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Public Act 098-0651 | ||||
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AN ACT concerning public aid.
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Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly:
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Article 1 | ||||
Section 1-5. The Illinois Public Aid Code is amended by | ||||
adding Article V-F as follows:
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(305 ILCS 5/Art. V-F heading new) | ||||
ARTICLE V-F. MEDICARE-MEDICAID ALIGNMENT | ||||
INITIATIVE (MMAI) NURSING HOME | ||||
RESIDENTS' MANAGED CARE RIGHTS LAW | ||||
(305 ILCS 5/5F-1 new) | ||||
Sec. 5F-1. Short title. This Article may be referred to as | ||||
the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home | ||||
Residents' Managed Care Rights Law.
| ||||
(305 ILCS 5/5F-5 new) | ||||
Sec. 5F-5. Findings. The General Assembly finds that | ||||
elderly Illinoisans residing in a nursing home have the right | ||||
to: | ||||
(1) quality health care regardless of the payer; | ||||
(2) receive medically necessary care prescribed by |
their doctors; | ||
(3) a simple appeal process when care is denied; and | ||
(4) make decisions about their care and where they | ||
receive it.
| ||
(305 ILCS 5/5F-10 new) | ||
Sec. 5F-10. Scope. This Article applies to policies and | ||
contracts amended, delivered, issued, or renewed on or after | ||
the effective date of this amendatory Act of the 98th General | ||
Assembly for the nursing home component of the | ||
Medicare-Medicaid Alignment Initiative. This Article does not | ||
diminish a managed care organization's duties and | ||
responsibilities under other federal or State laws or rules | ||
adopted under those laws and the 3-way Medicare-Medicaid | ||
Alignment Initiative contract.
| ||
(305 ILCS 5/5F-15 new) | ||
Sec. 5F-15. Definitions. As used in this Article: | ||
"Appeal" means any of the procedures that deal with the | ||
review of adverse organization determinations on the health | ||
care services the enrollee believes he or she is entitled to | ||
receive, including delay in providing, arranging for, or | ||
approving the health care services, such that a delay would | ||
adversely affect the health of the enrollee or on any amounts | ||
the enrollee must pay for a service, as defined under 42 CFR | ||
422.566(b). These procedures include reconsiderations by the |
managed care organization and, if necessary, an independent | ||
review entity as provided by the Health Carrier External Review | ||
Act, hearings before administrative law judges, review by the | ||
Medicare Appeals Council, and judicial review. | ||
"Demonstration Project" means the nursing home component | ||
of the Medicare-Medicaid Alignment Initiative Demonstration | ||
Project. | ||
"Department" means the Department of Healthcare and Family | ||
Services. | ||
"Enrollee" means an individual who resides in a nursing | ||
home or is qualified to be admitted to a nursing home and is | ||
enrolled with a managed care organization participating in the | ||
Demonstration Project. | ||
"Health care services" means the diagnosis, treatment, and | ||
prevention of disease and includes medication, primary care, | ||
nursing or medical care, mental health treatment, psychiatric | ||
rehabilitation, memory loss services, physical, occupational, | ||
and speech rehabilitation, enhanced care, medical supplies and | ||
equipment and the repair of such equipment, and assistance with | ||
activities of daily living. | ||
"Managed care organization" or "MCO" means an entity that | ||
meets the definition of health maintenance organization as | ||
defined in the Health Maintenance Organization Act, is | ||
licensed, regulated and in good standing with the Department of | ||
Insurance, and is authorized to participate in the nursing home | ||
component of the Medicare-Medicaid Alignment Initiative |
Demonstration Project by a 3-way contract with the Department | ||
of Healthcare and Family Services and the Centers for Medicare | ||
and Medicaid Services. | ||
"Medical professional" means a physician, physician | ||
assistant, or nurse practitioner. | ||
"Medically necessary" means health care services that a | ||
medical professional, exercising prudent clinical judgment, | ||
would provide to a patient for the purpose of preventing, | ||
evaluating, diagnosing, or treating an illness, injury, or | ||
disease or its symptoms, and that are: (i) in accordance with | ||
the generally accepted standards of medical practice; (ii) | ||
clinically appropriate, in terms of type, frequency, extent, | ||
site, and duration, and considered effective for the patient's | ||
illness, injury, or disease; and (iii) not primarily for the | ||
convenience of the patient, a medical professional, other | ||
health care provider, caregiver, family member, or other | ||
interested party. | ||
"Nursing home" means a facility licensed under the Nursing | ||
Home Care Act. | ||
"Nurse practitioner" means an individual properly licensed | ||
as a nurse practitioner under the Nurse Practice Act. | ||
"Physician" means an individual licensed to practice in all | ||
branches of medicine under the Medical Practice Act of 1987. | ||
"Physician assistant" means an individual properly | ||
licensed under the Physician Assistant Practice Act of 1987. | ||
"Resident" means an enrollee who is receiving personal or |
medical care, including, but not limited to, mental health | ||
treatment, psychiatric rehabilitation, physical | ||
rehabilitation, and assistance with activities of daily | ||
living, from a nursing home. | ||
"RAI Manual" means the most recent Resident Assessment | ||
Instrument Manual, published by the Centers for Medicare and | ||
Medicaid Services. | ||
"Resident's representative" means a person designated in | ||
writing by a resident to be the resident's representative or | ||
the resident's guardian, as described by the Nursing Home Care | ||
Act. | ||
"SNFist" means a medical professional specializing in the | ||
care of individuals residing in nursing homes employed by or | ||
under contract with a MCO. | ||
"Transition period" means a period of time immediately | ||
following enrollment into the Demonstration Project or an | ||
enrollee's movement from one managed care organization to | ||
another managed care organization or one care setting to | ||
another care setting.
| ||
(305 ILCS 5/5F-20 new) | ||
Sec. 5F-20. Network adequacy. | ||
(a) Every managed care organization shall allow every | ||
nursing home in its service area an opportunity to be a network | ||
contracted facility at the plan's standard terms, conditions, | ||
and rates. Either party may opt to limit the contract to |
existing residents only. | ||
(b) With the exception of subsection (c) of this Section, a | ||
managed care organization shall only terminate or refuse to | ||
renew a contract with a nursing home if the nursing home fails | ||
to meet quality standards if the following conditions are met: | ||
(1) the quality standards are made known to the nursing | ||
home; | ||
(2) the quality standards can be objectively measured | ||
through data; | ||
(3) the nursing home is measured on at least a year's | ||
worth of performance; | ||
(4) a nursing home that the MCO has determined did not | ||
meet a quality standard has the opportunity to contest that | ||
determination by challenging the accuracy or the | ||
measurement of the data through an arbitration process | ||
agreed to by contract; and | ||
(5) the Department may attempt to mediate a dispute | ||
prior to arbitration. | ||
(c) A managed care organization may terminate or refuse to | ||
renew a contract with a nursing home for a material breach of | ||
the contract, including, but not limited to, failure to grant | ||
reasonable and timely access to the MCO's care coordinators, | ||
SNFists and other providers, termination from the Medicare or | ||
Medicaid program, or revocation of license.
| ||
(305 ILCS 5/5F-25 new) |
Sec. 5F-25. Care coordination. Care coordination provided | ||
to all enrollees in the Demonstration Project shall conform to | ||
the following requirements: | ||
(1) care coordination services shall be | ||
enrollee-driven and person-centered; | ||
(2) all enrollees in the Demonstration Project shall | ||
have the right to receive health care services in the care | ||
setting of their choice, except as permitted by Part 4 of | ||
Article III of the Nursing Home Care Act with respect to | ||
involuntary transfers and discharges; and | ||
(3) decisions shall be based on the enrollee's best | ||
interests.
| ||
(305 ILCS 5/5F-30 new) | ||
Sec. 5F-30. Continuity of care. When a nursing home | ||
resident first transitions to a managed care organization from | ||
the fee-for-service system or from another managed care | ||
organization, the managed care organization shall honor the | ||
existing care plan and any necessary changes to that care plan | ||
until the MCO has completed a comprehensive assessment and new | ||
care plan, to the extent such services are covered benefits | ||
under the contract, which shall be consistent with the | ||
requirements of the RAI Manual. | ||
When an enrollee of a managed care organization is moving | ||
from a community setting to a nursing home, and the MCO is | ||
properly notified of the proposed admission by a network |
nursing home, and the managed care organization fails to | ||
participate in developing a care plan within the time frames | ||
required by nursing home regulations, the MCO must honor a care | ||
plan developed by the nursing home until the MCO has completed | ||
a comprehensive assessment and a new care plan to the extent | ||
such services are covered benefits under the contract, | ||
consistent with the requirements of the RAI Manual. | ||
A nursing home shall have the ability to refuse admission | ||
of an enrollee for whom care is required that the nursing home | ||
determines is outside the scope of its license and healthcare | ||
capabilities.
| ||
(305 ILCS 5/5F-32 new) | ||
Sec. 5F-32. Non-emergency prior approval and appeal. | ||
(a) MCOs must have a method of receiving prior approval | ||
requests 24 hours a day, 7 days a week, 365 days a year for | ||
nursing home residents. If a response is not provided within 24 | ||
hours of the request and the nursing home is required by | ||
regulation to provide a service because a physician ordered it, | ||
the MCO must pay for the service if it is a covered service | ||
under the MCO's contract in the Demonstration Project, provided | ||
that the request is consistent with the policies and procedures | ||
of the MCO. | ||
In a non-emergency situation, notwithstanding any | ||
provisions in State law to the contrary, in the event a | ||
resident's physician orders a service, treatment, or test that |
is not approved by the MCO, the physician and the provider may | ||
utilize an expedited appeal to the MCO. | ||
If an enrollee or provider requests an expedited appeal | ||
pursuant to 42 CFR 438.410, the MCO shall notify the enrollee | ||
or provider within 24 hours after the submission of the appeal | ||
of all information from the enrollee or provider that the MCO | ||
requires to evaluate the appeal. The MCO shall render a | ||
decision on an expedited appeal within 24 hours after receipt | ||
of the required information. | ||
(b) While the appeal is pending or if the ordered service, | ||
treatment, or test is denied after appeal, the Department of | ||
Public Health may not cite the nursing home for failure to | ||
provide the ordered service, treatment, or test. The nursing | ||
home shall not be liable or responsible for an injury in any | ||
regulatory proceeding for the following: | ||
(1) failure to follow the appealed or denied order; or | ||
(2) injury to the extent it was caused by the delay or | ||
failure to perform the appealed or denied service, | ||
treatment, or test. | ||
Provided however, a nursing home shall continue to monitor, | ||
document, and ensure the patient's safety. Nothing in this | ||
subsection (b) is intended to otherwise change the nursing | ||
home's existing obligations under State and federal law to | ||
appropriately care for its residents.
| ||
(305 ILCS 5/5F-35 new) |
Sec. 5F-35. Reimbursement. The Department shall provide | ||
each managed care organization with the quarterly | ||
facility-specific RUG-IV nursing component per diem along with | ||
any add-ons for enhanced care services, support component per | ||
diem, and capital component per diem effective for each nursing | ||
home under contract with the managed care organization.
| ||
(305 ILCS 5/5F-40 new) | ||
Sec. 5F-40. Contractual requirements. | ||
(a) Every contract shall contain a clause for termination | ||
consistent with the Managed Care Reform and Patient Rights Act | ||
providing nursing homes the ability to terminate the contract. | ||
(b) All changes to the contract by the MCO shall be | ||
preceded by 30 days' written notice sent to the nursing home.
| ||
(305 ILCS 5/5F-45 new) | ||
Sec. 5F-45. Prohibition. No managed care organization or | ||
contract shall contain any provision, policy, or procedure that | ||
limits, restricts, or waives any rights set forth in this | ||
Article or is expressly prohibited by this Article. Any such | ||
policy or procedure is void and unenforceable.
| ||
Section 1-10. The Health Maintenance Organization Act is | ||
amended by changing Section 1-2 as follows:
| ||
(215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
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Sec. 1-2. Definitions. As used in this Act, unless the | ||
context otherwise
requires, the following terms shall have the | ||
meanings ascribed to them:
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(1) "Advertisement" means any printed or published | ||
material,
audiovisual material and descriptive literature of | ||
the health care plan
used in direct mail, newspapers, | ||
magazines, radio scripts, television
scripts, billboards and | ||
similar displays; and any descriptive literature or
sales aids | ||
of all kinds disseminated by a representative of the health | ||
care
plan for presentation to the public including, but not | ||
limited to, circulars,
leaflets, booklets, depictions, | ||
illustrations, form letters and prepared
sales presentations.
| ||
(2) "Director" means the Director of Insurance.
| ||
(3) "Basic health care services" means emergency care, and | ||
inpatient
hospital and physician care, outpatient medical | ||
services, mental
health services and care for alcohol and drug | ||
abuse, including any
reasonable deductibles and co-payments, | ||
all of which are subject to the
limitations described in | ||
Section 4-20 of this Act and as determined by the Director | ||
pursuant to rule.
| ||
(4) "Enrollee" means an individual who has been enrolled in | ||
a health
care plan.
| ||
(5) "Evidence of coverage" means any certificate, | ||
agreement,
or contract issued to an enrollee setting out the | ||
coverage to which he is
entitled in exchange for a per capita | ||
prepaid sum.
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(6) "Group contract" means a contract for health care | ||
services which
by its terms limits eligibility to members of a | ||
specified group.
| ||
(7) "Health care plan" means any arrangement whereby any | ||
organization
undertakes to provide or arrange for and pay for | ||
or reimburse the
cost of basic health care services, excluding | ||
any reasonable deductibles and copayments, from providers | ||
selected by
the Health Maintenance Organization and such | ||
arrangement
consists of arranging for or the provision of such | ||
health care services, as
distinguished from mere | ||
indemnification against the cost of such services,
except as | ||
otherwise authorized by Section 2-3 of this Act,
on a per | ||
capita prepaid basis, through insurance or otherwise. A "health
| ||
care plan" also includes any arrangement whereby an | ||
organization undertakes to
provide or arrange for or pay for or | ||
reimburse the cost of any health care
service for persons who | ||
are enrolled under Article V of the Illinois Public Aid
Code or | ||
under the Children's Health Insurance Program Act through
| ||
providers selected by the organization and the arrangement | ||
consists of making
provision for the delivery of health care | ||
services, as distinguished from mere
indemnification. A | ||
"health care plan" also includes any arrangement pursuant
to | ||
Section 4-17. Nothing in this definition, however, affects the | ||
total
medical services available to persons eligible for | ||
medical assistance under the
Illinois Public Aid Code.
| ||
(8) "Health care services" means any services included in |
the furnishing
to any individual of medical or dental care, or | ||
the hospitalization or
incident to the furnishing of such care | ||
or hospitalization as well as the
furnishing to any person of | ||
any and all other services for the purpose of
preventing, | ||
alleviating, curing or healing human illness or injury.
| ||
(9) "Health Maintenance Organization" means any | ||
organization formed
under the laws of this or another state to | ||
provide or arrange for one or
more health care plans under a | ||
system which causes any part of the risk of
health care | ||
delivery to be borne by the organization or its providers.
| ||
(10) "Net worth" means admitted assets, as defined in | ||
Section 1-3 of
this Act, minus liabilities.
| ||
(11) "Organization" means any insurance company, a | ||
nonprofit
corporation authorized under the Dental
Service Plan | ||
Act or the Voluntary
Health Services Plans Act,
or a | ||
corporation organized under the laws of this or another state | ||
for the
purpose of operating one or more health care plans and | ||
doing no business other
than that of a Health Maintenance | ||
Organization or an insurance company.
"Organization" shall | ||
also mean the University of Illinois Hospital as
defined in the | ||
University of Illinois Hospital Act or a unit of local | ||
government health system operating within a county with a | ||
population of 3,000,000 or more .
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(12) "Provider" means any physician, hospital facility,
| ||
facility licensed under the Nursing Home Care Act, or other | ||
person which is licensed or otherwise authorized
to furnish |
health care services and also includes any other entity that
| ||
arranges for the delivery or furnishing of health care service.
| ||
(13) "Producer" means a person directly or indirectly | ||
associated with a
health care plan who engages in solicitation | ||
or enrollment.
| ||
(14) "Per capita prepaid" means a basis of prepayment by | ||
which a fixed
amount of money is prepaid per individual or any | ||
other enrollment unit to
the Health Maintenance Organization or | ||
for health care services which are
provided during a definite | ||
time period regardless of the frequency or
extent of the | ||
services rendered
by the Health Maintenance Organization, | ||
except for copayments and deductibles
and except as provided in | ||
subsection (f) of Section 5-3 of this Act.
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(15) "Subscriber" means a person who has entered into a | ||
contractual
relationship with the Health Maintenance | ||
Organization for the provision of
or arrangement of at least | ||
basic health care services to the beneficiaries
of such | ||
contract.
| ||
(Source: P.A. 97-1148, eff. 1-24-13.)
| ||
Section 1-15. The Managed Care Reform and Patient Rights | ||
Act is amended by changing Section 10 as follows:
| ||
(215 ILCS 134/10)
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Sec. 10. Definitions:
| ||
"Adverse determination" means a determination by a health |
care plan under
Section 45 or by a utilization review program | ||
under Section
85 that
a health care service is not medically | ||
necessary.
| ||
"Clinical peer" means a health care professional who is in | ||
the same
profession and the same or similar specialty as the | ||
health care provider who
typically manages the medical | ||
condition, procedures, or treatment under
review.
| ||
"Department" means the Department of Insurance.
| ||
"Emergency medical condition" means a medical condition | ||
manifesting itself by
acute symptoms of sufficient severity | ||
(including, but not limited to, severe
pain) such that a | ||
prudent
layperson, who possesses an average knowledge of health | ||
and medicine, could
reasonably expect the absence of immediate | ||
medical attention to result in:
| ||
(1) placing the health of the individual (or, with | ||
respect to a pregnant
woman, the
health of the woman or her | ||
unborn child) in serious jeopardy;
| ||
(2) serious
impairment to bodily functions; or
| ||
(3) serious dysfunction of any bodily organ
or part.
| ||
"Emergency medical screening examination" means a medical | ||
screening
examination and
evaluation by a physician licensed to | ||
practice medicine in all its branches, or
to the extent | ||
permitted
by applicable laws, by other appropriately licensed | ||
personnel under the
supervision of or in
collaboration with a | ||
physician licensed to practice medicine in all its
branches to | ||
determine whether
the need for emergency services exists.
|
"Emergency services" means, with respect to an enrollee of | ||
a health care
plan,
transportation services, including but not | ||
limited to ambulance services, and
covered inpatient and | ||
outpatient hospital services
furnished by a provider
qualified | ||
to furnish those services that are needed to evaluate or | ||
stabilize an
emergency medical condition. "Emergency services" | ||
does not
refer to post-stabilization medical services.
| ||
"Enrollee" means any person and his or her dependents | ||
enrolled in or covered
by a health care plan.
| ||
"Health care plan" means a plan , including, but not limited | ||
to, a health maintenance organization, a managed care community | ||
network as defined in the Illinois Public Aid Code, or an | ||
accountable care entity as defined in the Illinois Public Aid | ||
Code that receives capitated payments to cover medical services | ||
from the Department of Healthcare and Family Services, that | ||
establishes, operates, or maintains a
network of health care | ||
providers that has entered into an agreement with the
plan to | ||
provide health care services to enrollees to whom the plan has | ||
the
ultimate obligation to arrange for the provision of or | ||
payment for services
through organizational arrangements for | ||
ongoing quality assurance,
utilization review programs, or | ||
dispute resolution.
Nothing in this definition shall be | ||
construed to mean that an independent
practice association or a | ||
physician hospital organization that subcontracts
with
a | ||
health care plan is, for purposes of that subcontract, a health | ||
care plan.
|
For purposes of this definition, "health care plan" shall | ||
not include the
following:
| ||
(1) indemnity health insurance policies including | ||
those using a contracted
provider network;
| ||
(2) health care plans that offer only dental or only | ||
vision coverage;
| ||
(3) preferred provider administrators, as defined in | ||
Section 370g(g) of
the
Illinois Insurance Code;
| ||
(4) employee or employer self-insured health benefit | ||
plans under the
federal Employee Retirement Income | ||
Security Act of 1974;
| ||
(5) health care provided pursuant to the Workers' | ||
Compensation Act or the
Workers' Occupational Diseases | ||
Act; and
| ||
(6) not-for-profit voluntary health services plans | ||
with health maintenance
organization
authority in | ||
existence as of January 1, 1999 that are affiliated with a | ||
union
and that
only extend coverage to union members and | ||
their dependents.
| ||
"Health care professional" means a physician, a registered | ||
professional
nurse,
or other individual appropriately licensed | ||
or registered
to provide health care services.
| ||
"Health care provider" means any physician, hospital | ||
facility, facility licensed under the Nursing Home Care Act, or | ||
other
person that is licensed or otherwise authorized to | ||
deliver health care
services. Nothing in this
Act shall be |
construed to define Independent Practice Associations or
| ||
Physician-Hospital Organizations as health care providers.
| ||
"Health care services" means any services included in the | ||
furnishing to any
individual of medical care, or the
| ||
hospitalization incident to the furnishing of such care, as | ||
well as the
furnishing to any person of
any and all other | ||
services for the purpose of preventing,
alleviating, curing, or | ||
healing human illness or injury including home health
and | ||
pharmaceutical services and products.
| ||
"Medical director" means a physician licensed in any state | ||
to practice
medicine in all its
branches appointed by a health | ||
care plan.
| ||
"Person" means a corporation, association, partnership,
| ||
limited liability company, sole proprietorship, or any other | ||
legal entity.
| ||
"Physician" means a person licensed under the Medical
| ||
Practice Act of 1987.
| ||
"Post-stabilization medical services" means health care | ||
services
provided to an enrollee that are furnished in a | ||
licensed hospital by a provider
that is qualified to furnish | ||
such services, and determined to be medically
necessary and | ||
directly related to the emergency medical condition following
| ||
stabilization.
| ||
"Stabilization" means, with respect to an emergency | ||
medical condition, to
provide such medical treatment of the | ||
condition as may be necessary to assure,
within reasonable |
medical probability, that no material deterioration
of the | ||
condition is likely to result.
| ||
"Utilization review" means the evaluation of the medical | ||
necessity,
appropriateness, and efficiency of the use of health | ||
care services, procedures,
and facilities.
| ||
"Utilization review program" means a program established | ||
by a person to
perform utilization review.
| ||
(Source: P.A. 91-617, eff. 1-1-00.)
| ||
Article 5 | ||
Section 5-5. The Illinois Health Facilities Planning Act is | ||
amended by changing Sections 3 and 12 as follows:
| ||
(20 ILCS 3960/3) (from Ch. 111 1/2, par. 1153)
| ||
(Section scheduled to be repealed on December 31, 2019) | ||
Sec. 3. Definitions. As used in this Act:
| ||
"Health care facilities" means and includes
the following | ||
facilities, organizations, and related persons:
| ||
1. An ambulatory surgical treatment center required to | ||
be licensed
pursuant to the Ambulatory Surgical Treatment | ||
Center Act;
| ||
2. An institution, place, building, or agency required | ||
to be licensed
pursuant to the Hospital Licensing Act;
| ||
3. Skilled and intermediate long term care facilities | ||
licensed under the
Nursing
Home Care Act;
|
3.5. Skilled and intermediate care facilities licensed | ||
under the ID/DD Community Care Act; | ||
3.7. Facilities licensed under the Specialized Mental | ||
Health Rehabilitation Act of 2013 ;
| ||
4. Hospitals, nursing homes, ambulatory surgical | ||
treatment centers, or
kidney disease treatment centers
| ||
maintained by the State or any department or agency | ||
thereof;
| ||
5. Kidney disease treatment centers, including a | ||
free-standing
hemodialysis unit required to be licensed | ||
under the End Stage Renal Disease Facility Act;
| ||
6. An institution, place, building, or room used for | ||
the performance of
outpatient surgical procedures that is | ||
leased, owned, or operated by or on
behalf of an | ||
out-of-state facility;
| ||
7. An institution, place, building, or room used for | ||
provision of a health care category of service, including, | ||
but not limited to, cardiac catheterization and open heart | ||
surgery; and | ||
8. An institution, place, building, or room used for | ||
provision of major medical equipment used in the direct | ||
clinical diagnosis or treatment of patients, and whose | ||
project cost is in excess of the capital expenditure | ||
minimum. | ||
This Act shall not apply to the construction of any new | ||
facility or the renovation of any existing facility located on |
any campus facility as defined in Section 5-5.8b of the | ||
Illinois Public Aid Code, provided that the campus facility | ||
encompasses 30 or more contiguous acres and that the new or | ||
renovated facility is intended for use by a licensed | ||
residential facility. | ||
No federally owned facility shall be subject to the | ||
provisions of this
Act, nor facilities used solely for healing | ||
by prayer or spiritual means.
| ||
No facility licensed under the Supportive Residences | ||
Licensing Act or the
Assisted Living and Shared Housing Act
| ||
shall be subject to the provisions of this Act.
| ||
No facility established and operating under the | ||
Alternative Health Care Delivery Act as a children's respite | ||
care center alternative health care model demonstration | ||
program or as an Alzheimer's Disease Management Center | ||
alternative health care model demonstration program shall be | ||
subject to the provisions of this Act. | ||
A facility designated as a supportive living facility that | ||
is in good
standing with the program
established under Section | ||
5-5.01a of
the Illinois Public Aid Code shall not be subject to | ||
the provisions of this
Act.
| ||
This Act does not apply to facilities granted waivers under | ||
Section 3-102.2
of the Nursing Home Care Act. However, if a | ||
demonstration project under that
Act applies for a certificate
| ||
of need to convert to a nursing facility, it shall meet the | ||
licensure and
certificate of need requirements in effect as of |
the date of application. | ||
This Act does not apply to a dialysis facility that | ||
provides only dialysis training, support, and related services | ||
to individuals with end stage renal disease who have elected to | ||
receive home dialysis. This Act does not apply to a dialysis | ||
unit located in a licensed nursing home that offers or provides | ||
dialysis-related services to residents with end stage renal | ||
disease who have elected to receive home dialysis within the | ||
nursing home. The Board, however, may require these dialysis | ||
facilities and licensed nursing homes to report statistical | ||
information on a quarterly basis to the Board to be used by the | ||
Board to conduct analyses on the need for proposed kidney | ||
disease treatment centers.
| ||
This Act shall not apply to the closure of an entity or a | ||
portion of an
entity licensed under the Nursing Home Care Act, | ||
the Specialized Mental Health Rehabilitation Act of 2013 , or | ||
the ID/DD Community Care Act, with the exceptions of facilities | ||
operated by a county or Illinois Veterans Homes, that elects to | ||
convert, in
whole or in part, to an assisted living or shared | ||
housing establishment
licensed under the Assisted Living and | ||
Shared Housing Act and with the exception of a facility | ||
licensed under the Specialized Mental Health Rehabilitation | ||
Act of 2013 in connection with a proposal to close a facility | ||
and re-establish the facility in another location .
| ||
This Act does not apply to any change of ownership of a | ||
healthcare facility that is licensed under the Nursing Home |
Care Act, the Specialized Mental Health Rehabilitation Act of | ||
2013 , or the ID/DD Community Care Act, with the exceptions of | ||
facilities operated by a county or Illinois Veterans Homes. | ||
Changes of ownership of facilities licensed under the Nursing | ||
Home Care Act must meet the requirements set forth in Sections | ||
3-101 through 3-119 of the Nursing Home Care Act.
| ||
With the exception of those health care facilities | ||
specifically
included in this Section, nothing in this Act | ||
shall be intended to
include facilities operated as a part of | ||
the practice of a physician or
other licensed health care | ||
professional, whether practicing in his
individual capacity or | ||
within the legal structure of any partnership,
medical or | ||
professional corporation, or unincorporated medical or
| ||
professional group. Further, this Act shall not apply to | ||
physicians or
other licensed health care professional's | ||
practices where such practices
are carried out in a portion of | ||
a health care facility under contract
with such health care | ||
facility by a physician or by other licensed
health care | ||
professionals, whether practicing in his individual capacity
| ||
or within the legal structure of any partnership, medical or
| ||
professional corporation, or unincorporated medical or | ||
professional
groups, unless the entity constructs, modifies, | ||
or establishes a health care facility as specifically defined | ||
in this Section. This Act shall apply to construction or
| ||
modification and to establishment by such health care facility | ||
of such
contracted portion which is subject to facility |
licensing requirements,
irrespective of the party responsible | ||
for such action or attendant
financial obligation. | ||
No permit or exemption is required for a facility licensed | ||
under the ID/DD Community Care Act prior to the reduction of | ||
the number of beds at a facility. If there is a total reduction | ||
of beds at a facility licensed under the ID/DD Community Care | ||
Act, this is a discontinuation or closure of the facility. | ||
However, if a facility licensed under the ID/DD Community Care | ||
Act reduces the number of beds or discontinues the facility, | ||
that facility must notify the Board as provided in Section 14.1 | ||
of this Act.
| ||
"Person" means any one or more natural persons, legal | ||
entities,
governmental bodies other than federal, or any | ||
combination thereof.
| ||
"Consumer" means any person other than a person (a) whose | ||
major
occupation currently involves or whose official capacity | ||
within the last
12 months has involved the providing, | ||
administering or financing of any
type of health care facility, | ||
(b) who is engaged in health research or
the teaching of | ||
health, (c) who has a material financial interest in any
| ||
activity which involves the providing, administering or | ||
financing of any
type of health care facility, or (d) who is or | ||
ever has been a member of
the immediate family of the person | ||
defined by (a), (b), or (c).
| ||
"State Board" or "Board" means the Health Facilities and | ||
Services Review Board.
|
"Construction or modification" means the establishment, | ||
erection,
building, alteration, reconstruction, modernization, | ||
improvement,
extension, discontinuation, change of ownership, | ||
of or by a health care
facility, or the purchase or acquisition | ||
by or through a health care facility
of
equipment or service | ||
for diagnostic or therapeutic purposes or for
facility | ||
administration or operation, or any capital expenditure made by
| ||
or on behalf of a health care facility which
exceeds the | ||
capital expenditure minimum; however, any capital expenditure
| ||
made by or on behalf of a health care facility for (i) the | ||
construction or
modification of a facility licensed under the | ||
Assisted Living and Shared
Housing Act or (ii) a conversion | ||
project undertaken in accordance with Section 30 of the Older | ||
Adult Services Act shall be excluded from any obligations under | ||
this Act.
| ||
"Establish" means the construction of a health care | ||
facility or the
replacement of an existing facility on another | ||
site or the initiation of a category of service.
| ||
"Major medical equipment" means medical equipment which is | ||
used for the
provision of medical and other health services and | ||
which costs in excess
of the capital expenditure minimum, | ||
except that such term does not include
medical equipment | ||
acquired
by or on behalf of a clinical laboratory to provide | ||
clinical laboratory
services if the clinical laboratory is | ||
independent of a physician's office
and a hospital and it has | ||
been determined under Title XVIII of the Social
Security Act to |
meet the requirements of paragraphs (10) and (11) of Section
| ||
1861(s) of such Act. In determining whether medical equipment | ||
has a value
in excess of the capital expenditure minimum, the | ||
value of studies, surveys,
designs, plans, working drawings, | ||
specifications, and other activities
essential to the | ||
acquisition of such equipment shall be included.
| ||
"Capital Expenditure" means an expenditure: (A) made by or | ||
on behalf of
a health care facility (as such a facility is | ||
defined in this Act); and
(B) which under generally accepted | ||
accounting principles is not properly
chargeable as an expense | ||
of operation and maintenance, or is made to obtain
by lease or | ||
comparable arrangement any facility or part thereof or any
| ||
equipment for a facility or part; and which exceeds the capital | ||
expenditure
minimum.
| ||
For the purpose of this paragraph, the cost of any studies, | ||
surveys, designs,
plans, working drawings, specifications, and | ||
other activities essential
to the acquisition, improvement, | ||
expansion, or replacement of any plant
or equipment with | ||
respect to which an expenditure is made shall be included
in | ||
determining if such expenditure exceeds the capital | ||
expenditures minimum.
