AUTHORITY: Implementing and authorized by Articles III, IV, V and VI and Section 12-13 of the Illinois Public Aid Code [305 ILCS 5].

SOURCE: Adopted at 3 Ill. Reg. 24, p. 166, effective June 10, 1979; rule repealed and new rule adopted at 6 Ill. Reg. 8374, effective July 6, 1982; emergency amendment at 6 Ill. Reg. 8508, effective July 6, 1982, for a maximum of 150 days; amended at 7 Ill. Reg. 681, effective December 30, 1982; amended at 7 Ill. Reg. 7956, effective July 1, 1983; amended at 7 Ill. Reg. 8308, effective July 1, 1983; amended at 7 Ill. Reg. 8271, effective July 5, 1983; emergency amendment at 7 Ill. Reg. 8354, effective July 5, 1983, for a maximum of 150 days; amended at 7 Ill. Reg. 8540, effective July 15, 1983; amended at 7 Ill. Reg. 9382, effective July 22, 1983; amended at 7 Ill. Reg. 12868, effective September 20, 1983; peremptory amendment at 7 Ill. Reg. 15047, effective October 31, 1983; amended at 7 Ill. Reg. 17358, effective December 21, 1983; amended at 8 Ill. Reg. 254, effective December 21, 1983; emergency amendment at 8 Ill. Reg. 580, effective January 1, 1984, for a maximum of 150 days; codified at 8 Ill. Reg. 2483; amended at 8 Ill. Reg. 3012, effective February 22, 1984; amended at 8 Ill. Reg. 5262, effective April 9, 1984; amended at 8 Ill. Reg. 6785, effective April 27, 1984; amended at 8 Ill. Reg. 6983, effective May 9, 1984; amended at 8 Ill. Reg. 7258, effective May 16, 1984; emergency amendment at 8 Ill. Reg. 7910, effective May 22, 1984, for a maximum of 150 days; amended at 8 Ill. Reg. 7910, effective June 1, 1984; amended at 8 Ill. Reg. 10032, effective June 18, 1984; emergency amendment at 8 Ill. Reg. 10062, effective June 20, 1984, for a maximum of 150 days; amended at 8 Ill. Reg. 13343, effective July 17, 1984; amended at 8 Ill. Reg. 13779, effective July 24, 1984; Sections 140.72 and 140.73 recodified to 89 Ill. Adm. Code 141 at 8 Ill. Reg. 16354; amended (by adding sections being codified with no substantive change) at 8 Ill. Reg. 17899; peremptory amendment at 8 Ill. Reg. 18151, effective September 18, 1984; amended at 8 Ill. Reg. 21629, effective October 19, 1984; peremptory amendment at 8 Ill. Reg. 21677, effective October 24, 1984; amended at 8 Ill. Reg. 22097, effective October 24, 1984; peremptory amendment at 8 Ill. Reg. 22155, effective October 29, 1984; amended at 8 Ill. Reg. 23218, effective November 20, 1984; emergency amendment at 8 Ill. Reg. 23721, effective November 21, 1984, for a maximum of 150 days; amended at 8 Ill. Reg. 25067, effective December 19, 1984; emergency amendment at 9 Ill. Reg. 407, effective January 1, 1985, for a maximum of 150 days; amended at 9 Ill. Reg. 2697, effective February 22, 1985; amended at 9 Ill. Reg. 6235, effective April 19, 1985; amended at 9 Ill. Reg. 8677, effective May 28, 1985; amended at 9 Ill. Reg. 9564, effective June 5, 1985; amended at 9 Ill. Reg. 10025, effective June 26, 1985; emergency amendment at 9 Ill. Reg. 11403, effective June 27, 1985, for a maximum of 150 days; amended at 9 Ill. Reg. 11357, effective June 28, 1985; amended at 9 Ill. Reg. 12000, effective July 24, 1985; amended at 9 Ill. Reg. 12306, effective August 5, 1985; amended at 9 Ill. Reg. 13998, effective September 3, 1985; amended at 9 Ill. Reg. 14684, effective September 13, 1985; amended at 9 Ill. Reg. 15503, effective October 4, 1985; amended at 9 Ill. Reg. 16312, effective October 11, 1985; amended at 9 Ill. Reg. 19138, effective December 2, 1985; amended at 9 Ill. Reg. 19737, effective December 9, 1985; amended at 10 Ill. Reg. 238, effective December 27, 1985; emergency amendment at 10 Ill. Reg. 798, effective January 1, 1986, for a maximum of 150 days; amended at 10 Ill. Reg. 672, effective January 6, 1986; amended at 10 Ill. Reg. 1206, effective January 13, 1986; amended at 10 Ill. Reg. 3041, effective January 24, 1986; amended at 10 Ill. Reg. 6981, effective April 16, 1986; amended at 10 Ill. Reg. 7825, effective April 30, 1986; amended at 10 Ill. Reg. 8128, effective May 7, 1986; emergency amendment at 10 Ill. Reg. 8912, effective May 13, 1986, for a maximum of 150 days; amended at 10 Ill. Reg. 11440, effective June 20, 1986; amended at 10 Ill. Reg. 14714, effective August 27, 1986; amended at 10 Ill. Reg. 15211, effective September 12, 1986; emergency amendment at 10 Ill. Reg. 16729, effective September 18, 1986, for a maximum of 150 days; amended at 10 Ill. Reg. 18808, effective October 24, 1986; amended at 10 Ill. Reg. 19742, effective November 12, 1986; amended at 10 Ill. Reg. 21784, effective December 15, 1986; amended at 11 Ill. Reg. 698, effective December 19, 1986; amended at 11 Ill. Reg. 1418, effective December 31, 1986; amended at 11 Ill. Reg. 2323, effective January 16, 1987; amended at 11 Ill. Reg. 4002, effective February 25, 1987; Section 140.71 recodified to 89 Ill. Adm. Code 141 at 11 Ill. Reg. 4302; amended at 11 Ill. Reg. 4303, effective March 6, 1987; amended at 11 Ill. Reg. 7664, effective April 15, 1987; emergency amendment at 11 Ill. Reg. 9342, effective April 20, 1987, for a maximum of 150 days; amended at 11 Ill. Reg. 9169, effective April 28, 1987; amended at 11 Ill. Reg. 10903, effective June 1, 1987; amended at 11 Ill. Reg. 11528, effective June 22, 1987; amended at 11 Ill. Reg. 12011, effective June 30, 1987; amended at 11 Ill. Reg. 12290, effective July 6, 1987; amended at 11 Ill. Reg. 14048, effective August 14, 1987; amended at 11 Ill. Reg. 14771, effective August 25, 1987; amended at 11 Ill. Reg. 16758, effective September 28, 1987; amended at 11 Ill. Reg. 17295, effective September 30, 1987; amended at 11 Ill. Reg. 18696, effective October 27, 1987; amended at 11 Ill. Reg. 20909, effective December 14, 1987; amended at 12 Ill. Reg. 916, effective January 1, 1988; emergency amendment at 12 Ill. Reg. 1960, effective January 1, 1988, for a maximum of 150 days; amended at 12 Ill. Reg. 5427, effective March 15, 1988; amended at 12 Ill. Reg. 6246, effective March 16, 1988; amended at 12 Ill. Reg. 6728, effective March 22, 1988; Sections 140.900 thru 140.912 and 140.Table H and 140.Table I recodified to 89 Ill. Adm. Code 147.5 thru 147.205 and 147.Table A and 147.Table B at 12 Ill. Reg. 6956; amended at 12 Ill. Reg. 6927, effective April 5, 1988; Sections 140.940 thru 140.972 recodified to 89 Ill. Adm. Code 149.5 thru 149.325 at 12 Ill. Reg. 7401; amended at 12 Ill. Reg. 7695, effective April 21, 1988; amended at 12 Ill. Reg. 10497, effective June 3, 1988; amended at 12 Ill. Reg. 10717, effective June 14, 1988; emergency amendment at 12 Ill. Reg. 11868, effective July 1, 1988, for a maximum of 150 days; amended at 12 Ill. Reg. 12509, effective July 15, 1988; amended at 12 Ill. Reg. 14271, effective August 29, 1988; emergency amendment at 12 Ill. Reg. 16921, effective September 28, 1988, for a maximum of 150 days; amended at 12 Ill. Reg. 16738, effective October 5, 1988; amended at 12 Ill. Reg. 17879, effective October 24, 1988; amended at 12 Ill. Reg. 18198, effective November 4, 1988; amended at 12 Ill. Reg. 19396, effective November 6, 1988; amended at 12 Ill. Reg. 19734, effective November 15, 1988; amended at 13 Ill. Reg. 125, effective January 1, 1989; amended at 13 Ill. Reg. 2475, effective February 14, 1989; amended at 13 Ill. Reg. 3069, effective February 28, 1989; amended at 13 Ill. Reg. 3351, effective March 6, 1989; amended at 13 Ill. Reg. 3917, effective March 17, 1989; amended at 13 Ill. Reg. 5115, effective April 3, 1989; amended at 13 Ill. Reg. 5718, effective April 10, 1989; amended at 13 Ill. Reg. 7025, effective April 24, 1989; Sections 140.850 thru 140.896 recodified to 89 Ill. Adm. Code 146.5 thru 146.225 at 13 Ill. Reg. 7040; amended at 13 Ill. Reg. 7786, effective May 20, 1989; Sections 140.94 thru 140.398 recodified to 89 Ill. Adm. Code 148.10 thru 148.390 at 13 Ill. Reg. 9572; emergency amendment at 13 Ill. Reg. 10977, effective July 1, 1989, for a maximum of 150 days; emergency expired November 28, 1989; amended at 13 Ill. Reg. 11516, effective July 3, 1989; amended at 13 Ill. Reg. 12119, effective July 7, 1989; Section 140.110 recodified to 89 Ill. Adm. Code 148.120 at 13 Ill. Reg. 12118; amended at 13 Ill. Reg. 12562, effective July 17, 1989; amended at 13 Ill. Reg. 14391, effective August 31, 1989; emergency amendment at 13 Ill. Reg. 15473, effective September 12, 1989, for a maximum of 150 days; amended at 13 Ill. Reg. 16992, effective October 16, 1989; amended at 14 Ill. Reg. 190, effective December 21, 1989; amended at 14 Ill. Reg. 2564, effective February 9, 1990; emergency amendment at 14 Ill. Reg. 3241, effective February 14, 1990, for a maximum of 150 days; emergency expired July 14, 1990; amended at 14 Ill. Reg. 4543, effective March 12, 1990; emergency amendment at 14 Ill. Reg. 4577, effective March 6, 1990, for a maximum of 150 days; emergency expired August 3, 1990; emergency amendment at 14 Ill. Reg. 5575, effective April 1, 1990, for a maximum of 150 days; emergency expired August 29, 1990; emergency amendment at 14 Ill. Reg. 5865, effective April 3, 1990, for a maximum of 150 days; amended at 14 Ill. Reg. 7141, effective April 27, 1990; emergency amendment at 14 Ill. Reg. 7249, effective April 27, 1990, for a maximum of 150 days; amended at 14 Ill. Reg. 10062, effective June 12, 1990; amended at 14 Ill. Reg. 10409, effective June 19, 1990; emergency amendment at 14 Ill. Reg. 12082, effective July 5, 1990, for a maximum of 150 days; amended at 14 Ill. Reg. 13262, effective August 6, 1990; emergency amendment at 14 Ill. Reg. 14184, effective August 16, 1990, for a maximum of 150 days; emergency amendment at 14 Ill. Reg. 14570, effective August 22, 1990, for a maximum of 150 days; amended at 14 Ill. Reg. 14826, effective August 31, 1990; amended at 14 Ill. Reg. 15366, effective September 12, 1990; amended at 14 Ill. Reg. 15981, effective September 21, 1990; amended at 14 Ill. Reg. 17279, effective October 12, 1990; amended at 14 Ill. Reg. 18057, effective October 22, 1990; amended at 14 Ill. Reg. 18508, effective October 30, 1990; amended at 14 Ill. Reg. 18813, effective November 6, 1990; Notice of Corrections to Adopted Amendment at 15 Ill. Reg. 1174; amended at 14 Ill. Reg. 20478, effective December 7, 1990; amended at 14 Ill. Reg. 20729, effective December 12, 1990; amended at 15 Ill. Reg. 298, effective December 28, 1990; emergency amendment at 15 Ill. Reg. 592, effective January 1, 1991, for a maximum of 150 days; amended at 15 Ill. Reg. 1051, effective January 18, 1991; amended at 15 Ill. Reg. 6220, effective April 18, 1991; amended at 15 Ill. Reg. 6534, effective April 30, 1991; amended at 15 Ill. Reg. 8264, effective May 23, 1991; amended at 15 Ill. Reg. 8972, effective June 17, 1991; amended at 15 Ill. Reg. 10114, effective June 21, 1991; amended at 15 Ill. Reg. 10468, effective July 1, 1991; amended at 15 Ill. Reg. 11176, effective August 