
12		subparagraph (g), $50,000 for each such act; in cases
13		under subparagraph (h), $50,000 for each false record or
14		statement; in cases under subparagraph (i), $15,000 for
15		each day of the failure described in such subparagraph; or
16		in cases under subparagraph (k), $50,000 for each false
17		statement, omission, or misrepresentation of a material
18		fact). In addition, such a person shall be subject to an
19		assessment of not more than 3 times the amount claimed for
20		each such item or service in lieu of damages sustained by
21		the State because of such claim (or, in cases under
22		subparagraph (g), damages of not more than 3 times the
23		total amount of remuneration offered, paid, solicited, or
24		received, without regard to whether a portion of such
25		remuneration was offered, paid, solicited, or received for
26		a lawful purpose; or in cases under subparagraph (k), an

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1		assessment of not more than 3 times the total amount
2		claimed for each item or service for which payment was
3		made based upon the application, bid, or contract
4		containing the false statement, omission, or
5		misrepresentation of a material fact).
6		(3) In addition, the Director or his or her designee
7		may make a determination in the same proceeding to
8		exclude, terminate, suspend, or bar the person from
9		participation in the medical assistance program.
10		(4) The Illinois Department may seek the civil
11		monetary penalties and exclusion, termination, suspension,
12		or barment identified in this subsection (E-5). Prior to
13		the imposition of any penalties or sanctions, the affected
14		person shall be afforded an opportunity for a hearing
15		after reasonable notice. The Department shall establish
16		hearing procedures by rule.
17		(5) Any final order, decision, or other determination
18		made, issued, or executed by the Director under the
19		provisions of this subsection (E-5), whereby a person is
20		aggrieved, shall be subject to review in accordance with
21		the provisions of the Administrative Review Law, and the
22		rules adopted pursuant thereto, which shall apply to and
23		govern all proceedings for the judicial review of final
24		administrative decisions of the Director.
25		(6)(a) If a person has received an overpayment, the
26		person shall:

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1		(i) report and return the overpayment to the
2		Department at the correct address; and
3		(ii) notify the Department in writing of the
4		reason for the overpayment.
5		(b) An overpayment must be reported and returned under
6		subparagraph (a) by the later of:
7		(i) the date which is 60 days after the date on
8		which the overpayment was identified; or
9		(ii) the date any corresponding cost report is
10		due, if applicable.
11		(E-10) A vendor who disputes an overpayment identified as
12		part of a Department audit shall utilize the Department's
13		self-referral disclosure protocol as set forth under this Code
14		to identify, investigate, and return to the Department any
15		undisputed audit overpayment amount. Unless the disputed
16		overpayment amount is subject to a fraud payment suspension,
17		or involves a termination sanction, the Department shall defer
18		the recovery of the disputed overpayment amount up to one year
19		after the date of the Department's final audit determination,
20		or earlier, or as required by State or federal law. If the
21		administrative hearing extends beyond one year, and such delay
22		was not caused by the request of the vendor, then the
23		Department shall not recover the disputed overpayment amount
24		until the date of the final administrative decision. If a
25		final administrative decision establishes that the disputed
26		overpayment amount is owed to the Department, then the amount

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1		shall be immediately due to the Department. The Department
2		shall be entitled to recover interest from the vendor on the
3		overpayment amount from the date of the overpayment through
4		the date the vendor returns the overpayment to the Department
5		at a rate not to exceed the Wall Street Journal Prime Rate, as
6		published from time to time, but not to exceed 5%. Any interest
7		billed by the Department shall be due immediately upon receipt
8		of the Department's billing statement.
9		(F) The Illinois Department may withhold payments to any
10		vendor or alternate payee prior to or during the pendency of
11		any audit or proceeding under this Section, and through the
12		pendency of any administrative appeal or administrative review
13		by any court proceeding. The Illinois Department shall state
14		by rule with as much specificity as practicable the conditions
15		under which payments will not be withheld under this Section.
16		Payments may be denied for bills submitted with service dates
17		occurring during the pendency of a proceeding, after a final
18		decision has been rendered, or after the conclusion of any
19		administrative appeal, where the final administrative decision
20		is to terminate, exclude, or suspend eligibility to
21		participate in the medical assistance program. The Illinois
22		Department shall state by rule with as much specificity as
23		practicable the conditions under which payments will not be
24		denied for such bills. The Illinois Department shall state by
25		rule a process and criteria by which a vendor or alternate
26		payee may request full or partial release of payments withheld

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1		under this subsection. The Department must complete a
2		proceeding under this Section in a timely manner.
3		Notwithstanding recovery allowed under subsection (E) or
4		this subsection (F), the Illinois Department may withhold
5		payments to any vendor or alternate payee who is not properly
6		licensed, certified, or in compliance with State or federal
7		agency regulations. Payments may be denied for bills submitted
8		with service dates occurring during the period of time that a
9		vendor is not properly licensed, certified, or in compliance
10		with State or federal regulations. Facilities licensed under
11		the Nursing Home Care Act shall have payments denied or
12		withheld pursuant to subsection (I) of this Section.
13		(F-5) The Illinois Department may temporarily withhold
14		payments to a vendor or alternate payee if any of the following
15		individuals have been indicted or otherwise charged under a
16		law of the United States or this or any other state with an
17		offense that is based on alleged fraud or willful
18		misrepresentation on the part of the individual related to (i)
19		the medical assistance program under Article V of this Code,
20		(ii) a federal or another state's medical assistance or health
21		care program, or (iii) the provision of health care services:
22		(1) If the vendor or alternate payee is a corporation:
23		an officer of the corporation or an individual who owns,
24		either directly or indirectly, 5% or more of the shares of
25		stock or other evidence of ownership of the corporation.
26		(2) If the vendor is a sole proprietorship: the owner