Unless otherwise interdependent, or | ||
submitted as one project by the applicant, components of | ||
construction or modification undertaken by means of a single | ||
construction contract or financed through the issuance of a | ||
single debt instrument shall not be grouped together as one | ||
project. Donations of equipment
or facilities to a health care |
facility which if acquired directly by such
facility would be | ||
subject to review under this Act shall be considered capital
| ||
expenditures, and a transfer of equipment or facilities for | ||
less than fair
market value shall be considered a capital | ||
expenditure for purposes of this
Act if a transfer of the | ||
equipment or facilities at fair market value would
be subject | ||
to review.
| ||
"Capital expenditure minimum" means $11,500,000 for | ||
projects by hospital applicants, $6,500,000 for applicants for | ||
projects related to skilled and intermediate care long-term | ||
care facilities licensed under the Nursing Home Care Act, and | ||
$3,000,000 for projects by all other applicants, which shall be | ||
annually
adjusted to reflect the increase in construction costs | ||
due to inflation, for major medical equipment and for all other
| ||
capital expenditures.
| ||
"Non-clinical service area" means an area (i) for the | ||
benefit of the
patients, visitors, staff, or employees of a | ||
health care facility and (ii) not
directly related to the | ||
diagnosis, treatment, or rehabilitation of persons
receiving | ||
services from the health care facility. "Non-clinical service | ||
areas"
include, but are not limited to, chapels; gift shops; | ||
news stands; computer
systems; tunnels, walkways, and | ||
elevators; telephone systems; projects to
comply with life | ||
safety codes; educational facilities; student housing;
| ||
patient, employee, staff, and visitor dining areas; | ||
administration and
volunteer offices; modernization of |
structural components (such as roof
replacement and masonry | ||
work); boiler repair or replacement; vehicle
maintenance and | ||
storage facilities; parking facilities; mechanical systems for
| ||
heating, ventilation, and air conditioning; loading docks; and | ||
repair or
replacement of carpeting, tile, wall coverings, | ||
window coverings or treatments,
or furniture. Solely for the | ||
purpose of this definition, "non-clinical service
area" does | ||
not include health and fitness centers.
| ||
"Areawide" means a major area of the State delineated on a
| ||
geographic, demographic, and functional basis for health | ||
planning and
for health service and having within it one or | ||
more local areas for
health planning and health service. The | ||
term "region", as contrasted
with the term "subregion", and the | ||
word "area" may be used synonymously
with the term "areawide".
| ||
"Local" means a subarea of a delineated major area that on | ||
a
geographic, demographic, and functional basis may be | ||
considered to be
part of such major area. The term "subregion" | ||
may be used synonymously
with the term "local".
| ||
"Physician" means a person licensed to practice in | ||
accordance with
the Medical Practice Act of 1987, as amended.
| ||
"Licensed health care professional" means a person | ||
licensed to
practice a health profession under pertinent | ||
licensing statutes of the
State of Illinois.
| ||
"Director" means the Director of the Illinois Department of | ||
Public Health.
| ||
"Agency" means the Illinois Department of Public Health.
|
"Alternative health care model" means a facility or program | ||
authorized
under the Alternative Health Care Delivery Act.
| ||
"Out-of-state facility" means a person that is both (i) | ||
licensed as a
hospital or as an ambulatory surgery center under | ||
the laws of another state
or that
qualifies as a hospital or an | ||
ambulatory surgery center under regulations
adopted pursuant | ||
to the Social Security Act and (ii) not licensed under the
| ||
Ambulatory Surgical Treatment Center Act, the Hospital | ||
Licensing Act, or the
Nursing Home Care Act. Affiliates of | ||
out-of-state facilities shall be
considered out-of-state | ||
facilities. Affiliates of Illinois licensed health
care | ||
facilities 100% owned by an Illinois licensed health care | ||
facility, its
parent, or Illinois physicians licensed to | ||
practice medicine in all its
branches shall not be considered | ||
out-of-state facilities. Nothing in
this definition shall be
| ||
construed to include an office or any part of an office of a | ||
physician licensed
to practice medicine in all its branches in | ||
Illinois that is not required to be
licensed under the | ||
Ambulatory Surgical Treatment Center Act.
| ||
"Change of ownership of a health care facility" means a | ||
change in the
person
who has ownership or
control of a health | ||
care facility's physical plant and capital assets. A change
in | ||
ownership is indicated by
the following transactions: sale, | ||
transfer, acquisition, lease, change of
sponsorship, or other | ||
means of
transferring control.
| ||
"Related person" means any person that: (i) is at least 50% |
owned, directly
or indirectly, by
either the health care | ||
facility or a person owning, directly or indirectly, at
least | ||
50% of the health
care facility; or (ii) owns, directly or | ||
indirectly, at least 50% of the
health care facility.
| ||
"Charity care" means care provided by a health care | ||
facility for which the provider does not expect to receive | ||
payment from the patient or a third-party payer. | ||
"Freestanding emergency center" means a facility subject | ||
to licensure under Section 32.5 of the Emergency Medical | ||
Services (EMS) Systems Act. | ||
"Category of service" means a grouping by generic class of | ||
various types or levels of support functions, equipment, care, | ||
or treatment provided to patients or residents, including, but | ||
not limited to, classes such as medical-surgical, pediatrics, | ||
or cardiac catheterization. A category of service may include | ||
subcategories or levels of care that identify a particular | ||
degree or type of care within the category of service. Nothing | ||
in this definition shall be construed to include the practice | ||
of a physician or other licensed health care professional while | ||
functioning in an office providing for the care, diagnosis, or | ||
treatment of patients. A category of service that is subject to | ||
the Board's jurisdiction must be designated in rules adopted by | ||
the Board. | ||
(Source: P.A. 97-38, eff. 6-28-11; 97-277, eff. 1-1-12; 97-813, | ||
eff. 7-13-12; 97-980, eff. 8-17-12; 98-414, eff. 1-1-14.)
|
(20 ILCS 3960/12) (from Ch. 111 1/2, par. 1162)
| ||
(Section scheduled to be repealed on December 31, 2019) | ||
Sec. 12. Powers and duties of State Board. For purposes of | ||
this Act,
the State Board
shall
exercise the following powers | ||
and duties:
| ||
(1) Prescribe rules,
regulations, standards, criteria, | ||
procedures or reviews which may vary
according to the purpose | ||
for which a particular review is being conducted
or the type of | ||
project reviewed and which are required to carry out the
| ||
provisions and purposes of this Act. Policies and procedures of | ||
the State Board shall take into consideration the priorities | ||
and needs of medically underserved areas and other health care | ||
services identified through the comprehensive health planning | ||
process, giving special consideration to the impact of projects | ||
on access to safety net services.
| ||
(2) Adopt procedures for public
notice and hearing on all | ||
proposed rules, regulations, standards,
criteria, and plans | ||
required to carry out the provisions of this Act.
| ||
(3) (Blank).
| ||
(4) Develop criteria and standards for health care | ||
facilities planning,
conduct statewide inventories of health | ||
care facilities, maintain an updated
inventory on the Board's | ||
web site reflecting the
most recent bed and service
changes and | ||
updated need determinations when new census data become | ||
available
or new need formulae
are adopted,
and
develop health | ||
care facility plans which shall be utilized in the review of
|
applications for permit under
this Act. Such health facility | ||
plans shall be coordinated by the Board
with pertinent State | ||
Plans. Inventories pursuant to this Section of skilled or | ||
intermediate care facilities licensed under the Nursing Home | ||
Care Act, skilled or intermediate care facilities licensed | ||
under the ID/DD Community Care Act, facilities licensed under | ||
the Specialized Mental Health Rehabilitation Act, or nursing | ||
homes licensed under the Hospital Licensing Act shall be | ||
conducted on an annual basis no later than July 1 of each year | ||
and shall include among the information requested a list of all | ||
services provided by a facility to its residents and to the | ||
community at large and differentiate between active and | ||
inactive beds.
| ||
In developing health care facility plans, the State Board | ||
shall consider,
but shall not be limited to, the following:
| ||
(a) The size, composition and growth of the population | ||
of the area
to be served;
| ||
(b) The number of existing and planned facilities | ||
offering similar
programs;
| ||
(c) The extent of utilization of existing facilities;
| ||
(d) The availability of facilities which may serve as | ||
alternatives
or substitutes;
| ||
(e) The availability of personnel necessary to the | ||
operation of the
facility;
| ||
(f) Multi-institutional planning and the establishment | ||
of
multi-institutional systems where feasible;
|
(g) The financial and economic feasibility of proposed | ||
construction
or modification; and
| ||
(h) In the case of health care facilities established | ||
by a religious
body or denomination, the needs of the | ||
members of such religious body or
denomination may be | ||
considered to be public need.
| ||
The health care facility plans which are developed and | ||
adopted in
accordance with this Section shall form the basis | ||
for the plan of the State
to deal most effectively with | ||
statewide health needs in regard to health
care facilities.
| ||
(5) Coordinate with the Center for Comprehensive Health | ||
Planning and other state agencies having responsibilities
| ||
affecting health care facilities, including those of licensure | ||
and cost
reporting. Beginning no later than January 1, 2013, | ||
the Department of Public Health shall produce a written annual | ||
report to the Governor and the General Assembly regarding the | ||
development of the Center for Comprehensive Health Planning. | ||
The Chairman of the State Board and the State Board | ||
Administrator shall also receive a copy of the annual report.
| ||
(6) Solicit, accept, hold and administer on behalf of the | ||
State
any grants or bequests of money, securities or property | ||
for
use by the State Board or Center for Comprehensive Health | ||
Planning in the administration of this Act; and enter into | ||
contracts
consistent with the appropriations for purposes | ||
enumerated in this Act.
| ||
(7) The State Board shall prescribe procedures for review, |
standards,
and criteria which shall be utilized
to make | ||
periodic reviews and determinations of the appropriateness
of | ||
any existing health services being rendered by health care | ||
facilities
subject to the Act. The State Board shall consider | ||
recommendations of the
Board in making its
determinations.
| ||
(8) Prescribe, in consultation
with the Center for | ||
Comprehensive Health Planning, rules, regulations,
standards, | ||
and criteria for the conduct of an expeditious review of
| ||
applications
for permits for projects of construction or | ||
modification of a health care
facility, which projects are | ||
classified as emergency, substantive, or non-substantive in | ||
nature. | ||
Six months after June 30, 2009 (the effective date of | ||
Public Act 96-31), substantive projects shall include no more | ||
than the following: | ||
(a) Projects to construct (1) a new or replacement | ||
facility located on a new site or
(2) a replacement | ||
facility located on the same site as the original facility | ||
and the cost of the replacement facility exceeds the | ||
capital expenditure minimum, which shall be reviewed by the | ||
Board within 120 days; | ||
(b) Projects proposing a
(1) new service within an | ||
existing healthcare facility or
(2) discontinuation of a | ||
service within an existing healthcare facility, which | ||
shall be reviewed by the Board within 60 days; or | ||
(c) Projects proposing a change in the bed capacity of |
a health care facility by an increase in the total number | ||
of beds or by a redistribution of beds among various | ||
categories of service or by a relocation of beds from one | ||
physical facility or site to another by more than 20 beds | ||
or more than 10% of total bed capacity, as defined by the | ||
State Board, whichever is less, over a 2-year period. | ||
The Chairman may approve applications for exemption that | ||
meet the criteria set forth in rules or refer them to the full | ||
Board. The Chairman may approve any unopposed application that | ||
meets all of the review criteria or refer them to the full | ||
Board. | ||
Such rules shall
not abridge the right of the Center for | ||
Comprehensive Health Planning to make
recommendations on the | ||
classification and approval of projects, nor shall
such rules | ||
prevent the conduct of a public hearing upon the timely request
| ||
of an interested party. Such reviews shall not exceed 60 days | ||
from the
date the application is declared to be complete.
| ||
(9) Prescribe rules, regulations,
standards, and criteria | ||
pertaining to the granting of permits for
construction
and | ||
modifications which are emergent in nature and must be | ||
undertaken
immediately to prevent or correct structural | ||
deficiencies or hazardous
conditions that may harm or injure | ||
persons using the facility, as defined
in the rules and | ||
regulations of the State Board. This procedure is exempt
from | ||
public hearing requirements of this Act.
| ||
(10) Prescribe rules,
regulations, standards and criteria |
for the conduct of an expeditious
review, not exceeding 60 | ||
days, of applications for permits for projects to
construct or | ||
modify health care facilities which are needed for the care
and | ||
treatment of persons who have acquired immunodeficiency | ||
syndrome (AIDS)
or related conditions.
| ||
(11) Issue written decisions upon request of the applicant | ||
or an adversely affected party to the Board. Requests for a | ||
written decision shall be made within 15 days after the Board | ||
meeting in which a final decision has been made. A "final | ||
decision" for purposes of this Act is the decision to approve | ||
or deny an application, or take other actions permitted under | ||
this Act, at the time and date of the meeting that such action | ||
is scheduled by the Board. The staff of the Board shall prepare | ||
a written copy of the final decision and the Board shall | ||
approve a final copy for inclusion in the formal record. The | ||
Board shall consider, for approval, the written draft of the | ||
final decision no later than the next scheduled Board meeting. | ||
The written decision shall identify the applicable criteria and | ||
factors listed in this Act and the Board's regulations that | ||
were taken into consideration by the Board when coming to a | ||
final decision. If the Board denies or fails to approve an | ||
application for permit or exemption, the Board shall include in | ||
the final decision a detailed explanation as to why the | ||
application was denied and identify what specific criteria or | ||
standards the applicant did not fulfill. | ||
(12) Require at least one of its members to participate in |
any public hearing, after the appointment of a majority of the | ||
members to the Board. | ||
(13) Provide a mechanism for the public to comment on, and | ||
request changes to, draft rules and standards. | ||
(14) Implement public information campaigns to regularly | ||
inform the general public about the opportunity for public | ||
hearings and public hearing procedures. | ||
(15) Establish a separate set of rules and guidelines for | ||
long-term care that recognizes that nursing homes are a | ||
different business line and service model from other regulated | ||
facilities. An open and transparent process shall be developed | ||
that considers the following: how skilled nursing fits in the | ||
continuum of care with other care providers, modernization of | ||
nursing homes, establishment of more private rooms, | ||
development of alternative services, and current trends in | ||
long-term care services.
The Chairman of the Board shall | ||
appoint a permanent Health Services Review Board Long-term Care | ||
Facility Advisory Subcommittee that shall develop and | ||
recommend to the Board the rules to be established by the Board | ||
under this paragraph (15). The Subcommittee shall also provide | ||
continuous review and commentary on policies and procedures | ||
relative to long-term care and the review of related projects. | ||
In consultation with other experts from the health field of | ||
long-term care, the Board and the Subcommittee shall study new | ||
approaches to the current bed need formula and Health Service | ||
Area boundaries to encourage flexibility and innovation in |
design models reflective of the changing long-term care | ||
marketplace and consumer preferences. The Subcommittee shall | ||
evaluate, and make recommendations to the State Board | ||
regarding, the buying, selling, and exchange of beds between | ||
long-term care facilities within a specified geographic area or | ||
drive time. The Board shall file the proposed related | ||
administrative rules for the separate rules and guidelines for | ||
long-term care required by this paragraph (15) by no later than | ||
September 30, 2011. The Subcommittee shall be provided a | ||
reasonable and timely opportunity to review and comment on any | ||
review, revision, or updating of the criteria, standards, | ||
procedures, and rules used to evaluate project applications as | ||
provided under Section 12.3 of this Act. | ||
(16) Establish a separate set of rules and guidelines for | ||
facilities licensed under the Specialized Mental Health | ||
Rehabilitation Act of 2013. An application for the | ||
re-establishment of a facility in connection with the | ||
relocation of the facility shall not be granted unless the | ||
applicant has a contractual relationship with at least one | ||
hospital to provide emergency and inpatient mental health | ||
services required by facility consumers, and at least one | ||
community mental health agency to provide oversight and | ||
assistance to facility consumers while living in the facility, | ||
and appropriate services, including case management, to assist | ||
them to prepare for discharge and reside stably in the | ||
community thereafter. No new facilities licensed under the |
Specialized Mental Health Rehabilitation Act of 2013 shall be | ||
established after the effective date of this amendatory Act of | ||
the 98th General Assembly except in connection with the | ||
relocation of an existing facility to a new location. An | ||
application for a new location shall not be approved unless | ||
there are adequate community services accessible to the | ||
consumers within a reasonable distance, or by use of public | ||
transportation, so as to facilitate the goal of achieving | ||
maximum individual self-care and independence. At no time shall | ||
the total number of authorized beds under this Act in | ||
facilities licensed under the Specialized Mental Health | ||
Rehabilitation Act of 2013 exceed the number of authorized beds | ||
on the effective date of this amendatory Act of the 98th | ||
General Assembly. | ||
(Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813, | ||
eff. 7-13-12; 97-1045, eff. 8-21-13; 97-1115, eff. 8-27-12; | ||
98-414, eff. 1-1-14; 98-463, eff. 8-16-13.)
| ||
Section 5-10. The Illinois Public Aid Code is amended by | ||
changing Sections 5-5.12 and 5-30 and by adding Section 5-30.1 | ||
as follows:
| ||
(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
| ||
Sec. 5-5.12. Pharmacy payments.
| ||
(a) Every request submitted by a pharmacy for reimbursement | ||
under this
Article for prescription drugs provided to a |
recipient of aid under this
Article shall include the name of | ||
the prescriber or an acceptable
identification number as | ||
established by the Department.
| ||
(b) Pharmacies providing prescription drugs under
this | ||
Article shall be reimbursed at a rate which shall include
a | ||
professional dispensing fee as determined by the Illinois
| ||
Department, plus the current acquisition cost of the | ||
prescription
drug dispensed. The Illinois Department shall | ||
update its
information on the acquisition costs of all | ||
prescription drugs
no less frequently than every 30 days. | ||
However, the Illinois
Department may set the rate of | ||
reimbursement for the acquisition
cost, by rule, at a | ||
percentage of the current average wholesale
acquisition cost.
| ||
(c) (Blank).
| ||
(d) The Department shall review utilization of narcotic | ||
medications in the medical assistance program and impose | ||
utilization controls that protect against abuse.
| ||
(e) When making determinations as to which drugs shall be | ||
on a prior approval list, the Department shall include as part | ||
of the analysis for this determination, the degree to which a | ||
drug may affect individuals in different ways based on factors | ||
including the gender of the person taking the medication. | ||
(f) The Department shall cooperate with the Department of | ||
Public Health and the Department of Human Services Division of | ||
Mental Health in identifying psychotropic medications that, | ||
when given in a particular form, manner, duration, or frequency |
(including "as needed") in a dosage, or in conjunction with | ||
other psychotropic medications to a nursing home resident or to | ||
a resident of a facility licensed under the ID/DD Community | ||
Care Act, may constitute a chemical restraint or an | ||
"unnecessary drug" as defined by the Nursing Home Care Act or | ||
Titles XVIII and XIX of the Social Security Act and the | ||
implementing rules and regulations. The Department shall | ||
require prior approval for any such medication prescribed for a | ||
nursing home resident or to a resident of a facility licensed | ||
under the ID/DD Community Care Act, that appears to be a | ||
chemical restraint or an unnecessary drug. The Department shall | ||
consult with the Department of Human Services Division of | ||
Mental Health in developing a protocol and criteria for | ||
deciding whether to grant such prior approval. | ||
(g) The Department may by rule provide for reimbursement of | ||
the dispensing of a 90-day supply of a generic or brand name, | ||
non-narcotic maintenance medication in circumstances where it | ||
is cost effective. | ||
(g-5) On and after July 1, 2012, the Department may require | ||
the dispensing of drugs to nursing home residents be in a 7-day | ||
supply or other amount less than a 31-day supply. The | ||
Department shall pay only one dispensing fee per 31-day supply. | ||
(h) Effective July 1, 2011, the Department shall | ||
discontinue coverage of select over-the-counter drugs, | ||
including analgesics and cough and cold and allergy | ||
medications. |
(h-5) On and after July 1, 2012, the Department shall | ||
impose utilization controls, including, but not limited to, | ||
prior approval on specialty drugs, oncolytic drugs, drugs for | ||
the treatment of HIV or AIDS, immunosuppressant drugs, and | ||
biological products in order to maximize savings on these | ||
drugs. The Department may adjust payment methodologies for | ||
non-pharmacy billed drugs in order to incentivize the selection | ||
of lower-cost drugs. For drugs for the treatment of AIDS, the | ||
Department shall take into consideration the potential for | ||
non-adherence by certain populations, and shall develop | ||
protocols with organizations or providers primarily serving | ||
those with HIV/AIDS, as long as such measures intend to | ||
maintain cost neutrality with other utilization management | ||
controls such as prior approval.
For hemophilia, the Department | ||
shall develop a program of utilization review and control which | ||
may include, in the discretion of the Department, prior | ||
approvals. The Department may impose special standards on | ||
providers that dispense blood factors which shall include, in | ||
the discretion of the Department, staff training and education; | ||
patient outreach and education; case management; in-home | ||
patient assessments; assay management; maintenance of stock; | ||
emergency dispensing timeframes; data collection and | ||
reporting; dispensing of supplies related to blood factor | ||
infusions; cold chain management and packaging practices; care | ||
coordination; product recalls; and emergency clinical | ||
consultation. The Department may require patients to receive a |
comprehensive examination annually at an appropriate provider | ||
in order to be eligible to continue to receive blood factor. | ||
(i) On and after July 1, 2012, the Department shall reduce | ||
any rate of reimbursement for services or other payments or | ||
alter any methodologies authorized by this Code to reduce any | ||
rate of reimbursement for services or other payments in | ||
accordance with Section 5-5e. | ||
(j) On and after July 1, 2012, the Department shall impose | ||
limitations on prescription drugs such that the Department | ||
shall not provide reimbursement for more than 4 prescriptions, | ||
including 3 brand name prescriptions, for distinct drugs in a | ||
30-day period, unless prior approval is received for all | ||
prescriptions in excess of the 4-prescription limit. Drugs in | ||
the following therapeutic classes shall not be subject to prior | ||
approval as a result of the 4-prescription limit: | ||
immunosuppressant drugs, oncolytic drugs, and anti-retroviral | ||
drugs , and, on or after July 1, 2014, antipsychotic drugs . On | ||
or after July 1, 2014, the Department may exempt children with | ||
complex medical needs enrolled in a care coordination entity | ||
contracted with the Department to solely coordinate care for | ||
such children, if the Department determines that the entity has | ||
a comprehensive drug reconciliation program. | ||
(k) No medication therapy management program implemented | ||
by the Department shall be contrary to the provisions of the | ||
Pharmacy Practice Act. | ||
(l) Any provider enrolled with the Department that bills |
the Department for outpatient drugs and is eligible to enroll | ||
in the federal Drug Pricing Program under Section 340B of the | ||
federal Public Health Services Act shall enroll in that | ||
program. No entity participating in the federal Drug Pricing | ||
Program under Section 340B of the federal Public Health | ||
Services Act may exclude Medicaid from their participation in | ||
that program, although the Department may exclude entities | ||
defined in Section 1905(l)(2)(B) of the Social Security Act | ||
from this requirement. | ||
(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333, | ||
eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12; | ||
97-813, eff. 7-13-12; 98-463, eff. 8-16-13.)
| ||
(305 ILCS 5/5-30) | ||
Sec. 5-30. Care coordination. | ||
(a) At least 50% of recipients eligible for comprehensive | ||
medical benefits in all medical assistance programs or other | ||
health benefit programs administered by the Department, | ||
including the Children's Health Insurance Program Act and the | ||
Covering ALL KIDS Health Insurance Act, shall be enrolled in a | ||
care coordination program by no later than January 1, 2015. For | ||
purposes of this Section, "coordinated care" or "care | ||
coordination" means delivery systems where recipients will | ||
receive their care from providers who participate under | ||
contract in integrated delivery systems that are responsible | ||
for providing or arranging the majority of care, including |
primary care physician services, referrals from primary care | ||
physicians, diagnostic and treatment services, behavioral | ||
health services, in-patient and outpatient hospital services, | ||
dental services, and rehabilitation and long-term care | ||
services. The Department shall designate or contract for such | ||
integrated delivery systems (i) to ensure enrollees have a | ||
choice of systems and of primary care providers within such | ||
systems; (ii) to ensure that enrollees receive quality care in | ||
a culturally and linguistically appropriate manner; and (iii) | ||
to ensure that coordinated care programs meet the diverse needs | ||
of enrollees with developmental, mental health, physical, and | ||
age-related disabilities. | ||
(b) Payment for such coordinated care shall be based on | ||
arrangements where the State pays for performance related to | ||
health care outcomes, the use of evidence-based practices, the | ||
use of primary care delivered through comprehensive medical | ||
homes, the use of electronic medical records, and the | ||
appropriate exchange of health information electronically made | ||
either on a capitated basis in which a fixed monthly premium | ||
per recipient is paid and full financial risk is assumed for | ||
the delivery of services, or through other risk-based payment | ||
arrangements. | ||
(c) To qualify for compliance with this Section, the 50% | ||
goal shall be achieved by enrolling medical assistance | ||
enrollees from each medical assistance enrollment category, | ||
including parents, children, seniors, and people with |
disabilities to the extent that current State Medicaid payment | ||
laws would not limit federal matching funds for recipients in | ||
care coordination programs. In addition, services must be more | ||
comprehensively defined and more risk shall be assumed than in | ||
the Department's primary care case management program as of the | ||
effective date of this amendatory Act of the 96th General | ||
Assembly. | ||
(d) The Department shall report to the General Assembly in | ||
a separate part of its annual medical assistance program | ||
report, beginning April, 2012 until April, 2016, on the | ||
progress and implementation of the care coordination program | ||
initiatives established by the provisions of this amendatory | ||
Act of the 96th General Assembly. The Department shall include | ||
in its April 2011 report a full analysis of federal laws or | ||
regulations regarding upper payment limitations to providers | ||
and the necessary revisions or adjustments in rate | ||
methodologies and payments to providers under this Code that | ||
would be necessary to implement coordinated care with full | ||
financial risk by a party other than the Department.
| ||
(e) Integrated Care Program for individuals with chronic | ||
mental health conditions. | ||
(1) The Integrated Care Program shall encompass | ||
services administered to recipients of medical assistance | ||
under this Article to prevent exacerbations and | ||
complications using cost-effective, evidence-based | ||
practice guidelines and mental health management |
strategies. | ||
(2) The Department may utilize and expand upon existing | ||
contractual arrangements with integrated care plans under | ||
the Integrated Care Program for providing the coordinated | ||
care provisions of this Section. | ||
(3) Payment for such coordinated care shall be based on | ||
arrangements where the State pays for performance related | ||
to mental health outcomes on a capitated basis in which a | ||
fixed monthly premium per recipient is paid and full | ||
financial risk is assumed for the delivery of services, or | ||
through other risk-based payment arrangements such as | ||
provider-based care coordination. | ||
(4) The Department shall examine whether chronic | ||
mental health management programs and services for | ||
recipients with specific chronic mental health conditions | ||
do any or all of the following: | ||
(A) Improve the patient's overall mental health in | ||
a more expeditious and cost-effective manner. | ||
(B) Lower costs in other aspects of the medical | ||
assistance program, such as hospital admissions, | ||
emergency room visits, or more frequent and | ||
inappropriate psychotropic drug use. | ||
(5) The Department shall work with the facilities and | ||
any integrated care plan participating in the program to | ||
identify and correct barriers to the successful | ||
implementation of this subsection (e) prior to and during |
the implementation to best facilitate the goals and | ||
objectives of this subsection (e). | ||
(f) A hospital that is located in a county of the State in | ||
which the Department mandates some or all of the beneficiaries | ||
of the Medical Assistance Program residing in the county to | ||
enroll in a Care Coordination Program, as set forth in Section | ||
5-30 of this Code, shall not be eligible for any non-claims | ||
based payments not mandated by Article V-A of this Code for | ||
which it would otherwise be qualified to receive, unless the | ||
hospital is a Coordinated Care Participating Hospital no later | ||
than 60 days after the effective date of this amendatory Act of | ||
the 97th General Assembly or 60 days after the first mandatory | ||
enrollment of a beneficiary in a Coordinated Care program. For | ||
purposes of this subsection, "Coordinated Care Participating | ||
Hospital" means a hospital that meets one of the following | ||
criteria: | ||
(1) The hospital has entered into a contract to provide | ||
hospital services with one or more MCOs to enrollees of the | ||
care coordination program. | ||
(2) The hospital has not been offered a contract by a | ||
care coordination plan that the Department has determined | ||
to be a good faith offer and that pays at least as much as | ||
the Department would pay, on a fee-for-service basis, not | ||
including disproportionate share hospital adjustment | ||
payments or any other supplemental adjustment or add-on | ||
payment to the base fee-for-service rate , except to the |
extent such adjustments or add-on payments are | ||
incorporated into the development of the applicable MCO | ||
capitated rates . | ||
As used in this subsection (f), "MCO" means any entity | ||
which contracts with the Department to provide services where | ||
payment for medical services is made on a capitated basis. | ||
(g) No later than August 1, 2013, the Department shall | ||
issue a purchase of care solicitation for Accountable Care | ||
Entities (ACE) to serve any children and parents or caretaker | ||
relatives of children eligible for medical assistance under | ||
this Article. An ACE may be a single corporate structure or a | ||
network of providers organized through contractual | ||
relationships with a single corporate entity. The solicitation | ||
shall require that: | ||
(1) An ACE operating in Cook County be capable of | ||
serving at least 40,000 eligible individuals in that | ||
county; an ACE operating in Lake, Kane, DuPage, or Will | ||
Counties be capable of serving at least 20,000 eligible | ||
individuals in those counties and an ACE operating in other | ||
regions of the State be capable of serving at least 10,000 | ||
eligible individuals in the region in which it operates. | ||
During initial periods of mandatory enrollment, the | ||
Department shall require its enrollment services | ||
contractor to use a default assignment algorithm that | ||
ensures if possible an ACE reaches the minimum enrollment | ||
levels set forth in this paragraph. |
(2) An ACE must include at a minimum the following | ||
types of providers: primary care, specialty care, | ||
hospitals, and behavioral healthcare. | ||
(3) An ACE shall have a governance structure that | ||
includes the major components of the health care delivery | ||
system, including one representative from each of the | ||
groups listed in paragraph (2). | ||
(4) An ACE must be an integrated delivery system, | ||
including a network able to provide the full range of | ||
services needed by Medicaid beneficiaries and system | ||
capacity to securely pass clinical information across | ||
participating entities and to aggregate and analyze that | ||
data in order to coordinate care. | ||
(5) An ACE must be capable of providing both care | ||
coordination and complex case management, as necessary, to | ||
beneficiaries. To be responsive to the solicitation, a | ||
potential ACE must outline its care coordination and | ||
complex case management model and plan to reduce the cost | ||
of care. | ||
(6) In the first 18 months of operation, unless the ACE | ||
selects a shorter period, an ACE shall be paid care | ||
coordination fees on a per member per month basis that are | ||
projected to be cost neutral to the State during the term | ||
of their payment and, subject to federal approval, be | ||
eligible to share in additional savings generated by their | ||
care coordination. |
(7) In months 19 through 36 of operation, unless the | ||
ACE selects a shorter period, an ACE shall be paid on a | ||
pre-paid capitation basis for all medical assistance | ||
covered services, under contract terms similar to Managed | ||
Care Organizations (MCO), with the Department sharing the | ||
risk through either stop-loss insurance for extremely high | ||
cost individuals or corridors of shared risk based on the | ||
overall cost of the total enrollment in the ACE. The ACE | ||
shall be responsible for claims processing, encounter data | ||
submission, utilization control, and quality assurance. | ||
(8) In the fourth and subsequent years of operation, an | ||
ACE shall convert to a Managed Care Community Network | ||
(MCCN), as defined in this Article, or Health Maintenance | ||
Organization pursuant to the Illinois Insurance Code, | ||
accepting full-risk capitation payments. | ||
The Department shall allow potential ACE entities 5 months | ||
from the date of the posting of the solicitation to submit | ||
proposals. After the solicitation is released, in addition to | ||
the MCO rate development data available on the Department's | ||
website, subject to federal and State confidentiality and | ||
privacy laws and regulations, the Department shall provide 2 | ||
years of de-identified summary service data on the targeted | ||
population, split between children and adults, showing the | ||
historical type and volume of services received and the cost of | ||
those services to those potential bidders that sign a data use | ||
agreement. The Department may add up to 2 non-state government |
employees with expertise in creating integrated delivery | ||
systems to its review team for the purchase of care | ||
solicitation described in this subsection. Any such | ||
individuals must sign a no-conflict disclosure and | ||
confidentiality agreement and agree to act in accordance with | ||
all applicable State laws. | ||
During the first 2 years of an ACE's operation, the | ||
Department shall provide claims data to the ACE on its | ||
enrollees on a periodic basis no less frequently than monthly. | ||
Nothing in this subsection shall be construed to limit the | ||
Department's mandate to enroll 50% of its beneficiaries into | ||
care coordination systems by January 1, 2015, using all | ||
available care coordination delivery systems, including Care | ||
Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | ||
to affect the current CCEs, MCCNs, and MCOs selected to serve | ||
seniors and persons with disabilities prior to that date. | ||
Nothing in this subsection precludes the Department from | ||
considering future proposals for new ACEs or expansion of | ||
existing ACEs at the discretion of the Department. | ||
(h) Department contracts with MCOs and other entities | ||
reimbursed by risk based capitation shall have a minimum | ||
medical loss ratio of 85%, shall require the MCO or other | ||
entity to pay claims within 30 days of receiving a bill that | ||
contains all the essential information needed to adjudicate the | ||
bill, and shall require the entity to pay a penalty that is at | ||
least equal to the penalty imposed under the Illinois Insurance |
Code for any claims not paid within this time period shall | ||
require the entity to establish an appeals and grievances | ||
process for consumers and providers, and shall require the | ||
entity to provide a quality assurance and utilization review | ||
program. Entities contracted with the Department to coordinate | ||
healthcare regardless of risk shall be measured utilizing the | ||
same quality metrics. The quality metrics may be population | ||
specific. Any contracted entity serving at least 5,000 seniors | ||
or people with disabilities or 15,000 individuals in other | ||
populations covered by the Medical Assistance Program that has | ||
been receiving full-risk capitation for a year shall be | ||
accredited by a national accreditation organization authorized | ||
by the Department within 2 years after the date it is eligible | ||
to become accredited . The requirements of this subsection shall | ||
apply to contracts with MCOs entered into or renewed or | ||
extended after June 1, 2013. | ||
(h-5) The Department shall monitor and enforce compliance | ||
by MCOs with agreements they have entered into with providers | ||
on issues that include, but are not limited to, timeliness of | ||
payment, payment rates, and processes for obtaining prior | ||
approval. The Department may impose sanctions on MCOs for | ||
violating provisions of those agreements that include, but are | ||
not limited to, financial penalties, suspension of enrollment | ||
of new enrollees, and termination of the MCO's contract with | ||
the Department. As used in this subsection (h-5), "MCO" has the | ||
meaning ascribed to that term in Section 5-30.1 of this Code. |
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
| ||
(305 ILCS 5/5-30.1 new) | ||
Sec. 5-30.1. Managed care protections. | ||
(a) As used in this Section: | ||
"Managed care organization" or "MCO" means any entity which | ||
contracts with the Department to provide services where payment | ||
for medical services is made on a capitated basis. | ||
"Emergency services" include: | ||
(1) emergency services, as defined by Section 10 of the | ||
Managed Care Reform and Patient Rights Act; | ||
(2) emergency medical screening examinations, as | ||
defined by Section 10 of the Managed Care Reform and | ||
Patient Rights Act; | ||
(3) post-stabilization medical services, as defined by | ||
Section 10 of the Managed Care Reform and Patient Rights | ||
Act; and | ||
(4) emergency medical conditions, as defined by
| ||
Section 10 of the Managed Care Reform and Patient Rights
| ||
Act. | ||
(b) As provided by Section 5-16.12, managed care | ||
organizations are subject to the provisions of the Managed Care | ||
Reform and Patient Rights Act. | ||
(c) An MCO shall pay any provider of emergency services | ||
that does not have in effect a contract with the contracted | ||
Medicaid MCO. The default rate of reimbursement shall be the |
rate paid under Illinois Medicaid fee-for-service program | ||
methodology, including all policy adjusters, including but not | ||
limited to Medicaid High Volume Adjustments, Medicaid | ||
Percentage Adjustments, Outpatient High Volume Adjustments, | ||
and all outlier add-on adjustments to the extent such | ||
adjustments are incorporated in the development of the | ||
applicable MCO capitated rates. | ||
(d) An MCO shall pay for all post-stabilization services as | ||
a covered service in any of the following situations: | ||
(1) the MCO authorized such services; | ||
(2) such services were administered to maintain the | ||
enrollee's stabilized condition within one hour after a | ||
request to the MCO for authorization of further | ||
post-stabilization services; | ||
(3) the MCO did not respond to a request to authorize | ||
such services within one hour; | ||
(4) the MCO could not be contacted; or | ||
(5) the MCO and the treating provider, if the treating | ||
provider is a non-affiliated provider, could not reach an | ||
agreement concerning the enrollee's care and an affiliated | ||
provider was unavailable for a consultation, in which case | ||
the MCO
must pay for such services rendered by the treating | ||
non-affiliated provider until an affiliated provider was | ||
reached and either concurred with the treating | ||
non-affiliated provider's plan of care or assumed | ||
responsibility for the enrollee's care. Such payment shall |
be made at the default rate of reimbursement paid under | ||
Illinois Medicaid fee-for-service program methodology, | ||
including all policy adjusters, including but not limited | ||
to Medicaid High Volume Adjustments, Medicaid Percentage | ||
Adjustments, Outpatient High Volume Adjustments and all | ||
outlier add-on adjustments to the extent that such | ||
adjustments are incorporated in the development of the | ||
applicable MCO capitated rates. | ||
(e) The following requirements apply to MCOs in determining | ||
payment for all emergency services: | ||
(1) MCOs shall not impose any requirements for prior | ||
approval of emergency services. | ||
(2) The MCO shall cover emergency services provided to | ||
enrollees who are temporarily away from their residence and | ||
outside the contracting area to the extent that the | ||
enrollees would be entitled to the emergency services if | ||
they still were within the contracting area. | ||
(3) The MCO shall have no obligation to cover medical | ||
services provided on an emergency basis that are not | ||
covered services under the contract. | ||
(4) The MCO shall not condition coverage for emergency | ||
services on the treating provider notifying the MCO of the | ||
enrollee's screening and treatment within 10 days after | ||
presentation for emergency services. | ||
(5) The determination of the attending emergency | ||
physician, or the provider actually treating the enrollee, |
of whether an enrollee is sufficiently stabilized for | ||
discharge or transfer to another facility, shall be binding | ||
on the MCO. The MCO shall cover emergency services for all | ||
enrollees whether the emergency services are provided by an | ||
affiliated or non-affiliated provider. | ||
(6) The MCO's financial responsibility for | ||
post-stabilization care services it has not pre-approved | ||
ends when: | ||
(A) a plan physician with privileges at the | ||
treating hospital assumes responsibility for the | ||
enrollee's care; | ||
(B) a plan physician assumes responsibility for | ||
the enrollee's care through transfer; | ||
(C) a contracting entity representative and the | ||
treating physician reach an agreement concerning the | ||
enrollee's care; or | ||
(D) the enrollee is discharged. | ||
(f) Network adequacy. | ||
(1) The Department shall: | ||
(A) ensure that an adequate provider network is in | ||
place, taking into consideration health professional | ||
shortage areas and medically underserved areas; | ||
(B) publicly release an explanation of its process | ||
for analyzing network adequacy; | ||
(C) periodically ensure that an MCO continues to | ||
have an adequate network in place; and |
(D) require MCOs to maintain an updated and public | ||
list of network providers. | ||
(g) Timely payment of claims. | ||
(1) The MCO shall pay a claim within 30 days of | ||
receiving a claim that contains all the essential | ||
information needed to adjudicate the claim. | ||
(2) The MCO shall notify the billing party of its | ||
inability to adjudicate a claim within 30 days of receiving | ||
that claim. | ||
(3) The MCO shall pay a penalty that is at least equal | ||
to the penalty imposed under the Illinois Insurance Code | ||
for any claims not timely paid. | ||
(4) The Department may establish a process for MCOs to | ||
expedite payments to providers based on criteria | ||
established by the Department. | ||
(h) The Department shall not expand mandatory MCO | ||
enrollment into new counties beyond those counties already | ||
designated by the Department as of June 1, 2014 for the | ||
individuals whose eligibility for medical assistance is not the | ||
seniors or people with disabilities population until the | ||
Department provides an opportunity for accountable care | ||
entities and MCOs to participate in such newly designated | ||
counties. | ||
(i) The requirements of this Section apply to contracts | ||
with accountable care entities and MCOs entered into, amended, | ||
or renewed after the effective date of this amendatory Act of |
the 98th General Assembly.