1, 1991; emergency amendment at 15 Ill. Reg. 11515, effective July 25, 1991, for a maximum of 150 days; emergency expired December 22, 1991; emergency amendment at 15 Ill. Reg. 12919, effective August 15, 1991, for a maximum of 150 days; emergency expired January 12, 1992; emergency amendment at 15 Ill. Reg. 16366, effective October 22, 1991, for a maximum of 150 days; amended at 15 Ill. Reg. 17318, effective November 18, 1991; amended at 15 Ill. Reg. 17733, effective November 22, 1991; emergency amendment at 16 Ill. Reg. 300, effective December 20, 1991, for a maximum of 150 days; amended at 16 Ill. Reg. 174, effective December 24, 1991; amended at 16 Ill. Reg. 1877, effective January 24, 1992; amended at 16 Ill. Reg. 3552, effective February 28, 1992; amended at 16 Ill. Reg. 4006, effective March 6, 1992; amended at 16 Ill. Reg. 6408, effective March 20, 1992; expedited correction at 16 Ill. Reg. 11348, effective March 20, 1992; amended at 16 Ill. Reg. 6849, effective April 7, 1992; amended at 16 Ill. Reg. 7017, effective April 17, 1992; amended at 16 Ill. Reg. 10050, effective June 5, 1992; amended at 16 Ill. Reg. 11174, effective June 26, 1992; emergency amendment at 16 Ill. Reg. 11947, effective July 10, 1992, for a maximum of 150 days; amended at 16 Ill. Reg. 12186, effective July 24, 1992; emergency amendment at 16 Ill. Reg. 13337, effective August 14, 1992, for a maximum of 150 days; emergency amendment at 16 Ill. Reg. 15109, effective September 21, 1992, for a maximum of 150 days; amended at 16 Ill. Reg. 15561, effective September 30, 1992; amended at 16 Ill. Reg. 17302, effective November 2, 1992; emergency amendment at 16 Ill. Reg. 18097, effective November 17, 1992, for a maximum of 150 days; amended at 16 Ill. Reg. 19146, effective December 1, 1992; expedited correction at 17 Ill. Reg. 7078, effective December 1, 1992; amended at 16 Ill. Reg. 19879, effective December 7, 1992; amended at 17 Ill. Reg. 837, effective January 11, 1993; amended at 17 Ill. Reg. 1112, effective January 15, 1993; amended at 17 Ill. Reg. 2290, effective February 15, 1993; amended at 17 Ill. Reg. 2951, effective February 17, 1993; amended at 17 Ill. Reg. 3421, effective February 19, 1993; amended at 17 Ill. Reg. 6196, effective April 5, 1993; amended at 17 Ill. Reg. 6839, effective April 21, 1993; amended at 17 Ill. Reg. 7004, effective May 17, 1993; emergency amendment at 17 Ill. Reg. 11201, effective July 1, 1993, for a maximum of 150 days; emergency amendment at 17 Ill. Reg. 15162, effective September 2, 1993, for a maximum of 150 days; emergency amendment suspended at 17 Ill. Reg. 18902, effective October 12, 1993; emergency amendment at 17 Ill. Reg. 18152, effective October 1, 1993, for a maximum of 150 days; amended at 17 Ill. Reg. 18571, effective October 8, 1993; emergency amendment at 17 Ill. Reg. 18611, effective October 1, 1993, for a maximum of 150 days; amended at 17 Ill. Reg. 20999, effective November 24, 1993; emergency amendment repealed at 17 Ill. Reg. 22583, effective December 20, 1993; amended at 18 Ill. Reg. 3620, effective February 28, 1994; amended at 18 Ill. Reg. 4250, effective March 4, 1994; amended at 18 Ill. Reg. 5951, effective April 1, 1994; emergency amendment at 18 Ill. Reg. 10922, effective July 1, 1994, for a maximum of 150 days; emergency amendment suspended at 18 Ill. Reg. 17286, effective November 15, 1994; emergency amendment repealed at 19 Ill. Reg. 5839, effective April 4, 1995; amended at 18 Ill. Reg. 11244, effective July 1, 1994; amended at 18 Ill. Reg. 14126, effective August 29, 1994; amended at 18 Ill. Reg. 16675, effective November 1, 1994; amended at 18 Ill. Reg. 18059, effective December 19, 1994; amended at 19 Ill. Reg. 1082, effective January 20, 1995; amended at 19 Ill. Reg. 2933, effective March 1, 1995; emergency amendment at 19 Ill. Reg. 3529, effective March 1, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 5663, effective April 1, 1995; amended at 19 Ill. Reg. 7919, effective June 5, 1995; emergency amendment at 19 Ill. Reg. 8455, effective June 9, 1995, for a maximum of 150 days; emergency amendment at 19 Ill. Reg. 9297, effective July 1, 1995, for a maximum of 150 days; emergency amendment at 19 Ill. Reg. 10252, effective July 1, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 13019, effective September 5, 1995; amended at 19 Ill. Reg. 14440, effective September 29, 1995; emergency amendment at 19 Ill. Reg. 14833, effective October 6, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 15441, effective October 26, 1995; amended at 19 Ill. Reg. 15692, effective November 6, 1995; amended at 19 Ill. Reg. 16677, effective November 28, 1995; amended at 20 Ill. Reg. 1210, effective December 29, 1995; amended at 20 Ill. Reg. 4345, effective March 4, 1996; amended at 20 Ill. Reg. 5858, effective April 5, 1996; amended at 20 Ill. Reg. 6929, effective May 6, 1996; amended at 20 Ill. Reg. 7922, effective May 31, 1996; amended at 20 Ill. Reg. 9081, effective June 28, 1996; emergency amendment at 20 Ill. Reg. 9312, effective July 1, 1996, for a maximum of 150 days; amended at 20 Ill. Reg. 11332, effective August 1, 1996; amended at 20 Ill. Reg. 14845, effective October 31, 1996; emergency amendment at 21 Ill. Reg. 705, effective December 31, 1996, for a maximum of 150 days; emergency amendment at 21 Ill. Reg. 3734, effective March 5, 1997, for a maximum of 150 days; amended at 21 Ill. Reg. 4777, effective April 2, 1997; amended at 21 Ill. Reg. 6899, effective May 23, 1997; amended at 21 Ill. Reg. 9763, effective July 15, 1997; amended at 21 Ill. Reg. 11569, effective August 1, 1997; emergency amendment at 21 Ill. Reg. 13857, effective October 1, 1997, for a maximum of 150 days; amended at 22 Ill. Reg. 1416, effective December 29, 1997; amended at 22 Ill. Reg. 4412, effective February 27, 1998; amended at 22 Ill. Reg. 7024, effective April 1, 1998; amended at 22 Ill. Reg. 10606, effective June 1, 1998; emergency amendment at 22 Ill. Reg. 13117, effective July 1, 1998, for a maximum of 150 days; amended at 22 Ill. Reg. 16302, effective August 28, 1998; amended at 22 Ill. Reg. 18979, effective September 30, 1998; amended at 22 Ill. Reg. 19898, effective October 30, 1998; emergency amendment at 22 Ill. Reg. 22108, effective December 1, 1998, for a maximum of 150 days; emergency expired April 29, 1999; amended at 23 Ill. Reg. 5796, effective April 30, 1999; amended at 23 Ill. Reg. 7122, effective June 1, 1999; emergency amendment at 23 Ill. Reg. 8236, effective July 1, 1999, for a maximum of 150 days; amended at 23 Ill. Reg. 9874, effective August 3, 1999; amended at 23 Ill. Reg. 12697, effective October 1, 1999; amended at 23 Ill. Reg. 13646, effective November 1, 1999; amended at 23 Ill. Reg. 14567, effective December 1, 1999; amended at 24 Ill. Reg. 661, effective January 3, 2000; amended at 24 Ill. Reg. 10277, effective July 1, 2000; emergency amendment at 24 Ill. Reg. 10436, effective July 1, 2000, for a maximum of 150 days; amended at 24 Ill. Reg. 15086, effective October 1, 2000; amended at 24 Ill. Reg. 18320, effective December 1, 2000; emergency amendment at 24 Ill. Reg. 19344, effective December 15, 2000, for a maximum of 150 days; amended at 25 Ill. Reg. 3897, effective March 1, 2001; amended at 25 Ill. Reg. 6665, effective May 11, 2001; amended at 25 Ill. Reg. 8793, effective July 1, 2001; emergency amendment at 25 Ill. Reg. 8850, effective July 1, 2001, for a maximum of 150 days; amended at 25 Ill. Reg. 11880, effective September 1, 2001; amended at 25 Ill. Reg. 12820, effective October 8, 2001; amended at 25 Ill. Reg. 14957, effective November 1, 2001; emergency amendment at 25 Ill. Reg. 16127, effective November 28, 2001, for a maximum of 150 days; emergency amendment at 25 Ill. Reg. 16292, effective December 3, 2001, for a maximum of 150 days; emergency amendment at 26 Ill. Reg. 514, effective January 1, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 663, effective January 7, 2002; amended at 26 Ill. Reg. 4781, effective March 15, 2002; emergency amendment at 26 Ill. Reg. 5984, effective April 15, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 7285, effective April 29, 2002; emergency amendment at 26 Ill. Reg. 8594, effective June 1, 2002, for a maximum of 150 days; emergency amendment at 26 Ill. Reg. 11259, effective July 1, 2002, for a maximum of 150 days; emergency amendment at 26 Ill. Reg. 12461, effective July 29, 2002, for a maximum of 150 days; emergency amendment repealed at 26 Ill. Reg. 16593, effective October 22, 2002; emergency amendment at 26 Ill. Reg. 12772, effective August 12, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 13641, effective September 3, 2002; amended at 26 Ill. Reg. 14789, effective September 26, 2002; emergency amendment at 26 Ill. Reg. 15076, effective October 1, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 16303, effective October 25, 2002; amended at 26 Ill. Reg. 17751, effective November 27, 2002; amended at 27 Ill. Reg. 768, effective January 3, 2003; amended at 27 Ill. Reg. 3041, effective February 10, 2003; amended at 27 Ill. Reg. 4364, effective February 24, 2003; amended at 27 Ill. Reg. 7823, effective May 1, 2003; amended at 27 Ill. Reg. 9157, effective June 2, 2003; emergency amendment at 27 Ill. Reg. 10813, effective July 1, 2003, for a maximum of 150 days; amended at 27 Ill. Reg. 13784, effective August 1, 2003; amended at 27 Ill. Reg. 14799, effective September 5, 2003; emergency amendment at 27 Ill. Reg. 15584, effective September 20, 2003, for a maximum of 150 days; emergency amendment at 27 Ill. Reg. 16161, effective October 1, 2003, for a maximum of 150 days; amended at 27 Ill. Reg. 18629, effective November 26, 2003; amended at 28 Ill. Reg. 2744, effective February 1, 2004; amended at 28 Ill. Reg. 4958, effective March 3, 2004; emergency amendment at 28 Ill. Reg. 6622, effective April 19, 2004, for a maximum of 150 days; amended at 28 Ill. Reg. 7081, effective May 3, 2004; emergency amendment at 28 Ill. Reg. 8108, effective June 1, 2004, for a maximum of 150 days; amended at 28 Ill. Reg. 9640, effective July 1, 2004; emergency amendment at 28 Ill. Reg. 10135, effective July 1, 2004, for a maximum of 150 days; amended at 28 Ill. Reg. 11161, effective August 1, 2004; emergency amendment at 28 Ill. Reg. 12198, effective August 11, 2004, for a maximum of 150 days; amended at 28 Ill. Reg. 13775, effective October 1, 2004; amended at 28 Ill. Reg. 14804, effective October 27, 2004; amended at 28 Ill. Reg. 15513, effective November 24, 2004; amended at 29 Ill. Reg. 831, effective January 1, 2005; amended at 29 Ill. Reg. 6945, effective May 1, 2005; emergency amendment at 29 Ill. Reg. 8509, effective June 1, 2005, for a maximum of 150 days; emergency amendment at 29 Ill. Reg. 12534, effective August 1, 2005, for a maximum of 150 days; amended at 29 Ill. Reg. 