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1		of the sole proprietorship.
2		(3) If the vendor or alternate payee is a partnership:
3		a partner in the partnership.
4		(4) If the vendor or alternate payee is any other
5		business entity authorized by law to transact business in
6		this State: an officer of the entity or an individual who
7		owns, either directly or indirectly, 5% or more of the
8		evidences of ownership of the entity.
9		If the Illinois Department withholds payments to a vendor
10		or alternate payee under this subsection, the Department shall
11		not release those payments to the vendor or alternate payee
12		while any criminal proceeding related to the indictment or
13		charge is pending unless the Department determines that there
14		is good cause to release the payments before completion of the
15		proceeding. If the indictment or charge results in the
16		individual's conviction, the Illinois Department shall retain
17		all withheld payments, which shall be considered forfeited to
18		the Department. If the indictment or charge does not result in
19		the individual's conviction, the Illinois Department shall
20		release to the vendor or alternate payee all withheld
21		payments.
22		(F-10) If the Illinois Department establishes that the
23		vendor or alternate payee owes a debt to the Illinois
24		Department, and the vendor or alternate payee subsequently
25		fails to pay or make satisfactory payment arrangements with
26		the Illinois Department for the debt owed, the Illinois

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1		Department may seek all remedies available under the law of
2		this State to recover the debt, including, but not limited to,
3		wage garnishment or the filing of claims or liens against the
4		vendor or alternate payee.
5		(F-15) Enforcement of judgment.
6		(1) Any fine, recovery amount, other sanction, or
7		costs imposed, or part of any fine, recovery amount, other
8		sanction, or cost imposed, remaining unpaid after the
9		exhaustion of or the failure to exhaust judicial review
10		procedures under the Illinois Administrative Review Law is
11		a debt due and owing the State and may be collected using
12		all remedies available under the law.
13		(2) After expiration of the period in which judicial
14		review under the Illinois Administrative Review Law may be
15		sought for a final administrative decision, unless stayed
16		by a court of competent jurisdiction, the findings,
17		decision, and order of the Director may be enforced in the
18		same manner as a judgment entered by a court of competent
19		jurisdiction.
20		(3) In any case in which any person or entity has
21		failed to comply with a judgment ordering or imposing any
22		fine or other sanction, any expenses incurred by the
23		Illinois Department to enforce the judgment, including,
24		but not limited to, attorney's fees, court costs, and
25		costs related to property demolition or foreclosure, after
26		they are fixed by a court of competent jurisdiction or the

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1		Director, shall be a debt due and owing the State and may
2		be collected in accordance with applicable law. Prior to
3		any expenses being fixed by a final administrative
4		decision pursuant to this subsection (F-15), the Illinois
5		Department shall provide notice to the individual or
6		entity that states that the individual or entity shall
7		appear at a hearing before the administrative hearing
8		officer to determine whether the individual or entity has
9		failed to comply with the judgment. The notice shall set
10		the date for such a hearing, which shall not be less than 7
11		days from the date that notice is served. If notice is
12		served by mail, the 7-day period shall begin to run on the
13		date that the notice was deposited in the mail.
14		(4) Upon being recorded in the manner required by
15		Article XII of the Code of Civil Procedure or by the
16		Uniform Commercial Code, a lien shall be imposed on the
17		real estate or personal estate, or both, of the individual
18		or entity in the amount of any debt due and owing the State
19		under this Section. The lien may be enforced in the same
20		manner as a judgment of a court of competent jurisdiction.
21		A lien shall attach to all property and assets of such
22		person, firm, corporation, association, agency,
23		institution, or other legal entity until the judgment is
24		satisfied.
25		(5) The Director may set aside any judgment entered by
26		default and set a new hearing date upon a petition filed at

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1		any time (i) if the petitioner's failure to appear at the
2		hearing was for good cause, or (ii) if the petitioner
3		established that the Department did not provide proper
4		service of process. If any judgment is set aside pursuant
5		to this paragraph (5), the hearing officer shall have
6		authority to enter an order extinguishing any lien which
7		has been recorded for any debt due and owing the Illinois
8		Department as a result of the vacated default judgment.
9		(G) The provisions of the Administrative Review Law, as
10		now or hereafter amended, and the rules adopted pursuant
11		thereto, shall apply to and govern all proceedings for the
12		judicial review of final administrative decisions of the
13		Illinois Department under this Section. The term
14		"administrative decision" is defined as in Section 3-101 of
15		the Code of Civil Procedure.
16		(G-5) Vendors who pose a risk of fraud, waste, abuse, or
17		harm.
18		(1) Notwithstanding any other provision in this
19		Section, the Department may terminate, suspend, or exclude
20		vendors who pose a risk of fraud, waste, abuse, or harm
21		from participation in the medical assistance program prior
22		to an evidentiary hearing but after reasonable notice and
23		opportunity to respond as established by the Department by
24		rule.
25		(2) Vendors who pose a risk of fraud, waste, abuse, or
26		harm shall submit to a fingerprint-based criminal

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1		background check on current and future information
2		available in the State system and current information
3		available through the Federal Bureau of Investigation's
4		system by submitting all necessary fees and information in
5		the form and manner prescribed by the Illinois State
6		Police. The following individuals shall be subject to the
7		check:
8		(A) In the case of a vendor that is a corporation,
9		every shareholder who owns, directly or indirectly, 5%
10		or more of the outstanding shares of the corporation.
11		(B) In the case of a vendor that is a partnership,
12		every partner.
13		(C) In the case of a vendor that is a sole
14		proprietorship, the sole proprietor.
15		(D) Each officer or manager of the vendor.
16		Each such vendor shall be responsible for payment of
17		the cost of the criminal background check.
18		(3) Vendors who pose a risk of fraud, waste, abuse, or
19		harm may be required to post a surety bond. The Department
20		shall establish, by rule, the criteria and requirements
21		for determining when a surety bond must be posted and the
22		value of the bond.
23		(4) The Department, or its agents, may refuse to
24		accept requests for authorization from specific vendors
25		who pose a risk of fraud, waste, abuse, or harm, including
26		prior-approval and post-approval requests, if:

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1		(A) the Department has initiated a notice of
2		termination, suspension, or exclusion of the vendor
3		from participation in the medical assistance program;
4		or
5		(B) the Department has issued notification of its
6		withholding of payments pursuant to subsection (F-5)
7		of this Section; or
8		(C) the Department has issued a notification of
9		its withholding of payments due to reliable evidence
10		of fraud or willful misrepresentation pending
11		investigation.
12		(5) As used in this subsection, the following terms
13		are defined as follows:
14		(A) "Fraud" means an intentional deception or
15		misrepresentation made by a person with the knowledge
16		that the deception could result in some unauthorized
17		benefit to himself or herself or some other person. It
18		includes any act that constitutes fraud under
19		applicable federal or State law.
20		(B) "Abuse" means provider practices that are
21		inconsistent with sound fiscal, business, or medical
22		practices and that result in an unnecessary cost to
23		the medical assistance program or in reimbursement for
24		services that are not medically necessary or that fail
25		to meet professionally recognized standards for health
26		care. It also includes recipient practices that result

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1		in unnecessary cost to the medical assistance program.
2		Abuse does not include diagnostic or therapeutic
3		measures conducted primarily as a safeguard against
4		possible vendor liability.
5		(C) "Waste" means the unintentional misuse of
6		medical assistance resources, resulting in unnecessary
7		cost to the medical assistance program. Waste does not
8		include diagnostic or therapeutic measures conducted
9		primarily as a safeguard against possible vendor
10		liability.
11		(D) "Harm" means physical, mental, or monetary
12		damage to recipients or to the medical assistance
13		program.
14		(G-6) The Illinois Department, upon making a determination
15		based upon information in the possession of the Illinois
16		Department that continuation of participation in the medical
17		assistance program by a vendor would constitute an immediate
18		danger to the public, may immediately suspend such vendor's
19		participation in the medical assistance program without a
20		hearing. In instances in which the Illinois Department
21		immediately suspends the medical assistance program
22		participation of a vendor under this Section, a hearing upon
23		the vendor's participation must be convened by the Illinois
24		Department within 15 days after such suspension and completed
25		without appreciable delay. Such hearing shall be held to
26		determine whether to recommend to the Director that the

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1		vendor's medical assistance program participation be denied,
2		terminated, suspended, placed on provisional status, or
3		reinstated. In the hearing, any evidence relevant to the
4		vendor constituting an immediate danger to the public may be
5		introduced against such vendor; provided, however, that the
6		vendor, or his or her counsel, shall have the opportunity to
7		discredit, impeach, and submit evidence rebutting such
8		evidence.
9		(H) Nothing contained in this Code shall in any way limit
10		or otherwise impair the authority or power of any State agency
11		responsible for licensing of vendors.
12		(I) Based on a finding of noncompliance on the part of a
13		nursing home with any requirement for certification under
14		Title XVIII or XIX of the Social Security Act (42 U.S.C. Sec.
15		1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois
16		Department may impose one or more of the following remedies
17		after notice to the facility:
18		(1) Termination of the provider agreement.
19		(2) Temporary management.
20		(3) Denial of payment for new admissions.
21		(4) Civil money penalties.
22		(5) Closure of the facility in emergency situations or
23		transfer of residents, or both.
24		(6) State monitoring.
25		(7) Denial of all payments when the U.S. Department of
26		Health and Human Services has imposed this sanction.

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1		The Illinois Department shall by rule establish criteria
2		governing continued payments to a nursing facility subsequent
3		to termination of the facility's provider agreement if, in the
4		sole discretion of the Illinois Department, circumstances
5		affecting the health, safety, and welfare of the facility's
6		residents require those continued payments. The Illinois
7		Department may condition those continued payments on the
8		appointment of temporary management, sale of the facility to
9		new owners or operators, or other arrangements that the
10		Illinois Department determines best serve the needs of the
11		facility's residents.
12		Except in the case of a facility that has a right to a
13		hearing on the finding of noncompliance before an agency of
14		the federal government, a facility may request a hearing
15		before a State agency on any finding of noncompliance within
16		60 days after the notice of the intent to impose a remedy.
17		Except in the case of civil money penalties, a request for a
18		hearing shall not delay imposition of the penalty. The choice
19		of remedies is not appealable at a hearing. The level of
20		noncompliance may be challenged only in the case of a civil
21		money penalty. The Illinois Department shall provide by rule
22		for the State agency that will conduct the evidentiary
23		hearings.
24		The Illinois Department may collect interest on unpaid
25		civil money penalties.
26		The Illinois Department may adopt all rules necessary to

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1		implement this subsection (I).
2		(J) The Illinois Department, by rule, may permit
3		individual practitioners to designate that Department payments
4		that may be due the practitioner be made to an alternate payee
5		or alternate payees.
6		(a) Such alternate payee or alternate payees shall be
7		required to register as an alternate payee in the Medical
8		Assistance Program with the Illinois Department.
9		(b) If a practitioner designates an alternate payee,
10		the alternate payee and practitioner shall be jointly and
11		severally liable to the Department for payments made to
12		the alternate payee. Pursuant to subsection (E) of this
13		Section, any Department action to suspend or deny payment
14		or recover money or overpayments from an alternate payee
15		shall be subject to an administrative hearing.
16		(c) Registration as an alternate payee or alternate
17		payees in the Illinois Medical Assistance Program shall be
18		conditional. At any time, the Illinois Department may deny
19		or cancel any alternate payee's registration in the
20		Illinois Medical Assistance Program without cause. Any
21		such denial or cancellation is not subject to an
22		administrative hearing.
23		(d) The Illinois Department may seek a revocation of
24		any alternate payee, and all owners, officers, and
25		individuals with management responsibility for such
26		alternate payee shall be permanently prohibited from