| ||
Article 10 | ||
Section 10-5. The Specialized Mental Health Rehabilitation | ||
Act of 2013 is amended by changing Sections 1-101.5, 1-101.6, | ||
1-102, 4-108, and 5-101 and by adding Section 4-108.5 as | ||
follows:
| ||
(210 ILCS 49/1-101.5)
| ||
Sec. 1-101.5. Prior law. | ||
(a) This Act provides for licensure of long term care | ||
facilities that are federally designated as institutions for | ||
the mentally diseased on the effective date of this Act and | ||
specialize in providing services to individuals with a serious | ||
mental illness. On and after the effective date of this Act, | ||
these facilities shall be governed by this Act instead of the | ||
Nursing Home Care Act. | ||
(b) All consent decrees that apply to facilities federally | ||
designated as institutions for the mentally diseased shall | ||
continue to apply to facilities licensed under this Act.
| ||
(c) A facility licensed under this Act may voluntarily | ||
close, and the facility may reopen in an underserved region of | ||
the State, if the facility receives a certificate of need from | ||
the Health Facilities and Services Review Board. At no time | ||
shall the total number of licensed beds under this Act exceed |
the total number of licensed beds existing on July 22, 2013 | ||
(the effective date of Public Act 98-104). | ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
(210 ILCS 49/1-101.6)
| ||
Sec. 1-101.6. Mental health system planning. The General | ||
Assembly finds the services contained in this Act are necessary | ||
for the effective delivery of mental health services for the | ||
citizens of the State of Illinois. The General Assembly also | ||
finds that the mental health system in the State requires | ||
further review to develop additional needed services. To ensure | ||
the adequacy of community-based services and to offer choice to | ||
all individuals with serious mental illness who choose to live | ||
in the community, and for whom the community is the appropriate | ||
setting, but are at risk of institutional care, the Governor | ||
shall convene a working group to develop the process and | ||
procedure for identifying needed services in the different | ||
geographic regions of the State. The Governor shall include the | ||
Division of Mental Health of the Department of Human Services, | ||
the Department of Healthcare and Family Services, the | ||
Department of Public Health, community mental health | ||
providers, statewide associations of mental health providers, | ||
mental health advocacy groups, and any other entity as deemed | ||
appropriate for participation in the working group. The | ||
Department of Human Services shall provide staff and support to | ||
this working group.
|
Before September 1, 2014, the State shall develop and | ||
implement a service authorization system available 24 hours a | ||
day, 7 days a week for approval of services in the following 3 | ||
levels of care under this Act: crisis stabilization; recovery | ||
and rehabilitation supports; and transitional living units. | ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
(210 ILCS 49/1-102)
| ||
Sec. 1-102. Definitions. For the purposes of this Act, | ||
unless the context otherwise requires: | ||
"Abuse" means any physical or mental injury or sexual | ||
assault inflicted on a consumer other than by accidental means | ||
in a facility. | ||
"Accreditation" means any of the following: | ||
(1) the Joint Commission; | ||
(2) the Commission on Accreditation of Rehabilitation | ||
Facilities; | ||
(3) the Healthcare Facilities Accreditation Program; | ||
or | ||
(4) any other national standards of care as approved by | ||
the Department. | ||
"Applicant" means any person making application for a | ||
license or a provisional license under this Act. | ||
"Consumer" means a person, 18 years of age or older, | ||
admitted to a mental health rehabilitation facility for | ||
evaluation, observation, diagnosis, treatment, stabilization, |
recovery, and rehabilitation. | ||
"Consumer" does not mean any of the following: | ||
(i) an individual requiring a locked setting; | ||
(ii) an individual requiring psychiatric | ||
hospitalization because of an acute psychiatric crisis; | ||
(iii) an individual under 18 years of age; | ||
(iv) an individual who is actively suicidal or violent | ||
toward others; | ||
(v) an individual who has been found unfit to stand | ||
trial; | ||
(vi) an individual who has been found not guilty by | ||
reason of insanity based on committing a violent act, such | ||
as sexual assault, assault with a deadly weapon, arson, or | ||
murder; | ||
(vii) an individual subject to temporary detention and | ||
examination under Section 3-607 of the Mental Health and | ||
Developmental Disabilities Code; | ||
(viii) an individual deemed clinically appropriate for | ||
inpatient admission in a State psychiatric hospital; and | ||
(ix) an individual transferred by the Department of | ||
Corrections pursuant to Section 3-8-5 of the Unified Code | ||
of Corrections. | ||
"Consumer record" means a record that organizes all | ||
information on the care, treatment, and rehabilitation | ||
services rendered to a consumer in a specialized mental health | ||
rehabilitation facility. |
"Controlled drugs" means those drugs covered under the | ||
federal Comprehensive Drug Abuse Prevention Control Act of | ||
1970, as amended, or the Illinois Controlled Substances Act. | ||
"Department" means the Department of Public Health. | ||
"Discharge" means the full release of any consumer from a | ||
facility. | ||
"Drug administration" means the act in which a single dose | ||
of a prescribed drug or biological is given to a consumer. The | ||
complete act of administration entails removing an individual | ||
dose from a container, verifying the dose with the prescriber's | ||
orders, giving the individual dose to the consumer, and | ||
promptly recording the time and dose given. | ||
"Drug dispensing" means the act entailing the following of | ||
a prescription order for a drug or biological and proper | ||
selection, measuring, packaging, labeling, and issuance of the | ||
drug or biological to a consumer. | ||
"Emergency" means a situation, physical condition, or one | ||
or more practices, methods, or operations which present | ||
imminent danger of death or serious physical or mental harm to | ||
consumers of a facility. | ||
"Facility" means a specialized mental health | ||
rehabilitation facility that provides at least one of the | ||
following services: (1) triage center; (2) crisis | ||
stabilization; (3) recovery and rehabilitation supports; or | ||
(4) transitional living units for 3 or more persons. The | ||
facility shall provide a 24-hour program that provides |
intensive support and recovery services designed to assist | ||
persons, 18 years or older, with mental disorders to develop | ||
the skills to become self-sufficient and capable of increasing | ||
levels of independent functioning. It includes facilities that | ||
meet the following criteria: | ||
(1) 100% of the consumer population of the facility has | ||
a diagnosis of serious mental illness; | ||
(2) no more than 15% of the consumer population of the | ||
facility is 65 years of age or older; | ||
(3) none of the consumers are non-ambulatory; | ||
(4) none of the consumers have a primary diagnosis of | ||
moderate, severe, or profound intellectual disability; and | ||
(5) the facility must have been licensed under the | ||
Specialized Mental Health Rehabilitation Act or the | ||
Nursing Home Care Act immediately preceding the effective | ||
date of this Act and qualifies as a institute for mental | ||
disease under the federal definition of the term. | ||
"Facility" does not include the following: | ||
(1) a home, institution, or place operated by the | ||
federal government or agency thereof, or by the State of | ||
Illinois; | ||
(2) a hospital, sanitarium, or other institution whose | ||
principal activity or business is the diagnosis, care, and | ||
treatment of human illness through the maintenance and | ||
operation as organized facilities therefor which is | ||
required to be licensed under the Hospital Licensing Act; |
(3) a facility for child care as defined in the Child | ||
Care Act of 1969; | ||
(4) a community living facility as defined in the | ||
Community Living Facilities Licensing Act; | ||
(5) a nursing home or sanatorium operated solely by and | ||
for persons who rely exclusively upon treatment by | ||
spiritual means through prayer, in accordance with the | ||
creed or tenets of any well-recognized church or religious | ||
denomination; however, such nursing home or sanatorium | ||
shall comply with all local laws and rules relating to | ||
sanitation and safety; | ||
(6) a facility licensed by the Department of Human | ||
Services as a community-integrated living arrangement as | ||
defined in the Community-Integrated Living Arrangements | ||
Licensure and Certification Act; | ||
(7) a supportive residence licensed under the | ||
Supportive Residences Licensing Act; | ||
(8) a supportive living facility in good standing with | ||
the program established under Section 5-5.01a of the | ||
Illinois Public Aid Code, except only for purposes of the | ||
employment of persons in accordance with Section 3-206.01 | ||
of the Nursing Home Care Act; | ||
(9) an assisted living or shared housing establishment | ||
licensed under the Assisted Living and Shared Housing Act, | ||
except only for purposes of the employment of persons in | ||
accordance with Section 3-206.01 of the Nursing Home Care |
Act; | ||
(10) an Alzheimer's disease management center | ||
alternative health care model licensed under the | ||
Alternative Health Care Delivery Act; | ||
(11) a home, institution, or other place operated by or | ||
under the authority of the Illinois Department of Veterans' | ||
Affairs; | ||
(12) a facility licensed under the ID/DD Community Care | ||
Act; or | ||
(13) a facility licensed under the Nursing Home Care | ||
Act after the effective date of this Act. | ||
"Executive director" means a person who is charged with the | ||
general administration and supervision of a facility licensed | ||
under this Act. | ||
"Guardian" means a person appointed as a guardian of the | ||
person or guardian of the estate, or both, of a consumer under | ||
the Probate Act of 1975. | ||
"Identified offender" means a person who meets any of the | ||
following criteria: | ||
(1) Has been convicted of, found guilty of, adjudicated | ||
delinquent for, found not guilty by reason of insanity for, | ||
or found unfit to stand trial for, any felony offense | ||
listed in Section 25 of the Health Care Worker Background | ||
Check Act, except for the following: | ||
(i) a felony offense described in Section 10-5 of | ||
the Nurse Practice Act; |
(ii) a felony offense described in Section 4, 5, 6, | ||
8, or 17.02 of the Illinois Credit Card and Debit Card | ||
Act; | ||
(iii) a felony offense described in Section 5, 5.1, | ||
5.2, 7, or 9 of the Cannabis Control Act; | ||
(iv) a felony offense described in Section 401, | ||
401.1, 404, 405, 405.1, 407, or 407.1 of the Illinois | ||
Controlled Substances Act; and | ||
(v) a felony offense described in the | ||
Methamphetamine Control and Community Protection Act. | ||
(2) Has been convicted of, adjudicated delinquent
for, | ||
found not guilty by reason of insanity for, or found unfit | ||
to stand trial for, any sex offense as defined in | ||
subsection (c) of Section 10 of the Sex Offender Management | ||
Board Act. | ||
"Transitional living units" are residential units within a | ||
facility that have the purpose of assisting the consumer in | ||
developing and reinforcing the necessary skills to live | ||
independently outside of the facility. The duration of stay in | ||
such a setting shall not exceed 120 days for each consumer. | ||
Nothing in this definition shall be construed to be a | ||
prerequisite for transitioning out of a facility. | ||
"Licensee" means the person, persons, firm, partnership, | ||
association, organization, company, corporation, or business | ||
trust to which a license has been issued. | ||
"Misappropriation of a consumer's property" means the |
deliberate misplacement, exploitation, or wrongful temporary | ||
or permanent use of a consumer's belongings or money without | ||
the consent of a consumer or his or her guardian. | ||
"Neglect" means a facility's failure to provide, or willful | ||
withholding of, adequate medical care, mental health | ||
treatment, psychiatric rehabilitation, personal care, or | ||
assistance that is necessary to avoid physical harm and mental | ||
anguish of a consumer. | ||
"Personal care" means assistance with meals, dressing, | ||
movement, bathing, or other personal needs, maintenance, or | ||
general supervision and oversight of the physical and mental | ||
well-being of an individual who is incapable of maintaining a | ||
private, independent residence or who is incapable of managing | ||
his or her person, whether or not a guardian has been appointed | ||
for such individual. "Personal care" shall not be construed to | ||
confine or otherwise constrain a facility's pursuit to develop | ||
the skills and abilities of a consumer to become | ||
self-sufficient and capable of increasing levels of | ||
independent functioning. | ||
"Recovery and rehabilitation supports" means a program | ||
that facilitates a consumer's longer-term symptom management | ||
and stabilization while preparing the consumer for | ||
transitional living units by improving living skills and | ||
community socialization. The duration of stay in such a setting | ||
shall be established by the Department by rule. | ||
"Restraint" means: |
(i) a physical restraint that is any manual method or
| ||
physical or mechanical device, material, or equipment | ||
attached or adjacent to a consumer's body that the consumer | ||
cannot remove easily and restricts freedom of movement or | ||
normal access to one's body; devices used for positioning, | ||
including, but not limited to, bed rails, gait belts, and | ||
cushions, shall not be considered to be restraints for | ||
purposes of this Section; or | ||
(ii) a chemical restraint that is any drug used for
| ||
discipline or convenience and not required to treat medical | ||
symptoms; the Department shall, by rule, designate certain | ||
devices as restraints, including at least all those devices | ||
that have been determined to be restraints by the United | ||
States Department of Health and Human Services in | ||
interpretive guidelines issued for the purposes of | ||
administering Titles XVIII and XIX of the federal Social | ||
Security Act. For the purposes of this Act, restraint shall | ||
be administered only after utilizing a coercive free | ||
environment and culture. | ||
"Self-administration of medication" means consumers shall | ||
be responsible for the control, management, and use of their | ||
own medication. | ||
"Crisis stabilization" means a secure and separate unit | ||
that provides short-term behavioral, emotional, or psychiatric | ||
crisis stabilization as an alternative to hospitalization or | ||
re-hospitalization for consumers from residential or community |
placement. The duration of stay in such a setting shall not | ||
exceed 21 days for each consumer. | ||
"Therapeutic separation" means the removal of a consumer | ||
from the milieu to a room or area which is designed to aid in | ||
the emotional or psychiatric stabilization of that consumer. | ||
"Triage center" means a non-residential 23-hour center | ||
that serves as an alternative to emergency room care, | ||
hospitalization, or re-hospitalization for consumers in need | ||
of short-term crisis stabilization. Consumers may access a | ||
triage center from a number of referral sources, including | ||
family, emergency rooms, hospitals, community behavioral | ||
health providers, federally qualified health providers, or | ||
schools, including colleges or universities. A triage center | ||
may be located in a building separate from the licensed | ||
location of a facility, but shall not be more than 1,000 feet | ||
from the licensed location of the facility and must meet all of | ||
the facility standards applicable to the licensed location. If | ||
the triage center does operate in a separate building, safety | ||
personnel shall be provided, on site, 24 hours per day and the | ||
triage center shall meet all other staffing requirements | ||
without counting any staff employed in the main facility | ||
building.
| ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
(210 ILCS 49/4-108)
| ||
Sec. 4-108. Surveys and inspections. The Department shall |
conduct surveys of licensed facilities and their certified | ||
programs and services. The Department shall review the records | ||
or premises, or both, as it deems appropriate for the purpose | ||
of determining compliance with this Act and the rules | ||
promulgated under this Act. The Department shall have access to | ||
and may reproduce or photocopy any books, records, and other | ||
documents maintained by the facility to the extent necessary to | ||
carry out this Act and the rules promulgated under this Act. | ||
The Department shall not divulge or disclose the contents of a | ||
record under this Section as otherwise prohibited by this Act. | ||
Any holder of a license or applicant for a license shall be | ||
deemed to have given consent to any authorized officer, | ||
employee, or agent of the Department to enter and inspect the | ||
facility in accordance with this Article. Refusal to permit | ||
such entry or inspection shall constitute grounds for denial, | ||
suspension, or revocation of a license under this Act. | ||
(1) The Department shall conduct surveys to determine | ||
compliance and may conduct surveys to investigate | ||
complaints. | ||
(2) Determination of compliance with the service | ||
requirements shall be based on a survey centered on | ||
individuals that sample services being provided. | ||
(3) Determination of compliance with the general | ||
administrative requirements shall be based on a review of | ||
facility records and observation of individuals and staff.
| ||
(4) The Department shall conduct surveys of licensed |
facilities and their certified programs and services to | ||
determine the extent to which these facilities provide high | ||
quality interventions, especially evidence-based | ||
practices, appropriate to the assessed clinical needs of | ||
individuals in the various levels of care. | ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
(210 ILCS 49/4-108.5 new) | ||
Sec. 4-108.5. Provisional licensure period; surveys. | ||
During the provisional licensure period, the Department shall | ||
conduct surveys to determine compliance with timetables and | ||
benchmarks with a facility's provisional licensure application | ||
plan of operation. Timetables and benchmarks shall be | ||
established in rule and shall include, but not be limited to, | ||
the following: (1) training of new and existing staff; (2) | ||
establishment of a data collection and reporting program for | ||
the facility's Quality Assessment and Performance Improvement | ||
Program; and (3) compliance with building environment | ||
standards beyond compliance with Chapter 33 of the National | ||
Fire Protection Association (NFPA) 101 Life Safety Code. | ||
During the provisional licensure period, the Department | ||
shall conduct State licensure surveys as well as a conformance | ||
standard review to determine compliance with timetables and | ||
benchmarks associated with the accreditation process. | ||
Timetables and benchmarks shall be met in accordance with the | ||
preferred accrediting organization conformance standards and |
recommendations and shall include, but not be limited to, | ||
conducting a comprehensive facility self-evaluation in | ||
accordance with an established national accreditation program. | ||
The facility shall submit all data reporting and outcomes | ||
required by accrediting organization to the Department of | ||
Public Health for review to determine progress towards | ||
accreditation. Accreditation status shall supplement but not | ||
replace the State's licensure surveys of facilities licensed | ||
under this Act and their certified programs and services to | ||
determine the extent to which these facilities provide high | ||
quality interventions, especially evidence-based practices, | ||
appropriate to the assessed clinical needs of individuals in | ||
the 4 certified levels of care. | ||
Except for incidents involving the potential for harm, | ||
serious harm, death, or substantial facility failure to address | ||
a serious systemic issue within 60 days, findings of the | ||
facility's root cause analysis of problems and the facility's | ||
Quality Assessment and Performance Improvement program in | ||
accordance with item (22) of Section 4-104 shall not be used as | ||
a basis for non-compliance. | ||
The Department shall have the authority to hire licensed | ||
practitioners of the healing arts and qualified mental health | ||
professionals to consult with and participate in survey and | ||
inspection activities.
| ||
(210 ILCS 49/5-101)
|
Sec. 5-101. Managed care entity, coordinated care entity, | ||
and accountable care entity payments. For facilities licensed | ||
by the Department of Public Health under this Act, the payment | ||
for services provided shall be determined by negotiation with | ||
managed care entities, coordinated care entities, or | ||
accountable care entities. However, for 3 years after the | ||
effective date of this Act, in no event shall the reimbursement | ||
rate paid to facilities licensed under this Act be less than | ||
the rate in effect on June 30, 2013 less $7.07 times the number | ||
of occupied bed days, as that term is defined in Article V-B of | ||
the Illinois Public Aid Code, for each facility previously | ||
licensed under the Nursing Home Care Act on June 30, 2013; or | ||
the rate in effect on June 30, 2013 for each facility licensed | ||
under the Specialized Mental Health Rehabilitation Act on June | ||
30, 2013. Any adjustment in the support component or the | ||
capital component for facilities licensed by the Department of | ||
Public Health under the Nursing Home Care Act shall apply | ||
equally to facilities licensed by the Department of Public | ||
Health under this Act for the duration of the provisional | ||
licensure period as defined in Section 4-105 of this Act.
| ||
The Department of Healthcare and Family Services shall | ||
publish a reimbursement rate for triage, crisis stabilization, | ||
and transitional living services by December 1, 2014. | ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
Article 15 |
Section 15-5. The Illinois Public Aid Code is amended by | ||
changing Sections 5A-8 and 5A-12.2 as follows:
| ||
(305 ILCS 5/5A-8) (from Ch. 23, par. 5A-8)
| ||
Sec. 5A-8. Hospital Provider Fund.
| ||
(a) There is created in the State Treasury the Hospital | ||
Provider Fund.
Interest earned by the Fund shall be credited to | ||
the Fund. The
Fund shall not be used to replace any moneys | ||
appropriated to the
Medicaid program by the General Assembly.
| ||
(b) The Fund is created for the purpose of receiving moneys
| ||
in accordance with Section 5A-6 and disbursing moneys only for | ||
the following
purposes, notwithstanding any other provision of | ||
law:
| ||
(1) For making payments to hospitals as required under | ||
this Code, under the Children's Health Insurance Program | ||
Act, under the Covering ALL KIDS Health Insurance Act, and | ||
under the Long Term Acute Care Hospital Quality Improvement | ||
Transfer Program Act.
| ||
(2) For the reimbursement of moneys collected by the
| ||
Illinois Department from hospitals or hospital providers | ||
through error or
mistake in performing the
activities | ||
authorized under this Code.
| ||
(3) For payment of administrative expenses incurred by | ||
the
Illinois Department or its agent in performing | ||
activities
under this Code, under the Children's Health |
Insurance Program Act, under the Covering ALL KIDS Health | ||
Insurance Act, and under the Long Term Acute Care Hospital | ||
Quality Improvement Transfer Program Act.
| ||
(4) For payments of any amounts which are reimbursable | ||
to
the federal government for payments from this Fund which | ||
are
required to be paid by State warrant.
| ||
(5) For making transfers, as those transfers are | ||
authorized
in the proceedings authorizing debt under the | ||
Short Term Borrowing Act,
but transfers made under this | ||
paragraph (5) shall not exceed the
principal amount of debt | ||
issued in anticipation of the receipt by
the State of | ||
moneys to be deposited into the Fund.
| ||
(6) For making transfers to any other fund in the State | ||
treasury, but
transfers made under this paragraph (6) shall | ||
not exceed the amount transferred
previously from that | ||
other fund into the Hospital Provider Fund plus any | ||
interest that would have been earned by that fund on the | ||
monies that had been transferred.
| ||
(6.5) For making transfers to the Healthcare Provider | ||
Relief Fund, except that transfers made under this | ||
paragraph (6.5) shall not exceed $60,000,000 in the | ||
aggregate. | ||
(7) For making transfers not exceeding the following | ||
amounts, related to in State fiscal years 2013 through 2018 | ||
and 2014 , to the following designated funds: | ||
Health and Human Services Medicaid Trust |
Fund ..............................$20,000,000 | ||
Long-Term Care Provider Fund ..........$30,000,000 | ||
General Revenue Fund .................$80,000,000. | ||
Transfers under this paragraph shall be made within 7 days | ||
after the payments have been received pursuant to the | ||
schedule of payments provided in subsection (a) of Section | ||
5A-4. | ||
(7.1) (Blank). For making transfers not exceeding the | ||
following amounts, in State fiscal year 2015, to the | ||
following designated funds: | ||
Health and Human Services Medicaid Trust | ||
Fund $10,000,000 | ||
Long-Term Care Provider Fund $15,000,000 | ||
General Revenue Fund $40,000,000. | ||
Transfers under this paragraph shall be made within 7 days | ||
after the payments have been received pursuant to the | ||
schedule of payments provided in subsection (a) of Section | ||
5A-4.
| ||
(7.5) (Blank). | ||
(7.8) (Blank). | ||
(7.9) (Blank). | ||
(7.10) For State fiscal year years 2013 and 2014, for | ||
making transfers of the moneys resulting from the | ||
assessment under subsection (b-5) of Section 5A-2 and | ||
received from hospital providers under Section 5A-4 and | ||
transferred into the Hospital Provider Fund under Section |
5A-6 to the designated funds not exceeding the following | ||
amounts in that State fiscal year: | ||
Health Care Provider Relief Fund .....$100,000,000 | ||
$50,000,000 | ||
Transfers under this paragraph shall be made within 7 | ||
days after the payments have been received pursuant to the | ||
schedule of payments provided in subsection (a) of Section | ||
5A-4. | ||
The additional amount of transfers in this paragraph | ||
(7.10), authorized by this amendatory Act of the 98th | ||
General Assembly, shall be made within 10 State business | ||
days after the effective date of this amendatory Act of the | ||
98th General Assembly. That authority shall remain in | ||
effect even if this amendatory Act of the 98th General | ||
Assembly does not become law until State fiscal year 2015. | ||
(7.10a) For State fiscal years 2015 through 2018, for | ||
making transfers of the moneys resulting from the | ||
assessment under subsection (b-5) of Section 5A-2 and | ||
received from hospital providers under Section 5A-4 and | ||
transferred into the Hospital Provider Fund under Section | ||
5A-6 to the designated funds not exceeding the following | ||
amounts related to each State fiscal year: | ||
Health Care Provider Relief | ||
Fund .....................................$50,000,000 | ||
Transfers under this paragraph shall be made within 7 | ||
days after the payments have been received pursuant to the |
schedule of payments provided in subsection (a) of Section | ||
5A-4. | ||
(7.11) (Blank). For State fiscal year 2015, for making | ||
transfers of the moneys resulting from the assessment under | ||
subsection (b-5) of Section 5A-2 and received from hospital | ||
providers under Section 5A-4 and transferred into the | ||
Hospital Provider Fund under Section 5A-6 to the designated | ||
funds not exceeding the following amounts in that State | ||
fiscal year: | ||
Health Care Provider Relief Fund $25,000,000 | ||
Transfers under this paragraph shall be made within 7 | ||
days after the payments have been received pursuant to the | ||
schedule of payments provided in subsection (a) of Section | ||
5A-4. | ||
(7.12) For State fiscal year 2013, for increasing by | ||
21/365ths the transfer of the moneys resulting from the | ||
assessment under subsection (b-5) of Section 5A-2 and | ||
received from hospital providers under Section 5A-4 for the | ||
portion of State fiscal year 2012 beginning June 10, 2012 | ||
through June 30, 2012 and transferred into the Hospital | ||
Provider Fund under Section 5A-6 to the designated funds | ||
not exceeding the following amounts in that State fiscal | ||
year: | ||
Health Care Provider Relief Fund ......$2,870,000 | ||
Since the federal Centers for Medicare and Medicaid | ||
Services approval of the assessment authorized under |
subsection (b-5) of Section 5A-2, received from hospital | ||
providers under Section 5A-4 and the payment methodologies | ||
to hospitals required under Section 5A-12.4 was not | ||
received by the Department until State fiscal year 2014 and | ||
since the Department made retroactive payments during | ||
State fiscal year 2014 related to the referenced period of | ||
June 2012, the transfer authority granted in this paragraph | ||
(7.12) is extended through the date that is 10 State | ||
business days after the effective date of this amendatory | ||
Act of the 98th General Assembly. | ||
(8) For making refunds to hospital providers pursuant | ||
to Section 5A-10.
| ||
(9) For making payment to capitated managed care | ||
organizations as described in subsections (s) and (t) of | ||
Section 5A-12.2 of this Code. | ||
Disbursements from the Fund, other than transfers | ||
authorized under
paragraphs (5) and (6) of this subsection, | ||
shall be by
warrants drawn by the State Comptroller upon | ||
receipt of vouchers
duly executed and certified by the Illinois | ||
Department.
| ||
(c) The Fund shall consist of the following:
| ||
(1) All moneys collected or received by the Illinois
| ||
Department from the hospital provider assessment imposed | ||
by this
Article.
| ||
(2) All federal matching funds received by the Illinois
| ||
Department as a result of expenditures made by the Illinois
|
Department that are attributable to moneys deposited in the | ||
Fund.
| ||
(3) Any interest or penalty levied in conjunction with | ||
the
administration of this Article.
| ||
(3.5) As applicable, proceeds from surety bond | ||
payments payable to the Department as referenced in | ||
subsection (s) of Section 5A-12.2 of this Code. | ||
(4) Moneys transferred from another fund in the State | ||
treasury.
| ||
(5) All other moneys received for the Fund from any | ||
other
source, including interest earned thereon.
| ||
(d) (Blank).
| ||
(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12; | ||
98-104, eff. 7-22-13; 98-463, eff. 8-16-13; revised 10-21-13.)
| ||
(305 ILCS 5/5A-12.2) | ||
(Section scheduled to be repealed on January 1, 2015) | ||
Sec. 5A-12.2. Hospital access payments on or after July 1, | ||
2008. | ||
(a) To preserve and improve access to hospital services, | ||
for hospital services rendered on or after July 1, 2008, the | ||
Illinois Department shall, except for hospitals described in | ||
subsection (b) of Section 5A-3, make payments to hospitals as | ||
set forth in this Section. These payments shall be paid in 12 | ||
equal installments on or before the seventh State business day | ||
of each month, except that no payment shall be due within 100 |
days after the later of the date of notification of federal | ||
approval of the payment methodologies required under this | ||
Section or any waiver required under 42 CFR 433.68, at which | ||
time the sum of amounts required under this Section prior to | ||
the date of notification is due and payable. Payments under | ||
this Section are not due and payable, however, until (i) the | ||
methodologies described in this Section are approved by the | ||
federal government in an appropriate State Plan amendment and | ||
(ii) the assessment imposed under this Article is determined to | ||
be a permissible tax under Title XIX of the Social Security | ||
Act. | ||
(a-5) The Illinois Department may, when practicable, | ||
accelerate the schedule upon which payments authorized under | ||
this Section are made. | ||
(b) Across-the-board inpatient adjustment. | ||
(1) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay to each Illinois general | ||
acute care hospital an amount equal to 40% of the total | ||
base inpatient payments paid to the hospital for services | ||
provided in State fiscal year 2005. | ||
(2) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay to each freestanding | ||
Illinois specialty care hospital as defined in 89 Ill. Adm. | ||
Code 149.50(c)(1), (2), or (4) an amount equal to 60% of | ||
the total base inpatient payments paid to the hospital for | ||
services provided in State fiscal year 2005. |
(3) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay to each freestanding | ||
Illinois rehabilitation or psychiatric hospital an amount | ||
equal to $1,000 per Medicaid inpatient day multiplied by | ||
the increase in the hospital's Medicaid inpatient | ||
utilization ratio (determined using the positive | ||
percentage change from the rate year 2005 Medicaid | ||
inpatient utilization ratio to the rate year 2007 Medicaid | ||
inpatient utilization ratio, as calculated by the | ||
Department for the disproportionate share determination). | ||
(4) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay to each Illinois | ||
children's hospital an amount equal to 20% of the total | ||
base inpatient payments paid to the hospital for services | ||
provided in State fiscal year 2005 and an additional amount | ||
equal to 20% of the base inpatient payments paid to the | ||
hospital for psychiatric services provided in State fiscal | ||
year 2005. | ||
(5) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay to each Illinois | ||
hospital eligible for a pediatric inpatient adjustment | ||
payment under 89 Ill. Adm. Code 148.298, as in effect for | ||
State fiscal year 2007, a supplemental pediatric inpatient | ||
adjustment payment equal to: | ||
(i) For freestanding children's hospitals as | ||
defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5 |
multiplied by the hospital's pediatric inpatient | ||
adjustment payment required under 89 Ill. Adm. Code | ||
148.298, as in effect for State fiscal year 2008. | ||
(ii) For hospitals other than freestanding | ||
children's hospitals as defined in 89 Ill. Adm. Code | ||
149.50(c)(3)(B), 1.0 multiplied by the hospital's | ||
pediatric inpatient adjustment payment required under | ||
89 Ill. Adm. Code 148.298, as in effect for State | ||
fiscal year 2008. | ||
(c) Outpatient adjustment. | ||
(1) In addition to the rates paid for outpatient | ||
hospital services, the Department shall pay each Illinois | ||
hospital an amount equal to 2.2 multiplied by the | ||
hospital's ambulatory procedure listing payments for | ||
categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code | ||
148.140(b), for State fiscal year 2005. | ||
(2) In addition to the rates paid for outpatient | ||
hospital services, the Department shall pay each Illinois | ||
freestanding psychiatric hospital an amount equal to 3.25 | ||
multiplied by the hospital's ambulatory procedure listing | ||
payments for category 5b, as defined in 89 Ill. Adm. Code | ||
148.140(b)(1)(E), for State fiscal year 2005. | ||
(d) Medicaid high volume adjustment. In addition to rates | ||
paid for inpatient hospital services, the Department shall pay | ||
to each Illinois general acute care hospital that provided more | ||
than 20,500 Medicaid inpatient days of care in State fiscal |
year 2005 amounts as follows: | ||
(1) For hospitals with a case mix index equal to or | ||
greater than the 85th percentile of hospital case mix | ||
indices, $350 for each Medicaid inpatient day of care | ||
provided during that period; and | ||
(2) For hospitals with a case mix index less than the | ||
85th percentile of hospital case mix indices, $100 for each | ||
Medicaid inpatient day of care provided during that period. | ||
(e) Capital adjustment. In addition to rates paid for | ||
inpatient hospital services, the Department shall pay an | ||
additional payment to each Illinois general acute care hospital | ||
that has a Medicaid inpatient utilization rate of at least 10% | ||
(as calculated by the Department for the rate year 2007 | ||
disproportionate share determination) amounts as follows: | ||
(1) For each Illinois general acute care hospital that | ||
has a Medicaid inpatient utilization rate of at least 10% | ||
and less than 36.94% and whose capital cost is less than | ||
the 60th percentile of the capital costs of all Illinois | ||
hospitals, the amount of such payment shall equal the | ||
hospital's Medicaid inpatient days multiplied by the | ||
difference between the capital costs at the 60th percentile | ||
of the capital costs of all Illinois hospitals and the | ||
hospital's capital costs. | ||
(2) For each Illinois general acute care hospital that | ||
has a Medicaid inpatient utilization rate of at least | ||
36.94% and whose capital cost is less than the 75th |
percentile of the capital costs of all Illinois hospitals, | ||
the amount of such payment shall equal the hospital's | ||
Medicaid inpatient days multiplied by the difference | ||
between the capital costs at the 75th percentile of the | ||
capital costs of all Illinois hospitals and the hospital's | ||
capital costs. | ||
(f) Obstetrical care adjustment. | ||
(1) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay $1,500 for each Medicaid | ||
obstetrical day of care provided in State fiscal year 2005 | ||
by each Illinois rural hospital that had a Medicaid | ||
obstetrical percentage (Medicaid obstetrical days divided | ||
by Medicaid inpatient days) greater than 15% for State | ||
fiscal year 2005. | ||
(2) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay $1,350 for each Medicaid | ||
obstetrical day of care provided in State fiscal year 2005 | ||
by each Illinois general acute care hospital that was | ||
designated a level III perinatal center as of December 31, | ||
2006, and that had a case mix index equal to or greater | ||
than the 45th percentile of the case mix indices for all | ||
level III perinatal centers. | ||
(3) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay $900 for each Medicaid | ||
obstetrical day of care provided in State fiscal year 2005 | ||
by each Illinois general acute care hospital that was |
designated a level II or II+ perinatal center as of | ||
December 31, 2006, and that had a case mix index equal to | ||
or greater than the 35th percentile of the case mix indices | ||
for all level II and II+ perinatal centers. | ||
(g) Trauma adjustment. | ||
(1) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay each Illinois general | ||
acute care hospital designated as a trauma center as of | ||
July 1, 2007, a payment equal to 3.75 multiplied by the | ||
hospital's State fiscal year 2005 Medicaid capital | ||
payments. | ||
(2) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay $400 for each Medicaid | ||
acute inpatient day of care provided in State fiscal year | ||
2005 by each Illinois general acute care hospital that was | ||
designated a level II trauma center, as defined in 89 Ill. | ||
Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1, | ||
2007. | ||
(3) In addition to rates paid for inpatient hospital | ||
services, the Department shall pay $235 for each Illinois | ||
Medicaid acute inpatient day of care provided in State | ||
fiscal year 2005 by each level I pediatric trauma center | ||
located outside of Illinois that had more than 8,000 | ||
Illinois Medicaid inpatient days in State fiscal year 2005. | ||
(h) Supplemental tertiary care adjustment. In addition to | ||
rates paid for inpatient services, the Department shall pay to |
each Illinois hospital eligible for tertiary care adjustment | ||
payments under 89 Ill. Adm. Code 148.296, as in effect for | ||
State fiscal year 2007, a supplemental tertiary care adjustment | ||
payment equal to the tertiary care adjustment payment required | ||
under 89 Ill. Adm. Code 148.296, as in effect for State fiscal | ||
year 2007. | ||
(i) Crossover adjustment. In addition to rates paid for | ||
inpatient services, the Department shall pay each Illinois | ||
general acute care hospital that had a ratio of crossover days | ||
to total inpatient days for medical assistance programs | ||
administered by the Department (utilizing information from | ||
2005 paid claims) greater than 50%, and a case mix index | ||
greater than the 65th percentile of case mix indices for all | ||
Illinois hospitals, a rate of $1,125 for each Medicaid | ||
inpatient day including crossover days. | ||
(j) Magnet hospital adjustment. In addition to rates paid | ||
for inpatient hospital services, the Department shall pay to | ||
each Illinois general acute care hospital and each Illinois | ||
freestanding children's hospital that, as of February 1, 2008, | ||
was recognized as a Magnet hospital by the American Nurses | ||
Credentialing Center and that had a case mix index greater than | ||
the 75th percentile of case mix indices for all Illinois | ||
hospitals amounts as follows: | ||
(1) For hospitals located in a county whose eligibility | ||
growth factor is greater than the mean, $450 multiplied by | ||
the eligibility growth factor for the county in which the |
hospital is located for each Medicaid inpatient day of care | ||
provided by the hospital during State fiscal year 2005. | ||
(2) For hospitals located in a county whose eligibility | ||
growth factor is less than or equal to the mean, $225 | ||
multiplied by the eligibility growth factor for the county | ||
in which the hospital is located for each Medicaid | ||
inpatient day of care provided by the hospital during State | ||
fiscal year 2005. | ||
For purposes of this subsection, "eligibility growth | ||
factor" means the percentage by which the number of Medicaid | ||
recipients in the county increased from State fiscal year 1998 | ||
to State fiscal year 2005. | ||
(k) For purposes of this Section, a hospital that is | ||
enrolled to provide Medicaid services during State fiscal year | ||
2005 shall have its utilization and associated reimbursements | ||
annualized prior to the payment calculations being performed | ||
under this Section. | ||
(l) For purposes of this Section, the terms "Medicaid | ||
days", "ambulatory procedure listing services", and | ||
"ambulatory procedure listing payments" do not include any | ||
days, charges, or services for which Medicare or a managed care | ||
organization reimbursed on a capitated basis was liable for | ||
payment, except where explicitly stated otherwise in this | ||
Section. | ||
(m) For purposes of this Section, in determining the | ||
percentile ranking of an Illinois hospital's case mix index or |
capital costs, hospitals described in subsection (b) of Section | ||
5A-3 shall be excluded from the ranking. | ||
(n) Definitions. Unless the context requires otherwise or | ||
unless provided otherwise in this Section, the terms used in | ||
this Section for qualifying criteria and payment calculations | ||
shall have the same meanings as those terms have been given in | ||
the Illinois Department's administrative rules as in effect on | ||
March 1, 2008. Other terms shall be defined by the Illinois | ||
Department by rule. | ||
As used in this Section, unless the context requires | ||
otherwise: | ||
"Base inpatient payments" means, for a given hospital, the | ||
sum of base payments for inpatient services made on a per diem | ||
or per admission (DRG) basis, excluding those portions of per | ||
admission payments that are classified as capital payments. | ||
Disproportionate share hospital adjustment payments, Medicaid | ||
Percentage Adjustments, Medicaid High Volume Adjustments, and | ||
outlier payments, as defined by rule by the Department as of | ||
January 1, 2008, are not base payments. | ||
"Capital costs" means, for a given hospital, the total | ||
capital costs determined using the most recent 2005 Medicare | ||
cost report as contained in the Healthcare Cost Report | ||
Information System file, for the quarter ending on December 31, | ||
2006, divided by the total inpatient days from the same cost | ||
report to calculate a capital cost per day. The resulting | ||
capital cost per day is inflated to the midpoint of State |
fiscal year 2009 utilizing the national hospital market price | ||
proxies (DRI) hospital cost index. If a hospital's 2005 | ||
Medicare cost report is not contained in the Healthcare Cost | ||
Report Information System, the Department may obtain the data | ||
necessary to compute the hospital's capital costs from any | ||
source available, including, but not limited to, records | ||
maintained by the hospital provider, which may be inspected at | ||
all times during business hours of the day by the Illinois | ||
Department or its duly authorized agents and employees. | ||
"Case mix index" means, for a given hospital, the sum of | ||
the DRG relative weighting factors in effect on January 1, | ||
2005, for all general acute care admissions for State fiscal | ||
year 2005, excluding Medicare crossover admissions and | ||
transplant admissions reimbursed under 89 Ill. Adm. Code | ||
148.82, divided by the total number of general acute care | ||
admissions for State fiscal year 2005, excluding Medicare | ||
crossover admissions and transplant admissions reimbursed | ||
under 89 Ill. Adm. Code 148.82. | ||
"Medicaid inpatient day" means, for a given hospital, the | ||
sum of days of inpatient hospital days provided to recipients | ||
of medical assistance under Title XIX of the federal Social | ||
Security Act, excluding days for individuals eligible for | ||
Medicare under Title XVIII of that Act (Medicaid/Medicare | ||
crossover days), as tabulated from the Department's paid claims | ||
data for admissions occurring during State fiscal year 2005 | ||
that was adjudicated by the Department through March 23, 2007. |
"Medicaid obstetrical day" means, for a given hospital, the | ||
sum of days of inpatient hospital days grouped by the | ||
Department to DRGs of 370 through 375 provided to recipients of | ||
medical assistance under Title XIX of the federal Social | ||
Security Act, excluding days for individuals eligible for | ||
Medicare under Title XVIII of that Act (Medicaid/Medicare | ||
crossover days), as tabulated from the Department's paid claims | ||
data for admissions occurring during State fiscal year 2005 | ||
that was adjudicated by the Department through March 23, 2007. | ||
"Outpatient ambulatory procedure listing payments" means, | ||
for a given hospital, the sum of payments for ambulatory | ||
procedure listing services, as described in 89 Ill. Adm. Code | ||
148.140(b), provided to recipients of medical assistance under | ||
Title XIX of the federal Social Security Act, excluding | ||
payments for individuals eligible for Medicare under Title | ||
XVIII of the Act (Medicaid/Medicare crossover days), as | ||
tabulated from the Department's paid claims data for services | ||
occurring in State fiscal year 2005 that were adjudicated by | ||
the Department through March 23, 2007. | ||
(o) The Department may adjust payments made under this | ||
Section 5A-12.2 to comply with federal law or regulations | ||
regarding hospital-specific payment limitations on | ||
government-owned or government-operated hospitals. | ||
(p) Notwithstanding any of the other provisions of this | ||
Section, the Department is authorized to adopt rules that | ||
change the hospital access improvement payments specified in |
this Section, but only to the extent necessary to conform to | ||
any federally approved amendment to the Title XIX State plan. | ||
Any such rules shall be adopted by the Department as authorized | ||
by Section 5-50 of the Illinois Administrative Procedure Act. | ||
Notwithstanding any other provision of law, any changes | ||
implemented as a result of this subsection (p) shall be given | ||
retroactive effect so that they shall be deemed to have taken | ||
effect as of the effective date of this Section. | ||
(q) (Blank). | ||
(r) On and after July 1, 2012, the Department shall reduce | ||
any rate of reimbursement for services or other payments or | ||
alter any methodologies authorized by this Code to reduce any | ||
rate of reimbursement for services or other payments in | ||
accordance with Section 5-5e. | ||
(s) On or after July 1, 2014, but no later than October 1, | ||
2014, and no less than annually thereafter, the Department may | ||
increase capitation payments to capitated managed care | ||
organizations (MCOs) to equal the aggregate reduction of | ||
payments made in this Section and in Section 5A-12.4 by a | ||
uniform percentage on a regional basis to preserve access to | ||
hospital services for recipients under the Illinois Medical | ||
Assistance Program. The aggregate amount of all increased | ||
capitation payments to all MCOs for a fiscal year shall be the | ||
amount needed to avoid reduction in payments authorized under | ||
Section 5A-15. Payments to MCOs under this Section shall be | ||
consistent with actuarial certification and shall be published |
by the Department each year. Each MCO shall only expend the | ||
increased capitation payments it receives under this Section to | ||
support the availability of hospital services and to ensure | ||
access to hospital services, with such expenditures being made | ||
within 15 calendar days from when the MCO receives the | ||
increased capitation payment. The Department shall make | ||
available, on a monthly basis, a report of the capitation | ||
payments that are made to each MCO pursuant to this subsection, | ||
including the number of enrollees for which such payment is | ||
made, the per enrollee amount of the payment, and any | ||
adjustments that have been made. Payments made under this | ||
subsection shall be guaranteed by a surety bond obtained by the | ||
MCO in an amount established by the Department to approximate | ||
one month's liability of payments authorized under this | ||
subsection. The Department may advance the payments guaranteed | ||
by the surety bond. Payments to MCOs that would be paid | ||
consistent with actuarial certification and enrollment in the | ||
absence of the increased capitation payments under this Section | ||
shall not be reduced as a consequence of payments made under | ||
this subsection. | ||
As used in this subsection, "MCO" means an entity which | ||
contracts with the Department to provide services where payment | ||
for medical services is made on a capitated basis. | ||
(t) On or after July 1, 2014, the Department may increase | ||
capitation payments to capitated managed care organizations | ||
(MCOs) to equal the aggregate reduction of payments made in |
Section 5A-12.5 to preserve access to hospital services for | ||
recipients under the Illinois Medical Assistance Program. | ||
Payments to MCOs under this Section shall be consistent with | ||
actuarial certification and shall be published by the | ||
Department each year. Each MCO shall only expend the increased | ||
capitation payments it receives under this Section to support | ||
the availability of hospital services and to ensure access to | ||
hospital services, with such expenditures being made within 15 | ||
calendar days from when the MCO receives the increased | ||
capitation payment. The Department may advance the payments to | ||
hospitals under this subsection, in the event the MCO fails to | ||
make such payments. The Department shall make available, on a | ||
monthly basis, a report of the capitation payments that are | ||
made to each MCO pursuant to this subsection, including the | ||
number of enrollees for which such payment is made, the per | ||
enrollee amount of the payment, and any adjustments that have | ||
been made. Payments to MCOs that would be paid consistent with | ||
actuarial certification and enrollment in the absence of the | ||
increased capitation payments under this subsection shall not | ||
be reduced as a consequence of payments made under this | ||
subsection. | ||
As used in this subsection, "MCO" means an entity which | ||
contracts with the Department to provide services where payment | ||
for medical services is made on a capitated basis. | ||
(Source: P.A. 96-821, eff. 11-20-09; 97-689, eff. 6-14-12.)