14957, effective September 30, 2005; emergency amendment at 29 Ill. Reg. 15064, effective October 1, 2005, for a maximum of 150 days; emergency amendment repealed by emergency rulemaking at 29 Ill. Reg. 15985, effective October 5, 2005, for the remainder of the 150 days; emergency amendment at 29 Ill. Reg. 15610, effective October 1, 2005, for a maximum of 150 days; emergency amendment at 29 Ill. Reg. 16515, effective October 5, 2005, for a maximum of 150 days; amended at 30 Ill. Reg. 349, effective December 28, 2005; emergency amendment at 30 Ill. Reg. 573, effective January 1, 2006, for a maximum of 150 days; amended at 30 Ill. Reg. 796, effective January 1, 2006; amended at 30 Ill. Reg. 2802, effective February 24, 2006; amended at 30 Ill. Reg. 10370, effective May 26, 2006; emergency amendment at 30 Ill. Reg. 12376, effective July 1, 2006, for a maximum of 150 days; emergency amendment at 30 Ill. Reg. 13909, effective August 2, 2006, for a maximum of 150 days; amended at 30 Ill. Reg. 14280, effective August 18, 2006; expedited correction at 31 Ill. Reg. 1745, effective August 18, 2006; emergency amendment at 30 Ill. Reg. 17970, effective November 1, 2006, for a maximum of 150 days; amended at 30 Ill. Reg. 18648, effective November 27, 2006; emergency amendment at 30 Ill. Reg. 19400, effective December 1, 2006, for a maximum of 150 days; amended at 31 Ill. Reg. 388, effective December 29, 2006; emergency amendment at 31 Ill. Reg. 1580, effective January 1, 2007, for a maximum of 150 days; amended at 31 Ill. Reg. 2413, effective January 19, 2007; amended at 31 Ill. Reg. 5561, effective March 30, 2007; amended at 31 Ill. Reg. 6930, effective April 29, 2007; amended at 31 Ill. Reg. 8485, effective May 30, 2007; emergency amendment at 31 Ill. Reg. 10115, effective June 30, 2007, for a maximum of 150 days; amended at 31 Ill. Reg. 14749, effective October 22, 2007; emergency amendment at 32 Ill. Reg. 383, effective January 1, 2008, for a maximum of 150 days; peremptory amendment at 32 Ill. Reg. 6743, effective April 1, 2008; peremptory amendment suspended at 32 Ill. Reg. 8449, effective May 21, 2008; suspension withdrawn by the Joint Committee on Administrative Rules at 32 Ill. Reg. 18323, effective November 12, 2008; peremptory amendment repealed by emergency rulemaking at 32 Ill. Reg. 18422, effective November 12, 2008, for a maximum of 150 days; emergency expired April 10, 2009; peremptory amendment repealed at 33 Ill. Reg. 6667, effective April 29, 2009; amended at 32 Ill. Reg. 7727, effective May 5, 2008; emergency amendment at 32 Ill. Reg. 10480, effective July 1, 2008, for a maximum of 150 days; emergency expired November 27, 2008; amended at 32 Ill. Reg. 17133, effective October 15, 2008; amended at 33 Ill. Reg. 209, effective December 29, 2008; amended at 33 Ill. Reg. 9048, effective June 15, 2009; emergency amendment at 33 Ill. Reg. 10800, effective June 30, 2009, for a maximum of 150 days; amended at 33 Ill. Reg. 11287, effective July 14, 2009; amended at 33 Ill. Reg. 11938, effective August 17, 2009; amended at 33 Ill. Reg. 12227, effective October 1, 2009; emergency amendment at 33 Ill. Reg. 14324, effective October 1, 2009, for a maximum of 150 days; emergency expired February 27, 2010; amended at 33 Ill. Reg. 16573, effective November 16, 2009; amended at 34 Ill. Reg. 516, effective January 1, 2010; amended at 34 Ill. Reg. 903, effective January 29, 2010; amended at 34 Ill. Reg. 3761, effective March 14, 2010; amended at 34 Ill. Reg. 5215, effective March 25, 2010; amended at 34 Ill. Reg. 19517, effective December 6, 2010; amended at 35 Ill. Reg. 394, effective December 27, 2010; amended at 35 Ill. Reg. 7648, effective May 1, 2011; amended at 35 Ill. Reg. 7962, effective May 1, 2011; amended at 35 Ill. Reg. 10000, effective June 15, 2011; amended at 35 Ill. Reg. 12909, effective July 25, 2011; amended at 36 Ill. Reg. 2271, effective February 1, 2012; amended at 36 Ill. Reg. 7010, effective April 27, 2012; amended at 36 Ill. Reg. 7545, effective May 7, 2012; amended at 36 Ill. Reg. 9113, effective June 11, 2012; emergency amendment at 36 Ill. Reg. 11329, effective July 1, 2012 through June 30, 2013; emergency amendment to Section 140.442(e)(4) suspended at 36 Ill. Reg. 13736, effective August 15, 2012; suspension withdrawn from Section 140.442(e)(4) at 36 Ill. Reg. 14529, September 11, 2012; emergency amendment in response to Joint Committee on Administrative Rules action on Section 140.442(e)(4) at 36 Ill. Reg. 14820, effective September 21, 2012 through June 30, 2013; emergency amendment to Section 140.491 suspended at 36 Ill. Reg. 13738, effective August 15, 2012; suspension withdrawn by the Joint Committee on Administrative Rules from Section 140.491 at 37 Ill. Reg. 890, January 8, 2013; emergency amendment in response to Joint Committee on Administrative Rules action on Section 140.491 at 37 Ill. Reg. 1330, effective January 15, 2013 through June 30, 2013; amended at 36 Ill. Reg. 15361, effective October 15, 2012; emergency amendment at 37 Ill. Reg. 253, effective January 1, 2013 through June 30, 2013; emergency amendment at 37 Ill. Reg. 846, effective January 9, 2013 through June 30, 2013; emergency amendment at 37 Ill. Reg. 1774, effective January 28, 2013 through June 30, 2013; emergency amendment at 37 Ill. Reg. 2348, effective February 1, 2013 through June 30, 2013; amended at 37 Ill. Reg. 3831, effective March 13, 2013; emergency amendment at 37 Ill. Reg. 5058, effective April 1, 2013 through June 30, 2013; emergency amendment at 37 Ill. Reg. 5170, effective April 8, 2013 through June 30, 2013; amended at 37 Ill. Reg. 6196, effective April 29, 2013; amended at 37 Ill. Reg. 7985, effective May 29, 2013; amended at 37 Ill. Reg. 10282, effective June 27, 2013; amended at 37 Ill. Reg. 12855, effective July 24, 2013; emergency amendment at 37 Ill. Reg. 14196, effective August 20, 2013, for a maximum of 150 days; amended at 37 Ill. Reg. 17584, effective October 23, 2013; amended at 37 Ill. Reg. 18275, effective November 4, 2013; amended at 37 Ill. Reg. 20339, effective December 9, 2013; amended at 38 Ill. Reg. 859, effective December 23, 2013; emergency amendment at 38 Ill. Reg. 1174, effective January 1, 2014, for a maximum of 150 days; amended at 38 Ill. Reg. 4330, effective January 29, 2014; amended at 38 Ill. Reg. 7156, effective March 13, 2014; amended at 38 Ill. Reg. 12141, effective May 30, 2014; amended at 38 Ill. Reg. 15081, effective July 2, 2014; emergency amendment at 38 Ill. Reg. 15673, effective July 7, 2014, for a maximum of 150 days; emergency amendment at 38 Ill. Reg. 18216, effective August 18, 2014, for a maximum of 150 days; amended at 38 Ill. Reg. 18462, effective August 19, 2014; amended at 38 Ill. Reg. 23623, effective December 2, 2014; amended at 39 Ill. Reg. 4394, effective March 11, 2015; emergency amendment at 39 Ill. Reg. 6903, effective May 1, 2015 through June 30, 2015; emergency amendment at 39 Ill. Reg. 8137, effective May 20, 2015, for a maximum of 150 days; emergency amendment at 39 Ill. Reg. 10427, effective July 10, 2015, for a maximum of 150 days; emergency expired December 6, 2015; amended at 39 Ill. Reg. 12825, effective September 4, 2015; amended at 39 Ill. Reg. 13380, effective September 25, 2015; amended at 39 Ill. Reg. 14138, effective October 14, 2015; emergency amendment at 40 Ill. Reg. 13677, effective September 16, 2016, for a maximum of 150 days; emergency expired February 12, 2017; amended at 41 Ill. Reg. 999, effective January 19, 2017; amended at 41 Ill. Reg. 3296, effective March 8, 2017; amended at 41 Ill. Reg. 7526, effective June 15, 2017; amended at 41 Ill. Reg. 10950, effective August 9, 2017; amended at 42 Ill. Reg. 4829, effective March 1, 2018; amended at 42 Ill. Reg. 12986, effective June 25, 2018; emergency amendment at 42 Ill. Reg. 13688, effective July 2, 2018, for a maximum of 150 days; emergency amendment to emergency rule at 42 Ill. Reg. 16265, effective August 13, 2018, for the remainder of the 150 days; amended at 42 Ill. Reg. 14383, effective July 23, 2018; amended at 42 Ill. Reg. 20059, effective October 26, 2018; amended at 42 Ill. Reg. 22352, effective November 28, 2018; amended at 43 Ill. Reg. 1014, effective December 31, 2018; amended at 43 Ill. Reg. 2227, effective February 4, 2019; amended at 43 Ill. Reg. 4094, effective March 25, 2019; amended at 43 Ill. Reg. 5706, effective May 2, 2019; amended at 43 Ill. Reg. 6736, effective May 28, 2019; emergency amendment at 43 Ill. Reg. 12093, effective October 15, 2019, for a maximum of 150 days; amended at 44 Ill. Reg. 226, effective December 23, 2019; amended at 44 Ill. Reg. 4616, effective March 3, 2020; emergency amendment at 44 Ill. Reg. 5745, effective March 20, 2020, for a maximum of 150 days; emergency amendment at 44 Ill. Reg. 12778, effective July 17, 2020, for a maximum of 150 days; amended at 44 Ill. Reg. 13678, effective August 7, 2020; amended at 44 Ill. Reg. 19713, effective December 11, 2020; emergency amendment at 45 Ill. Reg. 1345, effective January 15, 2021, for a maximum of 150 days; emergency expired June 13, 2021; emergency amendment at 45 Ill. Reg. 2734, effective February 19, 2021, for a maximum of 150 days; emergency amendment at 45 Ill. Reg. 5419, effective April 9, 2021, for a maximum of 150 days; amended at 45 Ill. Reg. 5848, effective April 20, 2021; amended at 45 Ill. Reg. 8958, effective June 29, 2021; amended at 45 Ill. Reg. 10996, effective August 27, 2021; emergency amendment at 46 Ill. Reg. 512, effective December 16, 2021, for a maximum of 150 days; amended at 46 Ill. Reg. 2046, effective January 21, 2022; amended at 46 Ill. Reg. 5229, effective March 11, 2022; amended at 46 Ill. Reg. 5725, effective March 25, 2022; emergency amendment at 46 Ill. Reg. 8348, effective May 2, 2022, for a maximum of 150 days; emergency amendment at 46 Ill. Reg. 12115, effective July 1, 2022, for a maximum of 150 days; emergency expired November 27, 2022; amended at 46 Ill. Reg. 16740, effective September 20, 2022; amended at 46 Ill. Reg. 18061, effective October 27, 2022; amended at 46 Ill. Reg. 19641, effective November 28, 2022; amended at 47 Ill. Reg. 3738, effective March 1, 2023; amended at 47 Ill. Reg. 16385, effective November 3, 2023; amended at 47 Ill. Reg. 18024, effective November 21, 2023; amended at 48 Ill. Reg. 864, effective December 27, 2023; emergency amendment at 48 Ill. Reg. 5768, effective March 28, 2024, for a maximum of 150 days; amended at 48 Ill. Reg. 11981, effective July 25, 2024; amended at 48 Ill. Reg. 13507, effective August 26, 2024; amended at 49 Ill. Reg. 1819, effective January 30, 2025; amended at 49 Ill. Reg. 3081, effective February 26, 2025; amended at 49 Ill. Reg. 3537, effective March 10, 2025; amended at 49 Ill. Reg. 4026, effective March 20, 2025; amended at 49 Ill. Reg. 4457, effective March 27, 2025.