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1		participating as an owner, an officer, or an individual
2		with management responsibility with an alternate payee in
3		the Illinois Medical Assistance Program, if after
4		reasonable notice and opportunity for a hearing the
5		Illinois Department finds that:
6		(1) the alternate payee is not complying with the
7		Department's policy or rules and regulations, or with
8		the terms and conditions prescribed by the Illinois
9		Department in its alternate payee registration
10		agreement; or
11		(2) the alternate payee has failed to keep or make
12		available for inspection, audit, or copying, after
13		receiving a written request from the Illinois
14		Department, such records regarding payments claimed as
15		an alternate payee; or
16		(3) the alternate payee has failed to furnish any
17		information requested by the Illinois Department
18		regarding payments claimed as an alternate payee; or
19		(4) the alternate payee has knowingly made, or
20		caused to be made, any false statement or
21		representation of a material fact in connection with
22		the administration of the Illinois Medical Assistance
23		Program; or
24		(5) the alternate payee, a person with management
25		responsibility for an alternate payee, an officer or
26		person owning, either directly or indirectly, 5% or

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1		more of the shares of stock or other evidences of
2		ownership in a corporate alternate payee, or a partner
3		in a partnership which is an alternate payee:
4		(a) was previously terminated, suspended, or
5		excluded from participation as a vendor in the
6		Illinois Medical Assistance Program, or was
7		previously revoked as an alternate payee in the
8		Illinois Medical Assistance Program, or was
9		terminated, suspended, or excluded from
10		participation as a vendor in a medical assistance
11		program in another state that is of the same kind
12		as the program of medical assistance provided
13		under Article V of this Code; or
14		(b) was a person with management
15		responsibility for a vendor previously terminated,
16		suspended, or excluded from participation as a
17		vendor in the Illinois Medical Assistance Program,
18		or was previously revoked as an alternate payee in
19		the Illinois Medical Assistance Program, or was
20		terminated, suspended, or excluded from
21		participation as a vendor in a medical assistance
22		program in another state that is of the same kind
23		as the program of medical assistance provided
24		under Article V of this Code, during the time of
25		conduct which was the basis for that vendor's
26		termination, suspension, or exclusion or alternate

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1		payee's revocation; or
2		(c) was an officer, or person owning, either
3		directly or indirectly, 5% or more of the shares
4		of stock or other evidences of ownership in a
5		corporate vendor previously terminated, suspended,
6		or excluded from participation as a vendor in the
7		Illinois Medical Assistance Program, or was
8		previously revoked as an alternate payee in the
9		Illinois Medical Assistance Program, or was
10		terminated, suspended, or excluded from
11		participation as a vendor in a medical assistance
12		program in another state that is of the same kind
13		as the program of medical assistance provided
14		under Article V of this Code, during the time of
15		conduct which was the basis for that vendor's
16		termination, suspension, or exclusion; or
17		(d) was an owner of a sole proprietorship or
18		partner in a partnership previously terminated,
19		suspended, or excluded from participation as a
20		vendor in the Illinois Medical Assistance Program,
21		or was previously revoked as an alternate payee in
22		the Illinois Medical Assistance Program, or was
23		terminated, suspended, or excluded from
24		participation as a vendor in a medical assistance
25		program in another state that is of the same kind
26		as the program of medical assistance provided

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1		under Article V of this Code, during the time of
2		conduct which was the basis for that vendor's
3		termination, suspension, or exclusion or alternate
4		payee's revocation; or
5		(6) the alternate payee, a person with management
6		responsibility for an alternate payee, an officer or
7		person owning, either directly or indirectly, 5% or
8		more of the shares of stock or other evidences of
9		ownership in a corporate alternate payee, or a partner
10		in a partnership which is an alternate payee:
11		(a) has engaged in conduct prohibited by
12		applicable federal or State law or regulation
13		relating to the Illinois Medical Assistance
14		Program; or
15		(b) was a person with management
16		responsibility for a vendor or alternate payee at
17		the time that the vendor or alternate payee
18		engaged in practices prohibited by applicable
19		federal or State law or regulation relating to the
20		Illinois Medical Assistance Program; or
21		(c) was an officer, or person owning, either
22		directly or indirectly, 5% or more of the shares
23		of stock or other evidences of ownership in a
24		vendor or alternate payee at the time such vendor
25		or alternate payee engaged in practices prohibited
26		by applicable federal or State law or regulation

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1		relating to the Illinois Medical Assistance
2		Program; or
3		(d) was an owner of a sole proprietorship or
4		partner in a partnership which was a vendor or
5		alternate payee at the time such vendor or
6		alternate payee engaged in practices prohibited by
7		applicable federal or State law or regulation
8		relating to the Illinois Medical Assistance
9		Program; or
10		(7) the direct or indirect ownership of the vendor
11		or alternate payee (including the ownership of a
12		vendor or alternate payee that is a partner's interest
13		in a vendor or alternate payee, or ownership of 5% or
14		more of the shares of stock or other evidences of
15		ownership in a corporate vendor or alternate payee)
16		has been transferred by an individual who is
17		terminated, suspended, or excluded or barred from
18		participating as a vendor or is prohibited or revoked
19		as an alternate payee to the individual's spouse,
20		child, brother, sister, parent, grandparent,
21		grandchild, uncle, aunt, niece, nephew, cousin, or
22		relative by marriage.
23		(K) The Illinois Department of Healthcare and Family
24		Services may withhold payments, in whole or in part, to a
25		provider or alternate payee where there is credible evidence,
26		received from State or federal law enforcement or federal

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1		oversight agencies or from the results of a preliminary
2		Department audit, that the circumstances giving rise to the
3		need for a withholding of payments may involve fraud or
4		willful misrepresentation under the Illinois Medical
5		Assistance program. The Department shall by rule define what
6		constitutes "credible" evidence for purposes of this
7		subsection. The Department may withhold payments without first
8		notifying the provider or alternate payee of its intention to
9		withhold such payments. A provider or alternate payee may
10		request a reconsideration of payment withholding, and the
11		Department must grant such a request. The Department shall
12		state by rule a process and criteria by which a provider or
13		alternate payee may request full or partial release of
14		payments withheld under this subsection. This request may be
15		made at any time after the Department first withholds such
16		payments.
17		(a) The Illinois Department must send notice of its
18		withholding of program payments within 5 days of taking
19		such action. The notice must set forth the general
20		allegations as to the nature of the withholding action,
21		but need not disclose any specific information concerning
22		its ongoing investigation. The notice must do all of the
23		following:
24		(1) State that payments are being withheld in
25		accordance with this subsection.
26		(2) State that the withholding is for a temporary