|
Article 20 | ||
Section 20-5. The Illinois Administrative Procedure Act is | ||
amended by changing Section 5-45 as follows:
| ||
(5 ILCS 100/5-45) (from Ch. 127, par. 1005-45) | ||
Sec. 5-45. Emergency rulemaking. | ||
(a) "Emergency" means the existence of any situation that | ||
any agency
finds reasonably constitutes a threat to the public | ||
interest, safety, or
welfare. | ||
(b) If any agency finds that an
emergency exists that | ||
requires adoption of a rule upon fewer days than
is required by | ||
Section 5-40 and states in writing its reasons for that
| ||
finding, the agency may adopt an emergency rule without prior | ||
notice or
hearing upon filing a notice of emergency rulemaking | ||
with the Secretary of
State under Section 5-70. The notice | ||
shall include the text of the
emergency rule and shall be | ||
published in the Illinois Register. Consent
orders or other | ||
court orders adopting settlements negotiated by an agency
may | ||
be adopted under this Section. Subject to applicable | ||
constitutional or
statutory provisions, an emergency rule | ||
becomes effective immediately upon
filing under Section 5-65 or | ||
at a stated date less than 10 days
thereafter. The agency's | ||
finding and a statement of the specific reasons
for the finding | ||
shall be filed with the rule. The agency shall take
reasonable | ||
and appropriate measures to make emergency rules known to the
|
persons who may be affected by them. | ||
(c) An emergency rule may be effective for a period of not | ||
longer than
150 days, but the agency's authority to adopt an | ||
identical rule under Section
5-40 is not precluded. No | ||
emergency rule may be adopted more
than once in any 24 month | ||
period, except that this limitation on the number
of emergency | ||
rules that may be adopted in a 24 month period does not apply
| ||
to (i) emergency rules that make additions to and deletions | ||
from the Drug
Manual under Section 5-5.16 of the Illinois | ||
Public Aid Code or the
generic drug formulary under Section | ||
3.14 of the Illinois Food, Drug
and Cosmetic Act, (ii) | ||
emergency rules adopted by the Pollution Control
Board before | ||
July 1, 1997 to implement portions of the Livestock Management
| ||
Facilities Act, (iii) emergency rules adopted by the Illinois | ||
Department of Public Health under subsections (a) through (i) | ||
of Section 2 of the Department of Public Health Act when | ||
necessary to protect the public's health, (iv) emergency rules | ||
adopted pursuant to subsection (n) of this Section, (v) | ||
emergency rules adopted pursuant to subsection (o) of this | ||
Section, or (vi) emergency rules adopted pursuant to subsection | ||
(c-5) of this Section. Two or more emergency rules having | ||
substantially the same
purpose and effect shall be deemed to be | ||
a single rule for purposes of this
Section. | ||
(c-5) To facilitate the maintenance of the program of group | ||
health benefits provided to annuitants, survivors, and retired | ||
employees under the State Employees Group Insurance Act of |
1971, rules to alter the contributions to be paid by the State, | ||
annuitants, survivors, retired employees, or any combination | ||
of those entities, for that program of group health benefits, | ||
shall be adopted as emergency rules. The adoption of those | ||
rules shall be considered an emergency and necessary for the | ||
public interest, safety, and welfare. | ||
(d) In order to provide for the expeditious and timely | ||
implementation
of the State's fiscal year 1999 budget, | ||
emergency rules to implement any
provision of Public Act 90-587 | ||
or 90-588
or any other budget initiative for fiscal year 1999 | ||
may be adopted in
accordance with this Section by the agency | ||
charged with administering that
provision or initiative, | ||
except that the 24-month limitation on the adoption
of | ||
emergency rules and the provisions of Sections 5-115 and 5-125 | ||
do not apply
to rules adopted under this subsection (d). The | ||
adoption of emergency rules
authorized by this subsection (d) | ||
shall be deemed to be necessary for the
public interest, | ||
safety, and welfare. | ||
(e) In order to provide for the expeditious and timely | ||
implementation
of the State's fiscal year 2000 budget, | ||
emergency rules to implement any
provision of this amendatory | ||
Act of the 91st General Assembly
or any other budget initiative | ||
for fiscal year 2000 may be adopted in
accordance with this | ||
Section by the agency charged with administering that
provision | ||
or initiative, except that the 24-month limitation on the | ||
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this | ||
subsection (e). The adoption of emergency rules
authorized by | ||
this subsection (e) shall be deemed to be necessary for the
| ||
public interest, safety, and welfare. | ||
(f) In order to provide for the expeditious and timely | ||
implementation
of the State's fiscal year 2001 budget, | ||
emergency rules to implement any
provision of this amendatory | ||
Act of the 91st General Assembly
or any other budget initiative | ||
for fiscal year 2001 may be adopted in
accordance with this | ||
Section by the agency charged with administering that
provision | ||
or initiative, except that the 24-month limitation on the | ||
adoption
of emergency rules and the provisions of Sections | ||
5-115 and 5-125 do not apply
to rules adopted under this | ||
subsection (f). The adoption of emergency rules
authorized by | ||
this subsection (f) shall be deemed to be necessary for the
| ||
public interest, safety, and welfare. | ||
(g) In order to provide for the expeditious and timely | ||
implementation
of the State's fiscal year 2002 budget, | ||
emergency rules to implement any
provision of this amendatory | ||
Act of the 92nd General Assembly
or any other budget initiative | ||
for fiscal year 2002 may be adopted in
accordance with this | ||
Section by the agency charged with administering that
provision | ||
or initiative, except that the 24-month limitation on the | ||
adoption
of emergency rules and the provisions of Sections | ||
5-115 and 5-125 do not apply
to rules adopted under this | ||
subsection (g). The adoption of emergency rules
authorized by |
this subsection (g) shall be deemed to be necessary for the
| ||
public interest, safety, and welfare. | ||
(h) In order to provide for the expeditious and timely | ||
implementation
of the State's fiscal year 2003 budget, | ||
emergency rules to implement any
provision of this amendatory | ||
Act of the 92nd General Assembly
or any other budget initiative | ||
for fiscal year 2003 may be adopted in
accordance with this | ||
Section by the agency charged with administering that
provision | ||
or initiative, except that the 24-month limitation on the | ||
adoption
of emergency rules and the provisions of Sections | ||
5-115 and 5-125 do not apply
to rules adopted under this | ||
subsection (h). The adoption of emergency rules
authorized by | ||
this subsection (h) shall be deemed to be necessary for the
| ||
public interest, safety, and welfare. | ||
(i) In order to provide for the expeditious and timely | ||
implementation
of the State's fiscal year 2004 budget, | ||
emergency rules to implement any
provision of this amendatory | ||
Act of the 93rd General Assembly
or any other budget initiative | ||
for fiscal year 2004 may be adopted in
accordance with this | ||
Section by the agency charged with administering that
provision | ||
or initiative, except that the 24-month limitation on the | ||
adoption
of emergency rules and the provisions of Sections | ||
5-115 and 5-125 do not apply
to rules adopted under this | ||
subsection (i). The adoption of emergency rules
authorized by | ||
this subsection (i) shall be deemed to be necessary for the
| ||
public interest, safety, and welfare. |
(j) In order to provide for the expeditious and timely | ||
implementation of the provisions of the State's fiscal year | ||
2005 budget as provided under the Fiscal Year 2005 Budget | ||
Implementation (Human Services) Act, emergency rules to | ||
implement any provision of the Fiscal Year 2005 Budget | ||
Implementation (Human Services) Act may be adopted in | ||
accordance with this Section by the agency charged with | ||
administering that provision, except that the 24-month | ||
limitation on the adoption of emergency rules and the | ||
provisions of Sections 5-115 and 5-125 do not apply to rules | ||
adopted under this subsection (j). The Department of Public Aid | ||
may also adopt rules under this subsection (j) necessary to | ||
administer the Illinois Public Aid Code and the Children's | ||
Health Insurance Program Act. The adoption of emergency rules | ||
authorized by this subsection (j) shall be deemed to be | ||
necessary for the public interest, safety, and welfare.
| ||
(k) In order to provide for the expeditious and timely | ||
implementation of the provisions of the State's fiscal year | ||
2006 budget, emergency rules to implement any provision of this | ||
amendatory Act of the 94th General Assembly or any other budget | ||
initiative for fiscal year 2006 may be adopted in accordance | ||
with this Section by the agency charged with administering that | ||
provision or initiative, except that the 24-month limitation on | ||
the adoption of emergency rules and the provisions of Sections | ||
5-115 and 5-125 do not apply to rules adopted under this | ||
subsection (k). The Department of Healthcare and Family |
Services may also adopt rules under this subsection (k) | ||
necessary to administer the Illinois Public Aid Code, the | ||
Senior Citizens and Disabled Persons Property Tax Relief Act, | ||
the Senior Citizens and Disabled Persons Prescription Drug | ||
Discount Program Act (now the Illinois Prescription Drug | ||
Discount Program Act), and the Children's Health Insurance | ||
Program Act. The adoption of emergency rules authorized by this | ||
subsection (k) shall be deemed to be necessary for the public | ||
interest, safety, and welfare.
| ||
(l) In order to provide for the expeditious and timely | ||
implementation of the provisions of the
State's fiscal year | ||
2007 budget, the Department of Healthcare and Family Services | ||
may adopt emergency rules during fiscal year 2007, including | ||
rules effective July 1, 2007, in
accordance with this | ||
subsection to the extent necessary to administer the | ||
Department's responsibilities with respect to amendments to | ||
the State plans and Illinois waivers approved by the federal | ||
Centers for Medicare and Medicaid Services necessitated by the | ||
requirements of Title XIX and Title XXI of the federal Social | ||
Security Act. The adoption of emergency rules
authorized by | ||
this subsection (l) shall be deemed to be necessary for the | ||
public interest,
safety, and welfare.
| ||
(m) In order to provide for the expeditious and timely | ||
implementation of the provisions of the
State's fiscal year | ||
2008 budget, the Department of Healthcare and Family Services | ||
may adopt emergency rules during fiscal year 2008, including |
rules effective July 1, 2008, in
accordance with this | ||
subsection to the extent necessary to administer the | ||
Department's responsibilities with respect to amendments to | ||
the State plans and Illinois waivers approved by the federal | ||
Centers for Medicare and Medicaid Services necessitated by the | ||
requirements of Title XIX and Title XXI of the federal Social | ||
Security Act. The adoption of emergency rules
authorized by | ||
this subsection (m) shall be deemed to be necessary for the | ||
public interest,
safety, and welfare.
| ||
(n) In order to provide for the expeditious and timely | ||
implementation of the provisions of the State's fiscal year | ||
2010 budget, emergency rules to implement any provision of this | ||
amendatory Act of the 96th General Assembly or any other budget | ||
initiative authorized by the 96th General Assembly for fiscal | ||
year 2010 may be adopted in accordance with this Section by the | ||
agency charged with administering that provision or | ||
initiative. The adoption of emergency rules authorized by this | ||
subsection (n) shall be deemed to be necessary for the public | ||
interest, safety, and welfare. The rulemaking authority | ||
granted in this subsection (n) shall apply only to rules | ||
promulgated during Fiscal Year 2010. | ||
(o) In order to provide for the expeditious and timely | ||
implementation of the provisions of the State's fiscal year | ||
2011 budget, emergency rules to implement any provision of this | ||
amendatory Act of the 96th General Assembly or any other budget | ||
initiative authorized by the 96th General Assembly for fiscal |
year 2011 may be adopted in accordance with this Section by the | ||
agency charged with administering that provision or | ||
initiative. The adoption of emergency rules authorized by this | ||
subsection (o) is deemed to be necessary for the public | ||
interest, safety, and welfare. The rulemaking authority | ||
granted in this subsection (o) applies only to rules | ||
promulgated on or after the effective date of this amendatory | ||
Act of the 96th General Assembly through June 30, 2011. | ||
(p) In order to provide for the expeditious and timely | ||
implementation of the provisions of Public Act 97-689, | ||
emergency rules to implement any provision of Public Act 97-689 | ||
may be adopted in accordance with this subsection (p) by the | ||
agency charged with administering that provision or | ||
initiative. The 150-day limitation of the effective period of | ||
emergency rules does not apply to rules adopted under this | ||
subsection (p), and the effective period may continue through | ||
June 30, 2013. The 24-month limitation on the adoption of | ||
emergency rules does not apply to rules adopted under this | ||
subsection (p). The adoption of emergency rules authorized by | ||
this subsection (p) is deemed to be necessary for the public | ||
interest, safety, and welfare. | ||
(q) In order to provide for the expeditious and timely | ||
implementation of the provisions of Articles 7, 8, 9, 11, and | ||
12 of this amendatory Act of the 98th General Assembly, | ||
emergency rules to implement any provision of Articles 7, 8, 9, | ||
11, and 12 of this amendatory Act of the 98th General Assembly |
may be adopted in accordance with this subsection (q) by the | ||
agency charged with administering that provision or | ||
initiative. The 24-month limitation on the adoption of | ||
emergency rules does not apply to rules adopted under this | ||
subsection (q). The adoption of emergency rules authorized by | ||
this subsection (q) is deemed to be necessary for the public | ||
interest, safety, and welfare. | ||
(r) In order to provide for the expeditious and timely | ||
implementation of the provisions of this amendatory Act of the | ||
98th General Assembly, emergency rules to implement this | ||
amendatory Act of the 98th General Assembly may be adopted in | ||
accordance with this subsection (r) by the Department of | ||
Healthcare and Family Services. The 24-month limitation on the | ||
adoption of emergency rules does not apply to rules adopted | ||
under this subsection (r). The adoption of emergency rules | ||
authorized by this subsection (r) is deemed to be necessary for | ||
the public interest, safety, and welfare. | ||
(Source: P.A. 97-689, eff. 6-14-12; 97-695, eff. 7-1-12; | ||
98-104, eff. 7-22-13; 98-463, eff. 8-16-13.)
| ||
Section 20-10. The Children's Health Insurance Program Act | ||
is amended by changing Section 7 as follows:
| ||
(215 ILCS 106/7) | ||
Sec. 7. Eligibility verification. Notwithstanding any | ||
other provision of this Act, with respect to applications for |
benefits provided under the Program, eligibility shall be | ||
determined in a manner that ensures program integrity and that | ||
complies with federal law and regulations while minimizing | ||
unnecessary barriers to enrollment. To this end, as soon as | ||
practicable, and unless the Department receives written denial | ||
from the federal government, this Section shall be implemented: | ||
(a) The Department of Healthcare and Family Services or its | ||
designees shall: | ||
(1) By no later than July 1, 2011, require verification | ||
of, at a minimum, one month's income from all sources | ||
required for determining the eligibility of applicants to | ||
the Program. Such verification shall take the form of pay | ||
stubs, business or income and expense records for | ||
self-employed persons, letters from employers, and any | ||
other valid documentation of income including data | ||
obtained electronically by the Department or its designees | ||
from other sources as described in subsection (b) of this | ||
Section. | ||
(2) By no later than October 1, 2011, require | ||
verification of, at a minimum, one month's income from all | ||
sources required for determining the continued eligibility | ||
of recipients at their annual review of eligibility under | ||
the Program. Such verification shall take the form of pay | ||
stubs, business or income and expense records for | ||
self-employed persons, letters from employers, and any | ||
other valid documentation of income including data |
obtained electronically by the Department or its designees | ||
from other sources as described in subsection (b) of this | ||
Section. The Department shall send a notice to the | ||
recipient at least 60 days prior to the end of the period | ||
of eligibility that informs them of the requirements for | ||
continued eligibility. If a recipient does not fulfill the | ||
requirements for continued eligibility by the deadline | ||
established in the notice, a notice of cancellation shall | ||
be issued to the recipient and coverage shall end on the | ||
last day of the eligibility period. A recipient's | ||
eligibility may be reinstated without requiring a new | ||
application if the recipient fulfills the requirements for | ||
continued eligibility prior to the end of the third month | ||
following the last date of coverage (or longer period if | ||
required by federal regulations) . Nothing in this Section | ||
shall prevent an individual whose coverage has been | ||
cancelled from reapplying for health benefits at any time. | ||
(3) By no later than July 1, 2011, require verification | ||
of Illinois residency. | ||
(b) The Department shall establish or continue cooperative
| ||
arrangements with the Social Security Administration, the
| ||
Illinois Secretary of State, the Department of Human Services,
| ||
the Department of Revenue, the Department of Employment | ||
Security, and any other appropriate entity to gain electronic
| ||
access, to the extent allowed by law, to information available | ||
to those entities that may be appropriate for electronically
|
verifying any factor of eligibility for benefits under the
| ||
Program. Data relevant to eligibility shall be provided for no
| ||
other purpose than to verify the eligibility of new applicants | ||
or current recipients of health benefits under the Program. | ||
Data will be requested or provided for any new applicant or | ||
current recipient only insofar as that individual's | ||
circumstances are relevant to that individual's or another | ||
individual's eligibility. | ||
(c) Within 90 days of the effective date of this amendatory | ||
Act of the 96th General Assembly, the Department of Healthcare | ||
and Family Services shall send notice to current recipients | ||
informing them of the changes regarding their eligibility | ||
verification.
| ||
(Source: P.A. 96-1501, eff. 1-25-11.)
| ||
Section 20-15. The Covering ALL KIDS Health Insurance Act | ||
is amended by changing Sections 7 and 20 as follows:
| ||
(215 ILCS 170/7) | ||
(Section scheduled to be repealed on July 1, 2016) | ||
Sec. 7. Eligibility verification. Notwithstanding any | ||
other provision of this Act, with respect to applications for | ||
benefits provided under the Program, eligibility shall be | ||
determined in a manner that ensures program integrity and that | ||
complies with federal law and regulations while minimizing | ||
unnecessary barriers to enrollment. To this end, as soon as |
practicable, and unless the Department receives written denial | ||
from the federal government, this Section shall be implemented: | ||
(a) The Department of Healthcare and Family Services or its | ||
designees shall: | ||
(1) By July 1, 2011, require verification of, at a | ||
minimum, one month's income from all sources required for | ||
determining the eligibility of applicants to the Program.
| ||
Such verification shall take the form of pay stubs, | ||
business or income and expense records for self-employed | ||
persons, letters from employers, and any other valid | ||
documentation of income including data obtained | ||
electronically by the Department or its designees from | ||
other sources as described in subsection (b) of this | ||
Section. | ||
(2) By October 1, 2011, require verification of, at a | ||
minimum, one month's income from all sources required for | ||
determining the continued eligibility of recipients at | ||
their annual review of eligibility under the Program. Such | ||
verification shall take the form of pay stubs, business or | ||
income and expense records for self-employed persons, | ||
letters from employers, and any other valid documentation | ||
of income including data obtained electronically by the | ||
Department or its designees from other sources as described | ||
in subsection (b) of this Section. The Department shall | ||
send a notice to
recipients at least 60 days prior to the | ||
end of their period
of eligibility that informs them of the
|
requirements for continued eligibility. If a recipient
| ||
does not fulfill the requirements for continued | ||
eligibility by the
deadline established in the notice, a | ||
notice of cancellation shall be issued to the recipient and | ||
coverage shall end on the last day of the eligibility | ||
period. A recipient's eligibility may be reinstated | ||
without requiring a new application if the recipient | ||
fulfills the requirements for continued eligibility prior | ||
to the end of the third month following the last date of | ||
coverage (or longer period if required by federal | ||
regulations) . Nothing in this Section shall prevent an | ||
individual whose coverage has been cancelled from | ||
reapplying for health benefits at any time. | ||
(3) By July 1, 2011, require verification of Illinois | ||
residency. | ||
(b) The Department shall establish or continue cooperative
| ||
arrangements with the Social Security Administration, the
| ||
Illinois Secretary of State, the Department of Human Services,
| ||
the Department of Revenue, the Department of Employment
| ||
Security, and any other appropriate entity to gain electronic
| ||
access, to the extent allowed by law, to information available
| ||
to those entities that may be appropriate for electronically
| ||
verifying any factor of eligibility for benefits under the
| ||
Program. Data relevant to eligibility shall be provided for no
| ||
other purpose than to verify the eligibility of new applicants | ||
or current recipients of health benefits under the Program. |
Data will be requested or provided for any new applicant or | ||
current recipient only insofar as that individual's | ||
circumstances are relevant to that individual's or another | ||
individual's eligibility. | ||
(c) Within 90 days of the effective date of this amendatory | ||
Act of the 96th General Assembly, the Department of Healthcare | ||
and Family Services shall send notice to current recipients | ||
informing them of the changes regarding their eligibility | ||
verification.
| ||
(Source: P.A. 96-1501, eff. 1-25-11.)
| ||
(215 ILCS 170/20) | ||
(Section scheduled to be repealed on July 1, 2016)
| ||
Sec. 20. Eligibility. | ||
(a) To be eligible for the Program, a person must be a | ||
child:
| ||
(1) who is a resident of the State of Illinois; | ||
(2) who is ineligible for medical assistance under the | ||
Illinois Public Aid Code or benefits under the Children's | ||
Health Insurance Program Act;
| ||
(3) who either (i) effective July 1, 2014, who has in | ||
accordance with 42 CFR 457.805 (78 FR 42313, July 15, 2013) | ||
or any other federal requirement necessary to obtain | ||
federal financial participation for expenditures made | ||
under this Act, has been without health insurance coverage | ||
for 90 days; 12 months, (ii) whose parent has lost |
employment that made available affordable dependent health | ||
insurance coverage, until such time as affordable | ||
employer-sponsored dependent health insurance coverage is | ||
again available for the child as set forth by the | ||
Department in rules, (iii) (ii) who is a newborn whose | ||
responsible relative does not have available affordable | ||
private or employer-sponsored health insurance ; or (iii) , | ||
or (iv) who, within one year of applying for coverage under | ||
this Act, lost medical benefits under the Illinois Public | ||
Aid Code or the Children's Health Insurance Program Act; | ||
and | ||
(3.5) whose household income, as determined , effective | ||
October 1, 2013, by the Department, is at or below 300% of | ||
the federal poverty level as determined in compliance with | ||
42 U.S.C. 1397bb(b)(1)(B)(v) and applicable federal | ||
regulations . This item (3.5) is effective July 1, 2011. | ||
An entity that provides health insurance coverage (as | ||
defined in Section 2 of the Comprehensive Health Insurance Plan | ||
Act) to Illinois residents shall provide health insurance data | ||
match to the Department of Healthcare and Family Services as | ||
provided by and subject to Section 5.5 of the Illinois | ||
Insurance Code. The Department of Healthcare and Family | ||
Services may impose an administrative penalty as provided under | ||
Section 12-4.45 of the Illinois Public Aid Code on entities | ||
that have established a pattern of failure to provide the | ||
information required under this Section. |
The Department of Healthcare and Family Services, in | ||
collaboration with the Department of Insurance, shall adopt | ||
rules governing the exchange of information under this Section. | ||
The rules shall be consistent with all laws relating to the | ||
confidentiality or privacy of personal information or medical | ||
records, including provisions under the Federal Health | ||
Insurance Portability and Accountability Act (HIPAA). | ||
(b) The Department shall monitor the availability and | ||
retention of employer-sponsored dependent health insurance | ||
coverage and shall modify the period described in subdivision | ||
(a)(3) if necessary to promote retention of private or | ||
employer-sponsored health insurance and timely access to | ||
healthcare services, but at no time shall the period described | ||
in subdivision (a)(3) be less than 6 months.
| ||
(c) The Department, at its discretion, may take into | ||
account the affordability of dependent health insurance when | ||
determining whether employer-sponsored dependent health | ||
insurance coverage is available upon reemployment of a child's | ||
parent as provided in subdivision (a)(3). | ||
(d) A child who is determined to be eligible for the | ||
Program shall remain eligible for 12 months, provided that the | ||
child maintains his or her residence in this State, has not yet | ||
attained 19 years of age, and is not excluded under subsection | ||
(e). | ||
(e) A child is not eligible for coverage under the Program | ||
if: |
(1) the premium required under Section 40 has not been | ||
timely paid; if the required premiums are not paid, the | ||
liability of the Program shall be limited to benefits | ||
incurred under the Program for the time period for which | ||
premiums have been paid; re-enrollment shall be completed | ||
before the next covered medical visit, and the first | ||
month's required premium shall be paid in advance of the | ||
next covered medical visit; or | ||
(2) the child is an inmate of a public institution or | ||
an institution for mental diseases.
| ||
(f) The Department may adopt rules, including, but not | ||
limited to: rules regarding annual renewals of eligibility for | ||
the Program in conformance with Section 7 of this Act; rules | ||
providing for re-enrollment, grace periods, notice | ||
requirements, and hearing procedures under subdivision (e)(1) | ||
of this Section; and rules regarding what constitutes | ||
availability and affordability of private or | ||
employer-sponsored health insurance, with consideration of | ||
such factors as the percentage of income needed to purchase | ||
children or family health insurance, the availability of | ||
employer subsidies, and other relevant factors.
| ||
(g) Each child enrolled in the Program as of July 1, 2011 | ||
whose family income, as established by the Department, exceeds | ||
300% of the federal poverty level may remain enrolled in the | ||
Program for 12 additional months commencing July 1, 2011. | ||
Continued enrollment pursuant to this subsection shall be |
available only if the child continues to meet all eligibility | ||
criteria established under the Program as of the effective date | ||
of this amendatory Act of the 96th General Assembly without a | ||
break in coverage. Nothing contained in this subsection shall | ||
prevent a child from qualifying for any other health benefits | ||
program operated by the Department. | ||
(Source: P.A. 98-130, eff. 8-2-13.)
| ||
Section 20-20. The Illinois Public Aid Code is amended by | ||
changing Sections 5-2.1a and 11-5.1 as follows:
| ||
(305 ILCS 5/5-2.1a)
| ||
Sec. 5-2.1a. Treatment of trust amounts. To the extent | ||
required by
federal
law, the Department of Healthcare and | ||
Family Services Illinois Department shall provide by rule for | ||
the consideration of
trusts and similar legal instruments or | ||
devices established by a person in the
Illinois Department's | ||
determination of the person's eligibility for and the
amount of | ||
assistance provided under this Article.