SUBPART A: GENERAL PROVISIONS

 

Section 140.1  Incorporation By Reference

 

Any rules or regulations of an agency of the United States or of a nationally recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified, and do not include any later amendments or editions.

 

(Source:  Added at 9 Ill. Reg. 2697, effective February 22, 1985)

 

Section 140.2  Medical Assistance Programs

 

a)         Under the Medical Assistance Programs, the Department pays participating providers for necessary medical services, specified in Section 140.3 through 140.7 for:

 

1)         persons eligible for financial assistance under the Aid to the Aged, Blind or Disabled-State Supplemental Payment (AABD-SSP) and Temporary Assistance to Needy Families (TANF) programs (Medicaid-MAG);

 

2)         persons who would be eligible for financial assistance but who have resources in excess of the Department's eligibility standards and who have incurred medical expenses greater than the difference between their income and the Department's standards (Medicaid-MANG);

 

3)         individuals under age 18 who do not qualify for TANF/TANF-MANG and infants under age one year (see Section 140.7);

 

4)         pregnant women who would not be eligible for TANF/TANF-MANG if the child were born and who do not qualify as mandatory categorically needy (see Section 140.9);

 

5)         persons who are eligible for Title IV-E adoption assistance/foster care assistance from another State and who are living in Illinois;

 

6)         noncitizens who have an emergency medical condition (see 89 Ill. Adm. Code 120.310); however, payment is not included for care and services related to an organ transplant procedure;

 

7)         persons eligible for medical assistance under the Aid to the Aged, Blind or Disabled (AABD) program who reside in specified Supportive Living Facilities (SLFs), as described at 89 Ill. Adm. Code 146, Subpart B;

 

8)         persons eligible for FamilyCare as described in 89 Ill. Adm. Code 120.32;

 

9)         beginning January 1, 2014, persons eligible as ACA Adults as described in 89 Ill. Adm. Code 120.10(h); and

 

10)         beginning January 1, 2014, persons eligible as Former Foster Care as described in 89 Ill. Adm. Code 120.10(i).

 

b)         "Necessary medical care" is that which is generally recognized as standard medical care required because of disease, disability, infirmity or impairment.

 

c)         The Department may impose prior approval requirements, as specified by rule, to determine whether the medical care is necessary and eligible for payment from the Department in individual situations.  Such requirements shall be based on recommendations of technical and professional staff and advisory committees.

 

d)         When recipients are entitled to Medicare benefits, the Department shall assume responsibility for their deductible and coinsurance obligations, unless the recipients have income and/or resources available to meet these needs.  The total payment to a provider from both Medicare and the Department shall not exceed either the amount that Medicare determines to be a reasonable charge or the Department standard for the services provided, whichever is applicable.

 

e)         The Department shall pay for services and items not allowed by Medicare only if they are provided in accordance with Department policy for recipients not entitled to Medicare benefits.