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1		period, as stated in paragraph (b) of this subsection,
2		and cite the circumstances under which withholding
3		will be terminated.
4		(3) Specify, when appropriate, which type or types
5		of Medicaid claims withholding is effective.
6		(4) Inform the provider or alternate payee of the
7		right to submit written evidence for reconsideration
8		of the withholding by the Illinois Department.
9		(5) Inform the provider or alternate payee that a
10		written request may be made to the Illinois Department
11		for full or partial release of withheld payments and
12		that such requests may be made at any time after the
13		Department first withholds such payments.
14		(b) All withholding-of-payment actions under this
15		subsection shall be temporary and shall not continue after
16		any of the following:
17		(1) The Illinois Department or the prosecuting
18		authorities determine that there is insufficient
19		evidence of fraud or willful misrepresentation by the
20		provider or alternate payee.
21		(2) Legal proceedings related to the provider's or
22		alternate payee's alleged fraud, willful
23		misrepresentation, violations of this Act, or
24		violations of the Illinois Department's administrative
25		rules are completed.
26		(3) The withholding of payments for a period of 3

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1		years.
2		(c) The Illinois Department may adopt all rules
3		necessary to implement this subsection (K).
4		(K-5) The Illinois Department may withhold payments, in
5		whole or in part, to a provider or alternate payee upon
6		initiation of an audit, quality of care review, investigation
7		when there is a credible allegation of fraud, or the provider
8		or alternate payee demonstrating a clear failure to cooperate
9		with the Illinois Department such that the circumstances give
10		rise to the need for a withholding of payments. As used in this
11		subsection, "credible allegation" is defined to include an
12		allegation from any source, including, but not limited to,
13		fraud hotline complaints, claims data mining, patterns
14		identified through provider audits, civil actions filed under
15		the Illinois False Claims Act, and law enforcement
16		investigations. An allegation is considered to be credible
17		when it has indicia of reliability. The Illinois Department
18		may withhold payments without first notifying the provider or
19		alternate payee of its intention to withhold such payments. A
20		provider or alternate payee may request a hearing or a
21		reconsideration of payment withholding, and the Illinois
22		Department must grant such a request. The Illinois Department
23		shall state by rule a process and criteria by which a provider
24		or alternate payee may request a hearing or a reconsideration
25		for the full or partial release of payments withheld under
26		this subsection. This request may be made at any time after the

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1		Illinois Department first withholds such payments.
2		(a) The Illinois Department must send notice of its
3		withholding of program payments within 5 days of taking
4		such action. The notice must set forth the general
5		allegations as to the nature of the withholding action but
6		need not disclose any specific information concerning its
7		ongoing investigation. The notice must do all of the
8		following:
9		(1) State that payments are being withheld in
10		accordance with this subsection.
11		(2) State that the withholding is for a temporary
12		period, as stated in paragraph (b) of this subsection,
13		and cite the circumstances under which withholding
14		will be terminated.
15		(3) Specify, when appropriate, which type or types
16		of claims are withheld.
17		(4) Inform the provider or alternate payee of the
18		right to request a hearing or a reconsideration of the
19		withholding by the Illinois Department, including the
20		ability to submit written evidence.
21		(5) Inform the provider or alternate payee that a
22		written request may be made to the Illinois Department
23		for a hearing or a reconsideration for the full or
24		partial release of withheld payments and that such
25		requests may be made at any time after the Illinois
26		Department first withholds such payments.

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1		(b) All withholding of payment actions under this
2		subsection shall be temporary and shall not continue after
3		any of the following:
4		(1) The Illinois Department determines that there
5		is insufficient evidence of fraud, or the provider or
6		alternate payee demonstrates clear cooperation with
7		the Illinois Department, as determined by the Illinois
8		Department, such that the circumstances do not give
9		rise to the need for withholding of payments; or
10		(2) The withholding of payments has lasted for a
11		period in excess of 3 years.
12		(c) The Illinois Department may adopt all rules
13		necessary to implement this subsection (K-5).
14		(L) The Illinois Department shall establish a protocol to
15		enable health care providers to disclose an actual or
16		potential violation of this Section pursuant to a
17		self-referral disclosure protocol, referred to in this
18		subsection as "the protocol". The protocol shall include
19		direction for health care providers on a specific person,
20		official, or office to whom such disclosures shall be made.
21		The Illinois Department shall post information on the protocol
22		on the Illinois Department's public website. The Illinois
23		Department may adopt rules necessary to implement this
24		subsection (L). In addition to other factors that the Illinois
25		Department finds appropriate, the Illinois Department may
26		consider a health care provider's timely use or failure to use

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1		the protocol in considering the provider's failure to comply
2		with this Code.
3		(M) Notwithstanding any other provision of this Code, the
4		Illinois Department, at its discretion, may exempt an entity
5		licensed under the Nursing Home Care Act, the ID/DD Community
6		Care Act, or the MC/DD Act from the provisions of subsections
7		(A-15), (B), and (C) of this Section if the licensed entity is
8		in receivership.
9		(O) Enforcement of advance payment agreements. To the
10		extent not prohibited by federal or State law, and
11		notwithstanding any other provision of this Code, if a
12		provider fails to comply with the terms of an advance payment
13		agreement, the Department is authorized to collect any unpaid
14		advance balance through one or more of the following methods:
15		(1) Direct withholding of Department reimbursements.
16		The Department may withhold reimbursement or other amounts
17		otherwise payable by the Department to the provider,
18		including, but not limited to, fee-for-service claims
19		payments, supplemental payments, and any other amounts the
20		Department is obligated to pay the provider under the
21		medical assistance program, and apply such withheld
22		amounts as repayment of the unpaid advance.
23		(2) Managed care organizations remittance. If a
24		provider participates in a managed care program
25		administered by the Department, the Department may direct
26		the managed care organization to remit to the Department