This Section shall be | ||
enforced by the Department of Human Services, acting as
| ||
successor to the Department of Public Aid under the Department | ||
of Human
Services Act.
| ||
(Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
| ||
(305 ILCS 5/11-5.1) | ||
Sec. 11-5.1. Eligibility verification. Notwithstanding any |
other provision of this Code, with respect to applications for | ||
medical assistance provided under Article V of this Code, | ||
eligibility shall be determined in a manner that ensures | ||
program integrity and complies with federal laws and | ||
regulations while minimizing unnecessary barriers to | ||
enrollment. To this end, as soon as practicable, and unless the | ||
Department receives written denial from the federal | ||
government, this Section shall be implemented: | ||
(a) The Department of Healthcare and Family Services or its | ||
designees shall: | ||
(1) By no later than July 1, 2011, require verification | ||
of, at a minimum, one month's income from all sources | ||
required for determining the eligibility of applicants for | ||
medical assistance under this Code. Such verification | ||
shall take the form of pay stubs, business or income and | ||
expense records for self-employed persons, letters from | ||
employers, and any other valid documentation of income | ||
including data obtained electronically by the Department | ||
or its designees from other sources as described in | ||
subsection (b) of this Section. | ||
(2) By no later than October 1, 2011, require | ||
verification of, at a minimum, one month's income from all | ||
sources required for determining the continued eligibility | ||
of recipients at their annual review of eligibility for | ||
medical assistance under this Code. Such verification | ||
shall take the form of pay stubs, business or income and |
expense records for self-employed persons, letters from | ||
employers, and any other valid documentation of income | ||
including data obtained electronically by the Department | ||
or its designees from other sources as described in | ||
subsection (b) of this Section. The
Department shall send a | ||
notice to
recipients at least 60 days prior to the end of | ||
their period
of eligibility that informs them of the
| ||
requirements for continued eligibility. If a recipient
| ||
does not fulfill the requirements for continued | ||
eligibility by the
deadline established in the notice a | ||
notice of cancellation shall be issued to the recipient and | ||
coverage shall end on the last day of the eligibility | ||
period. A recipient's eligibility may be reinstated | ||
without requiring a new application if the recipient | ||
fulfills the requirements for continued eligibility prior | ||
to the end of the third month following the last date of | ||
coverage (or longer period if required by federal | ||
regulations) . Nothing in this Section shall prevent an | ||
individual whose coverage has been cancelled from | ||
reapplying for health benefits at any time. | ||
(3) By no later than July 1, 2011, require verification | ||
of Illinois residency. | ||
(b) The Department shall establish or continue cooperative
| ||
arrangements with the Social Security Administration, the
| ||
Illinois Secretary of State, the Department of Human Services,
| ||
the Department of Revenue, the Department of Employment
|
Security, and any other appropriate entity to gain electronic
| ||
access, to the extent allowed by law, to information available
| ||
to those entities that may be appropriate for electronically
| ||
verifying any factor of eligibility for benefits under the
| ||
Program. Data relevant to eligibility shall be provided for no
| ||
other purpose than to verify the eligibility of new applicants | ||
or current recipients of health benefits under the Program. | ||
Data shall be requested or provided for any new applicant or | ||
current recipient only insofar as that individual's | ||
circumstances are relevant to that individual's or another | ||
individual's eligibility. | ||
(c) Within 90 days of the effective date of this amendatory | ||
Act of the 96th General Assembly, the Department of Healthcare | ||
and Family Services shall send notice to current recipients | ||
informing them of the changes regarding their eligibility | ||
verification.
| ||
(Source: P.A. 96-1501, eff. 1-25-11.)
| ||
Article 25 | ||
Section 25-5. The State Finance Act is amended by changing | ||
Section 6z-30 as follows:
| ||
(30 ILCS 105/6z-30) | ||
Sec. 6z-30. University of Illinois Hospital Services Fund. | ||
(a) The University of Illinois Hospital Services Fund is |
created as a
special fund in the State Treasury. The following | ||
moneys shall be deposited
into the Fund: | ||
(1) As soon as possible after the beginning of fiscal | ||
year 2010, and in no event later than July 30, the State
| ||
Comptroller and the State Treasurer shall automatically | ||
transfer $30,000,000
from the General Revenue Fund to the | ||
University of Illinois Hospital Services
Fund. | ||
(1.5) Starting in fiscal year 2011, as soon as
possible | ||
after the beginning of each fiscal year, and in no event | ||
later than July 30, the State Comptroller and the State | ||
Treasurer shall automatically transfer $45,000,000 from | ||
the General Revenue Fund to the University of Illinois | ||
Hospital Services Fund; except that, in fiscal year 2012 | ||
only, the State Comptroller and the State Treasurer shall | ||
transfer $90,000,000 from the General Revenue Fund to the | ||
University of Illinois Hospital Services Fund under this | ||
paragraph, and, in fiscal year 2013 only, the State | ||
Comptroller and the State Treasurer shall transfer no | ||
amounts from the General Revenue Fund to the University of | ||
Illinois Hospital Services Fund under this paragraph. | ||
(2) All intergovernmental transfer payments to the | ||
Department of Healthcare and Family Services by the | ||
University of Illinois made pursuant to an
| ||
intergovernmental agreement under subsection (b) or (c) of | ||
Section 5A-3 of
the Illinois Public Aid Code. | ||
(3) All federal matching funds received by the |
Department of Healthcare and Family Services (formerly
| ||
Illinois Department of
Public Aid) as a result of | ||
expenditures made by the Department that are
attributable | ||
to moneys that were deposited in the Fund. | ||
(4) All other moneys received for the Fund from any
| ||
other source, including interest earned thereon. | ||
(b) Moneys in the fund may be used by the Department of | ||
Healthcare and Family Services,
subject to appropriation and to | ||
an interagency agreement between that Department and the Board | ||
of Trustees of the University of Illinois, to reimburse the | ||
University of Illinois Hospital for
hospital and pharmacy | ||
services, to reimburse practitioners who are employed by the | ||
University of Illinois, to reimburse other health care | ||
facilities and health plans operated by the University of | ||
Illinois, and to pass through to the University of Illinois | ||
federal financial participation earned by the State as a result | ||
of expenditures made by the University of Illinois. | ||
(c) (Blank). | ||
(Source: P.A. 96-45, eff. 7-15-09; 96-959, eff. 7-1-10; 97-732, | ||
eff. 6-30-12.)
| ||
Section 25-10. The Illinois Public Aid Code is amended by | ||
changing Section 12-9 as follows:
| ||
(305 ILCS 5/12-9) (from Ch. 23, par. 12-9)
| ||
Sec. 12-9. Public Aid Recoveries Trust Fund; uses. The |
Public Aid Recoveries Trust Fund shall consist of (1)
| ||
recoveries by the Department of Healthcare and Family Services | ||
(formerly Illinois Department of Public Aid) authorized by this | ||
Code
in respect to applicants or recipients under Articles III, | ||
IV, V, and VI,
including recoveries made by the Department of | ||
Healthcare and Family Services (formerly Illinois Department | ||
of Public
Aid) from the estates of deceased recipients, (2) | ||
recoveries made by the
Department of Healthcare and Family | ||
Services (formerly Illinois Department of Public Aid) in | ||
respect to applicants and recipients under
the Children's | ||
Health Insurance Program Act, and the Covering ALL KIDS Health | ||
Insurance Act, (2.5) recoveries made by the Department of | ||
Healthcare and Family Services in connection with the | ||
imposition of an administrative penalty as provided under | ||
Section 12-4.45, (3) federal funds received on
behalf of and | ||
earned by State universities and local governmental entities
| ||
for services provided to
applicants or recipients covered under | ||
this Code, the Children's Health Insurance Program Act, and the | ||
Covering ALL KIDS Health Insurance Act, (3.5) federal financial | ||
participation revenue related to eligible disbursements made | ||
by the Department of Healthcare and Family Services from | ||
appropriations required by this Section, and (4) all other | ||
moneys received to the Fund, including interest thereon. The | ||
Fund shall be held
as a special fund in the State Treasury.
| ||
Disbursements from this Fund shall be only (1) for the | ||
reimbursement of
claims collected by the Department of |
Healthcare and Family Services (formerly Illinois Department | ||
of Public Aid) through error
or mistake, (2) for payment to | ||
persons or agencies designated as payees or
co-payees on any | ||
instrument, whether or not negotiable, delivered to the
| ||
Department of Healthcare and Family Services (formerly
| ||
Illinois Department of Public Aid) as a recovery under this | ||
Section, such
payment to be in proportion to the respective | ||
interests of the payees in the
amount so collected, (3) for | ||
payments to the Department of Human Services
for collections | ||
made by the Department of Healthcare and Family Services | ||
(formerly Illinois Department of Public Aid) on behalf of
the | ||
Department of Human Services under this Code, the Children's | ||
Health Insurance Program Act, and the Covering ALL KIDS Health | ||
Insurance Act, (4) for payment of
administrative expenses | ||
incurred in performing the
activities authorized under this | ||
Code, the Children's Health Insurance Program Act, and the | ||
Covering ALL KIDS Health Insurance Act, (5)
for payment of fees | ||
to persons or agencies in the performance of activities
| ||
pursuant to the collection of monies owed the State that are | ||
collected
under this Code, the Children's Health Insurance | ||
Program Act, and the Covering ALL KIDS Health Insurance Act, | ||
(6) for payments of any amounts which are
reimbursable to the | ||
federal government which are required to be paid by State
| ||
warrant by either the State or federal government, and (7) for | ||
payments
to State universities and local governmental entities | ||
of federal funds for
services provided to
applicants or |
recipients covered under this Code, the Children's Health | ||
Insurance Program Act, and the Covering ALL KIDS Health | ||
Insurance Act. Disbursements
from this Fund for purposes of | ||
items (4) and (5) of this
paragraph shall be subject to | ||
appropriations from the Fund to the Department of Healthcare | ||
and Family Services (formerly Illinois
Department of Public | ||
Aid).
| ||
The balance in this Fund on the first day of each calendar | ||
quarter, after
payment therefrom of any amounts reimbursable to | ||
the federal government, and
minus the amount reasonably | ||
anticipated to be needed to make the disbursements
during that | ||
quarter authorized by this Section during the current and | ||
following 3 calendar months , shall be certified by the
Director | ||
of Healthcare and Family Services and transferred by the
State | ||
Comptroller to the Drug Rebate Fund or the Healthcare Provider | ||
Relief Fund in
the State Treasury, as appropriate, on at least | ||
an annual basis by June 30th of each fiscal year within 30 days | ||
of the first day of
each calendar quarter . The Director of | ||
Healthcare and Family Services may certify and the State | ||
Comptroller shall transfer to the Drug Rebate Fund or the | ||
Healthcare Provider Relief Fund amounts on a more frequent | ||
basis.
| ||
On July 1, 1999, the State Comptroller shall transfer the | ||
sum of $5,000,000
from the Public Aid Recoveries Trust Fund | ||
(formerly the Public Assistance
Recoveries Trust Fund) into the | ||
DHS Recoveries Trust Fund.
|
(Source: P.A. 97-647, eff. 1-1-12; 97-689, eff. 6-14-12; | ||
98-130, eff. 8-2-13.)
| ||
Article 30 | ||
Section 30-5. The Illinois Public Aid Code is amended by | ||
adding Section 5A-12.5 as follows:
| ||
(305 ILCS 5/5A-12.5 new) | ||
Sec. 5A-12.5. Affordable Care Act adults; hospital access | ||
payments. The Department shall, subject to federal approval, | ||
mirror the Medical Assistance hospital reimbursement | ||
methodology, including hospital access payments as defined in | ||
Section 5A-12.2 of this Article and hospital access improvement | ||
payments as defined in Section 5A-12.4 of this Article, in | ||
compliance with the equivalent rate provisions of the | ||
Affordable Care Act. | ||
As used in this Section, "Affordable Care Act" is the | ||
collective term for the Patient Protection and Affordable Care | ||
Act (Pub. L. 111-148) and the Health Care and Education | ||
Reconciliation Act of 2010 (Pub. L. 111-152).
| ||
Article 35 | ||
Section 35-5. The Hospital Licensing Act is amended by | ||
changing Section 6.09 as follows:
|
(210 ILCS 85/6.09) (from Ch. 111 1/2, par. 147.09) | ||
Sec. 6.09. (a) In order to facilitate the orderly | ||
transition of aged
and disabled patients from hospitals to | ||
post-hospital care, whenever a
patient who qualifies for the
| ||
federal Medicare program is hospitalized, the patient shall be | ||
notified
of discharge at least
24 hours prior to discharge from
| ||
the hospital. With regard to pending discharges to a skilled | ||
nursing facility, the hospital must notify the case | ||
coordination unit, as defined in 89 Ill. Adm. Code 240.260, at | ||
least 24 hours prior to discharge . When the assessment is | ||
completed in the hospital, the case coordination unit shall | ||
provide the discharge planner with a copy of the prescreening | ||
information and accompanying materials, which the discharge | ||
planner shall transmit when the patient is discharged to a | ||
skilled nursing facility. If or, if home health services are | ||
ordered, the hospital must inform its designated case | ||
coordination unit, as defined in 89 Ill. Adm. Code 240.260, of | ||
the pending discharge and must provide the patient with the | ||
case coordination unit's telephone number and other contact | ||
information.
| ||
(b) Every hospital shall develop procedures for a physician | ||
with medical
staff privileges at the hospital or any | ||
appropriate medical staff member to
provide the discharge | ||
notice prescribed in subsection (a) of this Section. The | ||
procedures must include prohibitions against discharging or |
referring a patient to any of the following if unlicensed, | ||
uncertified, or unregistered: (i) a board and care facility, as | ||
defined in the Board and Care Home Act; (ii) an assisted living | ||
and shared housing establishment, as defined in the Assisted | ||
Living and Shared Housing Act; (iii) a facility licensed under | ||
the Nursing Home Care Act, the Specialized Mental Health | ||
Rehabilitation Act of 2013, or the ID/DD Community Care Act; | ||
(iv) a supportive living facility, as defined in Section | ||
5-5.01a of the Illinois Public Aid Code; or (v) a free-standing | ||
hospice facility licensed under the Hospice Program Licensing | ||
Act if licensure, certification, or registration is required. | ||
The Department of Public Health shall annually provide | ||
hospitals with a list of licensed, certified, or registered | ||
board and care facilities, assisted living and shared housing | ||
establishments, nursing homes, supportive living facilities, | ||
facilities licensed under the ID/DD Community Care Act or the | ||
Specialized Mental Health Rehabilitation Act of 2013, and | ||
hospice facilities. Reliance upon this list by a hospital shall | ||
satisfy compliance with this requirement.
The procedure may | ||
also include a waiver for any case in which a discharge
notice | ||
is not feasible due to a short length of stay in the hospital | ||
by the patient,
or for any case in which the patient | ||
voluntarily desires to leave the
hospital before the expiration | ||
of the
24 hour period. | ||
(c) At least
24 hours prior to discharge from the hospital, | ||
the
patient shall receive written information on the patient's |
right to appeal the
discharge pursuant to the
federal Medicare | ||
program, including the steps to follow to appeal
the discharge | ||
and the appropriate telephone number to call in case the
| ||
patient intends to appeal the discharge. | ||
(d) Before transfer of a patient to a long term care | ||
facility licensed under the Nursing Home Care Act where elderly | ||
persons reside, a hospital shall as soon as practicable | ||
initiate a name-based criminal history background check by | ||
electronic submission to the Department of State Police for all | ||
persons between the ages of 18 and 70 years; provided, however, | ||
that a hospital shall be required to initiate such a background | ||
check only with respect to patients who: | ||
(1) are transferring to a long term care facility for | ||
the first time; | ||
(2) have been in the hospital more than 5 days; | ||
(3) are reasonably expected to remain at the long term | ||
care facility for more than 30 days; | ||
(4) have a known history of serious mental illness or | ||
substance abuse; and | ||
(5) are independently ambulatory or mobile for more | ||
than a temporary period of time. | ||
A hospital may also request a criminal history background | ||
check for a patient who does not meet any of the criteria set | ||
forth in items (1) through (5). | ||
A hospital shall notify a long term care facility if the | ||
hospital has initiated a criminal history background check on a |
patient being discharged to that facility. In all circumstances | ||
in which the hospital is required by this subsection to | ||
initiate the criminal history background check, the transfer to | ||
the long term care facility may proceed regardless of the | ||
availability of criminal history results. Upon receipt of the | ||
results, the hospital shall promptly forward the results to the | ||
appropriate long term care facility. If the results of the | ||
background check are inconclusive, the hospital shall have no | ||
additional duty or obligation to seek additional information | ||
from, or about, the patient. | ||
(Source: P.A. 97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813, | ||
eff. 7-13-12; 98-104, eff. 7-22-13.)
| ||
Section 35-10. The Illinois Public Aid Code is amended by | ||
changing Section 11-5.4 as follows:
| ||
(305 ILCS 5/11-5.4) | ||
Sec. 11-5.4. Expedited long-term care eligibility | ||
determination and enrollment. | ||
(a) An expedited long-term care eligibility determination | ||
and enrollment system shall be established to reduce long-term | ||
care determinations to 90 days or fewer by July 1, 2014 and | ||
streamline the long-term care enrollment process. | ||
Establishment of the system shall be a joint venture of the | ||
Department of Human Services and Healthcare and Family Services | ||
and the Department on Aging. The Governor shall name a lead |
agency no later than 30 days after the effective date of this | ||
amendatory Act of the 98th General Assembly to assume | ||
responsibility for the full implementation of the | ||
establishment and maintenance of the system. Project outcomes | ||
shall include an enhanced eligibility determination tracking | ||
system accessible to providers and a centralized application | ||
review and eligibility determination with all applicants | ||
reviewed within 90 days of receipt by the State of a complete | ||
application. If the Department of Healthcare and Family | ||
Services' Office of the Inspector General determines that there | ||
is a likelihood that a non-allowable transfer of assets has | ||
occurred, and the facility in which the applicant resides is | ||
notified, an extension of up to 90 days shall be permissible. | ||
On or before December 31, 2015, a streamlined application and | ||
enrollment process shall be put in place based on the following | ||
principles: | ||
(1) Minimize the burden on applicants by collecting | ||
only the data necessary to determine eligibility for | ||
medical services, long-term care services, and spousal | ||
impoverishment offset. | ||
(2) Integrate online data sources to simplify the | ||
application process by reducing the amount of information | ||
needed to be entered and to expedite eligibility | ||
verification. | ||
(3) Provide online prompts to alert the applicant that | ||
information is missing or not complete. |
(b) The Department shall, on or before July 1, 2014, assess | ||
the feasibility of incorporating all information needed to | ||
determine eligibility for long-term care services, including | ||
asset transfer and spousal impoverishment financials, into the | ||
State's integrated eligibility system identifying all | ||
resources needed and reasonable timeframes for achieving the | ||
specified integration. | ||
(c) The lead agency shall file interim reports with the | ||
Chairs and Minority Spokespersons of the House and Senate Human | ||
Services Committees no later than September 1, 2013 and on | ||
February 1, 2014. The Department of Healthcare and Family | ||
Services shall include in the annual Medicaid report for State | ||
Fiscal Year 2014 and every fiscal year thereafter information | ||
concerning implementation of the provisions of this Section. | ||
(d) No later than August 1, 2014, the Auditor General shall | ||
report to the General Assembly concerning the extent to which | ||
the timeframes specified in this Section have been met and the | ||
extent to which State staffing levels are adequate to meet the | ||
requirements of this Section.
| ||
(e) The Department of Healthcare and Family Services, the | ||
Department of Human Services, and the Department on Aging shall | ||
take the following steps to achieve federally established | ||
timeframes for eligibility determinations for Medicaid and | ||
long-term care benefits and shall work toward the federal goal | ||
of real time determinations: | ||
(1) The Departments shall review, in collaboration |
with representatives of affected providers, all forms and | ||
procedures currently in use, federal guidelines either | ||
suggested or mandated, and staff deployment by September | ||
30, 2014 to identify additional measures that can improve | ||
long-term care eligibility processing and make adjustments | ||
where possible. | ||
(2) No later than June 30, 2014, the Department of | ||
Healthcare and Family Services shall issue vouchers for | ||
advance payments not to exceed $50,000,000 to nursing | ||
facilities with significant outstanding Medicaid liability | ||
associated with services provided to residents with | ||
Medicaid applications pending and residents facing the | ||
greatest delays. Each facility with an advance payment | ||
shall state in writing whether its own recoupment schedule | ||
will be in 3 or 6 equal monthly installments, as long as | ||
all advances are recouped by June 30, 2015. | ||
(3) The Department of Healthcare and Family Services' | ||
Office of Inspector General and the Department of Human | ||
Services shall immediately forgo resource review and | ||
review of transfers during the relevant look-back period | ||
for applications that were submitted prior to September 1, | ||
2013. An applicant who applied prior to September 1, 2013, | ||
who was denied for failure to cooperate in providing | ||
required information, and whose application was | ||
incorrectly reviewed under the wrong look-back period | ||
rules may request review and correction of the denial based |
on this subsection. If found eligible upon review, such | ||
applicants shall be retroactively enrolled. | ||
(4) As soon as practicable, the Department of | ||
Healthcare and Family Services shall implement policies | ||
and promulgate rules to simplify financial eligibility | ||
verification in the following instances: (A) for | ||
applicants or recipients who are receiving Supplemental | ||
Security Income payments or who had been receiving such | ||
payments at the time they were admitted to a nursing | ||
facility and (B) for applicants or recipients with verified | ||
income at or below 100% of the federal poverty level when | ||
the declared value of their countable resources is no | ||
greater than the allowable amounts pursuant to Section 5-2 | ||
of this Code for classes of eligible persons for whom a | ||
resource limit applies. Such simplified verification | ||
policies shall apply to community cases as well as | ||
long-term care cases. | ||
(5) As soon as practicable, but not later than July 1, | ||
2014, the Department of Healthcare and Family Services and | ||
the Department of Human Services shall jointly begin a | ||
special enrollment project by using simplified eligibility | ||
verification policies and by redeploying caseworkers | ||
trained to handle long-term care cases to prioritize those | ||
cases, until the backlog is eliminated and processing time | ||
is within 90 days. This project shall apply to applications | ||
for long-term care received by the State on or before May |
15, 2014. | ||
(6) As soon as practicable, but not later than | ||
September 1, 2014, the Department on Aging shall make | ||
available to long-term care facilities and community | ||
providers upon request, through an electronic method, the | ||
information contained within the Interagency Certification | ||
of Screening Results completed by the pre-screener, in a | ||
form and manner acceptable to the Department of Human | ||
Services. | ||
(7) Effective 30 days after the completion of 3 | ||
regionally based trainings, nursing facilities shall | ||
submit all applications for medical assistance online via | ||
the Application for Benefits Eligibility (ABE) website. | ||
This requirement shall extend to scanning and uploading | ||
with the online application any required additional forms | ||
such as the Long Term Care Facility Notification and the | ||
Additional Financial Information for Long Term Care | ||
Applicants as well as scanned copies of any supporting | ||
documentation. Long-term care facility admission documents | ||
must be submitted as required in Section 5-5 of this Code. | ||
No local Department of Human Services office shall refuse | ||
to accept an electronically filed application. | ||
(8) Notwithstanding any other provision of this Code, | ||
the Department of Human Services and the Department of | ||
Healthcare and Family Services' Office of the Inspector | ||
General shall, upon request, allow an applicant additional |
time to submit information and documents needed as part of | ||
a review of available resources or resources transferred | ||
during the look-back period. The initial extension shall | ||
not exceed 30 days. A second extension of 30 days may be | ||
granted upon request. Any request for information issued by | ||
the State to an applicant shall include the following: an | ||
explanation of the information required and the date by | ||
which the information must be submitted; a statement that | ||
failure to respond in a timely manner can result in denial | ||
of the application; a statement that the applicant or the | ||
facility in the name of the applicant may seek an | ||
extension; and the name and contact information of a | ||
caseworker in case of questions. Any such request for | ||
information shall also be sent to the facility. In deciding | ||
whether to grant an extension, the Department of Human | ||
Services or the Department of Healthcare and Family | ||
Services' Office of the Inspector General shall take into | ||
account what is in the best interest of the applicant. The | ||
time limits for processing an application shall be tolled | ||
during the period of any extension granted under this | ||
subsection. | ||
(9) The Department of Human Services and the Department | ||
of Healthcare and Family Services must jointly compile data | ||
on pending applications and post a monthly report on each | ||
Department's website for the purposes of monitoring | ||
long-term care eligibility processing. The report must |
specify the number of applications pending long-term care | ||
eligibility determination and admission in the following | ||
categories: | ||
(A) Length of time application is pending - 0 to 90 | ||
days, 91 days to 180 days, 181 days to 12 months, over | ||
12 months to 18 months, over 18 months to 24 months, | ||
and over 24 months. | ||
(B) Percentage of applications pending in the | ||
Department of Human Services' Family Community | ||
Resource Centers, in the Department of Human Services' | ||
long-term care hubs, with the Department of Healthcare | ||
and Family Services' Office of Inspector General, and | ||
those applications which are being tolled due to | ||
requests for extension of time for additional | ||
information. | ||
(C) Status of pending applications. | ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
Article 40 | ||
Section 40-5. The Illinois Public Aid Code is amended by | ||
changing Sections 5A-2, 5A-5, 5A-10, and 5A-14 as follows:
| ||
(305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2) | ||
(Section scheduled to be repealed on January 1, 2015) | ||
Sec. 5A-2. Assessment.
|
(a)
Subject to Sections 5A-3 and 5A-10, for State fiscal | ||
years 2009 through 2018 2014, and from July 1, 2014 through | ||
December 31, 2014 , an annual assessment on inpatient services | ||
is imposed on each hospital provider in an amount equal to | ||
$218.38 multiplied by the difference of the hospital's occupied | ||
bed days less the hospital's Medicare bed days , provided, | ||
however, that the amount of $218.38 shall be increased by a | ||
uniform percentage to generate an amount equal to 75% of the | ||
State share of the payments authorized under Section 12-5, with | ||
such increase only taking effect upon the date that a State | ||
share for such payments is required under federal law . | ||
For State fiscal years 2009 through 2014 , and after , a | ||
hospital's occupied bed days and Medicare bed days shall be | ||
determined using the most recent data available from each | ||
hospital's 2005 Medicare cost report as contained in the | ||
Healthcare Cost Report Information System file, for the quarter | ||
ending on December 31, 2006, without regard to any subsequent | ||
adjustments or changes to such data. If a hospital's 2005 | ||
Medicare cost report is not contained in the Healthcare Cost | ||
Report Information System, then the Illinois Department may | ||
obtain the hospital provider's occupied bed days and Medicare | ||
bed days from any source available, including, but not limited | ||
to, records maintained by the hospital provider, which may be | ||
inspected at all times during business hours of the day by the | ||
Illinois Department or its duly authorized agents and | ||
employees. |
(b) (Blank).
| ||
(b-5) Subject to Sections 5A-3 and 5A-10, for the portion | ||
of State fiscal year 2012, beginning June 10, 2012 through June | ||
30, 2012, and for State fiscal years 2013 through 2018 2014, | ||
and July 1, 2014 through December 31, 2014 , an annual | ||
assessment on outpatient services is imposed on each hospital | ||
provider in an amount equal to .008766 multiplied by the | ||
hospital's outpatient gross revenue , provided, however, that | ||
the amount of .008766 shall be increased by a uniform | ||
percentage to generate an amount equal to 25% of the State | ||
share of the payments authorized under Section 12-5, with such | ||
increase only taking effect upon the date that a State share | ||
for such payments is required under federal law . For the period | ||
beginning June 10, 2012 through June 30, 2012, the annual | ||
assessment on outpatient services shall be prorated by | ||
multiplying the assessment amount by a fraction, the numerator | ||
of which is 21 days and the denominator of which is 365 days. | ||
For the portion of State fiscal year 2012, beginning June | ||
10, 2012 through June 30, 2012, and State fiscal years 2013 | ||
through 2018 2014, and July 1, 2014 through December 31, 2014 , | ||
a hospital's outpatient gross revenue shall be determined using | ||
the most recent data available from each hospital's 2009 | ||
Medicare cost report as contained in the Healthcare Cost Report | ||
Information System file, for the quarter ending on June 30, | ||
2011, without regard to any subsequent adjustments or changes | ||
to such data. If a hospital's 2009 Medicare cost report is not |
contained in the Healthcare Cost Report Information System, | ||
then the Department may obtain the hospital provider's | ||
outpatient gross revenue from any source available, including, | ||
but not limited to, records maintained by the hospital | ||
provider, which may be inspected at all times during business | ||
hours of the day by the Department or its duly authorized | ||
agents and employees. | ||
(c) (Blank).
| ||
(d) Notwithstanding any of the other provisions of this | ||
Section, the Department is authorized to adopt rules to reduce | ||
the rate of any annual assessment imposed under this Section, | ||
as authorized by Section 5-46.2 of the Illinois Administrative | ||
Procedure Act.
| ||
(e) Notwithstanding any other provision of this Section, | ||
any plan providing for an assessment on a hospital provider as | ||
a permissible tax under Title XIX of the federal Social | ||
Security Act and Medicaid-eligible payments to hospital | ||
providers from the revenues derived from that assessment shall | ||
be reviewed by the Illinois Department of Healthcare and Family | ||
Services, as the Single State Medicaid Agency required by | ||
federal law, to determine whether those assessments and | ||
hospital provider payments meet federal Medicaid standards. If | ||
the Department determines that the elements of the plan may | ||
meet federal Medicaid standards and a related State Medicaid | ||
Plan Amendment is prepared in a manner and form suitable for | ||
submission, that State Plan Amendment shall be submitted in a |
timely manner for review by the Centers for Medicare and | ||
Medicaid Services of the United States Department of Health and | ||
Human Services and subject to approval by the Centers for | ||
Medicare and Medicaid Services of the United States Department | ||
of Health and Human Services. No such plan shall become | ||
effective without approval by the Illinois General Assembly by | ||
the enactment into law of related legislation. Notwithstanding | ||
any other provision of this Section, the Department is | ||
authorized to adopt rules to reduce the rate of any annual | ||
assessment imposed under this Section. Any such rules may be | ||
adopted by the Department under Section 5-50 of the Illinois | ||
Administrative Procedure Act. | ||
(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12; | ||
98-104, eff. 7-22-13.)
| ||
(305 ILCS 5/5A-5) (from Ch. 23, par. 5A-5) | ||
Sec. 5A-5. Notice; penalty; maintenance of records.
| ||
(a)
The Illinois Department shall send a
notice of | ||
assessment to every hospital provider subject
to assessment | ||
under this Article. The notice of assessment shall notify the | ||
hospital of its assessment and shall be sent after receipt by | ||
the Department of notification from the Centers for Medicare | ||
and Medicaid Services of the U.S. Department of Health and | ||
Human Services that the payment methodologies required under | ||
this Article and, if necessary, the waiver granted under 42 CFR | ||
433.68 have been approved. The notice
shall be on a form
|
prepared by the Illinois Department and shall state the | ||
following:
| ||
(1) The name of the hospital provider.
| ||
(2) The address of the hospital provider's principal | ||
place
of business from which the provider engages in the | ||
occupation of hospital
provider in this State, and the name | ||
and address of each hospital
operated, conducted, or | ||
maintained by the provider in this State.
| ||
(3) The occupied bed days, occupied bed days less | ||
Medicare days, adjusted gross hospital revenue, or | ||
outpatient gross revenue of the
hospital
provider | ||
(whichever is applicable), the amount of
assessment | ||
imposed under Section 5A-2 for the State fiscal year
for | ||
which the notice is sent, and the amount of
each
| ||
installment to be paid during the State fiscal year.
| ||
(4) (Blank).
| ||
(5) Other reasonable information as determined by the | ||
Illinois
Department.
| ||
(b) If a hospital provider conducts, operates, or
maintains | ||
more than one hospital licensed by the Illinois
Department of | ||
Public Health, the provider shall pay the
assessment for each | ||
hospital separately.
| ||
(c) Notwithstanding any other provision in this Article, in
| ||
the case of a person who ceases to conduct, operate, or | ||
maintain a
hospital in respect of which the person is subject | ||
to assessment
under this Article as a hospital provider, the |
assessment for the State
fiscal year in which the cessation | ||
occurs shall be adjusted by
multiplying the assessment computed | ||
under Section 5A-2 by a
fraction, the numerator of which is the | ||
number of days in the
year during which the provider conducts, | ||
operates, or maintains
the hospital and the denominator of | ||
which is 365. Immediately
upon ceasing to conduct, operate, or | ||
maintain a hospital, the person
shall pay the assessment
for | ||
the year as so adjusted (to the extent not previously paid).
| ||
(d) Notwithstanding any other provision in this Article, a
| ||
provider who commences conducting, operating, or maintaining a
| ||
hospital, upon notice by the Illinois Department,
shall pay the | ||
assessment computed under Section 5A-2 and
subsection (e) in | ||
installments on the due dates stated in the
notice and on the | ||
regular installment due dates for the State
fiscal year | ||
occurring after the due dates of the initial
notice.
| ||
(e)
Notwithstanding any other provision in this Article, | ||
for State fiscal years 2009 through 2018 2014 , in the case of a | ||
hospital provider that did not conduct, operate, or maintain a | ||
hospital in 2005, the assessment for that State fiscal year | ||
shall be computed on the basis of hypothetical occupied bed | ||
days for the full calendar year as determined by the Illinois | ||
Department. Notwithstanding any other provision in this | ||
Article, for the portion of State fiscal year 2012 beginning | ||
June 10, 2012 through June 30, 2012, and for State fiscal years | ||
2013 through 2018 2014, and for July 1, 2014 through December | ||
31, 2014 , in the case of a hospital provider that did not |
conduct, operate, or maintain a hospital in 2009, the | ||
assessment under subsection (b-5) of Section 5A-2 for that | ||
State fiscal year shall be computed on the basis of | ||
hypothetical gross outpatient revenue for the full calendar | ||
year as determined by the Illinois Department.
| ||
(f) Every hospital provider subject to assessment under | ||
this Article shall keep sufficient records to permit the | ||
determination of adjusted gross hospital revenue for the | ||
hospital's fiscal year. All such records shall be kept in the | ||
English language and shall, at all times during regular | ||
business hours of the day, be subject to inspection by the | ||
Illinois Department or its duly authorized agents and | ||
employees.
| ||
(g) The Illinois Department may, by rule, provide a | ||
hospital provider a reasonable opportunity to request a | ||
clarification or correction of any clerical or computational | ||
errors contained in the calculation of its assessment, but such | ||
corrections shall not extend to updating the cost report | ||
information used to calculate the assessment.
| ||
(h) (Blank).
| ||
(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12; | ||
98-104, eff. 7-22-13; 98-463, eff. 8-16-13; revised 10-21-13.)
| ||
(305 ILCS 5/5A-10) (from Ch. 23, par. 5A-10)
| ||
Sec. 5A-10. Applicability.
| ||
(a) The assessment imposed by subsection (a) of Section |
5A-2 shall cease to be imposed and the Department's obligation | ||
to make payments shall immediately cease, and
any moneys
| ||
remaining in the Fund shall be refunded to hospital providers
| ||
in proportion to the amounts paid by them, if:
| ||
(1) The payments to hospitals required under this | ||
Article are not eligible for federal matching funds under | ||
Title XIX or XXI of the Social Security Act;
| ||
(2) For State fiscal years 2009 through 2018 2014, and | ||
July 1, 2014 through December 31, 2014 , the
Department of | ||
Healthcare and Family Services adopts any administrative | ||
rule change to reduce payment rates or alters any payment | ||
methodology that reduces any payment rates made to | ||
operating hospitals under the approved Title XIX or Title | ||
XXI State plan in effect January 1, 2008 except for: | ||
(A) any changes for hospitals described in | ||
subsection (b) of Section 5A-3; | ||
(B) any rates for payments made under this Article | ||
V-A; | ||
(C) any changes proposed in State plan amendment | ||
transmittal numbers 08-01, 08-02, 08-04, 08-06, and | ||
08-07; | ||
(D) in relation to any admissions on or after | ||
January 1, 2011, a modification in the methodology for | ||
calculating outlier payments to hospitals for | ||
exceptionally costly stays, for hospitals reimbursed | ||
under the diagnosis-related grouping methodology in |
effect on July 1, 2011; provided that the Department | ||
shall be limited to one such modification during the | ||
36-month period after the effective date of this | ||
amendatory Act of the 96th General Assembly; or | ||
(E) any changes affecting hospitals authorized by | ||
Public Act 97-689 ; or .
| ||
(F) any changes authorized by Section 14-12 of this | ||
Code, or for any changes authorized under Section 5A-15 | ||
of this Code. | ||
(b) The assessment imposed by Section 5A-2 shall not take | ||
effect or
shall
cease to be imposed, and the Department's | ||
obligation to make payments shall immediately cease, if the | ||
assessment is determined to be an impermissible
tax under Title | ||
XIX
of the Social Security Act. Moneys in the Hospital Provider | ||
Fund derived
from assessments imposed prior thereto shall be
| ||
disbursed in accordance with Section 5A-8 to the extent federal | ||
financial participation is
not reduced due to the | ||
impermissibility of the assessments, and any
remaining
moneys | ||
shall be
refunded to hospital providers in proportion to the | ||
amounts paid by them.
| ||
(c) The assessments imposed by subsection (b-5) of Section | ||
5A-2 shall not take effect or shall cease to be imposed, the | ||
Department's obligation to make payments shall immediately | ||
cease, and any moneys remaining in the Fund shall be refunded | ||
to hospital providers in proportion to the amounts paid by | ||
them, if the payments to hospitals required under Section |
5A-12.4 are not eligible for federal matching funds under Title | ||
XIX of the Social Security Act. | ||
(d) The assessments imposed by Section 5A-2 shall not take | ||
effect or shall cease to be imposed, the Department's | ||
obligation to make payments shall immediately cease, and any | ||
moneys remaining in the Fund shall be refunded to hospital | ||
providers in proportion to the amounts paid by them, if: | ||
(1) for State fiscal years 2013 through 2018 2014, and | ||
July 1, 2014 through December 31, 2014 , the Department | ||
reduces any payment rates to hospitals as in effect on May | ||
1, 2012, or alters any payment methodology as in effect on | ||
May 1, 2012, that has the effect of reducing payment rates | ||
to hospitals, except for any changes affecting hospitals | ||
authorized in Public Act 97-689 and any changes authorized | ||
by Section 14-12 of this Code , and except for any changes | ||
authorized under Section 5A-15; or | ||
(2) for State fiscal years 2013 through 2018 2014, and | ||
July 1, 2014 through December 31, 2014 , the Department | ||
reduces any supplemental payments made to hospitals below | ||
the amounts paid for services provided in State fiscal year | ||
2011 as implemented by administrative rules adopted and in | ||
effect on or prior to June 30, 2011, except for any changes | ||
affecting hospitals authorized in Public Act 97-689 and any | ||
changes authorized by Section 14-12 of this Code , and | ||
except for any changes authorized under Section 5A-15 ; or . | ||
(3) for State fiscal years 2015 through 2018, the |
Department reduces the overall effective rate of | ||
reimbursement to hospitals below the level authorized | ||
under Section 14-12 of this Code, except for any changes | ||
under Section 14-12 or Section 5A-15 of this Code. | ||
(Source: P.A. 97-72, eff. 7-1-11; 97-74, eff. 6-30-11; 97-688, | ||
eff. 6-14-12; 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)
| ||
(305 ILCS 5/5A-14) | ||
Sec. 5A-14. Repeal of assessments and disbursements. | ||
(a) Section 5A-2 is repealed on July 1, 2018 January 1, | ||
2015 . | ||
(b) Section 5A-12 is repealed on July 1, 2005.
| ||
(c) Section 5A-12.1 is repealed on July 1, 2008.
| ||
(d) Section 5A-12.2 and Section 5A-12.4 are repealed on | ||
July 1, 2018 January 1, 2015 . | ||
(e) Section 5A-12.3 is repealed on July 1, 2011. | ||
(Source: P.A. 96-821, eff. 11-20-09; 96-1530, eff. 2-16-11; | ||
97-688, eff. 6-14-12; 97-689, eff. 6-14-12.)
| ||
Article 45 | ||
Section 45-5. The Illinois Public Aid Code is amended by | ||
changing Section 14-8 and by adding Section 14-12 as follows:
| ||
(305 ILCS 5/14-8) (from Ch. 23, par. 14-8)
| ||
Sec. 14-8. Disbursements to Hospitals.
|
(a) For inpatient hospital services rendered on and after | ||
September 1,
1991, the Illinois Department shall reimburse
| ||
hospitals for inpatient services at an inpatient payment rate | ||
calculated for
each hospital based upon the Medicare | ||
Prospective Payment System as set forth
in Sections 1886(b), | ||
(d), (g), and (h) of the federal Social Security Act, and
the | ||
regulations, policies, and procedures promulgated thereunder, | ||
except as
modified by this Section. Payment rates for inpatient | ||
hospital services
rendered on or after September 1, 1991 and on | ||
or before September 30, 1992
shall be calculated using the | ||
Medicare Prospective Payment rates in effect on
September 1, | ||
1991. Payment rates for inpatient hospital services rendered on
| ||
or after October 1, 1992 and on or before March 31, 1994 shall | ||
be calculated
using the Medicare Prospective Payment rates in | ||
effect on September 1, 1992.