 

f)         The Department may contract with qualified practitioners, hospitals and all other dispensers of medical services for the provision and reimbursement of any and all medical care or services as specified in the contract on a prepaid capitation basis (i.e., payment of a fixed amount per enrollee made in advance of the service); volume purchase basis (i.e., purchase of a volume of goods or services for a price specified in the contract); ambulatory visit basis (i.e., one comprehensive payment for each visit regardless of the services provided during that visit) or per discharge basis (i.e., one comprehensive payment per discharge regardless of the services provided during the stay).  Such contracts shall be based either on formally solicited competitive bid proposals or individually negotiated rates with providers willing to enter into special contractual arrangements with the State.

 

g)         The Department may require that recipients of medical assistance under any of the Department's programs exercise their freedom of choice by choosing to receive medical care under the traditional fee for service system or through a prepaid capitation plan or under one of the other alternative contractual arrangements described in subsection (f) of this Section.  The categories of recipients who may choose or be assigned to an alternative plan will be specified in the contract.  Recipients required to make such a choice will be notified in writing by the Department.  If a recipient does not choose to exercise his/her freedom of choice, the Department may assign that recipient to a prepaid plan.  Under such a plan, recipients would obtain certain medical services or supplies from a single source or limited source.  The Department will notify recipients in writing if they are assigned to a prepaid plan. Recipients enrolled in or assigned to a prepaid plan will receive written notification advising them of the services which they will receive from the plan.  Covered services not provided by the plan will be reimbursed by the Department on a fee for service basis.  Recipients will receive a medical eligibility card, which will apply to such services.

 

h)         The Department may enter into contracts for the provision of medical care on a prepaid capitation basis from a Health Maintenance Organization (HMO) whereby the recipient who chooses to receive medical care through an HMO must stay in the HMO for a certain period of time, not to exceed six months (the enrollment period).  Upon written notice, the recipient may choose to disenroll from such an HMO at any time within the first month of each enrollment period. The Department will send the recipient a notice at least 30 days prior to the end of the enrollment period, which gives the recipient a specified period of time in which to inform the Department if the recipient does not wish to re-enroll in the HMO for a new enrollment period.  The recipient may then disenroll at the end of the enrollment period only if the recipient responds to the notice and indicates in writing a choice to disenroll.  Failure to respond to the notice will result in automatic re-enrollment for a new enrollment period.  Recipients shall also be allowed to disenroll at any time for cause.

 

i)          The Department may enter into contracts for the provision of medical care on a prepaid capitation basis from a Health Maintenance Organization whereby the recipient who chooses to receive medical care through an HMO may choose to disenroll at any time, upon written notice.

 

j)          The Department shall pay for services under the Maternal and Child Health Program, a primary health care program for pregnant women and children (see Subpart G).

 

k)         Services covered for persons who are confined or detained as described in 89 Ill. Adm. Code 120.318(b) shall be limited as described in Section 140.10.

 

(Source:  Amended at 38 Ill. Reg. 12141, effective May 30, 2014)

 

Section 140.3  Covered Services Under Medical Assistance Programs

 

a)         As described in this Section, medical services shall be covered for:

 

1)         recipients of financial assistance under the AABD (Aid to the Aged, Blind or Disabled), TANF (Temporary Assistance to Needy Families), or Refugee/Entrant/Repatriate program;

 

2)         recipients of medical assistance only under the AABD program (AABD-MANG);

 

3)         recipients of medical assistance only under the TANF program (TANF-MANG);

 

4)         individuals under age 18 not eligible for TANF (see Section 140.7), pregnant women who would be eligible if the child were born and pregnant women and children under age eight who do not qualify as mandatory categorically needy (see Section 140.9);

 

5)         disabled persons under age 21 who may qualify for Medicaid or in-home care under the Illinois Home and Community-Based Services Waiver for Medically Fragile Technology Dependent Children;

 

6)         individuals 19 years of age or older eligible under the KidCare Parent Coverage Waiver described at 89 Ill. Adm. Code 120.32, except for services provided only through a waiver approved under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c));

 

7)         beginning January 1, 2014, ACA Adults as described in 89 Ill. Adm. Code 120.10(h).  Notwithstanding any rule to the contrary in Title 89, the services that shall be covered are services for which the Department obtains federal approval and receives federal matching funds; and

 

8)         beginning January 1, 2014, Former Foster Care as described in 89 Ill. Adm. Code 120.10(i).

 

b)         The following medical services shall be covered for recipients under age 21 who are included under subsection (a):

 

1)         Inpatient hospital services;

 

2)         Hospital outpatient and clinic services;

 

3)         Hospital emergency room visits.  The visit must be for the alleviation of severe pain or for immediate diagnosis and/or treatment of conditions or injuries that might result in disability or death if there is not immediate treatment;

 

4)         Encounter rate clinic visits;

 

5)         Physician services;

 

6)         Pharmacy services;

 

7)         Home health agency visits;

 

8)         Laboratory and x-ray services;

 

9)         Group care services;

 

10)         Family planning services and supplies;

 

11)         Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies;

 

12)         Transportation to secure medical services;

 

13)         EPSDT services pursuant to Section 140.485;

 

14)         Dental services;

 

15)         Chiropractic services;

 

16)         Podiatric services;

 

17)         Optical services and supplies;

 

18)         Subacute alcoholism and substance abuse services pursuant to Sections 140.390 through 140.396;

 

19)         Hospice services;

 

20)         Nursing care pursuant to Section 140.472;

 

21)         Nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting pursuant to 89 Ill. Adm. Code 146, Subpart D;

 

22)         Telehealth services pursuant to Section 140.403;

 

23)         Preventive services;

 

24)         Licensed Clinical Social Worker services;

 

25)         Licensed Clinical Psychologist services;

 

26)         Effective January 1, 2018, abortion services; and

 

27)         Effective January 1, 2022, coverage of routine patient cost for items and services in connection with participation in a qualified clinical trial, as defined in Section 1905(gg) of the Social Security Act.

 

c)         Effective July 1, 2012, the following medical services shall be covered for recipients age 21 or over who are included under subsection (a):

 

1)         Inpatient hospital services;

 

2)         Hospital outpatient and clinic services;

 

3)         Hospital emergency room visits.  The visit must be for the alleviation of severe pain or for immediate diagnosis and/or treatment of conditions or injuries that might result in disability or death if there is not immediate treatment;

 

4)         Encounter rate clinic visits;

 

5)         Physician services;

 

6)         Pharmacy services;

 

7)         Home health agency visits;

 

8)         Laboratory and x-ray services;

 

9)         Group care services;

 

10)         Family planning services and supplies;

 

11)         Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies;

 

12)         Transportation to secure medical services;

 

13)         Subacute alcoholism and substance abuse services pursuant to Sections 140.390 through 140.396;

 

14)         Hospice services;

 

15)         Dental services, pursuant to Section 140.420;

 

16)         Podiatric services, pursuant to Section 140.425 for individuals with a diagnosis of diabetes;

 

17)         Optical services and supplies;

 

18)         Telehealth services pursuant to Section 140.403;

 

19)         Preventive services;

 

20)         Licensed Clinical Social Worker services;

 

21)         Licensed Clinical Psychologist services;

 

22)         Effective January 1, 2018, abortion services; and

 

23)         Effective January 1, 2022, coverage of routine patient cost for items and services in connection with participation in a qualified clinical trial, as defined in Section 1905(gg) of the Social Security Act.

 

(Source:  Amended at 46 Ill. Reg. 18061, effective October 27, 2022)

 

Section 140.4  Covered Medical Services Under AFDC-MANG for non-pregnant persons who are 18 years of age or older (Repealed)

 

(Source:  Repealed at 9 Ill. Reg. 14684, effective September 13, 1985)

 

Section 140.5  Covered Medical Services Under General Assistance

 

This program is no longer in effect as of July 1, 2012.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.6  Medical Services Not Covered

 

The following services are not covered under the Department's medical assistance programs:

 

a)         Services available without charge;

 

b)         Services prohibited by State or federal law;

 

c)         Experimental procedures;

 

d)         Research oriented procedures; other than those described in Section 140.3(b)(27) and 140.3(c)(23);

 

e)         Medical examinations required for entrance into educational or vocational programs;

 

f)         Autopsy examinations;

 

g)         Artificial insemination;

 

h)         Medical or surgical procedures performed for cosmetic purposes;

 

i)          Medical or surgical transsexual treatment, for dates of service prior to April 1, 2015;

 

j)          Diagnostic and/or therapeutic procedures related to primary infertility/sterility;

 

k)         Subsequent treatment for venereal disease, when those services are available through State and/or local health agencies;

 

l)          Medical care provided by mail or telephone;

 

m)        Unkept appointments;

 

n)         Non-medically necessary items and services provided for the convenience of recipients and/or their families; and

 

o)         Preparation of routine records, forms and reports.

 

p)         Visits with persons other than a recipient, such as family members or group care facility staff.

 

(Source:  Amended at 49 Ill. Reg. 4026, effective March 20, 2025)

 

Section 140.7  Medical Assistance Provided to Individuals Under the Age of Eighteen Who Do Not Qualify for AFDC and Children Under Age Eight

 

a)         Individuals Under Age Eighteen (18)

 

1)         Medical assistance shall be provided to individuals under the age of eighteen who do not qualify for AFDC under the definition of dependent child as defined in 89 Ill. Adm. Code 101.20 and 112.60 through 112.64.  However, such individuals must meet the eligibility requirements and other provisions of 89 Ill. Adm. Code 112.10, 112.20, 112. Subparts C and D, 112.303, 112.304 and 112.307 through 112.309.

 

2)         If non-exempt countable income is equal to or less than the appropriate MANG (AFDC) standard the individual is eligible for payment of his/her allowable medical care costs.

 

3)         Persons whose income exceeds the appropriate MANG (AFDC) standard are eligible for medical assistance each month incurred or paid medical care costs equals the amount of excess non-exempt income over the standard.  When income exceeds the MANG (AFDC) standard, eligibility begins on the day in the month incurred or paid medical care costs equals excess monthly income.  Eligibility ends on the last day of the same month.

 

b)         Children Under Age Eight (8) Medical assistance shall be provided to children under age six (6) who do not qualify as mandatory categorically needy (Social Security Act (42 U.S.C. 1902(a)(10)(A)(i) and 1905(n)) and meet the eligibility requirements of 89 Ill. Adm. Code 120.11, 120.31 and 120.64.