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1		amounts otherwise payable by the managed care organization
2		to the provider, and apply such remitted amounts as
3		repayment of the unpaid advance.
4		The requirements of this subsection may be waived by the
5		Department in instances when a nursing home provider has
6		entered into and remains in compliance with a renegotiated
7		advance payment agreement. A renegotiated advance payment
8		agreement must be entered into no later than 60 days after the
9		effective date of this amendatory Act of the 104th General
10		Assembly.
11		A nursing home must enter into a renegotiated advance
12		payment agreement with the Department that includes terms for
13		repayment of the total amount owed for all outstanding amounts
14		over a 12-month period, repaid in equal payment increments.
15		Payments shall begin within 30 days of the signed agreement
16		date.
17		Failure to remain in compliance with a renegotiated
18		advance payment agreement shall cause immediate termination of
19		such an agreement unless there is prior written consent from
20		the Department for a period of non-compliance.
21		Beginning September 1, 2026, the Department shall
22		immediately collect all overdue unpaid advance debts through
23		the collection methods authorized under this Section, unless a
24		renegotiated advance payment agreement has already been agreed
25		to.
26		(Source: P.A. 102-538, eff. 8-20-21.)

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1		ARTICLE 265.
2		Section 265-5. The State Finance Act is amended by adding
3		Sections 5.1039 and 6z-149 as follows:
4		(30 ILCS 105/5.1039 new)
5		Sec. 5.1039. The Staffing Improvement and Long Term Care
6		Oversight Fund.
7		(30 ILCS 105/6z-149 new)
8		Sec. 6z-149. The Staffing Improvement and Long Term Care
9		Oversight Fund.
10		(a) The Staffing Improvement and Long Term Care Oversight
11		Fund is created as a special fund in the State treasury.
12		Interest earned by the Fund shall be credited to the Fund.
13		(b) Any moneys generated from penalties imposed for
14		non-compliance with minimum staffing standards under Section
15		3-202.05 of the Nursing Home Care Act shall be deposited into
16		the Fund. Any funds distributed and granted pursuant to this
17		Section shall be contingent on the Department's actual
18		collection of staffing fines under Section 3-202.02 of the
19		Nursing Home Care Act. Beginning in Fiscal Year 2027, funds
20		shall be distributed as follows:
21		(1) $1,000,000 shall be used in each State fiscal year
22		by the Department of Public Health to train surveyors for

SB3365 Enrolled - 558 - LRB104 18483 SSS 31925 b
1		administration of the Bureau of Long Term Care Training.
2		This funding shall not be used to used to replace any other
3		funding appropriated by the General Assembly for this
4		purpose.
5		(2) 15% of the funding shall be used by the of Public
6		Health to fund Nursing Home Care Act compliance efforts.
7		(3) $2,000,000 or 50% of the remainder of the moneys
8		deposited under this subsection after the allocations
9		under paragraphs (1) and (2) have been completed,
10		whichever is higher, shall be allocated in each State
11		fiscal year to be ordered transferred by the State
12		Comptroller and transferred by the State Treasurer from
13		the Staffing Improvement and Long Term Care Oversight Fund
14		to be used by the Department to support a Certified
15		Nursing Assistant Workforce Pipeline Program to recruit,
16		support, and train individuals to work as certified
17		nursing assistants at nursing facilities, with a focus on
18		facilities in disadvantaged communities, those serving
19		residents of color, and understaffed facilities. The
20		program shall be administered by a labor-management
21		organization acting on behalf of a partnership between
22		nursing facilities and a labor organization representing
23		nursing home workers. The labor-management organization
24		must demonstrate the ability to recruit, support, train,
25		and place individuals in careers in health care with a
26		specific focus on addressing staff shortages. Program

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1		training and instruction must meet State and federal
2		education regulations and must provide a pathway for
3		participants to receive certification as nursing
4		assistants. Any funds distributed pursuant to this Section
5		shall be compliant with the Grant Accountability and
6		Transparency Act and its regulations, as applicable.
7		The program may provide supportive services to program
8		participants, including, but not limited to, mentoring and
9		a wraparound support stipend that would cover expenses
10		such as utilities, dependent care, and transportation.
11		(4) $2,000,000 shall be used in each State fiscal year
12		by the Department of Public Health to administer the
13		identified offenders and other safety activities.
14		(5) 40% of the remainder of the moneys deposited under
15		this subsection after the allocations under paragraphs
16		(1), (2), (3), and (4) have been completed shall, in each
17		fiscal year, be ordered transferred by the State
18		Comptroller and transferred by the State Treasurer from
19		the Staffing Improvement and Long Term Care Fund to the
20		State Board of Education Special Purposes Trust Fund to be
21		used by the State Board of Education to support the
22		allocation of formula grants for the purposes of
23		supporting programs and coursework that provide vocational
24		training of certified nursing assistants at the secondary
25		level of education, provided that the funds are allocated
26		for the purpose of increasing staffing in Illinois nursing

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1		homes. Entities eligible for award include area career
2		centers and Education for Employment regional CTE systems,
3		as approved by rule of the State Board of Education. Each
4		eligible entity shall receive a formula grant based on
5		student enrollment, credential attainment, and employment.
6		The total appropriation that the State Board of Education
7		receives shall be divided into formula grants proportional
8		to each eligible entity's student participation,
9		credential attainment, and employment according to the
10		following: 50% shall be divided among all entities with
11		students enrolled in all health sciences pathways, 15%
12		shall be divided across all entities with students earning
13		CNA certificates, 20% shall be divided by each student
14		placed at elder care facilities for work-based learning in
15		the prior school year, and 15% shall be divided by the
16		total number of graduates from the prior fiscal year who
17		are employed at elder care facilities. Recipients will
18		provide mid-year and annual reports on templates provided
19		by rhe State Board of Education. Any entity receiving
20		funds under paragraph (3) is not eligible to receive
21		funding under this subsection.
22		(6) 40% of the remainder of the moneys deposited under
23		this subsection after the allocations under paragraphs
24		(1), (2), (3), and (4) have been completed shall, in each
25		fiscal year, be ordered transferred by the State
26		Comptroller and transferred by the State Treasurer from