Payment rates for inpatient | ||
hospital services rendered on or after April 1,
1994 shall be | ||
calculated using the Medicare Prospective Payment rates
| ||
(including the Medicare grouping methodology and weighting | ||
factors as adjusted
pursuant to paragraph (1) of this | ||
subsection) in effect 90 days prior to the
date of admission. | ||
For services rendered on or after July 1, 1995, the
| ||
reimbursement methodology implemented under this subsection | ||
shall not include
those costs referred to in Sections | ||
1886(d)(5)(B) and 1886(h) of the Social
Security Act. The | ||
additional payment amounts required under Section
| ||
1886(d)(5)(F) of the Social Security Act, for hospitals serving |
a
disproportionate share of low-income or indigent patients, | ||
are not required
under this Section. For hospital inpatient | ||
services rendered on or after July
1, 1995 and on or before | ||
June 30, 2014 , the Illinois Department shall
reimburse | ||
hospitals using the relative weighting factors and the base | ||
payment
rates calculated for each hospital that were in effect | ||
on June 30, 1995, less
the portion of such rates attributed by | ||
the Illinois Department to the cost of
medical education.
| ||
(1) The weighting factors established under Section | ||
1886(d)(4) of the
Social Security Act shall not be used in | ||
the reimbursement system
established under this Section. | ||
Rather, the Illinois Department shall
establish by rule | ||
Medicaid weighting factors to be used in the reimbursement
| ||
system established under this Section.
| ||
(2) The Illinois Department shall define by rule those | ||
hospitals or
distinct parts of hospitals that shall be | ||
exempt from the reimbursement
system established under | ||
this Section. In defining such hospitals, the
Illinois | ||
Department shall take into consideration those hospitals | ||
exempt
from the Medicare Prospective Payment System as of | ||
September 1, 1991. For
hospitals defined as exempt under | ||
this subsection, the Illinois Department
shall by rule | ||
establish a reimbursement system for payment of inpatient
| ||
hospital services rendered on and after September 1, 1991. | ||
For all
hospitals that are children's hospitals as defined | ||
in Section 5-5.02 of
this Code, the reimbursement |
methodology shall, through June 30, 1992, net
of all | ||
applicable fees, at least equal each children's hospital | ||
1990 ICARE
payment rates, indexed to the current year by | ||
application of the DRI hospital
cost index from 1989 to the | ||
year in which payments are made. Excepting county
providers | ||
as defined in Article XV of this Code, hospitals licensed | ||
under the
University of Illinois Hospital Act, and | ||
facilities operated by the
Department of Mental Health and | ||
Developmental Disabilities (or its successor,
the | ||
Department of Human Services) for hospital inpatient | ||
services rendered on
or after July 1, 1995 and on or before | ||
June 30, 2014 , the Illinois Department shall reimburse | ||
children's
hospitals, as defined in 89 Illinois | ||
Administrative Code Section 149.50(c)(3),
at the rates in | ||
effect on June 30, 1995, and shall reimburse all other
| ||
hospitals at the rates in effect on June 30, 1995, less the | ||
portion of such
rates attributed by the Illinois Department | ||
to the cost of medical education.
For inpatient hospital | ||
services provided on or after August 1, 1998, the
Illinois | ||
Department may establish by rule a means of adjusting the | ||
rates of
children's hospitals, as defined in 89 Illinois | ||
Administrative Code Section
149.50(c)(3), that did not | ||
meet that definition on June 30, 1995, in order
for the | ||
inpatient hospital rates of such hospitals to take into | ||
account the
average inpatient hospital rates of those | ||
children's hospitals that did meet
the definition of |
children's hospitals on June 30, 1995.
| ||
(3) (Blank).
| ||
(4) Notwithstanding any other provision of this | ||
Section, hospitals
that on August 31, 1991, have a contract | ||
with the Illinois Department under
Section 3-4 of the | ||
Illinois Health Finance Reform Act may elect to continue
to | ||
be reimbursed at rates stated in such contracts for general | ||
and specialty
care.
| ||
(5) In addition to any payments made under this | ||
subsection (a), the
Illinois Department shall make the | ||
adjustment payments required by Section
5-5.02 of this | ||
Code; provided, that in the case of any hospital reimbursed
| ||
under a per case methodology, the Illinois Department shall | ||
add an amount
equal to the product of the hospital's | ||
average length of stay, less one
day, multiplied by 20, for | ||
inpatient hospital services rendered on or
after September | ||
1, 1991 and on or before September 30, 1992.
| ||
(b) (Blank).
| ||
(b-5) Excepting county providers as defined in Article XV | ||
of this Code,
hospitals licensed under the University of | ||
Illinois Hospital Act, and
facilities operated by the Illinois | ||
Department of Mental Health and
Developmental Disabilities (or | ||
its successor, the Department of Human
Services), for | ||
outpatient services rendered on or after July 1, 1995
and | ||
before July 1, 1998 the Illinois Department shall reimburse
| ||
children's hospitals, as defined in the Illinois |
Administrative Code
Section 149.50(c)(3), at the rates in | ||
effect on June 30, 1995, less that
portion of such rates | ||
attributed by the Illinois Department to the outpatient
| ||
indigent volume adjustment and shall reimburse all other | ||
hospitals at the rates
in effect on June 30, 1995, less the | ||
portions of such rates attributed by the
Illinois Department to | ||
the cost of medical education and attributed by the
Illinois | ||
Department to the outpatient indigent volume adjustment. For
| ||
outpatient services provided on or after July 1, 1998 and on or | ||
before June 30, 2014 , reimbursement rates
shall be established | ||
by rule.
| ||
(c) In addition to any other payments under this Code, the | ||
Illinois
Department shall develop a hospital disproportionate | ||
share reimbursement
methodology that, effective July 1, 1991, | ||
through September 30, 1992,
shall reimburse hospitals | ||
sufficiently to expend the fee monies described
in subsection | ||
(b) of Section 14-3 of this Code and the federal matching
funds | ||
received by the Illinois Department as a result of expenditures | ||
made
by the Illinois Department as required by this subsection | ||
(c) and Section
14-2 that are attributable to fee monies | ||
deposited in the Fund, less
amounts applied to adjustment | ||
payments under Section 5-5.02.
| ||
(d) Critical Care Access Payments.
| ||
(1) In addition to any other payments made under this | ||
Code,
the Illinois Department shall develop a | ||
reimbursement methodology that shall
reimburse Critical |
Care Access Hospitals for the specialized services that
| ||
qualify them as Critical Care Access Hospitals. No | ||
adjustment payments shall be
made under this subsection on | ||
or after July 1, 1995.
| ||
(2) "Critical Care Access Hospitals" includes, but is | ||
not limited to,
hospitals that meet at least one of the | ||
following criteria:
| ||
(A) Hospitals located outside of a metropolitan | ||
statistical area that
are designated as Level II | ||
Perinatal Centers and that provide a
disproportionate | ||
share of perinatal services to recipients; or
| ||
(B) Hospitals that are designated as Level I Trauma | ||
Centers (adult
or pediatric) and certain Level II | ||
Trauma Centers as determined by the
Illinois | ||
Department; or
| ||
(C) Hospitals located outside of a metropolitan | ||
statistical area and
that provide a disproportionate | ||
share of obstetrical services to recipients.
| ||
(e) Inpatient high volume adjustment. For hospital | ||
inpatient services,
effective with rate periods beginning on or | ||
after October 1, 1993, in
addition to rates paid for inpatient | ||
services by the Illinois Department, the
Illinois Department | ||
shall make adjustment payments for inpatient services
| ||
furnished by Medicaid high volume hospitals. The Illinois | ||
Department shall
establish by rule criteria for qualifying as a | ||
Medicaid high volume hospital
and shall establish by rule a |
reimbursement methodology for calculating these
adjustment | ||
payments to Medicaid high volume hospitals. No adjustment | ||
payment
shall be made under this subsection for services | ||
rendered on or after July 1,
1995.
| ||
(f) The Illinois Department shall modify its current rules | ||
governing
adjustment payments for targeted access, critical | ||
care access, and
uncompensated care to classify those | ||
adjustment payments as not being payments
to disproportionate | ||
share hospitals under Title XIX of the federal Social
Security | ||
Act. Rules adopted under this subsection shall not be effective | ||
with
respect to services rendered on or after July 1, 1995. The | ||
Illinois Department
has no obligation to adopt or implement any | ||
rules or make any payments under
this subsection for services | ||
rendered on or after July 1, 1995.
| ||
(f-5) The State recognizes that adjustment payments to | ||
hospitals providing
certain services or incurring certain | ||
costs may be necessary to assure that
recipients of medical | ||
assistance have adequate access to necessary medical
services. | ||
These adjustments include payments for teaching costs and
| ||
uncompensated care, trauma center payments, rehabilitation | ||
hospital payments,
perinatal center payments, obstetrical care | ||
payments, targeted access payments,
Medicaid high volume | ||
payments, and outpatient indigent volume payments. On or
before | ||
April 1, 1995, the Illinois Department shall issue | ||
recommendations
regarding (i) reimbursement mechanisms or | ||
adjustment payments to reflect these
costs and services, |
including methods by which the payments may be calculated
and | ||
the method by which the payments may be financed, and (ii) | ||
reimbursement
mechanisms or adjustment payments to reflect | ||
costs and services of federally
qualified health centers with | ||
respect to recipients of medical assistance.
| ||
(g) If one or more hospitals file suit in any court | ||
challenging any part of
this Article XIV, payments to hospitals | ||
under this Article XIV shall be made
only to the extent that | ||
sufficient monies are available in the Fund and only to
the | ||
extent that any monies in the Fund are not prohibited from | ||
disbursement
under any order of the court.
| ||
(h) Payments under the disbursement methodology described | ||
in this Section
are subject to approval by the federal | ||
government in an appropriate State plan
amendment.
| ||
(i) The Illinois Department may by rule establish criteria | ||
for and develop
methodologies for adjustment payments to | ||
hospitals participating under this
Article.
| ||
(j) Hospital Residing Long Term Care Services. In addition | ||
to any other
payments made under this Code, the Illinois | ||
Department may by rule establish
criteria and develop | ||
methodologies for payments to hospitals for Hospital
Residing | ||
Long Term Care Services.
| ||
(k) Critical Access Hospital outpatient payments. In | ||
addition to any other payments authorized under this Code, the | ||
Illinois Department shall reimburse critical access hospitals, | ||
as designated by the Illinois Department of Public Health in |
accordance with 42 CFR 485, Subpart F, for outpatient services | ||
at an amount that is no less than the cost of providing such | ||
services, based on Medicare cost principles. Payments under | ||
this subsection shall be subject to appropriation. | ||
(l) On and after July 1, 2012, the Department shall reduce | ||
any rate of reimbursement for services or other payments or | ||
alter any methodologies authorized by this Code to reduce any | ||
rate of reimbursement for services or other payments in | ||
accordance with Section 5-5e. | ||
(Source: P.A. 97-689, eff. 6-14-12; 98-463, eff. 8-16-13.)
| ||
(305 ILCS 5/14-12 new) | ||
Sec. 14-12. Hospital rate reform payment system. The | ||
hospital payment system pursuant to Section 14-11 of this | ||
Article shall be as follows: | ||
(a) Inpatient hospital services. Effective for discharges | ||
on and after July 1, 2014, reimbursement for inpatient general | ||
acute care services shall utilize the All Patient Refined | ||
Diagnosis Related Grouping (APR-DRG) software, version 30, | ||
distributed by 3M TM Health Information System. | ||
(1) The Department shall establish Medicaid weighting | ||
factors to be used in the reimbursement system established | ||
under this subsection. Initial weighting factors shall be | ||
the weighting factors as published by 3M Health Information | ||
System, associated with Version 30.0 adjusted for the | ||
Illinois experience. |
(2) The Department shall establish a | ||
statewide-standardized amount to be used in the inpatient | ||
reimbursement system. The Department shall publish these | ||
amounts on its website no later than 10 calendar days prior | ||
to their effective date. | ||
(3) In addition to the statewide-standardized amount, | ||
the Department shall develop adjusters to adjust the rate | ||
of reimbursement for critical Medicaid providers or | ||
services for trauma, transplantation services, perinatal | ||
care, and Graduate Medical Education (GME). | ||
(4) The Department shall develop add-on payments to | ||
account for exceptionally costly inpatient stays, | ||
consistent with Medicare outlier principles. Outlier fixed | ||
loss thresholds may be updated to control for excessive | ||
growth in outlier payments no more frequently than on an | ||
annual basis, but at least triennially. Upon updating the | ||
fixed loss thresholds, the Department shall be required to | ||
update base rates within 12 months. | ||
(5) The Department shall define those hospitals or | ||
distinct parts of hospitals that shall be exempt from the | ||
APR-DRG reimbursement system established under this | ||
Section. The Department shall publish these hospitals' | ||
inpatient rates on its website no later than 10 calendar | ||
days prior to their effective date. | ||
(6) Beginning July 1, 2014 and ending on June 30, 2018, | ||
in addition to the statewide-standardized amount, the |
Department shall develop an adjustor to adjust the rate of | ||
reimbursement for safety-net hospitals defined in Section | ||
5-5e.1 of this Code excluding pediatric hospitals. | ||
(7) Beginning July 1, 2014 and ending on June 30, 2018, | ||
in addition to the statewide-standardized amount, the | ||
Department shall develop an adjustor to adjust the rate of | ||
reimbursement for Illinois freestanding inpatient | ||
psychiatric hospitals that are not designated as | ||
children's hospitals by the Department but are primarily | ||
treating patients under the age of 21. | ||
(b) Outpatient hospital services. Effective for dates of | ||
service on and after July 1, 2014, reimbursement for outpatient | ||
services shall utilize the Enhanced Ambulatory Procedure | ||
Grouping (E-APG) software, version 3.7 distributed by 3M TM | ||
Health Information System. | ||
(1) The Department shall establish Medicaid weighting | ||
factors to be used in the reimbursement system established | ||
under this subsection. The initial weighting factors shall | ||
be the weighting factors as published by 3M Health | ||
Information System, associated with Version 3.7. | ||
(2) The Department shall establish service specific | ||
statewide-standardized amounts to be used in the | ||
reimbursement system. | ||
(A) The initial statewide standardized amounts, | ||
with the labor portion adjusted by the Calendar Year | ||
2013 Medicare Outpatient Prospective Payment System |
wage index with reclassifications, shall be published | ||
by the Department on its website no later than 10 | ||
calendar days prior to their effective date. | ||
(B) The Department shall establish adjustments to | ||
the statewide-standardized amounts for each Critical | ||
Access Hospital, as designated by the Department of | ||
Public Health in accordance with 42 CFR 485, Subpart F. | ||
The EAPG standardized amounts are determined | ||
separately for each critical access hospital such that | ||
simulated EAPG payments using outpatient base period | ||
paid claim data plus payments under Section 5A-12.4 of | ||
this Code net of the associated tax costs are equal to | ||
the estimated costs of outpatient base period claims | ||
data with a rate year cost inflation factor applied. | ||
(3) In addition to the statewide-standardized amounts, | ||
the Department shall develop adjusters to adjust the rate | ||
of reimbursement for critical Medicaid hospital outpatient | ||
providers or services, including outpatient high volume or | ||
safety-net hospitals. | ||
(c) In consultation with the hospital community, the | ||
Department is authorized to replace 89 Ill. Admin. Code 152.150 | ||
as published in 38 Ill. Reg. 4980 through 4986 within 12 months | ||
of the effective date of this amendatory Act of the 98th | ||
General Assembly. If the Department does not replace these | ||
rules within 12 months of the effective date of this amendatory | ||
Act of the 98th General Assembly, the rules in effect for |
152.150 as published in 38 Ill. Reg. 4980 through 4986 shall | ||
remain in effect until modified by rule by the Department. | ||
Nothing in this subsection shall be construed to mandate that | ||
the Department file a replacement rule. | ||
(d) Transition period.
There shall be a transition period | ||
to the reimbursement systems authorized under this Section that | ||
shall begin on the effective date of these systems and continue | ||
until June 30, 2018, unless extended by rule by the Department. | ||
To help provide an orderly and predictable transition to the | ||
new reimbursement systems and to preserve and enhance access to | ||
the hospital services during this transition, the Department | ||
shall allocate a transitional hospital access pool of at least | ||
$290,000,000 annually so that transitional hospital access | ||
payments are made to hospitals. | ||
(1) After the transition period, the Department may | ||
begin incorporating the transitional hospital access pool | ||
into the base rate structure. | ||
(2) After the transition period, if the Department | ||
reduces payments from the transitional hospital access | ||
pool, it shall increase base rates, develop new adjustors, | ||
adjust current adjustors, develop new hospital access | ||
payments based on updated information, or any combination | ||
thereof by an amount equal to the decreases proposed in the | ||
transitional hospital access pool payments, ensuring that | ||
the entire transitional hospital access pool amount shall | ||
continue to be used for hospital payments. |
(e) Beginning 36 months after initial implementation, the | ||
Department shall update the reimbursement components in | ||
subsections (a) and (b), including standardized amounts and | ||
weighting factors, and at least triennially and no more | ||
frequently than annually thereafter. The Department shall | ||
publish these updates on its website no later than 30 calendar | ||
days prior to their effective date. | ||
(f) Continuation of supplemental payments. Any | ||
supplemental payments authorized under Illinois Administrative | ||
Code 148 effective January 1, 2014 and that continue during the | ||
period of July 1, 2014 through December 31, 2014 shall remain | ||
in effect as long as the assessment imposed by Section 5A-2 is | ||
in effect. | ||
(g) Notwithstanding subsections (a) through (f) of this | ||
Section, any updates to the system shall not result in any | ||
diminishment of the overall effective rates of reimbursement as | ||
of the implementation date of the new system (July 1, 2014). | ||
These updates shall not preclude variations in any individual | ||
component of the system or hospital rate variations. Nothing in | ||
this Section shall prohibit the Department from increasing the | ||
rates of reimbursement or developing payments to ensure access | ||
to hospital services. Nothing in this Section shall be | ||
construed to guarantee a minimum amount of spending in the | ||
aggregate or per hospital as spending may be impacted by | ||
factors including but not limited to the number of individuals | ||
in the medical assistance program and the severity of illness |
of the individuals. | ||
(h) The Department shall have the authority to modify by | ||
rulemaking any changes to the rates or methodologies in this | ||
Section as required by the federal government to obtain federal | ||
financial participation for expenditures made under this | ||
Section. | ||
(i) Except for subsections (g) and (h) of this Section, the | ||
Department shall, pursuant to subsection (c) of Section 5-40 of | ||
the Illinois Administrative Procedure Act, provide for | ||
presentation at the June 2014 hearing of the Joint Committee on | ||
Administrative Rules (JCAR) additional written notice to JCAR | ||
of the following rules in order to commence the second notice | ||
period for the following rules: rules published in the Illinois | ||
Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559 | ||
(Medical Payment), 4628 (Specialized Health Care Delivery | ||
Systems), 4640 (Hospital Services), 4932 (Diagnostic Related | ||
Grouping (DRG) Prospective Payment System (PPS)), and 4977 | ||
(Hospital Reimbursement Changes), and published in the | ||
Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499 | ||
(Specialized Health Care Delivery Systems) and 6505 (Hospital | ||
Services).
| ||
Article 50 | ||
Section 50-5. The Specialized Mental Health Rehabilitation | ||
Act of 2013 is amended by changing Sections 3-116 and 3-205 as |
follows:
| ||
(210 ILCS 49/3-116)
| ||
Sec. 3-116. Experimental research. No consumer shall be | ||
subjected to experimental research or treatment without first | ||
obtaining his or her informed, written consent. The conduct of | ||
any experimental research or treatment shall be authorized and | ||
monitored by an institutional review board appointed by the | ||
Director of the Department executive director . The membership, | ||
operating procedures and review criteria for the institutional | ||
review board shall be prescribed under rules and regulations of | ||
the Department and shall comply with the requirements for | ||
institutional review boards established by the federal Food and | ||
Drug Administration. No person who has received compensation in | ||
the prior 3 years from an entity that manufactures, | ||
distributes, or sells pharmaceuticals, biologics, or medical | ||
devices may serve on the institutional review board. | ||
No facility shall permit experimental research or | ||
treatment to be conducted on a consumer, or give access to any | ||
person or person's records for a retrospective study about the | ||
safety or efficacy of any care or treatment, without the prior | ||
written approval of the institutional review board. No | ||
executive director, or person licensed by the State to provide | ||
medical care or treatment to any person, may assist or | ||
participate in any experimental research on or treatment of a | ||
consumer, including a retrospective study, that does not have |
the prior written approval of the board. Such conduct shall be | ||
grounds for professional discipline by the Department of | ||
Financial and Professional Regulation. | ||
The institutional review board may exempt from ongoing | ||
review research or treatment initiated on a consumer before the | ||
individual's admission to a facility and for which the board | ||
determines there is adequate ongoing oversight by another | ||
institutional review board. Nothing in this Section shall | ||
prevent a facility, any facility employee, or any other person | ||
from assisting or participating in any experimental research on | ||
or treatment of a consumer, if the research or treatment began | ||
before the person's admission to a facility, until the board | ||
has reviewed the research or treatment and decided to grant or | ||
deny approval or to exempt the research or treatment from | ||
ongoing review.
| ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
(210 ILCS 49/3-205)
| ||
Sec. 3-205. Disclosure of information to public. Standards | ||
for the disclosure of information to the public shall be | ||
established by rule. These information disclosure standards | ||
shall include, but are not limited to, the following: staffing | ||
and personnel levels, licensure and inspection information, | ||
national accreditation information, consumer charges cost and | ||
reimbursement information , and consumer complaint information. | ||
Rules for the public disclosure of information shall be in |
accordance with the provisions for inspection and copying of | ||
public records in the Freedom of Information Act. The | ||
Department of Healthcare and Family Services shall make | ||
facility cost reports available on its website.
| ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
Article 55 | ||
Section 55-5. The State Finance Act is amended by adding | ||
Section 5.855 as follows:
| ||
(30 ILCS 105/5.855 new) | ||
Sec. 5.855. The Supportive Living Facility Fund.
| ||
Section 55-10. The Specialized Mental Health | ||
Rehabilitation Act of 2013 is amended by adding Section 5-102 | ||
as follows:
| ||
(210 ILCS 49/5-102 new) | ||
Sec. 5-102. Transition payments. In addition to payments | ||
already required by law, the Department of Healthcare and | ||
Family Services shall make payments to facilities licensed | ||
under this Act in the amount of $29.43 per licensed bed, per | ||
day, for the period beginning June 1, 2014 and ending June 30, | ||
2014.
|
Section 55-15. The Illinois Public Aid Code is amended by | ||
changing Sections 5-5, 5-5.01a, 5-5.2, 5-5.4h, 5-5e, 5-5e.1, | ||
5-5f, 5B-1, 5C-1, 5C-2, and 5C-7 and by adding Section 5C-10 | ||
and Article V-G as follows:
| ||
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||
Sec. 5-5. Medical services. The Illinois Department, by | ||
rule, shall
determine the quantity and quality of and the rate | ||
of reimbursement for the
medical assistance for which
payment | ||
will be authorized, and the medical services to be provided,
| ||
which may include all or part of the following: (1) inpatient | ||
hospital
services; (2) outpatient hospital services; (3) other | ||
laboratory and
X-ray services; (4) skilled nursing home | ||
services; (5) physicians'
services whether furnished in the | ||
office, the patient's home, a
hospital, a skilled nursing home, | ||
or elsewhere; (6) medical care, or any
other type of remedial | ||
care furnished by licensed practitioners; (7)
home health care | ||
services; (8) private duty nursing service; (9) clinic
| ||
services; (10) dental services, including prevention and | ||
treatment of periodontal disease and dental caries disease for | ||
pregnant women, provided by an individual licensed to practice | ||
dentistry or dental surgery; for purposes of this item (10), | ||
"dental services" means diagnostic, preventive, or corrective | ||
procedures provided by or under the supervision of a dentist in | ||
the practice of his or her profession; (11) physical therapy | ||
and related
services; (12) prescribed drugs, dentures, and |
prosthetic devices; and
eyeglasses prescribed by a physician | ||
skilled in the diseases of the eye,
or by an optometrist, | ||
whichever the person may select; (13) other
diagnostic, | ||
screening, preventive, and rehabilitative services, including | ||
to ensure that the individual's need for intervention or | ||
treatment of mental disorders or substance use disorders or | ||
co-occurring mental health and substance use disorders is | ||
determined using a uniform screening, assessment, and | ||
evaluation process inclusive of criteria, for children and | ||
adults; for purposes of this item (13), a uniform screening, | ||
assessment, and evaluation process refers to a process that | ||
includes an appropriate evaluation and, as warranted, a | ||
referral; "uniform" does not mean the use of a singular | ||
instrument, tool, or process that all must utilize; (14)
| ||
transportation and such other expenses as may be necessary; | ||
(15) medical
treatment of sexual assault survivors, as defined | ||
in
Section 1a of the Sexual Assault Survivors Emergency | ||
Treatment Act, for
injuries sustained as a result of the sexual | ||
assault, including
examinations and laboratory tests to | ||
discover evidence which may be used in
criminal proceedings | ||
arising from the sexual assault; (16) the
diagnosis and | ||
treatment of sickle cell anemia; and (17)
any other medical | ||
care, and any other type of remedial care recognized
under the | ||
laws of this State, but not including abortions, or induced
| ||
miscarriages or premature births, unless, in the opinion of a | ||
physician,
such procedures are necessary for the preservation |
of the life of the
woman seeking such treatment, or except an | ||
induced premature birth
intended to produce a live viable child | ||
and such procedure is necessary
for the health of the mother or | ||
her unborn child. The Illinois Department,
by rule, shall | ||
prohibit any physician from providing medical assistance
to | ||
anyone eligible therefor under this Code where such physician | ||
has been
found guilty of performing an abortion procedure in a | ||
wilful and wanton
manner upon a woman who was not pregnant at | ||
the time such abortion
procedure was performed. The term "any | ||
other type of remedial care" shall
include nursing care and | ||
nursing home service for persons who rely on
treatment by | ||
spiritual means alone through prayer for healing.
| ||
Notwithstanding any other provision of this Section, a | ||
comprehensive
tobacco use cessation program that includes | ||
purchasing prescription drugs or
prescription medical devices | ||
approved by the Food and Drug Administration shall
be covered | ||
under the medical assistance
program under this Article for | ||
persons who are otherwise eligible for
assistance under this | ||
Article.
| ||
Notwithstanding any other provision of this Code, the | ||
Illinois
Department may not require, as a condition of payment | ||
for any laboratory
test authorized under this Article, that a | ||
physician's handwritten signature
appear on the laboratory | ||
test order form. The Illinois Department may,
however, impose | ||
other appropriate requirements regarding laboratory test
order | ||
documentation.
|
Upon receipt of federal approval of an amendment to the | ||
Illinois Title XIX State Plan for this purpose, the Department | ||
shall authorize the Chicago Public Schools (CPS) to procure a | ||
vendor or vendors to manufacture eyeglasses for individuals | ||
enrolled in a school within the CPS system. CPS shall ensure | ||
that its vendor or vendors are enrolled as providers in the | ||
medical assistance program and in any capitated Medicaid | ||
managed care entity (MCE) serving individuals enrolled in a | ||
school within the CPS system. Under any contract procured under | ||
this provision, the vendor or vendors must serve only | ||
individuals enrolled in a school within the CPS system. Claims | ||
for services provided by CPS's vendor or vendors to recipients | ||
of benefits in the medical assistance program under this Code, | ||
the Children's Health Insurance Program, or the Covering ALL | ||
KIDS Health Insurance Program shall be submitted to the | ||
Department or the MCE in which the individual is enrolled for | ||
payment and shall be reimbursed at the Department's or the | ||
MCE's established rates or rate methodologies for eyeglasses. | ||
On and after July 1, 2012, the Department of Healthcare and | ||
Family Services may provide the following services to
persons
| ||
eligible for assistance under this Article who are | ||
participating in
education, training or employment programs | ||
operated by the Department of Human
Services as successor to | ||
the Department of Public Aid:
| ||
(1) dental services provided by or under the | ||
supervision of a dentist; and
|
(2) eyeglasses prescribed by a physician skilled in the | ||
diseases of the
eye, or by an optometrist, whichever the | ||
person may select.
| ||
Notwithstanding any other provision of this Code and | ||
subject to federal approval, the Department may adopt rules to | ||
allow a dentist who is volunteering his or her service at no | ||
cost to render dental services through an enrolled | ||
not-for-profit health clinic without the dentist personally | ||
enrolling as a participating provider in the medical assistance | ||
program. A not-for-profit health clinic shall include a public | ||
health clinic or Federally Qualified Health Center or other | ||
enrolled provider, as determined by the Department, through | ||
which dental services covered under this Section are performed. | ||
The Department shall establish a process for payment of claims | ||
for reimbursement for covered dental services rendered under | ||
this provision. | ||
The Illinois Department, by rule, may distinguish and | ||
classify the
medical services to be provided only in accordance | ||
with the classes of
persons designated in Section 5-2.
| ||
The Department of Healthcare and Family Services must | ||
provide coverage and reimbursement for amino acid-based | ||
elemental formulas, regardless of delivery method, for the | ||
diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||
short bowel syndrome when the prescribing physician has issued | ||
a written order stating that the amino acid-based elemental | ||
formula is medically necessary.
|
The Illinois Department shall authorize the provision of, | ||
and shall
authorize payment for, screening by low-dose | ||
mammography for the presence of
occult breast cancer for women | ||
35 years of age or older who are eligible
for medical | ||
assistance under this Article, as follows: | ||
(A) A baseline
mammogram for women 35 to 39 years of | ||
age.
| ||
(B) An annual mammogram for women 40 years of age or | ||
older. | ||
(C) A mammogram at the age and intervals considered | ||
medically necessary by the woman's health care provider for | ||
women under 40 years of age and having a family history of | ||
breast cancer, prior personal history of breast cancer, | ||
positive genetic testing, or other risk factors. | ||
(D) A comprehensive ultrasound screening of an entire | ||
breast or breasts if a mammogram demonstrates | ||
heterogeneous or dense breast tissue, when medically | ||
necessary as determined by a physician licensed to practice | ||
medicine in all of its branches. | ||
All screenings
shall
include a physical breast exam, | ||
instruction on self-examination and
information regarding the | ||
frequency of self-examination and its value as a
preventative | ||
tool. For purposes of this Section, "low-dose mammography" | ||
means
the x-ray examination of the breast using equipment | ||
dedicated specifically
for mammography, including the x-ray | ||
tube, filter, compression device,
and image receptor, with an |
average radiation exposure delivery
of less than one rad per | ||
breast for 2 views of an average size breast.