 

(Source:  Amended at 15 Ill. Reg. 11176, effective August 1, 1991)

 

Section 140.8  Medical Assistance For Qualified Severely Impaired Individuals

 

Medical assistance shall be provided under the AABD program to a qualified severly impaired individual whose Supplemental Security Income (SSI) payment status is based on Section 1619 of the Social Security Act (the Act) (42 U.S.C. 1382h)) if he/she was eligible for Medicaid in the month prior to first becoming eligible under Section 1619 of the Act (see 89 Ill. Adm. Code 113:  Subparts B and C, and 89 Ill. Adm. Code 120.10 and 120.60).  A qualified severely impaired individual is any person under age 65 who received either SSI, State Supplemental Payment or special Section 1619(a) of the Act benefits and was eligible for Medicaid and who the Social Security Administration determines meets all of the following criteria:

 

a)         is blind or disabled under Title XVI of the Act (see 42 U.S.C. 1382c);

 

b)         meets all SSI requirements except for earned income;

 

c)         would be seriously inhibited by the lack of Medicaid coverage from continuing to work or obtaining employment; and

 

d)         has earnings insufficient to provide a reasonable equivalent of Medicaid, SSI and Title XX (42 U.S.C. 1397 et seq.) attendant care benefits that would be available if he/she did not work.

 

(Source:  Added at 12 Ill. Reg. 916, effective January 1, 1988)

 

Section 140.9  Medical Assistance for a Pregnant Woman Who Would Not Be Categorically Eligible for AFDC/AFDC-MANG if the Child Were Already Born Or Who Do Not Qualify As Mandatory Categorically Needy

 

a)         Pregnant Women Who Would Not Be Categorically Eligible for AFDC/AFDC‑MANG if the Child Were Already Born

 

1)         Medical assistance will be provided to applicants of any age who are pregnant and meet the asset standards of the AFDC medical assistance program and who would not be eligible for AFDC if the child were already born because:

 

A)        the father is not absent, and

 

B)        neither parent is incapacitated and the principal wage earner does not meet the Department's definition of unemployment (see 89 Ill. Adm. Code 112.64).

 

2)         Medical Assistance for up to sixty (60) days following the last day of pregnancy

 

A)        Medical assistance shall be provided for the woman and newborn child for 60 days following the last day of the pregnancy.  The sixty (60) day medical coverage continues through the last day of the calendar month in which the sixty (60) day period ends.

 

B)        In order for a pregnant woman to qualify for the extended sixty (60) day medical coverage, an AFDC MANG application must have been filed prior to the date the pregnancy ended.

 

b)         Pregnant Women Who Do Not Qualify As Mandatory Categorically Needy

 

1)         Medical assistance shall be provided to women of any age who do not qualify as mandatory categorically needy (Sections 1902(a)(10)(A)(i) and 1905(n) of the Social Security Act) and meet the eligibility requirements of 89 Ill. Adm. Code 120.11, 120.31 and 120.64).

 

2)         Medical Assistance shall be provided for the woman and newborn child(ren) for up to sixty (60) days following the last day of the pregnancy.  The sixty (60) day medical coverage continues through the last day of the calendar month in which the sixty (60) day period ends.

 

(Source:  Amended at 12 Ill. Reg. 19734, effective November 15, 1988)

 

Section 140.10  Medical Assistance Provided to Persons Confined or Detained by the Criminal Justice System

 

a)         The Department shall pay for certain medical services provided to the following groups of individuals who are confined or detained in county jails or other detention facilities in Illinois, that are not operated by the State, and who are eligible for, and enrolled in, medical assistance administered under Article V of the Illinois Public Aid Code [305 ILCS 5]:

 

1)         Individuals who, at the time of confinement or detention, were already enrolled for medical assistance.

 

2)         Individuals who, subsequent to their confinement or detention, were determined eligible and enrolled for medical assistance.

 

b)         Reimbursement of hospital inpatient services.  The Department will directly reimburse hospitals pursuant to 89 Ill. Adm. Code 147, 148 and 152 for inpatient hospital services provided to those covered under subsections (a)(1) and (2) of this Section.

 

c)         Reimbursement of other services:

 

1)         With respect to medical services provided to individuals described in subsection (a)(1), the Department shall reimburse the county or arresting authority (a unit of local government other than a county that employs peace officers who make the arrest) for a portion of the cost of medical services, other than hospital inpatient services, that are:

 

A)        Provided to the individual during his or her period of confinement or detention;

 

B)        Covered for the class of persons described in Section 5-2 of the Public Aid Code under which the individual is enrolled;

 

C)        Provided by medical providers that are enrolled with the Department to participate in the medical assistance program; and

 

D)        Provided pursuant to a county or arresting authority ordinance or resolution providing for reimbursement for the cost of medical services at the reimbursement levels established by the Department for medical assistance under Article V of the Public Aid Code.

 

2)         The county or arresting authority requesting reimbursement from the Department must submit the following documentation in a form and format specified by the Department:

 

A)        Information necessary to adjudicate a claim for each service provided, including, but not limited to:

 

i)          the name, birth date, Social Security number and recipient identification number of the individual receiving the medical service;

 

ii)         the name, address and provider number of the health care provider that provided the service;

 

iii)        the service provided, including applicable diagnosis, procedure and national drug codes; and

 

iv)        the provider charges and the amount paid by the county or arresting authority for the services.

 

B)        The date of confinement and, if applicable, the date of release or transfer to another criminal justice authority.

 

C)        Verification that the services claimed for reimbursement correspond to the services rendered.

 

D)        A copy of the ordinance or resolution providing for reimbursement for the cost of medical services at the reimbursement levels established by the Department for medical assistance pursuant to Article V of the Public Aid Code.

 

3)         The Department will adjudicate each claim applying its reimbursement rates and, to the extent that the cost of care for the individual exceeds $500 accumulated over the individual's period of confinement, will reimburse the county or arresting authority the amount in excess of $500.

 

(Source:  Amended at 35 Ill. Reg. 394, effective December 27, 2010)

SUBPART B: MEDICAL PROVIDER PARTICIPATION

 

Section 140.11  Enrollment Conditions for Medical Providers

 

a)         In order to enroll for participation, providers shall:

 

1)         Hold a valid, appropriate license where State law requires licensure of medical practitioners, agencies, institutions and other medical vendors.

 

2)         Be certified for participation in the Title XVIII Medicare program where federal or State rules and regulations require such certification for Title XIX participation.

 

3)         Be certified for Title XIX when federal or State rules and regulations so require.

 

4)         Provide enrollment information to the Department in the prescribed format, and notify the Department, in writing, immediately whenever there is a change in any such information which the provider has previously submitted.

 

5)         Provide disclosure, as requested by the Department, of 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 to public aid recipients.

 

6)         Have a written provider agreement on file with the Department.

 

b)         Approval of a corporate entity such as a pharmacy, laboratory, durable medical equipment and supplies provider, medical transportation provider, nursing home or renal satellite facility, as a participant in the Medical Assistance Program, applies only to the entity's existing ownership, corporate structure and location; therefore, participation approval is not transferable.

 

c)         Except for children's hospitals described at 89 Ill. Adm. Code 148.25(d)(3)(B), hospitals providing inpatient care that are certified under a single Centers for Medicare and Medicaid Services certification number shall be enrolled as a single entity in the Medical Assistance Program.  A children's hospital must be separately enrolled from the general care hospital with which it is affiliated.

 

d)         Upon notification from the Illinois Department of Public Health of a change of ownership, the Department shall notify the prospective buyer of its obligation under Section 140.12(l) to assume liability for repayment to the Department for overpayments made to the current owner or operator.  Such notification shall inform the prospective buyer of all outstanding known liabilities due to the Department by the facility and of any known pending Department actions against the facility that may result in further liability. For long term care providers, when there is a change of ownership of a facility or a facility is leased to a new operator, the provider agreement shall be automatically assigned to the new owner or lessee. Such assigned agreement shall be subject to all conditions under which it was originally issued, including, but not limited to, any existing plans of correction, all requirements of participation as set forth in Section 140.12 or additional requirements imposed by the Department.

 

e)         For purposes of administrative efficiency, the Department may periodically require classes of providers to re-enroll in the Medical Assistance Program.  Under such re-enrollments, the Department shall request classes of providers to submit updated enrollment information.  Failure of a provider to submit such information within the requested time frames will result in the disenrollment of the provider from the Program.  Such disenrollment shall have no effect on the future eligibility of the provider to participate in the Program and is intended only for purposes of the Department’s efficient administration of the Program.  A disenrolled provider may reapply to the Program and all such re-applications must meet the requirements for enrollment.

 

f)         For purposes of this Section, a vendor whose investor ownership has changed by 50 percent or more from the date the vendor was initially approved for enrollment in the Medical Assistance Program shall be required to submit a new application for enrollment in the Medical Assistance Program.  All such applications must meet the requirements for enrollment.

 

g)         Anything in this Subpart B to the contrary notwithstanding, enrollment of a vendor is subject to a provisional period and shall be conditional for one year unless limited by the Department.  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.  Upon termination of a vendor under this subsection (g), the following individuals shall be barred from participation in the Medical Assistance Program:

 

1)         Individuals with management responsibility;

 

2)         All owners or partners in a partnership;

 

3)         All officers of a corporation or individuals owning, directly or indirectly, five percent or more of the shares of stock or other evidence of ownership in a corporation; or

 

4)         An owner of a sole proprietorship.

 

h)         Unless otherwise specified, the termination of eligibility or vendor disenrollment, as described in subsection (g) of this Section, and resulting barrments are not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty.