SB3365 Enrolled - 561 - LRB104 18483 SSS 31925 b
1		the Staffing Improvement and Long Term Care Oversight Fund
2		to the Education Assistance Fund for the Long Term Care
3		Nursing Scholarship Program for scholarships to be awarded
4		to applicants pursuing or intending to pursue employment
5		as a nurse in a licensed nursing home in Illinois. The
6		Illinois Student Assistance Commission shall adopt
7		administrative rules governing the amount, criteria, and
8		award of scholarships to be awarded under this Section.
9		Section 265-10. The Nursing Home Care Act is amended by
10		changing Section 3-202.05 as follows:
11		(210 ILCS 45/3-202.05)
12		Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
13		thereafter.
14		(a) For the purpose of computing staff to resident ratios,
15		direct care staff shall include:
16		(1) registered nurses;
17		(2) licensed practical nurses;
18		(3) certified nurse assistants;
19		(4) psychiatric services rehabilitation aides;
20		(5) rehabilitation and therapy aides;
21		(6) psychiatric services rehabilitation coordinators;
22		(7) assistant directors of nursing;
23		(8) 50% of the Director of Nurses' time; and
24		(9) 30% of the Social Services Directors' time.

SB3365 Enrolled - 562 - LRB104 18483 SSS 31925 b
1		The Department shall, by rule, allow certain facilities
2		subject to 77 Ill. Adm. Code 300.4000 and following (Subpart
3		S) to utilize specialized clinical staff, as defined in rules,
4		to count towards the staffing ratios.
5		Within 120 days of June 14, 2012 (the effective date of
6		Public Act 97-689), the Department shall promulgate rules
7		specific to the staffing requirements for facilities federally
8		defined as Institutions for Mental Disease. These rules shall
9		recognize the unique nature of individuals with chronic mental
10		health conditions, shall include minimum requirements for
11		specialized clinical staff, including clinical social workers,
12		psychiatrists, psychologists, and direct care staff set forth
13		in paragraphs (4) through (6) and any other specialized staff
14		which may be utilized and deemed necessary to count toward
15		staffing ratios.
16		Within 120 days of June 14, 2012 (the effective date of
17		Public Act 97-689), the Department shall promulgate rules
18		specific to the staffing requirements for facilities licensed
19		under the Specialized Mental Health Rehabilitation Act of
20		2013. These rules shall recognize the unique nature of
21		individuals with chronic mental health conditions, shall
22		include minimum requirements for specialized clinical staff,
23		including clinical social workers, psychiatrists,
24		psychologists, and direct care staff set forth in paragraphs
25		(4) through (6) and any other specialized staff which may be
26		utilized and deemed necessary to count toward staffing ratios.

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1		(a-5) The Centers for Medicare and Medicaid Services'
2		payroll-based journal job title codes, which correspond to the
3		staff used for the staffing ratios in subsection (a), are as
4		follows:
5		(1) Registered Nurse Director of Nursing, job title
6		code 5.
7		(2) Registered Nurse with Administrative Duties, job
8		title code 6.
9		(3) Registered Nurse, job title code 7.
10		(4) Licensed Practical/Vocational Nurse with
11		Administrative Duties, job title code 8.
12		(5) Licensed Practical/Vocational Nurse, job title
13		code 9.
14		(6) Certified Nurse Aide, job title code 10.
15		(7) Nurse Aide in Training, job title code 11.
16		(8) Medication Aide/Technician, job title code 12.
17		(9) Nurse Practitioner, job title code 13.
18		(10) Clinical Nurse Specialist, job title code 14.
19		(11) Occupational Therapist, job title code 18.
20		(12) Occupational Therapy Assistant, job title code
21		19.
22		(13) Occupational Therapy Aide, job title code 20.
23		(14) Physical Therapist, job title code 21.
24		(15) Physical Therapy Assistant, job title code 22.
25		(16) Physical Therapy Assistant, job title code 23.
26		(17) Respiratory Therapist, job title code 24.

SB3365 Enrolled - 564 - LRB104 18483 SSS 31925 b
1		(18) Respiratory Therapy Technician, job title code
2		25.
3		(19) Speech/Language Pathologist, job title code 26.
4		(20) Qualified Activities Professional, job title code
5		28.
6		(21) Other Activities Staff, job title code 29.
7		(22) Qualified Social Worker, job title code 30.
8		(23) Other Social Worker, job title code 31.
9		(24) Mental Health Service Worker, job title code 34.
10		For all job title codes in this subsection, 100% of the
11		hours worked by the staff must be counted toward the
12		staff-to-resident ratio, except job code title 5, which is
13		limited to 50%, and job title codes 28, 30, and 31, which are
14		limited to 30%.
15		(b) (Blank).
16		(b-5) For purposes of the minimum staffing ratios in this
17		Section, all residents shall be classified as requiring either
18		skilled care or intermediate care.
19		As used in this subsection:
20		"Intermediate care" means basic nursing care and other
21		restorative services under periodic medical direction.
22		"Skilled care" means skilled nursing care, continuous
23		skilled nursing observations, restorative nursing, and other
24		services under professional direction with frequent medical
25		supervision.
26		(c) Facilities shall notify the Department within 60 days