The term also | ||
includes digital mammography.
| ||
On and after January 1, 2012, providers participating in a | ||
quality improvement program approved by the Department shall be | ||
reimbursed for screening and diagnostic mammography at the same | ||
rate as the Medicare program's rates, including the increased | ||
reimbursement for digital mammography. | ||
The Department shall convene an expert panel including | ||
representatives of hospitals, free-standing mammography | ||
facilities, and doctors, including radiologists, to establish | ||
quality standards. | ||
Subject to federal approval, the Department shall | ||
establish a rate methodology for mammography at federally | ||
qualified health centers and other encounter-rate clinics. | ||
These clinics or centers may also collaborate with other | ||
hospital-based mammography facilities. | ||
The Department shall establish a methodology to remind | ||
women who are age-appropriate for screening mammography, but | ||
who have not received a mammogram within the previous 18 | ||
months, of the importance and benefit of screening mammography. | ||
The Department shall establish a performance goal for | ||
primary care providers with respect to their female patients | ||
over age 40 receiving an annual mammogram. This performance | ||
goal shall be used to provide additional reimbursement in the | ||
form of a quality performance bonus to primary care providers |
who meet that goal. | ||
The Department shall devise a means of case-managing or | ||
patient navigation for beneficiaries diagnosed with breast | ||
cancer. This program shall initially operate as a pilot program | ||
in areas of the State with the highest incidence of mortality | ||
related to breast cancer. At least one pilot program site shall | ||
be in the metropolitan Chicago area and at least one site shall | ||
be outside the metropolitan Chicago area. An evaluation of the | ||
pilot program shall be carried out measuring health outcomes | ||
and cost of care for those served by the pilot program compared | ||
to similarly situated patients who are not served by the pilot | ||
program. | ||
Any medical or health care provider shall immediately | ||
recommend, to
any pregnant woman who is being provided prenatal | ||
services and is suspected
of drug abuse or is addicted as | ||
defined in the Alcoholism and Other Drug Abuse
and Dependency | ||
Act, referral to a local substance abuse treatment provider
| ||
licensed by the Department of Human Services or to a licensed
| ||
hospital which provides substance abuse treatment services. | ||
The Department of Healthcare and Family Services
shall assure | ||
coverage for the cost of treatment of the drug abuse or
| ||
addiction for pregnant recipients in accordance with the | ||
Illinois Medicaid
Program in conjunction with the Department of | ||
Human Services.
| ||
All medical providers providing medical assistance to | ||
pregnant women
under this Code shall receive information from |
the Department on the
availability of services under the Drug | ||
Free Families with a Future or any
comparable program providing | ||
case management services for addicted women,
including | ||
information on appropriate referrals for other social services
| ||
that may be needed by addicted women in addition to treatment | ||
for addiction.
| ||
The Illinois Department, in cooperation with the | ||
Departments of Human
Services (as successor to the Department | ||
of Alcoholism and Substance
Abuse) and Public Health, through a | ||
public awareness campaign, may
provide information concerning | ||
treatment for alcoholism and drug abuse and
addiction, prenatal | ||
health care, and other pertinent programs directed at
reducing | ||
the number of drug-affected infants born to recipients of | ||
medical
assistance.
| ||
Neither the Department of Healthcare and Family Services | ||
nor the Department of Human
Services shall sanction the | ||
recipient solely on the basis of
her substance abuse.
| ||
The Illinois Department shall establish such regulations | ||
governing
the dispensing of health services under this Article | ||
as it shall deem
appropriate. The Department
should
seek the | ||
advice of formal professional advisory committees appointed by
| ||
the Director of the Illinois Department for the purpose of | ||
providing regular
advice on policy and administrative matters, | ||
information dissemination and
educational activities for | ||
medical and health care providers, and
consistency in | ||
procedures to the Illinois Department.
|
The Illinois Department may develop and contract with | ||
Partnerships of
medical providers to arrange medical services | ||
for persons eligible under
Section 5-2 of this Code. | ||
Implementation of this Section may be by
demonstration projects | ||
in certain geographic areas. The Partnership shall
be | ||
represented by a sponsor organization. The Department, by rule, | ||
shall
develop qualifications for sponsors of Partnerships. | ||
Nothing in this
Section shall be construed to require that the | ||
sponsor organization be a
medical organization.
| ||
The sponsor must negotiate formal written contracts with | ||
medical
providers for physician services, inpatient and | ||
outpatient hospital care,
home health services, treatment for | ||
alcoholism and substance abuse, and
other services determined | ||
necessary by the Illinois Department by rule for
delivery by | ||
Partnerships. Physician services must include prenatal and
| ||
obstetrical care. The Illinois Department shall reimburse | ||
medical services
delivered by Partnership providers to clients | ||
in target areas according to
provisions of this Article and the | ||
Illinois Health Finance Reform Act,
except that:
| ||
(1) Physicians participating in a Partnership and | ||
providing certain
services, which shall be determined by | ||
the Illinois Department, to persons
in areas covered by the | ||
Partnership may receive an additional surcharge
for such | ||
services.
| ||
(2) The Department may elect to consider and negotiate | ||
financial
incentives to encourage the development of |
Partnerships and the efficient
delivery of medical care.
| ||
(3) Persons receiving medical services through | ||
Partnerships may receive
medical and case management | ||
services above the level usually offered
through the | ||
medical assistance program.
| ||
Medical providers shall be required to meet certain | ||
qualifications to
participate in Partnerships to ensure the | ||
delivery of high quality medical
services. These | ||
qualifications shall be determined by rule of the Illinois
| ||
Department and may be higher than qualifications for | ||
participation in the
medical assistance program. Partnership | ||
sponsors may prescribe reasonable
additional qualifications | ||
for participation by medical providers, only with
the prior | ||
written approval of the Illinois Department.
| ||
Nothing in this Section shall limit the free choice of | ||
practitioners,
hospitals, and other providers of medical | ||
services by clients.
In order to ensure patient freedom of | ||
choice, the Illinois Department shall
immediately promulgate | ||
all rules and take all other necessary actions so that
provided | ||
services may be accessed from therapeutically certified | ||
optometrists
to the full extent of the Illinois Optometric | ||
Practice Act of 1987 without
discriminating between service | ||
providers.
| ||
The Department shall apply for a waiver from the United | ||
States Health
Care Financing Administration to allow for the | ||
implementation of
Partnerships under this Section.
|
The Illinois Department shall require health care | ||
providers to maintain
records that document the medical care | ||
and services provided to recipients
of Medical Assistance under | ||
this Article. Such records must be retained for a period of not | ||
less than 6 years from the date of service or as provided by | ||
applicable State law, whichever period is longer, except that | ||
if an audit is initiated within the required retention period | ||
then the records must be retained until the audit is completed | ||
and every exception is resolved. The Illinois Department shall
| ||
require health care providers to make available, when | ||
authorized by the
patient, in writing, the medical records in a | ||
timely fashion to other
health care providers who are treating | ||
or serving persons eligible for
Medical Assistance under this | ||
Article. All dispensers of medical services
shall be required | ||
to maintain and retain business and professional records
| ||
sufficient to fully and accurately document the nature, scope, | ||
details and
receipt of the health care provided to persons | ||
eligible for medical
assistance under this Code, in accordance | ||
with regulations promulgated by
the Illinois Department. The | ||
rules and regulations shall require that proof
of the receipt | ||
of prescription drugs, dentures, prosthetic devices and
| ||
eyeglasses by eligible persons under this Section accompany | ||
each claim
for reimbursement submitted by the dispenser of such | ||
medical services.
No such claims for reimbursement shall be | ||
approved for payment by the Illinois
Department without such | ||
proof of receipt, unless the Illinois Department
shall have put |
into effect and shall be operating a system of post-payment
| ||
audit and review which shall, on a sampling basis, be deemed | ||
adequate by
the Illinois Department to assure that such drugs, | ||
dentures, prosthetic
devices and eyeglasses for which payment | ||
is being made are actually being
received by eligible | ||
recipients. Within 90 days after the effective date of
this | ||
amendatory Act of 1984, the Illinois Department shall establish | ||
a
current list of acquisition costs for all prosthetic devices | ||
and any
other items recognized as medical equipment and | ||
supplies reimbursable under
this Article and shall update such | ||
list on a quarterly basis, except that
the acquisition costs of | ||
all prescription drugs shall be updated no
less frequently than | ||
every 30 days as required by Section 5-5.12.
| ||
The rules and regulations of the Illinois Department shall | ||
require
that a written statement including the required opinion | ||
of a physician
shall accompany any claim for reimbursement for | ||
abortions, or induced
miscarriages or premature births. This | ||
statement shall indicate what
procedures were used in providing | ||
such medical services.
| ||
Notwithstanding any other law to the contrary, the Illinois | ||
Department shall, within 365 days after July 22, 2013, the | ||
effective date of Public Act 98-104 this amendatory Act of the | ||
98th General Assembly , establish procedures to permit skilled | ||
care facilities licensed under the Nursing Home Care Act to | ||
submit monthly billing claims for reimbursement purposes. | ||
Following development of these procedures, the Department |
shall have an additional 365 days to test the viability of the | ||
new system and to ensure that any necessary operational or | ||
structural changes to its information technology platforms are | ||
implemented. | ||
The Illinois Department shall require all dispensers of | ||
medical
services, other than an individual practitioner or | ||
group of practitioners,
desiring to participate in the Medical | ||
Assistance program
established under this Article to disclose | ||
all financial, beneficial,
ownership, equity, surety or other | ||
interests in any and all firms,
corporations, partnerships, | ||
associations, business enterprises, joint
ventures, agencies, | ||
institutions or other legal entities providing any
form of | ||
health care services in this State under this Article.
| ||
The Illinois Department may require that all dispensers of | ||
medical
services desiring to participate in the medical | ||
assistance program
established under this Article disclose, | ||
under such terms and conditions as
the Illinois Department may | ||
by rule establish, all inquiries from clients
and attorneys | ||
regarding medical bills paid by the Illinois Department, which
| ||
inquiries could indicate potential existence of claims or liens | ||
for the
Illinois Department.
| ||
Enrollment of a vendor
shall be
subject to a provisional | ||
period and shall be conditional for one year. During the period | ||
of conditional enrollment, the Department may
terminate the | ||
vendor's eligibility to participate in, or may disenroll the | ||
vendor from, the medical assistance
program without cause. |
Unless otherwise specified, such termination of eligibility or | ||
disenrollment is not subject to the
Department's hearing | ||
process.
However, a disenrolled vendor may reapply without | ||
penalty.
| ||
The Department has the discretion to limit the conditional | ||
enrollment period for vendors based upon category of risk of | ||
the vendor. | ||
Prior to enrollment and during the conditional enrollment | ||
period in the medical assistance program, all vendors shall be | ||
subject to enhanced oversight, screening, and review based on | ||
the risk of fraud, waste, and abuse that is posed by the | ||
category of risk of the vendor. The Illinois Department shall | ||
establish the procedures for oversight, screening, and review, | ||
which may include, but need not be limited to: criminal and | ||
financial background checks; fingerprinting; license, | ||
certification, and authorization verifications; unscheduled or | ||
unannounced site visits; database checks; prepayment audit | ||
reviews; audits; payment caps; payment suspensions; and other | ||
screening as required by federal or State law. | ||
The Department shall define or specify the following: (i) | ||
by provider notice, the "category of risk of the vendor" for | ||
each type of vendor, which shall take into account the level of | ||
screening applicable to a particular category of vendor under | ||
federal law and regulations; (ii) by rule or provider notice, | ||
the maximum length of the conditional enrollment period for | ||
each category of risk of the vendor; and (iii) by rule, the |
hearing rights, if any, afforded to a vendor in each category | ||
of risk of the vendor that is terminated or disenrolled during | ||
the conditional enrollment period. | ||
To be eligible for payment consideration, a vendor's | ||
payment claim or bill, either as an initial claim or as a | ||
resubmitted claim following prior rejection, must be received | ||
by the Illinois Department, or its fiscal intermediary, no | ||
later than 180 days after the latest date on the claim on which | ||
medical goods or services were provided, with the following | ||
exceptions: | ||
(1) In the case of a provider whose enrollment is in | ||
process by the Illinois Department, the 180-day period | ||
shall not begin until the date on the written notice from | ||
the Illinois Department that the provider enrollment is | ||
complete. | ||
(2) In the case of errors attributable to the Illinois | ||
Department or any of its claims processing intermediaries | ||
which result in an inability to receive, process, or | ||
adjudicate a claim, the 180-day period shall not begin | ||
until the provider has been notified of the error. | ||
(3) In the case of a provider for whom the Illinois | ||
Department initiates the monthly billing process. | ||
(4) In the case of a provider operated by a unit of | ||
local government with a population exceeding 3,000,000 | ||
when local government funds finance federal participation | ||
for claims payments. |
For claims for services rendered during a period for which | ||
a recipient received retroactive eligibility, claims must be | ||
filed within 180 days after the Department determines the | ||
applicant is eligible. For claims for which the Illinois | ||
Department is not the primary payer, claims must be submitted | ||
to the Illinois Department within 180 days after the final | ||
adjudication by the primary payer. | ||
In the case of long term care facilities, within 5 days of | ||
receipt by the facility of required prescreening information, | ||
data for new admissions shall be entered into the Medical | ||
Electronic Data Interchange (MEDI) or the Recipient | ||
Eligibility Verification (REV) System or successor system, and | ||
within 15 days of receipt by the facility of required | ||
prescreening information, admission documents shall be | ||
submitted within 30 days of an admission to the facility | ||
through MEDI or REV the Medical Electronic Data Interchange | ||
(MEDI) or the Recipient Eligibility Verification (REV) System, | ||
or shall be submitted directly to the Department of Human | ||
Services using required admission forms. Effective September
| ||
1, 2014, admission documents, including all prescreening
| ||
information, must be submitted through MEDI or REV. | ||
Confirmation numbers assigned to an accepted transaction shall | ||
be retained by a facility to verify timely submittal. Once an | ||
admission transaction has been completed, all resubmitted | ||
claims following prior rejection are subject to receipt no | ||
later than 180 days after the admission transaction has been |
completed. | ||
Claims that are not submitted and received in compliance | ||
with the foregoing requirements shall not be eligible for | ||
payment under the medical assistance program, and the State | ||
shall have no liability for payment of those claims. | ||
To the extent consistent with applicable information and | ||
privacy, security, and disclosure laws, State and federal | ||
agencies and departments shall provide the Illinois Department | ||
access to confidential and other information and data necessary | ||
to perform eligibility and payment verifications and other | ||
Illinois Department functions. This includes, but is not | ||
limited to: information pertaining to licensure; | ||
certification; earnings; immigration status; citizenship; wage | ||
reporting; unearned and earned income; pension income; | ||
employment; supplemental security income; social security | ||
numbers; National Provider Identifier (NPI) numbers; the | ||
National Practitioner Data Bank (NPDB); program and agency | ||
exclusions; taxpayer identification numbers; tax delinquency; | ||
corporate information; and death records. | ||
The Illinois Department shall enter into agreements with | ||
State agencies and departments, and is authorized to enter into | ||
agreements with federal agencies and departments, under which | ||
such agencies and departments shall share data necessary for | ||
medical assistance program integrity functions and oversight. | ||
The Illinois Department shall develop, in cooperation with | ||
other State departments and agencies, and in compliance with |
applicable federal laws and regulations, appropriate and | ||
effective methods to share such data. At a minimum, and to the | ||
extent necessary to provide data sharing, the Illinois | ||
Department shall enter into agreements with State agencies and | ||
departments, and is authorized to enter into agreements with | ||
federal agencies and departments, including but not limited to: | ||
the Secretary of State; the Department of Revenue; the | ||
Department of Public Health; the Department of Human Services; | ||
and the Department of Financial and Professional Regulation. | ||
Beginning in fiscal year 2013, the Illinois Department | ||
shall set forth a request for information to identify the | ||
benefits of a pre-payment, post-adjudication, and post-edit | ||
claims system with the goals of streamlining claims processing | ||
and provider reimbursement, reducing the number of pending or | ||
rejected claims, and helping to ensure a more transparent | ||
adjudication process through the utilization of: (i) provider | ||
data verification and provider screening technology; and (ii) | ||
clinical code editing; and (iii) pre-pay, pre- or | ||
post-adjudicated predictive modeling with an integrated case | ||
management system with link analysis. Such a request for | ||
information shall not be considered as a request for proposal | ||
or as an obligation on the part of the Illinois Department to | ||
take any action or acquire any products or services. | ||
The Illinois Department shall establish policies, | ||
procedures,
standards and criteria by rule for the acquisition, | ||
repair and replacement
of orthotic and prosthetic devices and |
durable medical equipment. Such
rules shall provide, but not be | ||
limited to, the following services: (1)
immediate repair or | ||
replacement of such devices by recipients; and (2) rental, | ||
lease, purchase or lease-purchase of
durable medical equipment | ||
in a cost-effective manner, taking into
consideration the | ||
recipient's medical prognosis, the extent of the
recipient's | ||
needs, and the requirements and costs for maintaining such
| ||
equipment. Subject to prior approval, such rules shall enable a | ||
recipient to temporarily acquire and
use alternative or | ||
substitute devices or equipment pending repairs or
| ||
replacements of any device or equipment previously authorized | ||
for such
recipient by the Department.
| ||
The Department shall execute, relative to the nursing home | ||
prescreening
project, written inter-agency agreements with the | ||
Department of Human
Services and the Department on Aging, to | ||
effect the following: (i) intake
procedures and common | ||
eligibility criteria for those persons who are receiving
| ||
non-institutional services; and (ii) the establishment and | ||
development of
non-institutional services in areas of the State | ||
where they are not currently
available or are undeveloped; and | ||
(iii) notwithstanding any other provision of law, subject to | ||
federal approval, on and after July 1, 2012, an increase in the | ||
determination of need (DON) scores from 29 to 37 for applicants | ||
for institutional and home and community-based long term care; | ||
if and only if federal approval is not granted, the Department | ||
may, in conjunction with other affected agencies, implement |
utilization controls or changes in benefit packages to | ||
effectuate a similar savings amount for this population; and | ||
(iv) no later than July 1, 2013, minimum level of care | ||
eligibility criteria for institutional and home and | ||
community-based long term care; and (v) no later than October | ||
1, 2013, establish procedures to permit long term care | ||
providers access to eligibility scores for individuals with an | ||
admission date who are seeking or receiving services from the | ||
long term care provider. In order to select the minimum level | ||
of care eligibility criteria, the Governor shall establish a | ||
workgroup that includes affected agency representatives and | ||
stakeholders representing the institutional and home and | ||
community-based long term care interests. This Section shall | ||
not restrict the Department from implementing lower level of | ||
care eligibility criteria for community-based services in | ||
circumstances where federal approval has been granted.
| ||
The Illinois Department shall develop and operate, in | ||
cooperation
with other State Departments and agencies and in | ||
compliance with
applicable federal laws and regulations, | ||
appropriate and effective
systems of health care evaluation and | ||
programs for monitoring of
utilization of health care services | ||
and facilities, as it affects
persons eligible for medical | ||
assistance under this Code.
| ||
The Illinois Department shall report annually to the | ||
General Assembly,
no later than the second Friday in April of | ||
1979 and each year
thereafter, in regard to:
|
(a) actual statistics and trends in utilization of | ||
medical services by
public aid recipients;
| ||
(b) actual statistics and trends in the provision of | ||
the various medical
services by medical vendors;
| ||
(c) current rate structures and proposed changes in | ||
those rate structures
for the various medical vendors; and
| ||
(d) efforts at utilization review and control by the | ||
Illinois Department.
| ||
The period covered by each report shall be the 3 years | ||
ending on the June
30 prior to the report. The report shall | ||
include suggested legislation
for consideration by the General | ||
Assembly. The filing of one copy of the
report with the | ||
Speaker, one copy with the Minority Leader and one copy
with | ||
the Clerk of the House of Representatives, one copy with the | ||
President,
one copy with the Minority Leader and one copy with | ||
the Secretary of the
Senate, one copy with the Legislative | ||
Research Unit, and such additional
copies
with the State | ||
Government Report Distribution Center for the General
Assembly | ||
as is required under paragraph (t) of Section 7 of the State
| ||
Library Act shall be deemed sufficient to comply with this | ||
Section.
| ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for |
whatever reason, is unauthorized. | ||
On and after July 1, 2012, the Department shall reduce any | ||
rate of reimbursement for services or other payments or alter | ||
any methodologies authorized by this Code to reduce any rate of | ||
reimbursement for services or other payments in accordance with | ||
Section 5-5e. | ||
Because kidney transplantation can be an appropriate, cost | ||
effective
alternative to renal dialysis when medically | ||
necessary and notwithstanding the provisions of Section 1-11 of | ||
this Code, beginning October 1, 2014, the Department shall | ||
cover kidney transplantation for noncitizens with end-stage | ||
renal disease who are not eligible for comprehensive medical | ||
benefits, who meet the residency requirements of Section 5-3 of | ||
this Code, and who would otherwise meet the financial | ||
requirements of the appropriate class of eligible persons under | ||
Section 5-2 of this Code. To qualify for coverage of kidney | ||
transplantation, such person must be receiving emergency renal | ||
dialysis services covered by the Department. Providers under | ||
this Section shall be prior approved and certified by the | ||
Department to perform kidney transplantation and the services | ||
under this Section shall be limited to services associated with | ||
kidney transplantation. | ||
(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, | ||
eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section | ||
9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. | ||
7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; revised |
9-19-13.)
| ||
(305 ILCS 5/5-5.01a)
| ||
Sec. 5-5.01a. Supportive living facilities program. The
| ||
Department shall establish and provide oversight for a program | ||
of supportive living facilities that seek to promote
resident | ||
independence, dignity, respect, and well-being in the most
| ||
cost-effective manner.
| ||
A supportive living facility is either a free-standing | ||
facility or a distinct
physical and operational entity within a | ||
nursing facility. A supportive
living facility integrates | ||
housing with health, personal care, and supportive
services and | ||
is a designated setting that offers residents their own
| ||
separate, private, and distinct living units.
| ||
Sites for the operation of the program
shall be selected by | ||
the Department based upon criteria
that may include the need | ||
for services in a geographic area, the
availability of funding, | ||
and the site's ability to meet the standards.
| ||
Beginning July 1, 2014, subject to federal approval, the | ||
Medicaid rates for supportive living facilities shall be equal | ||
to the supportive living facility Medicaid rate effective on | ||
June 30, 2014 increased by 8.85%.
Once the assessment imposed | ||
at Article V-G of this Code is determined to be a permissible | ||
tax under Title XIX of the Social Security Act, the Department | ||
shall increase the Medicaid rates for supportive living | ||
facilities effective on July 1, 2014 by 9.09%. The Department |
shall apply this increase retroactively to coincide with the | ||
imposition of the assessment in Article V-G of this Code in | ||
accordance with the approval for federal financial | ||
participation by the Centers for Medicare and Medicaid | ||
Services. | ||
The Department may adopt rules to implement this Section. | ||
Rules that
establish or modify the services, standards, and | ||
conditions for participation
in the program shall be adopted by | ||
the Department in consultation
with the Department on Aging, | ||
the Department of Rehabilitation Services, and
the Department | ||
of Mental Health and Developmental Disabilities (or their
| ||
successor agencies).
| ||
Facilities or distinct parts of facilities which are | ||
selected as supportive
living facilities and are in good | ||
standing with the Department's rules are
exempt from the | ||
provisions of the Nursing Home Care Act and the Illinois Health
| ||
Facilities Planning Act.
| ||
(Source: P.A. 94-342, eff. 7-26-05.)
| ||
(305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)
| ||
Sec. 5-5.2. Payment.
| ||
(a) All nursing facilities that are grouped pursuant to | ||
Section
5-5.1 of this Act shall receive the same rate of | ||
payment for similar
services.
| ||
(b) It shall be a matter of State policy that the Illinois | ||
Department
shall utilize a uniform billing cycle throughout the |
State for the
long-term care providers.
| ||
(c) Notwithstanding any other provisions of this Code, the | ||
methodologies for reimbursement of nursing services as | ||
provided under this Article shall no longer be applicable for | ||
bills payable for nursing services rendered on or after a new | ||
reimbursement system based on the Resource Utilization Groups | ||
(RUGs) has been fully operationalized, which shall take effect | ||
for services provided on or after January 1, 2014. | ||
(d) The new nursing services reimbursement methodology | ||
utilizing RUG-IV 48 grouper model, which shall be referred to | ||
as the RUGs reimbursement system, taking effect January 1, | ||
2014, shall be based on the following: | ||
(1) The methodology shall be resident-driven, | ||
facility-specific, and cost-based. | ||
(2) Costs shall be annually rebased and case mix index | ||
quarterly updated. The nursing services methodology will | ||
be assigned to the Medicaid enrolled residents on record as | ||
of 30 days prior to the beginning of the rate period in the | ||
Department's Medicaid Management Information System (MMIS) | ||
as present on the last day of the second quarter preceding | ||
the rate period. | ||
(3) Regional wage adjustors based on the Health Service | ||
Areas (HSA) groupings and adjusters in effect on April 30, | ||
2012 shall be included. | ||
(4) Case mix index shall be assigned to each resident | ||
class based on the Centers for Medicare and Medicaid |
Services staff time measurement study in effect on July 1, | ||
2013, utilizing an index maximization approach. | ||
(5) The pool of funds available for distribution by | ||
case mix and the base facility rate shall be determined | ||
using the formula contained in subsection (d-1). | ||
(d-1) Calculation of base year Statewide RUG-IV nursing | ||
base per diem rate. | ||
(1) Base rate spending pool shall be: | ||
(A) The base year resident days which are | ||
calculated by multiplying the number of Medicaid | ||
residents in each nursing home as indicated in the MDS | ||
data defined in paragraph (4) by 365. | ||
(B) Each facility's nursing component per diem in | ||
effect on July 1, 2012 shall be multiplied by | ||
subsection (A). | ||
(C) Thirteen million is added to the product of | ||
subparagraph (A) and subparagraph (B) to adjust for the | ||
exclusion of nursing homes defined in paragraph (5). | ||
(2) For each nursing home with Medicaid residents as | ||
indicated by the MDS data defined in paragraph (4), | ||
weighted days adjusted for case mix and regional wage | ||
adjustment shall be calculated. For each home this | ||
calculation is the product of: | ||
(A) Base year resident days as calculated in | ||
subparagraph (A) of paragraph (1). | ||
(B) The nursing home's regional wage adjustor |
based on the Health Service Areas (HSA) groupings and | ||
adjustors in effect on April 30, 2012. | ||
(C) Facility weighted case mix which is the number | ||
of Medicaid residents as indicated by the MDS data | ||
defined in paragraph (4) multiplied by the associated | ||
case weight for the RUG-IV 48 grouper model using | ||
standard RUG-IV procedures for index maximization. | ||
(D) The sum of the products calculated for each | ||
nursing home in subparagraphs (A) through (C) above | ||
shall be the base year case mix, rate adjusted weighted | ||
days. | ||
(3) The Statewide RUG-IV nursing base per diem rate : | ||
(A) on January 1, 2014 shall be the quotient of the | ||
paragraph (1) divided by the sum calculated under | ||
subparagraph (D) of paragraph (2) ; and . | ||
(B) on and after July 1, 2014, shall be the amount | ||
calculated under subparagraph (A) of this paragraph | ||
(3) plus $1.76. | ||
(4) Minimum Data Set (MDS) comprehensive assessments | ||
for Medicaid residents on the last day of the quarter used | ||
to establish the base rate. | ||
(5) Nursing facilities designated as of July 1, 2012 by | ||
the Department as "Institutions for Mental Disease" shall | ||
be excluded from all calculations under this subsection. | ||
The data from these facilities shall not be used in the | ||
computations described in paragraphs (1) through (4) above |
to establish the base rate. | ||
(e) Beginning July 1, 2014, the Department shall allocate | ||
funding in the amount up to $10,000,000 for per diem add-ons to | ||
the RUGS methodology for dates of service on and after July 1, | ||
2014: | ||
(1) $0.63 for each resident who scores in I4200 | ||
Alzheimer's Disease or I4800 non-Alzheimer's Dementia. | ||
(2) $2.67 for each resident who scores either a "1" or | ||
"2" in any items S1200A through S1200I and also scores in | ||
RUG groups PA1, PA2, BA1, or BA2. | ||
Notwithstanding any other provision of this Code, the | ||
Department shall by rule develop a reimbursement methodology | ||
reflective of the intensity of care and services requirements | ||
of low need residents in the lowest RUG IV groupers and | ||
corresponding regulations. Only that portion of the RUGs | ||
Reimbursement System spending pool described in subsection | ||
(d-1) attributed to the groupers as of July 1, 2013 for which | ||
the methodology in this Section is developed may be diverted | ||
for this purpose. The Department shall submit the rules no | ||
later than January 1, 2014 for an implementation date no later | ||
than January 1, 2015. | ||
If the Department does not implement this reimbursement | ||
methodology by the required date, the nursing component per | ||
diem on January 1, 2015 for residents classified in RUG-IV | ||
groups PA1, PA2, BA1, and BA2 shall be the blended rate of the | ||
calculated RUG-IV nursing component per diem and the nursing |
component per diem in effect on July 1, 2012. This blended rate | ||
shall be applied only to nursing homes whose resident | ||
population is greater than or equal to 70% of the total | ||
residents served and whose RUG-IV nursing component per diem | ||
rate is less than the nursing component per diem in effect on | ||
July 1, 2012. This blended rate shall be in effect until the | ||
reimbursement methodology is implemented or until July 1, 2019, | ||
whichever is sooner. | ||
(e-1) (Blank). Notwithstanding any other provision of this | ||
Article, rates established pursuant to this subsection shall | ||
not apply to any and all nursing facilities designated by the | ||
Department as "Institutions for Mental Disease" and shall be | ||
excluded from the RUGs Reimbursement System applicable to | ||
facilities not designated as "Institutions for the Mentally | ||
Diseased" by the Department. | ||
(e-2) For dates of services beginning January 1, 2014, the | ||
RUG-IV nursing component per diem for a nursing home shall be | ||
the product of the statewide RUG-IV nursing base per diem rate, | ||
the facility average case mix index, and the regional wage | ||
adjustor. Transition rates for services provided between | ||
January 1, 2014 and December 31, 2014 shall be as follows: | ||
(1) The transition RUG-IV per diem nursing rate for | ||
nursing homes whose rate calculated in this subsection | ||
(e-2) is greater than the nursing component rate in effect | ||
July 1, 2012 shall be paid the sum of: | ||
(A) The nursing component rate in effect July 1, |
2012; plus | ||
(B) The difference of the RUG-IV nursing component | ||
per diem calculated for the current quarter minus the | ||
nursing component rate in effect July 1, 2012 | ||
multiplied by 0.88. | ||
(2) The transition RUG-IV per diem nursing rate for | ||
nursing homes whose rate calculated in this subsection | ||
(e-2) is less than the nursing component rate in effect | ||
July 1, 2012 shall be paid the sum of: | ||
(A) The nursing component rate in effect July 1, | ||
2012; plus | ||
(B) The difference of the RUG-IV nursing component | ||
per diem calculated for the current quarter minus the | ||
nursing component rate in effect July 1, 2012 | ||
multiplied by 0.13. | ||
(f) Notwithstanding any other provision of this Code, on | ||
and after July 1, 2012, reimbursement rates associated with the | ||
nursing or support components of the current nursing facility | ||
rate methodology shall not increase beyond the level effective | ||
May 1, 2011 until a new reimbursement system based on the RUGs | ||
IV 48 grouper model has been fully operationalized. | ||
(g) Notwithstanding any other provision of this Code, on | ||
and after July 1, 2012, for facilities not designated by the | ||
Department of Healthcare and Family Services as "Institutions | ||
for Mental Disease", rates effective May 1, 2011 shall be | ||
adjusted as follows: |
(1) Individual nursing rates for residents classified | ||
in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter | ||
ending March 31, 2012 shall be reduced by 10%; | ||
(2) Individual nursing rates for residents classified | ||
in all other RUG IV groups shall be reduced by 1.0%; | ||
(3) Facility rates for the capital and support | ||
components shall be reduced by 1.7%. | ||
(h) Notwithstanding any other provision of this Code, on | ||
and after July 1, 2012, nursing facilities designated by the | ||
Department of Healthcare and Family Services as "Institutions | ||
for Mental Disease" and "Institutions for Mental Disease" that | ||
are facilities licensed under the Specialized Mental Health | ||
Rehabilitation Act of 2013 shall have the nursing, | ||
socio-developmental, capital, and support components of their | ||
reimbursement rate effective May 1, 2011 reduced in total by | ||
2.7%. | ||
(i) On and after July 1, 2014, the reimbursement rates for | ||
the support component of the nursing facility rate for | ||
facilities licensed under the Nursing Home Care Act as skilled | ||
or intermediate care facilities shall be the rate in effect on | ||
June 30, 2014 increased by 8.17%. | ||
(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section | ||
6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. | ||
7-22-13; revised 9-19-13.)
| ||
(305 ILCS 5/5-5.4h) |
Sec. 5-5.4h. Medicaid reimbursement for long-term care | ||
facilities for persons under 22 years of age pediatric skilled | ||
nursing facilities . | ||
(a) Facilities licensed as long-term care facilities for | ||
persons under 22 years of age uniquely licensed as pediatric | ||
skilled nursing facilities that serve severely and chronically | ||
ill pediatric patients shall have a specific reimbursement | ||
system designed to recognize the characteristics and needs of | ||
the patients they serve. | ||
(b) For dates of services starting July 1, 2013 and until a | ||
new reimbursement system is designed, long-term care | ||
facilities for persons under 22 years of age pediatric skilled | ||
nursing facilities that meet the following criteria: | ||
(1) serve exceptional care patients; and | ||
(2) have 30% or more of their patients receiving | ||
ventilator care; | ||
shall receive Medicaid reimbursement on a 30-day expedited | ||
schedule.
| ||
(c) Subject to federal approval of changes to the Title XIX | ||
State Plan, for dates of services starting July 1, 2014 and | ||
until a new reimbursement system is designed, long-term care | ||
facilities for persons under 22 years of age which meet the | ||
criteria in subsection (b) of this Section shall receive a per | ||
diem rate for clinically complex residents of $304. Clinically | ||
complex residents on a ventilator shall receive a per diem rate | ||
of $669. |
(d) To qualify for the per diem rate of $669 for clinically | ||
complex residents on a ventilator pursuant to subsection (c), | ||
facilities shall have a policy documenting their method of | ||
routine assessment of a resident's weaning potential with | ||
interventions implemented noted in the resident's record. | ||
(e) For the purposes of this Section, a resident is | ||
considered clinically complex if the resident requires at least | ||
one of the following medical services: | ||
(1) Tracheostomy care with dependence on mechanical | ||
ventilation for a minimum of 6 hours each day. | ||
(2) Tracheostomy care requiring suctioning at least | ||
every 6 hours, room air mist or oxygen as needed, and | ||
dependence on one of the treatment procedures listed under | ||
paragraph (4) excluding the procedure listed in | ||
subparagraph (A) of paragraph (4). | ||
(3) Total parenteral nutrition or other intravenous | ||
nutritional support and one of the treatment procedures | ||
listed under paragraph (4). | ||
(4) The following treatment procedures apply to the | ||
conditions in paragraphs (2) and (3) of this subsection: | ||
(A) Intermittent suctioning at least every 8 hours | ||
and room air mist or oxygen as needed. | ||
(B) Continuous intravenous therapy including | ||
administration of therapeutic agents necessary for | ||
hydration or of intravenous pharmaceuticals; or | ||
intravenous pharmaceutical administration of more than |
one agent via a peripheral or central line, without | ||
continuous infusion. | ||
(C) Peritoneal dialysis treatments requiring at | ||
least 4 exchanges every 24 hours. | ||
(D) Tube feeding via nasogastric or gastrostomy | ||
tube. | ||
(E) Other medical technologies required | ||
continuously, which in the opinion of the attending | ||
physician require the services of a professional | ||
nurse. | ||
(Source: P.A. 98-104, eff. 7-22-13.)
| ||
(305 ILCS 5/5-5e) | ||
Sec. 5-5e. Adjusted rates of reimbursement. | ||
(a) Rates or payments for services in effect on June 30, | ||
2012 shall be adjusted and
services shall be affected as | ||
required by any other provision of this amendatory Act of
the | ||
97th General Assembly. In addition, the Department shall do the | ||
following: | ||
(1) Delink the per diem rate paid for supportive living | ||
facility services from the per diem rate paid for nursing | ||
facility services, effective for services provided on or | ||
after May 1, 2011. | ||
(2) Cease payment for bed reserves in nursing | ||
facilities and specialized mental health rehabilitation | ||
facilities. |
(2.5) Cease payment for bed reserves for purposes of | ||
inpatient hospitalizations to intermediate care facilities | ||
for persons with development disabilities, except in the | ||
instance of residents who are under 21 years of age. | ||
(3) Cease payment of the $10 per day add-on payment to | ||
nursing facilities for certain residents with | ||
developmental disabilities. | ||
(b) After the application of subsection (a), | ||
notwithstanding any other provision of this
Code to the | ||
contrary and to the extent permitted by federal law, on and | ||
after July 1,
2012, the rates of reimbursement for services and | ||
other payments provided under this
Code shall further be | ||
reduced as follows: | ||
(1) Rates or payments for physician services, dental | ||
services, or community health center services reimbursed | ||
through an encounter rate, and services provided under the | ||
Medicaid Rehabilitation Option of the Illinois Title XIX | ||
State Plan shall not be further reduced. | ||
(2) Rates or payments, or the portion thereof, paid to | ||
a provider that is operated by a unit of local government | ||
or State University that provides the non-federal share of | ||
such services shall not be further reduced. | ||
(3) Rates or payments for hospital services delivered | ||
by a hospital defined as a Safety-Net Hospital under | ||
Section 5-5e.1 of this Code shall not be further reduced. | ||
(4) Rates or payments for hospital services delivered |
by a Critical Access Hospital, which is an Illinois | ||
hospital designated as a critical care hospital by the | ||
Department of Public Health in accordance with 42 CFR 485, | ||
Subpart F, shall not be further reduced. | ||
(5) Rates or payments for Nursing Facility Services | ||
shall only be further adjusted pursuant to Section 5-5.2 of | ||
this Code. | ||
(6) Rates or payments for services delivered by long | ||
term care facilities licensed under the ID/DD Community | ||
Care Act and developmental training services shall not be | ||
further reduced. | ||
(7) Rates or payments for services provided under | ||
capitation rates shall be adjusted taking into | ||
consideration the rates reduction and covered services | ||
required by this amendatory Act of the 97th General | ||
Assembly. | ||
(8) For hospitals not previously described in this | ||
subsection, the rates or payments for hospital services | ||
shall be further reduced by 3.5%, except for payments | ||
authorized under Section 5A-12.4 of this Code. | ||
(9) For all other rates or payments for services | ||
delivered by providers not specifically referenced in | ||
paragraphs (1) through (8), rates or payments shall be | ||
further reduced by 2.7%. | ||
(c) Any assessment imposed by this Code shall continue and | ||
nothing in this Section shall be construed to cause it to |
cease.