 

(Source:  Amended at 38 Ill. Reg. 15081, effective July 2, 2014)

 

Section 140.12  Participation Requirements for Medical Providers

 

The provider shall agree to:

 

a)         Verify eligibility of recipients prior to providing each service;

 

b)         Allow recipients the choice of accepting or rejecting medical or surgical care or treatment;

 

c)         Provide supplies and services in full compliance with all applicable provisions of State and federal laws and regulations pertaining to nondiscrimination and equal employment opportunity including but not limited to:

 

1)         Full compliance with Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color or national origin;

 

2)         Full compliance with Section 504 of the Rehabilitation Act of 1973 and 45 CFR 84, which prohibit discrimination on the basis of handicap; and

 

3)         Without discrimination on the basis of religious belief, political affiliation, sex, age or disability;

 

d)         Comply with the requirements of applicable federal and State laws and not engage in practices prohibited by such laws;

 

e)         Provide, and upon demand present documentation of, education of employees, contractors and agents regarding the federal False Claims Act (31 USC 3729‑3733) that complies with all requirements of 42 USC 1396a(a)(68).  Providers subject to this requirement include a governmental agency, organization, unit, corporation, partnership, or other business arrangement (including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists), whether for-profit or no‑for‑profit, that receives or makes payments totaling at least $5 million annually;

 

f)         Hold confidential, and use for authorized program purposes only, all Medical Assistance information regarding recipients;

 

g)         Furnish to the Department, in the form and manner requested by it, any information it requests regarding payments for providing goods or services, or in connection with the rendering of goods or services or supplies to recipients by the provider, his agent, employer or employee;

 

h)         Make charges for the provision of services and supplies to recipients in amounts not to exceed the provider's usual and customary charges and in the same quality and mode of delivery as are provided to the general public;

 

i)          Accept as payment in full the amounts established by the Department.

 

1)         If a provider accepts an individual eligible for medical assistance from the Department as a Medicaid recipient, such provider shall not bill, demand or otherwise seek reimbursement from that individual or from a financially responsible relative or representative of the individual for any service for which reimbursement would have been available from the Department if the provider had timely and properly billed the Department.  For purposes of this subsection, "accepts" shall be deemed to include:

 

A)        an affirmative representation to an individual that payment for services will be sought from the Department;

 

B)        an individual presents the provider with his or her medical card and the provider does not indicate that other payment arrangements will be necessary; or

 

C)        billing the Department for the covered medical service provided an eligible individual.

 

2)         If an eligible individual is entitled to medical assistance with respect to a service for which a third party is liable for payment, the provider furnishing the service may not seek to collect from the individual payment for that service if the total liability of the third party for that service is at least equal to the amount payable for that service by the Department.

 

j)          Accept assignment of Medicare benefits for public aid recipients eligible for Medicare, when payment for services to such persons is sought from the Department;

 

k)         Complete an MCH (Maternal and Child Health) Primary Care Provider Agreement in order to participate in the Maternal and Child Health Program (see Section 140.924(a)(1)(D)); and

 

l)          In the case of long term care providers, assume liability for repayment to the Department of any overpayment made to a facility regardless of whether the overpayment was incurred by a current owner or operator or by a previous owner or operator.  Liability of current and previous providers to the Department shall be joint and several.  Recoveries by the Department under this Section may be made pursuant to Sections 140.15 and 140.25.  A current or previous owner or lessee may request from the Department a list of all known outstanding liabilities due the Department by the facility and of any known pending Department actions against a facility that may result in further liability.  For purposes of this Section, "overpayment" shall include, but not be limited to:

 

1)         Amounts established by final administrative decisions pursuant to 89 Ill. Adm. Code 104;

 

2)         Overpayments resulting from advance C-13 payments made pursuant to Section 140.71;

 

3)         Liabilities resulting from nonpayment or delinquent payment of assessments pursuant to Sections 140.82, 140.84 and 140.94; and

 

4)         Amounts identified during past, pending or future audits that pertain to audit periods prior to a change in ownership and are conducted pursuant to Sections 140.30 and 140.590.  Liability of current owners or operators for amounts identified during such audits shall be as follows:

 

A)        For past audits (audits completed before changes in ownership), liability shall be the amount established by final administrative decision.

 

B)        For pending audits (audits initiated, but not completed prior to the change in ownership), liability shall be limited to the lesser of the amounts established by final administrative decision or two months of service revenue. Two months of service revenue is defined as the most recent two months of Medicaid patient days multiplied by the total Medicaid rate in effect on the date the new owner or operator is enrolled in the Program as a provider by the Department. The Medicaid rate in effect on the date of enrollment shall be used even if that rate is subsequently changed.

 

C)        For future audits (audits initiated after the change in ownership but pertaining to an audit period prior to a change in ownership), liability shall be limited as described in subsection (l)(4)(B) of this Section.

 

m)        A provider that is eligible to participate in the 340B federal Drug Pricing Program under section 340B of the federal Public Health Service Act (47 USC 201 et seq.), 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. A provider enrolled in the 340B federal Drug Pricing Program must charge the Department no more than its actual acquisition cost for the drug product, plus the Department established dispensing fee.  This requirement is effective October 1, 2012 for 340B providers who own and/or operate a pharmacy that bills the Department for drugs, unless the 340B provider is a Hemophilia Treatment Center (HTC); July 1, 2013 for providers who are eligible to participate in the 340B program as HTCs; and January 1, 2013 for all other 340B-eligible providers who bill the Department for drugs.  Contract pharmacies are exempt from the requirements of this subsection (m).

 

(Source:  Amended at 38 Ill. Reg. 18462, effective August 19, 2014)

 

Section 140.13  Definitions

 

"Abuse".  For purposes of this Part and 89 Ill. Adm. Code 104, "abuse" means provider practices that are inconsistent with sound fiscal, business or medical practices and that result in an unnecessary cost to the Medical Assistance Program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also includes recipient practices that result in unnecessary cost to the Medical Assistance Program.  Abuse does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.

 

"Alternate Payee".  For purposes of this Part, "Alternate Payee" shall mean an entity that is registered as an alternate payee in the Medical Assistance Program.  An individual practitioner may designate payments due the practitioner be made to an alternate payee.

 

"Code".  For purposes of this Part, "Code" means the Public Aid Code [305 ILCS 5].

 

"Credible Allegation". For purposes of this Part, "credible allegation" includes an allegation from any source, including, but not limited to, fraud hotline complaints, claims data mining, patterns identified through provider audits, civil actions filed under the False Claims Act [740 ILCS 175], and law enforcement investigations.  An allegation is considered to be credible when it has indicia of reliability.

 

"Credible Evidence". For purposes of this Part, "credible evidence" shall mean evidence that reasonable people would agree as being trustworthy and reliable.

 

"Department Policy".  For purposes of this Part, "Department policy" shall mean the written requirements of the Department set forth in the Medical Assistance Program Handbooks, and the Department's written manuals, bulletins and releases.  It shall also include any additional policy statements transmitted in writing to a vendor.

 

"Entity".  For purposes of this Part, "entity" means any person, firm, corporation, partnership, association, agency, institution, or other legal organization.

 

"Fraud".  For purposes of this Part and 89 Ill. Adm. Code 104, "fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person.  It includes any act that constitutes fraud under applicable federal or State law.

 

"Harm".  For purposes of this Part and 89 Ill. Adm. Code 104, "harm" means physical, mental or monetary damage to recipients or to the Medical Assistance Program.

 

"Investor".  For purposes of this Part, "investor" shall mean any entity that owns (directly or indirectly) five percent or more of the shares of stock or other evidences of ownership of a vendor, or holds (directly or indirectly) five percent or more of the debt of a vendor, or owns and holds (directly or indirectly) three percent or more of the combined debt and equity of a vendor.

 

"Management Responsibility".  For purposes of this Part, a person with management responsibility includes a person vested with discretion or judgment who either alone or in conjunction with others, conducts, administers or oversees either the general concerns of the vendor or a portion of the vendor's concerns.  A person with management responsibility shall specifically include the pharmacist in a pharmacy, the medical director of a laboratory, the administrator of a hospital or nursing home, the dispatcher in a transportation vendor, dispatchers and all individuals in charge of day to day operations of a non-emergency transportation vendor, the person or persons responsible for preparation and submittal of billings for services to the Department, and the manager of a group practice, clinic or shared health facility.

 

"Non-Emergency Transportation Vendor".  For purposes of this Part, non-emergency transportation vendor shall mean any transportation provider identified in Section 140.490(a) other than those identified in Section 140.490(a)(1) and (a)(6).

 

"Technical or Other Advisor".  For purposes of this Part, "technical or other advisor" shall mean any entity that provides any form of advice to a vendor regarding the vendor's business or participation in the Medical Assistance Program in return for compensation, directly or indirectly, in any form.

 

"Vendor".  For purposes of this Part, "vendor" or "provider" shall mean a person, firm, corporation, association, agency, institution, or other legal entity that provides goods or services to a recipient or recipients, and is enrolled to participate in the Medical Assistance Program pursuant to 89 Ill. Adm. Code 140.11 and 140.12.

 

"Waste".  For purposes of this Part and 89 Ill. Adm. Code 104, "waste" means the unintentional misuse of medical assistance resources, resulting in unnecessary cost to the Medical Assistance Program.  Waste does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.14  Denial of Application to Participate in the Medical Assistance Program

 

a)         The Department may deny an application to participate in the Medical Assistance Program if the vendor has engaged in activities which constitute grounds for termination, suspension or exclusion under Section 140.16.  If the activities were engaged in prior to December 1, 1977, they may be used as the basis for denial of an application only if the vendor had actual or constructive knowledge of the requirements which applied to his conduct or activities.

 

b)         Denial of Application

 

1)         The Department may deny an application submitted by a vendor if:

 

A)        the vendor cannot reasonably be expected to meet the written requirements of the Department including those set forth in the Medical Assistance Program Handbooks and the Department's manuals, bulletins and releases; or

 

B)        the Department determines, after reviewing the activities that served as the basis for the earlier termination or barring, that the application should not be approved.  Factors to be considered by the Department in making this determination shall include:

 

i)          length of time the vendor has not participated in the Medical Assistance Program;

 

ii)         magnitude and severity of the activities that led to the binding administrative decision which served as the basis for the vendor's termination, barring or denied participation;

 

iii)        mitigating circumstances presented by the vendor;

 

iv)        whether the deficiencies that served as the basis for the vendor to be terminated, barred or denied participation are corrected;

 

v)         whether the vendor demonstrates a fitness to participate in the Medical Assistance Program; and

 

vi)        the extent to which any legally enforceable debts owed to the Department by the applicant or an entity in which the applicant or his or her nominee held a substantial ownership interest have been paid.