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1		after July 29, 2010 (the effective date of Public Act
2		96-1372), in a form and manner prescribed by the Department,
3		of the staffing ratios in effect on July 29, 2010 (the
4		effective date of Public Act 96-1372) for both intermediate
5		and skilled care and the number of residents receiving each
6		level of care.
7		(d)(1) (Blank).
8		(2) (Blank).
9		(3) (Blank).
10		(4) (Blank).
11		(5) Effective January 1, 2014, the minimum staffing ratios
12		shall be increased to 3.8 hours of nursing and personal care
13		each day for a resident needing skilled care and 2.5 hours of
14		nursing and personal care each day for a resident needing
15		intermediate care.
16		(e) Ninety days after June 14, 2012 (the effective date of
17		Public Act 97-689), a minimum of 25% of nursing and personal
18		care time shall be provided by licensed nurses, with at least
19		10% of nursing and personal care time provided by registered
20		nurses. These minimum requirements shall remain in effect
21		until an acuity based registered nurse requirement is
22		promulgated by rule concurrent with the adoption of the
23		Resource Utilization Group classification-based payment
24		methodology, as provided in Section 5-5.2 of the Illinois
25		Public Aid Code. Registered nurses and licensed practical
26		nurses employed by a facility in excess of these requirements

SB3365 Enrolled - 566 - LRB104 18483 SSS 31925 b
1		may be used to satisfy the remaining 75% of the nursing and
2		personal care time requirements. Notwithstanding this
3		subsection, no staffing requirement in statute in effect on
4		June 14, 2012 (the effective date of Public Act 97-689) shall
5		be reduced on account of this subsection.
6		(f) The Department shall submit proposed rules for
7		adoption by January 1, 2020 establishing a system for
8		determining compliance with minimum staffing set forth in this
9		Section and the requirements of 77 Ill. Adm. Code 300.1230
10		adjusted for any waivers granted under Section 3-303.1.
11		Compliance shall be determined quarterly by comparing the
12		number of hours provided per resident per day using the
13		Centers for Medicare and Medicaid Services' payroll-based
14		journal and the facility's daily census, broken down by
15		intermediate and skilled care as self-reported by the facility
16		to the Department on a quarterly basis. The Department shall
17		use the quarterly payroll-based journal and the self-reported
18		census to calculate the number of hours provided per resident
19		per day and compare this ratio to the minimum staffing
20		standards required under this Section, as impacted by any
21		waivers granted under Section 3-303.1. Discrepancies between
22		job titles contained in this Section and the payroll-based
23		journal shall be addressed by rule. The manner in which the
24		Department requests payroll-based journal information to be
25		submitted shall align with the federal Centers for Medicare
26		and Medicaid Services' requirements that allow providers to

SB3365 Enrolled - 567 - LRB104 18483 SSS 31925 b
1		submit the quarterly data in an aggregate manner.
2		(g) Monetary penalties for non-compliance. The Department
3		shall submit proposed rules for adoption by January 1, 2020
4		establishing monetary penalties for facilities not in
5		compliance with minimum staffing standards under this Section.
6		Facilities shall be required to comply with the provisions of
7		this subsection beginning January 1, 2025. No monetary penalty
8		may be issued for noncompliance prior to the revised
9		implementation date, which shall be January 1, 2025. If a
10		facility is found to be noncompliant prior to the revised
11		implementation date, the Department shall provide a written
12		notice identifying the staffing deficiencies and require the
13		facility to provide a sufficiently detailed correction plan
14		that describes proposed and completed actions the facility
15		will take or has taken, including hiring actions, to address
16		the facility's failure to meet the statutory minimum staffing
17		levels. Monetary penalties shall be imposed beginning no later
18		than July 1, 2025, based on data for the quarter beginning
19		January 1, 2025 through March 31, 2025 and quarterly
20		thereafter. Monetary penalties shall be established based on a
21		formula that calculates on a daily basis the cost of wages and
22		benefits for the missing staffing hours. All notices of
23		noncompliance shall include the computations used to determine
24		noncompliance and establishing the variance between minimum
25		staffing ratios and the Department's computations. The penalty
26		for the first offense shall be 125% of the cost of wages and

SB3365 Enrolled - 568 - LRB104 18483 SSS 31925 b
1		benefits for the missing staffing hours. The penalty shall
2		increase to 150% of the cost of wages and benefits for the
3		missing staffing hours for the second offense and 200% the
4		cost of wages and benefits for the missing staffing hours for
5		the third and all subsequent offenses. The penalty shall be
6		imposed regardless of whether the facility has committed other
7		violations of this Act during the same period that the
8		staffing offense occurred. The penalty may not be waived,
9		except where there is no more than a 10% deviation from the
10		staffing requirements, in which case the facility shall not
11		receive a violation or penalty. The Department is granted
12		discretion to waive the violation and penalty when unforeseen
13		circumstances have occurred that resulted in call-offs of
14		scheduled staff. This provision shall be applied no more than
15		6 times per quarter. Nothing in this Section diminishes a
16		facility's right to appeal the imposition of a monetary
17		penalty. No facility may appeal a notice of noncompliance
18		issued during the revised implementation period. The changes
19		made to this subsection by this amendatory Act of the 104th
20		General Assembly in regard to nursing home staffing fines
21		shall apply to the July 1, 2025 fines based on data for the
22		quarter beginning January 1, 2025 through March 31, 2025 and
23		quarterly thereafter.
24		Moneys generated from the monetary penalties imposed on
25		facilities that are not in compliance with minimum staffing
26		standards under this subsection and rules adopted under this

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1		subsection shall be deposited into the Staffing Improvement
2		and Long Term Care Oversight Fund and shall be used as provided
3		in Section 6z-149 of the State Finance Act.
4		(Source: P.A. 104-9, eff. 6-16-25.)
5		ARTICLE 800.
6		Section 800-95. No acceleration or delay. Where this Act
7		makes changes in a statute that is represented in this Act by
8		text that is not yet or no longer in effect (for example, a
9		Section represented by multiple versions), the use of that
10		text does not accelerate or delay the taking effect of (i) the
11		changes made by this Act or (ii) provisions derived from any
12		other Public Act.
13		ARTICLE 999.
14		Section 999-99. Effective date. This Act takes effect upon
15		becoming law, except that Section 257-10 of Article 257 and
16		Articles 2, 10, 15, and 225 take effect July 1, 2026, and
17		Article 6 takes effect January 1, 2027, and Article 65 takes
18		effect July 1, 2027.