| ||
(d) Notwithstanding any other provision of this Code to the | ||
contrary, subject to federal approval under Title XIX of the | ||
Social Security Act, for dates of service on and after July 1, | ||
2014, rates or payments for services provided for the purpose | ||
of transitioning children from a hospital to home placement or | ||
other appropriate setting by a children's community-based | ||
health care center authorized under the Alternative Health Care | ||
Delivery Act shall be $683 per day. | ||
(e) Notwithstanding any other provision of this Code to the | ||
contrary, subject to federal approval under Title XIX of the | ||
Social Security Act, for dates of service on and after July 1, | ||
2014, rates or payments for home health visits shall be $72. | ||
(f) Notwithstanding any other provision of this Code to the | ||
contrary, subject to federal approval under Title XIX of the | ||
Social Security Act, for dates of service on and after July 1, | ||
2014, rates or payments for the certified nursing assistant | ||
component of the home health agency rate shall be $20. | ||
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
| ||
(305 ILCS 5/5-5e.1) | ||
Sec. 5-5e.1. Safety-Net Hospitals. | ||
(a) A Safety-Net Hospital is an Illinois hospital that: | ||
(1) is licensed by the Department of Public Health as a | ||
general acute care or pediatric hospital; and | ||
(2) is a disproportionate share hospital, as described |
in Section 1923 of the federal Social Security Act, as | ||
determined by the Department; and | ||
(3) meets one of the following: | ||
(A) has a MIUR of at least 40% and a charity | ||
percent of at least 4%; or | ||
(B) has a MIUR of at least 50%. | ||
(b) Definitions. As used in this Section: | ||
(1) "Charity percent" means the ratio of (i) the | ||
hospital's charity charges for services provided to | ||
individuals without health insurance or another source of | ||
third party coverage to (ii) the Illinois total hospital | ||
charges, each as reported on the hospital's OBRA form. | ||
(2) "MIUR" means Medicaid Inpatient Utilization Rate | ||
and is defined as a fraction, the numerator of which is the | ||
number of a hospital's inpatient days provided in the | ||
hospital's fiscal year ending 3 years prior to the rate | ||
year, to patients who, for such days, were eligible for | ||
Medicaid under Title XIX of the federal Social Security | ||
Act, 42 USC 1396a et seq., excluding those persons eligible | ||
for medical assistance pursuant to 42 U.S.C. | ||
1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of | ||
Section 5-2 of this Article, and the denominator of which | ||
is the total number of the hospital's inpatient days in | ||
that same period, excluding those persons eligible for | ||
medical assistance pursuant to 42 U.S.C. | ||
1396a(a)(10)(A)(i)(VIII) as set forth in paragraph 18 of |
Section 5-2 of this Article. | ||
(3) "OBRA form" means form HFS-3834, OBRA '93 data | ||
collection form, for the rate year. | ||
(4) "Rate year" means the 12-month period beginning on | ||
October 1. | ||
(c) Beginning July 1, 2012 and ending on June 30, 2018, For | ||
the 27-month period beginning July 1, 2012, a hospital that | ||
would have qualified for the rate year beginning October 1, | ||
2011, shall be a Safety-Net Hospital. | ||
(d) No later than August 15 preceding the rate year, each | ||
hospital shall submit the OBRA form to the Department. Prior to | ||
October 1, the Department shall notify each hospital whether it | ||
has qualified as a Safety-Net Hospital. | ||
(e) The Department may promulgate rules in order to | ||
implement this Section.
| ||
(f) Nothing in this Section shall be construed as limiting | ||
the ability of the Department to include the Safety-Net | ||
Hospitals in the hospital rate reform mandated by Section 14-11 | ||
of this Code and implemented under Section 14-12 of this Code | ||
and by administrative rulemaking. | ||
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
| ||
(305 ILCS 5/5-5f)
| ||
Sec. 5-5f. Elimination and limitations of medical | ||
assistance services. Notwithstanding any other provision of | ||
this Code to the contrary, on and after July 1, 2012: |
(a) The following services shall no longer be a covered | ||
service available under this Code: group psychotherapy for | ||
residents of any facility licensed under the Nursing Home Care | ||
Act or the Specialized Mental Health Rehabilitation Act of | ||
2013; and adult chiropractic services. | ||
(b) The Department shall place the following limitations on | ||
services: (i) the Department shall limit adult eyeglasses to | ||
one pair every 2 years; (ii) the Department shall set an annual | ||
limit of a maximum of 20 visits for each of the following | ||
services: adult speech, hearing, and language therapy | ||
services, adult occupational therapy services, and physical | ||
therapy services; on or after October 1, 2014, the annual | ||
maximum limit of 20 visits shall expire but the Department | ||
shall require prior approval for all individuals for speech, | ||
hearing, and language therapy services, occupational therapy | ||
services, and physical therapy services; (iii) the Department | ||
shall limit adult podiatry services to individuals with | ||
diabetes; on or after October 1, 2014, podiatry services shall | ||
not be limited to individuals with diabetes; (iv) the | ||
Department shall pay for caesarean sections at the normal | ||
vaginal delivery rate unless a caesarean section was medically | ||
necessary; (v) the Department shall limit adult dental services | ||
to emergencies; beginning July 1, 2013, the Department shall | ||
ensure that the following conditions are recognized as | ||
emergencies: (A) dental services necessary for an individual in | ||
order for the individual to be cleared for a medical procedure, |
such as a transplant;
(B) extractions and dentures necessary | ||
for a diabetic to receive proper nutrition;
(C) extractions and | ||
dentures necessary as a result of cancer treatment; and (D) | ||
dental services necessary for the health of a pregnant woman | ||
prior to delivery of her baby; on or after July 1, 2014, adult | ||
dental services shall no longer be limited to emergencies, and | ||
dental services necessary for the health of a pregnant woman | ||
prior to delivery of her baby shall continue to be covered; and | ||
(vi) effective July 1, 2012, the Department shall place | ||
limitations and require concurrent review on every inpatient | ||
detoxification stay to prevent repeat admissions to any | ||
hospital for detoxification within 60 days of a previous | ||
inpatient detoxification stay. The Department shall convene a | ||
workgroup of hospitals, substance abuse providers, care | ||
coordination entities, managed care plans, and other | ||
stakeholders to develop recommendations for quality standards, | ||
diversion to other settings, and admission criteria for | ||
patients who need inpatient detoxification, which shall be | ||
published on the Department's website no later than September | ||
1, 2013. | ||
(c) The Department shall require prior approval of the | ||
following services: wheelchair repairs costing more than $400, | ||
coronary artery bypass graft, and bariatric surgery consistent | ||
with Medicare standards concerning patient responsibility. | ||
Wheelchair repair prior approval requests shall be adjudicated | ||
within one business day of receipt of complete supporting |
documentation. Providers may not break wheelchair repairs into | ||
separate claims for purposes of staying under the $400 | ||
threshold for requiring prior approval. The wholesale price of | ||
manual and power wheelchairs, durable medical equipment and | ||
supplies, and complex rehabilitation technology products and | ||
services shall be defined as actual acquisition cost including | ||
all discounts. | ||
(d) The Department shall establish benchmarks for | ||
hospitals to measure and align payments to reduce potentially | ||
preventable hospital readmissions, inpatient complications, | ||
and unnecessary emergency room visits. In doing so, the | ||
Department shall consider items, including, but not limited to, | ||
historic and current acuity of care and historic and current | ||
trends in readmission. The Department shall publish | ||
provider-specific historical readmission data and anticipated | ||
potentially preventable targets 60 days prior to the start of | ||
the program. In the instance of readmissions, the Department | ||
shall adopt policies and rates of reimbursement for services | ||
and other payments provided under this Code to ensure that, by | ||
June 30, 2013, expenditures to hospitals are reduced by, at a | ||
minimum, $40,000,000. | ||
(e) The Department shall establish utilization controls | ||
for the hospice program such that it shall not pay for other | ||
care services when an individual is in hospice. | ||
(f) For home health services, the Department shall require | ||
Medicare certification of providers participating in the |
program and implement the Medicare face-to-face encounter | ||
rule. The Department shall require providers to implement | ||
auditable electronic service verification based on global | ||
positioning systems or other cost-effective technology. | ||
(g) For the Home Services Program operated by the | ||
Department of Human Services and the Community Care Program | ||
operated by the Department on Aging, the Department of Human | ||
Services, in cooperation with the Department on Aging, shall | ||
implement an electronic service verification based on global | ||
positioning systems or other cost-effective technology. | ||
(h) Effective with inpatient hospital admissions on or | ||
after July 1, 2012, the Department shall reduce the payment for | ||
a claim that indicates the occurrence of a provider-preventable | ||
condition during the admission as specified by the Department | ||
in rules. The Department shall not pay for services related to | ||
an other provider-preventable condition. | ||
As used in this subsection (h): | ||
"Provider-preventable condition" means a health care | ||
acquired condition as defined under the federal Medicaid | ||
regulation found at 42 CFR 447.26 or an other | ||
provider-preventable condition. | ||
"Other provider-preventable condition" means a wrong | ||
surgical or other invasive procedure performed on a patient, a | ||
surgical or other invasive procedure performed on the wrong | ||
body part, or a surgical procedure or other invasive procedure | ||
performed on the wrong patient. |
(i) The Department shall implement cost savings | ||
initiatives for advanced imaging services, cardiac imaging | ||
services, pain management services, and back surgery. Such | ||
initiatives shall be designed to achieve annual costs savings.
| ||
(j) The Department shall ensure that beneficiaries with a | ||
diagnosis of epilepsy or seizure disorder in Department records | ||
will not require prior approval for anticonvulsants. | ||
(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section | ||
6-240, eff. 7-22-13; 98-104, Article 9, Section 9-5, eff. | ||
7-22-13; revised 9-19-13.)
| ||
(305 ILCS 5/5B-1) (from Ch. 23, par. 5B-1)
| ||
Sec. 5B-1. Definitions. As used in this Article, unless the
| ||
context requires otherwise:
| ||
"Fund" means the Long-Term Care Provider Fund.
| ||
"Long-term care facility" means (i) a nursing facility, | ||
whether
public or private and whether organized for profit or
| ||
not-for-profit, that is subject to licensure by the Illinois | ||
Department
of Public Health under the Nursing Home Care Act or | ||
the ID/DD Community Care Act, including a
county nursing home | ||
directed and maintained under Section
5-1005 of the Counties | ||
Code, and (ii) a part of a hospital in
which skilled or | ||
intermediate long-term care services within the
meaning of | ||
Title XVIII or XIX of the Social Security Act are
provided; | ||
except that the term "long-term care facility" does
not include | ||
a facility operated by a State agency or operated solely as an |
intermediate care
facility for the mentally retarded within the | ||
meaning of Title
XIX of the Social Security Act.
| ||
"Long-term care provider" means (i) a person licensed
by | ||
the Department of Public Health to operate and maintain a
| ||
skilled nursing or intermediate long-term care facility or (ii) | ||
a hospital provider that
provides skilled or intermediate | ||
long-term care services within
the meaning of Title XVIII or | ||
XIX of the Social Security Act.
For purposes of this paragraph, | ||
"person" means any political
subdivision of the State, | ||
municipal corporation, individual,
firm, partnership, | ||
corporation, company, limited liability
company, association, | ||
joint stock association, or trust, or a
receiver, executor, | ||
trustee, guardian, or other representative
appointed by order | ||
of any court. "Hospital provider" means a
person licensed by | ||
the Department of Public Health to conduct,
operate, or | ||
maintain a hospital.
| ||
"Occupied bed days" shall be computed separately for
each | ||
long-term care facility operated or maintained by a long-term
| ||
care provider, and means the sum for all beds of the number
of | ||
days during the month on which each bed was occupied by a
| ||
resident, other than a resident for whom Medicare Part A is the | ||
primary payer. For a resident whose care is covered by the | ||
Medicare Medicaid Alignment initiative demonstration, Medicare | ||
Part A is considered the primary payer.
| ||
(Source: P.A. 96-339, eff. 7-1-10; 96-1530, eff. 2-16-11; | ||
97-38, eff. 6-28-11; 97-227, eff. 1-1-12; 97-813, eff. |
7-13-12.)
| ||
(305 ILCS 5/5C-1) (from Ch. 23, par. 5C-1)
| ||
Sec. 5C-1. Definitions. As used in this Article, unless the | ||
context
requires otherwise:
| ||
"Fund" means the Care Provider Fund for Persons with a | ||
Developmental Disability.
| ||
"Developmentally disabled care facility" means an | ||
intermediate care
facility for the intellectually disabled | ||
within the meaning of Title XIX of the
Social Security Act, | ||
whether public or private and whether organized for
profit or | ||
not-for-profit, but shall not include any facility operated by
| ||
the State.
| ||
"Developmentally disabled care provider" means a person | ||
conducting,
operating, or maintaining a developmentally | ||
disabled care facility. For
this purpose, "person" means any | ||
political subdivision of the State,
municipal corporation, | ||
individual, firm, partnership, corporation, company,
limited | ||
liability company, association, joint stock association, or | ||
trust,
or a receiver, executor, trustee, guardian or other | ||
representative
appointed by order of any court.
| ||
"Adjusted gross developmentally disabled care revenue" | ||
shall be computed
separately for each developmentally disabled | ||
care facility conducted,
operated, or maintained by a | ||
developmentally disabled care provider, and
means the | ||
developmentally disabled care provider's total revenue for
|
inpatient residential services less contractual allowances and | ||
discounts on
patients' accounts, but does not include | ||
non-patient revenue from sources
such as contributions, | ||
donations or bequests, investments, day training
services, | ||
television and telephone service, and rental of facility space.
| ||
"Long-term care facility for persons under 22 years of age | ||
serving clinically complex residents" means a facility | ||
licensed by the Department of Public Health as a long-term care | ||
facility for persons under 22 meeting the qualifications of | ||
Section 5-5.4h of this Code. | ||
(Source: P.A. 97-227, eff. 1-1-12; 98-463, eff. 8-16-13.)
| ||
(305 ILCS 5/5C-2) (from Ch. 23, par. 5C-2)
| ||
Sec. 5C-2. Assessment; no local authorization to tax.
| ||
(a) For the privilege of engaging in the occupation of | ||
developmentally
disabled care provider, an assessment is | ||
imposed upon each developmentally
disabled care provider in an | ||
amount equal to 6%, or the maximum allowed under federal | ||
regulation, whichever is less, of its adjusted
gross | ||
developmentally disabled care revenue for the prior State | ||
fiscal
year. Notwithstanding any provision of any other Act to | ||
the contrary, this
assessment shall be construed as a tax, but | ||
may not be added to the charges
of an individual's nursing home | ||
care that is paid for in whole, or in part,
by a federal, | ||
State, or combined federal-state medical care program, except
| ||
those individuals receiving Medicare Part B benefits solely.
|
(b) Nothing in this amendatory Act of 1995 shall be | ||
construed
to authorize any home rule unit or other unit of | ||
local government to license
for revenue or impose a tax or | ||
assessment upon a developmentally disabled care
provider or the | ||
occupation of developmentally disabled care provider, or a tax
| ||
or assessment measured by the income or earnings of a | ||
developmentally disabled
care provider.
| ||
(c) Effective July 1, 2013, for the privilege of engaging | ||
in the occupation of long-term care facility for persons under | ||
22 years of age serving clinically complex residents provider, | ||
an assessment is imposed upon each long-term care facility for | ||
persons under 22 years of age serving clinically complex | ||
residents provider in the same amount and upon the same | ||
conditions and requirements as imposed in Article V-B of this | ||
Code and a license fee is imposed in the same amount and upon | ||
the same conditions and requirements as imposed in Article V-E | ||
of this Code. Notwithstanding any provision of any other Act to | ||
the contrary, the assessment and license fee imposed by this | ||
subsection (c) shall be construed as a tax, but may not be | ||
added to the charges of an individual's nursing home care that | ||
is paid for in whole, or in part, by a federal, State, or | ||
combined federal-State medical care program, except for those | ||
individuals receiving Medicare Part B benefits solely. | ||
(Source: P.A. 95-707, eff. 1-11-08.)
| ||
(305 ILCS 5/5C-7) (from Ch. 23, par. 5C-7)
|
Sec. 5C-7. Care Provider Fund for Persons with a | ||
Developmental Disability.
| ||
(a) There is created in the State Treasury the
Care | ||
Provider Fund for Persons with a Developmental Disability. | ||
Interest earned by the Fund shall be credited to the
Fund. The | ||
Fund shall not be used to replace any moneys appropriated to | ||
the
Medicaid program by the General Assembly.
| ||
(b) The Fund is created for the purpose of receiving and
| ||
disbursing assessment moneys in accordance with this Article.
| ||
Disbursements from the Fund shall be made only as follows:
| ||
(1) For payments to intermediate care facilities for | ||
the
developmentally disabled under Title XIX of the Social | ||
Security
Act and Article V of this Code.
| ||
(2) For the reimbursement of moneys collected by the
| ||
Illinois Department through error or mistake, and to make
| ||
required payments under Section 5-4.28(a)(1) of this Code | ||
if
there are no moneys available for such payments in the | ||
Medicaid
Developmentally Disabled Provider Participation | ||
Fee Trust Fund.
| ||
(3) For payment of administrative expenses incurred by | ||
the Department of Human Services or its
agent or the | ||
Illinois Department or its agent in performing the | ||
activities
authorized by this Article.
| ||
(4) For payments of any amounts which are reimbursable | ||
to
the federal government for payments from this Fund which | ||
are
required to be paid by State warrant.
|
(5) For making transfers to the General Obligation Bond
| ||
Retirement and Interest Fund as those transfers are | ||
authorized in
the proceedings authorizing debt under the | ||
Short Term Borrowing Act,
but transfers made under this | ||
paragraph (5) shall not exceed the
principal amount of debt | ||
issued in anticipation of the receipt by
the State of | ||
moneys to be deposited into the Fund.
| ||
(6) For making refunds as required under Section 5C-10 | ||
of this Article. | ||
Disbursements from the Fund, other than transfers to the
| ||
General Obligation Bond Retirement and Interest Fund, shall be | ||
by
warrants drawn by the State Comptroller upon receipt of | ||
vouchers
duly executed and certified by the Illinois | ||
Department.
| ||
(c) The Fund shall consist of the following:
| ||
(1) All moneys collected or received by the Illinois
| ||
Department from the developmentally disabled care provider
| ||
assessment imposed by this Article.
| ||
(2) All federal matching funds received by the Illinois
| ||
Department as a result of expenditures made by the Illinois
| ||
Department that are attributable to moneys deposited in the | ||
Fund.
| ||
(3) Any interest or penalty levied in conjunction with | ||
the
administration of this Article.
| ||
(4) Any balance in the Medicaid Developmentally | ||
Disabled
Care Provider Participation Fee Trust Fund in the |
State Treasury.
The balance shall be transferred to the | ||
Fund upon certification
by the Illinois Department to the | ||
State Comptroller that all of
the disbursements required by | ||
Section 5-4.21(b) of this Code have
been made.
| ||
(5) All other moneys received for the Fund from any | ||
other
source, including interest earned thereon.
| ||
(Source: P.A. 98-463, eff. 8-16-13.)
| ||
(305 ILCS 5/5C-10 new) | ||
Sec. 5C-10. Adjustments. For long-term care facilities for | ||
persons under 22 years of age serving clinically complex | ||
residents previously classified as developmentally disabled | ||
care facilities under this Article, the Department shall refund | ||
any amounts paid under this Article in State fiscal year 2014 | ||
by the end of State fiscal year 2015 with at least half the | ||
refund amount being made prior to December 31, 2014. The | ||
amounts refunded shall be based on amounts paid by the | ||
facilities to the Department as the assessment under subsection | ||
(a) of Section 5C-2 less any assessment and license fee due for | ||
State fiscal year 2014.
| ||
(305 ILCS 5/Art. V-G heading new) | ||
ARTICLE V-G. SUPPORTIVE LIVING FACILITY FUNDING. | ||
(305 ILCS 5/5G-5 new) | ||
Sec. 5G-5. Definitions. As used in this Article, unless the |
context requires otherwise: | ||
"Care days" shall be computed separately for each | ||
supportive living facility, and means the sum for all apartment | ||
units, the number of days during the month which each apartment | ||
unit was occupied by a resident. | ||
"Department" means the Department of Healthcare and Family | ||
Services. | ||
"Fund" means the Supportive Living Facility Fund. | ||
"Supportive living facility" means an enrolled supportive | ||
living site as described under Section 5-5.01a of this Code | ||
that meets the participation requirements under Section | ||
146.215 of Title 89 of the Illinois Administrative Code.
| ||
(305 ILCS 5/5G-10 new) | ||
Sec. 5G-10. Assessment. | ||
(a) Subject to Section 5G-45, beginning July 1, 2014, an | ||
annual assessment on health care services is imposed on each | ||
supportive living facility in an amount equal to $2.30 | ||
multiplied by the supportive living facility's care days. This
| ||
assessment shall not be billed or passed on to any resident of | ||
a supportive living facility. | ||
(b) Nothing in this Section shall be construed to authorize | ||
any home rule unit or other unit of local government to license | ||
for revenue or impose a tax or assessment upon supportive | ||
living facilities or the occupation of operating a supportive | ||
living facility, or a tax or assessment measured by the income |
or earnings or care days of a supportive living facility. | ||
(c) The assessment imposed by this Section shall not be due | ||
and payable, however, until after the Department notifies the | ||
supportive living facilities, in writing, that the payment | ||
methodologies to supportive living facilities required under | ||
Section 5-5.01a of this Code have been approved by the Centers | ||
for Medicare and Medicaid Services of the U.S. Department of | ||
Health and Human Services and the waivers under 42 CFR 433.68 | ||
for the assessment imposed by this Section, if necessary, have | ||
been granted by the Centers for Medicare and Medicaid Services | ||
of the U.S. Department of Health and Human Services.
| ||
(305 ILCS 5/5G-15 new) | ||
Sec. 5G-15. Payment of assessment; penalty. | ||
(a) The assessment imposed by Section 5G-10 shall be due | ||
and payable in monthly installments on the last State business | ||
day of the month for care days reported for the preceding third | ||
month prior to the month in which the assessment is payable and | ||
due. A facility that has delayed payment due to the State's | ||
failure to reimburse for services rendered may request an | ||
extension on the due date for payment pursuant to subsection | ||
(c) and shall pay the assessment within 30 days of | ||
reimbursement by the Department. | ||
(b) The Department shall provide for an electronic | ||
submission process for each supportive living facility to | ||
report at a minimum the number of care days of the supportive |
living facility for the reporting period and other reasonable | ||
information the Department requires for the administration of | ||
its responsibilities under this Code. The Department shall | ||
prepare an assessment bill stating the amount due and payable | ||
each month and submit it to each supportive living facility via | ||
an electronic process. To the extent practicable, the | ||
Department shall coordinate the assessment reporting | ||
requirements with other reporting required of supportive | ||
living facilities. | ||
(c) The Department is authorized to establish delayed | ||
payment schedules for supportive living facilities that are | ||
unable to make assessment payments when due under this Section | ||
due to financial difficulties, as determined by the Department. | ||
The Department may not deny a request for delay of payment of | ||
the assessment imposed under this Article if the supportive | ||
living facility has not been paid for services provided during | ||
the month in which the assessment is levied. | ||
(d) If a supportive living facility fails to pay the full | ||
amount of an assessment payment when due (including any | ||
extensions granted under subsection (c)), there shall, unless | ||
waived by the Department for reasonable cause, be added to the | ||
assessment imposed by Section 5G-10 a penalty assessment equal | ||
to the lesser of (i) 1% of the amount of the assessment payment | ||
not paid on or before the due date plus 1% of the portion | ||
thereof remaining unpaid on the last day of each month | ||
thereafter or (ii) 100% of the assessment payment amount not |
paid on or before the due date. For purposes of this | ||
subsection, payments will be credited first to unpaid | ||
assessment payment amounts (rather than to penalty or | ||
interest), beginning with the most delinquent assessment | ||
payments. Payment cycles of longer than 30 days shall be one | ||
factor the Director takes into account in granting a waiver | ||
under this Section. | ||
(e) No installment of the assessment imposed by Section | ||
5G-10 shall be due and payable until after the Department | ||
notifies the supportive living facilities, in writing, that the | ||
payment methodologies to supportive living facilities required | ||
under Section 5-5.01a of this Code have been approved by the | ||
Centers for Medicare and Medicaid Services of the U.S. | ||
Department of Health and Human Services and the waivers under | ||
42 CFR 433.68 for the assessment imposed by this Section, if | ||
necessary, have been granted by the Centers for Medicare and | ||
Medicaid Services of the U.S. Department of Health and Human | ||
Services. Upon notification to the Department of approval of | ||
the payment methodologies required under Section 5-5.01a of | ||
this Code and the waivers granted under 42 CFR 433.68, all | ||
installments otherwise due under this Section prior to the date | ||
of notification shall be due and payable to the Department upon | ||
written direction from the Department within 90 days after | ||
issuance by the Comptroller of the payments required under | ||
Section 5-5.01a of this Code.
|
(305 ILCS 5/5G-20 new) | ||
Sec. 5G-20. Reporting; penalty; maintenance of records. | ||
(a) Every supportive living facility subject to assessment | ||
under this Article shall report the number care days of the | ||
supportive living facility for the reporting period on or | ||
before the last business day of the month following the | ||
reporting period. Each supportive living facility shall ensure | ||
that an accurate e-mail address is on file with the Department | ||
in order for the Department to prepare and send an electronic | ||
bill to the supportive living facility. | ||
(b) If a supportive living facility fails to file its | ||
monthly report with the Department when due, there shall, | ||
unless waived by the Illinois Department for reasonable cause, | ||
be added to the assessment due a penalty assessment equal to | ||
25% of the assessment due. | ||
(c) Every supportive living facility subject to assessment | ||
under this Article shall keep records and books that will | ||
permit the determination of care days on a calendar year basis. | ||
All such books and records shall be kept in the English | ||
language and shall, at all times during business hours of the | ||
day, be subject to inspection by the Department or its duly | ||
authorized agents and employees. | ||
(d) Notwithstanding any other provision of this Article, a | ||
facility that commences operating or maintaining a supportive | ||
living facility that was under a prior ownership and remained | ||
enrolled as a Medicaid facility by the Department shall notify |
the Department of the change in ownership and shall be | ||
responsible to immediately pay any prior amounts owed by the | ||
facility. | ||
(e) The Department shall develop a procedure for sharing | ||
with a potential buyer of a facility information regarding | ||
outstanding assessments and penalties owed by that facility.
| ||
(305 ILCS 5/5G-25 new) | ||
Sec. 5G-25. Disposition of proceeds. The Department shall | ||
pay all moneys received from supportive living facilities under | ||
this Article into the Supportive Living Facility Fund. Upon | ||
certification by the Department to the State Comptroller of its | ||
intent to withhold from a facility under Section 5G-30(b), the | ||
State Comptroller shall draw a warrant on the treasury or other | ||
fund held by the State Treasurer, as appropriate. The warrant | ||
shall state the amount for which the facility is entitled to a | ||
warrant, the amount of the deduction, and the reason therefor | ||
and shall direct the State Treasurer to pay the balance to the | ||
facility, all in accordance with Section 10.05 of the State | ||
Comptroller Act. The warrant also shall direct the State | ||
Treasurer to transfer the amount of the deduction so ordered | ||
from the treasury or other fund into the Supportive Living | ||
Facility Fund.
| ||
(305 ILCS 5/5G-30 new) | ||
Sec. 5G-30. Administration; enforcement provisions. |
(a) The Department shall administer and enforce this | ||
Article and collect the assessments and penalty assessments | ||
imposed under this Article using procedures employed in its | ||
administration of this Code generally and as follows: | ||
(1) The Department may initiate either administrative | ||
or judicial proceedings, or both, to enforce provisions of | ||
this Article. Administrative enforcement proceedings | ||
initiated hereunder shall be governed by the Department's | ||
administrative rules. Judicial enforcement proceedings | ||
initiated hereunder shall be governed by the rules of | ||
procedure applicable in the courts of this State. | ||
(2) No proceedings for collection, refund, credit, or | ||
other adjustment of an assessment amount shall be issued | ||
more than 3 years after the due date of the assessment, | ||
except in the case of an extended period agreed to in | ||
writing by the Department and the supportive living | ||
facility before the expiration of this limitation period. | ||
(3) Any unpaid assessment under this Article shall | ||
become a lien upon the assets of the supportive living | ||
facility upon which it was assessed. If any supportive | ||
living facility, outside the usual course of its business, | ||
sells or transfers the major part of any one or more of (A) | ||
the real property and improvements, (B) the machinery and | ||
equipment, or (C) the furniture or fixtures, of any | ||
supportive living facility that is subject to the | ||
provisions of this Article, the seller or transferor shall |
pay the Department the amount of any assessment, assessment | ||
penalty, and interest (if any) due from it under this | ||
Article up to the date of the sale or transfer. If the | ||
seller or transferor fails to pay any assessment, | ||
assessment penalty, and interest (if any) due, the | ||
purchaser or transferee of such asset shall be liable for | ||
the amount of the assessment, penalty, and interest (if | ||
any) up to the amount of the reasonable value of the | ||
property acquired by the purchaser or transferee. The | ||
purchaser or transferee shall continue to be liable until | ||
the purchaser or transferee pays the full amount of the | ||
assessment, penalty, and interest (if any) up to the amount | ||
of the reasonable value of the property acquired by the | ||
purchaser or transferee or until the purchaser or | ||
transferee receives from the Department a certificate | ||
showing that such assessment, penalty, and interest have | ||
been paid or a certificate from the Department showing that | ||
no assessment, penalty, or interest is due from the seller | ||
or transferor under this Article. | ||
(b) In addition to any other remedy provided for and | ||
without sending a notice of assessment liability, the | ||
Department may collect an unpaid assessment by withholding, as | ||
payment of the assessment, reimbursements or other amounts | ||
otherwise payable by the Department to the supportive living | ||
facility.
|
(305 ILCS 5/5G-35 new) | ||
Sec. 5G-35. Supportive Living Facility Fund. | ||
(a) There is created in the State treasury the Supportive | ||
Living Facility Fund. Interest earned by the Fund shall be | ||
credited to the Fund. The Fund shall not be used to replace any | ||
moneys appropriated to the Medicaid program by the General | ||
Assembly. | ||
(b) The Fund is created for the purpose of receiving and | ||
disbursing moneys in accordance with this Article. | ||
Disbursements from the Fund, other than transfers authorized | ||
under paragraphs (5) and (6) of this subsection, shall be by | ||
warrants drawn by the State Comptroller upon receipt of | ||
vouchers duly executed and certified by the Department. | ||
Disbursements from the Fund shall be made only as follows: | ||
(1) For making payments to supportive living | ||
facilities as required under this Code, under the | ||
Children's Health Insurance Program Act, under the | ||
Covering ALL KIDS Health Insurance Act, and under the Long | ||
Term Acute Care Hospital Quality Improvement Transfer | ||
Program Act. | ||
(2) For the reimbursement of moneys collected by the | ||
Department from supportive living facilities through error | ||
or mistake in performing the activities authorized under | ||
this Code. | ||
(3) For payment of administrative expenses incurred by | ||
the Department or its agent in performing administrative |
oversight activities for the supportive living program or | ||
review of new supportive living facility applications. | ||
(4) For payments of any amounts which are reimbursable | ||
to the federal government for payments from this Fund which | ||
are required to be paid by State warrant. | ||
(5) For making transfers, as those transfers are | ||
authorized in the proceedings authorizing debt under the | ||
Short Term Borrowing Act, but transfers made under this | ||
paragraph (5) shall not exceed the principal amount of debt | ||
issued in anticipation of the receipt by the State of | ||
moneys to be deposited into the Fund. | ||
(6) For making transfers to any other fund in the State | ||
treasury, but transfers made under this paragraph (6) shall | ||
not exceed the amount transferred previously from that | ||
other fund into the Supportive Living Facility Fund plus | ||
any interest that would have been earned by that fund on | ||
the money that had been transferred. | ||
(c) The Fund shall consist of the following: | ||
(1) All moneys collected or received by the Department | ||
from the supportive living facility assessment imposed by | ||
this Article. | ||
(2) All moneys collected or received by the Department | ||
from the supportive living facility certification fee | ||
imposed by this Article. | ||
(3) All federal matching funds received by the | ||
Department as a result of expenditures made by the |
Department that are attributable to moneys deposited in the | ||
Fund. | ||
(4) Any interest or penalty levied in conjunction with | ||
the administration of this Article. | ||
(5) Moneys transferred from another fund in the State | ||
treasury. | ||
(6) All other moneys received for the Fund from any | ||
other source, including interest earned thereon.
| ||
(305 ILCS 5/5G-40 new) | ||
Sec. 5G-40. Certification fee. | ||
(a) The Department shall collect an annual certification | ||
fee of $100 per each operational or approved supportive living | ||
facility for the purposes of funding the administrative process | ||
of reviewing new supportive living facility applications and | ||
administrative oversight of the health care services delivered | ||
by supportive living facilities. | ||
(b) The certification fee shall be deposited into the | ||
Supportive Living Facility Fund. The Department shall maintain | ||
a separate accounting of amounts collected under this Section.
| ||
(305 ILCS 5/5G-45 new) | ||
Sec. 5G-45. Applicability. | ||
(a) The Department must submit any necessary documentation | ||
to the Centers for Medicare and Medicaid Services which allows | ||
for an effective date of July 1, 2014 for the requirements of |
this Article. The documents shall include any necessary | ||
documents that satisfy federal public notice requirements, | ||
Medicaid state plan amendments, and any Medicaid waiver | ||
amendments. | ||
(b) The assessment imposed by Section 5G-10 shall cease to | ||
be imposed if the amount of matching federal funds under Title | ||
XIX of the Social Security Act is eliminated or significantly | ||
reduced on account of the assessment. Any remaining assessments | ||
shall be refunded to supportive living facilities in proportion | ||
to the amounts of the assessments paid by them. | ||
(c) The certification fee imposed by Section 5G-40 shall | ||
cease to be imposed if the amount of matching federal funds | ||
under Title XIX of the Social Security Act is eliminated or | ||
significantly reduced on account of the certification fee.
| ||
Section 55-20. The Immunization Data Registry Act is | ||
amended by changing Section 20 as follows:
| ||
(410 ILCS 527/20)
| ||
Sec. 20. Confidentiality of information; release of | ||
information; statistics;
panel on expanding access.
| ||
(a) Records maintained as part of the immunization data
| ||
registry are confidential.
| ||
(b) The Department may release an individual's | ||
confidential
information to the individual or to the | ||
individual's parent or guardian
if the individual is less than |
18 years of age.
| ||
(c) Subject to subsection (d) of this Section, the | ||
Department may release
information in the immunization data | ||
registry concerning an
individual to the following entities:
| ||
(1) The immunization data registry of another state.
| ||
(2) A health care provider or a health care provider's | ||
designee.
| ||
(3) A local health department.
| ||
(4) An elementary or secondary school that is attended | ||
by the
individual.
| ||
(5) A licensed child care center in
which the | ||
individual is enrolled.
| ||
(6) A licensed child-placing agency.
| ||
(7) A college or university that is
attended by the | ||
individual.
| ||
(8) The Department of Healthcare and Family Services or | ||
a managed care entity contracted with the Department of | ||
Healthcare and Family Services to coordinate the provision | ||
of medical care to enrollees of the medical assistance | ||
program. | ||
(d) Before immunization data may be released to an entity, | ||
the
entity must enter into an agreement with the Department | ||
that
provides that information that identifies a patient will | ||
not be released
to any other person without the written consent | ||
of the patient.
| ||
(e) The Department may release summary statistics |
regarding
information in the immunization data registry if the | ||
summary
statistics do not reveal the identity of an individual.
| ||
(Source: P.A. 97-117, eff. 7-14-11.)
| ||
Article 60 | ||
Section 60-5. The Lead Poisoning Prevention Act is amended | ||
by adding Section 15.1 as follows:
| ||
(410 ILCS 45/15.1 new) | ||
Sec. 15.1. Funding. Beginning July 1, 2014 and ending June | ||
30, 2018, a hospital satisfying the definition, as of July 1, | ||
2014, of Section 5-5e.1 of the Illinois Public Aid Code and | ||
located in DuPage County shall pay the sum of $2,000,000 | ||
annually in 4 equal quarterly installments to the human poison | ||
control center in existence as of July 1, 2014 and established | ||
under the authority of this Act.
| ||
Article 99 | ||
Section 99-1. Severability. If any clause, sentence, | ||
Section, exemption, provision, or part of this Act or the | ||
application thereof to any person or circumstance shall be | ||
adjudged to be unconstitutional or otherwise invalid, the | ||
remainder of this Act or its application to persons or | ||
circumstances other than those to which it is held invalid |
shall not be affected thereby and to this end the provisions of | ||
this Act are declared to be severable.
| ||
Section 99-2. Any action required by this Act to occur | ||
prior to or on June 30, 2014 shall be completed within 30 days | ||
after the effective date of this Act.
|