 

2)         These factors must be established by submission of documentary evidence in support of the application.

 

c)         The Department may deny an application of a previously terminated or barred applicant if the applicant, without special permission from the Department, has already become a vendor, an entity with management responsibility for a vendor, an incorporator, officer or member of the board of directors of a vendor, an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an owner of a sole proprietorship vendor, a partner in a partnership vendor, a technical or other advisor to a vendor, or an investor in a vendor.

 

d)         Effective July 1, 2012, the Department shall deny an application to participate in the Medical Assistance Program of any person, firm, corporation, association, agency, institution or other legal entity:

 

1)         immediately, if the vendor is not properly licensed, certified or authorized;

 

2)         within 30 days after the date when the vendor's professional license, certification or other authorization has been refused renewal, restricted or revoked, suspended or otherwise terminated; or

 

3)         if the vendor has been convicted of a violation of the Public Aid Code, as provided in Article VIIIA of the Code.

 

e)         Effective July 1, 2012, the Department may deny the eligibility of any person, firm, corporation, association, agency, institution or other legal entity to participate as a vendor if, after reasonable notice and opportunity for a hearing, the Department finds:

 

1)         The applicant or any person with management responsibility for the applicant; an officer or member of the board of directors of an applicant; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor applicant; an owner of a sole proprietorship applicant; a partner in a partnership applicant; or a technical or other advisor to an applicant has a debt owed to the Department, and no payment arrangements acceptable to the Department have been made by the applicant.

 

2)         The applicant or any person with management responsibility for the applicant; an officer or member of the board of directors of an applicant; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor applicant; an owner of a sole proprietorship applicant; a partner in a partnership vendor applicant; or a technical or other advisor to an applicant, during a period of time when the conduct of that vendor resulted in a debt owed to the Department and no payment arrangements acceptable to the Department have been made by that vendor, was:

 

A)        a person with management responsibility;

 

B)        an officer or member of the board of directors of an applicant;

 

C)        an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor;

 

D)        an owner of a sole proprietorship;

 

E)        a partner in a partnership vendor; or

 

F)         a technical or other advisor to a vendor.

 

3)         There is a credible allegation, as defined in Section 140.13, of the use, transfer or lease of assets of any kind to an applicant from a current or prior vendor who has a debt owed to the Department, no payment arrangements acceptable to the Department have been made by that vendor or the vendor's alternate payee, and the applicant knows or should have known of the debt.

 

4)         There is a credible allegation of a transfer of management responsibilities, or direct or indirect ownership, to an applicant from a current or prior vendor who has debt owed to the Department, and no payment arrangements acceptable to the Department have been made by the vendor or the vendor's alternate payee, and the applicant knows or should have known of the debt.

 

5)         There is a credible allegation of the use, transfer or lease of assets of any kind to an applicant who is a spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, relative by marriage, nephew, cousin or other relative of a current or prior vendor who has a debt owed to the Department and no payment arrangements acceptable to the Department have been made.

 

6)         There is a credible allegation that the applicant's previous affiliations with a provider of medical services that has an uncollected debt, a provider that has been or is subject to a payment suspension under a federal health care program, or a provider that has been previously excluded from participation in the Medical Assistance Program, poses a risk of fraud, waste or abuse to the Department.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.15  Suspension and Denial of Payment, Recovery of Money and Penalties

 

a)         Effective July 1, 2012, theDepartment may suspend or deny payment, in whole or in part, to a vendor or the vendor's alternate payee if the payment would be improper or erroneous or would otherwise result in overpayment.  The Department may recover money improperly or erroneously paid, or overpayments (see subsection (b) of this Section for exception to recovery of money), made to a vendor or vendor's alternate payee, either by setoff (deducting from Department obligations to the vendor or the designated alternate payee), deductions from future billings or by requiring direct repayment. Payments may be suspended, denied or recovered from a vendor or alternate payee:

 

1)         for services rendered in violation of the Department's provider notices, statutes, rules and regulations;

 

2)         for services rendered in violation of the terms and conditions prescribed by the Department in its vendor agreement;

 

3)         for any vendor who fails to grant the Office of Inspector General of the Department timely access to full and complete records, including, but not limited to, records relating to recipients under the Medical Assistance Program for the most recent six years, in accordance with Section 140.28, and other information for the purpose of audits, investigations or other program integrity functions, after reasonable written request by the Inspector General; provided, however, that this subsection (a)(3) does not require vendors to make available the medical records of patients for whom services are not reimbursed under this Part or to provide access to medical records more than six years old;

 

4)         when the vendor has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the Medical Assistance Program;

 

5)         when the vendor previously rendered services while terminated, suspended or excluded from participation in the Medical Assistance Program or while terminated or excluded from participation in another state or federal medical assistance or health care program; or

 

6)         for ground ambulance services rendered as the result of improper or false certification.  Overpayments can be recovered from a vendor, including, but not limited to, from the discharging physician, the discharging facility, and the ground ambulance service provider.

 

b)         If a practitioner designates an alternate payee, the practitioner and the alternate payee shall be jointly and severally liable to the Department for payments made to the alternate payee.  Recoveries by the Department may be made against either party or both, at the Department's option.

 

c)         The Department shall not recoup from any long term care provider any amounts subsequently determined to be owed by a client due to an error in the initial determination of medical eligibility.

 

d)         Effective July 1, 2012, if  it is established through an administrative hearing that an overpayment resulted from a vendor or the designated alternate payee knowingly making, using, or causing to be made or used, a false record or statement to obtain payment or other benefit from the medical assistance program, in addition to any other penalties that may be prescribed by law:

 

1)         the Department may recover interest (based on criteria in 89 Ill. Adm. Code 104.206(d)(2)) on the amount of the overpayment or other benefit from the vendor or alternate payee at the rate of 5% per annum;

 

2)         the vendor or alternate payee shall be subject to civil penalties consisting of an amount not to exceed three times the amount of payment or other benefit resulting from each false record or statement; and

 

3)         the vendor or alternate payee shall be subject to payment of a penalty of $2,000 for each false record or statement for payment or other benefit.

 

e)         Effective July 1, 2012, for purposes of this Section, "knowingly" means that a vendor or alternate payee, with respect to information:

 

1)         has actual knowledge of the information;

 

2)         acts in deliberate ignorance of the truth or falsity of the information; or

 

3)         acts in reckless disregard of the truth or falsity of the information.  No proof of specific intent to defraud is required.

 

f)         If a vendor has the same taxpayer identification number (assigned under section 6109 of the Internal Revenue Code of 1986) as is assigned to a vendor with past-due financial obligations to the Department, the Department may make any necessary adjustments to payments to that vendor in order to satisfy any past-due obligations, regardless of whether the vendor is assigned a different billing number under the Medical Assistance Program.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.16  Termination, Suspension or Exclusion of a Vendor's Eligibility to Participate in the Medical Assistance Program

 

a)         The Department may terminate or suspend a vendor's eligibility to participate in the Medical Assistance Program, terminate or not renew a vendor's provider agreement, or exclude a person or entity from participation in the Medical Assistance Program, when it determines that, at any time:

 

1)         The vendor is not complying with the Department's policy or rules, or with the terms and conditions prescribed by the Department in any vendor agreement developed as a result of negotiations with the vendor category, or with the covenants contained in certifications bearing the vendor's signature on claims submitted to the Department by the vendor, or with restrictions on participation imposed pursuant to Section 140.32;

 

2)         The vendor, person or entity is not properly licensed, certified, authorized or otherwise qualified, or the vendor person's or entity's professional license, certificate or other authorization has not been renewed or has been restricted, revoked, suspended or otherwise terminated as determined by the appropriate licensing, certifying or authorizing agency.  The termination, suspension or exclusion shall be immediately effective;

 

3)         The vendor violates records requirements as set forth in statute or Department rules, provider handbooks or policies.

 

A)        The vendor has failed to keep or timely make available for inspection, audit or copying (including photocopying), after receiving a written request from the Department:

 

i)          records required to be maintained by the Department or necessary to fully and completely disclose the extent of the services or supplies provided; or

 

ii)         full and complete records required to be maintained by the Department regarding payments claimed for providing services.

 

B)        This subsection (a)(3) does not require vendors to make available medical records of patients for whom services are not reimbursed under the Illinois Public Aid Code;

 

4)         The vendor has failed to furnish any information requested by the Department regarding payments for providing goods or services, or has failed to furnish all information required by the Department in connection with the rendering of services or supplies to recipients of public assistance by the vendor or his or her agent, employer or employee;

 

5)         The vendor has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the Medical Assistance Program.  For purposes of this subsection (a)(5), statements or representations made "knowingly" shall include statements or representations made with actual knowledge that they were false as well as those statements made when the individual making the statement had knowledge of such facts or information as would cause one to be aware that the statements or representations were false when made;

 

6)         The vendor has submitted claims for services or supplies that were not rendered or delivered by that vendor;

 

7)         The vendor has furnished goods or services to a recipient that, when based upon competent medical judgment and evaluation, are determined to be:

 

A)        in excess of needs;

 

B)        harmful (for the purpose of this subsection (a)(7)(B), "harmful" goods or services cause actual harm as defined in Section 140.13 or place an individual at risk of harm, or of adverse side effects, that outweigh the medical benefits sought); or

 

C)        of grossly inferior quality;

 

8)         The vendor knew or should have known that a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an investor in the vendor, a technical or other advisor of the vendor, an owner of a sole proprietorship that is a vendor, or a partner in a partnership that is a vendor was previously terminated, suspended, excluded or barred from participation in the Medical Assistance Program, or in another state or federal medical assistance or health care program;

 

9)         The vendor has a delinquent debt owed to the Department;

 

10)         The vendor engaged in practices prohibited by federal or State law or regulation.

 

A)        The vendor, a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor, an owner of a sole proprietorship that is a vendor, or a partner in a partnership that is a vendor, either:

 

i)          has engaged in practices prohibited by applicable federal or State law or regulation; or

 

ii)         was a person with management responsibility for a vendor at the time that the vendor engaged in practices prohibited by applicable federal or State law or regulation; or

 

iii)        was an officer, or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a vendor at the time the vendor engaged in practices prohibited by applicable federal or State law or regulation; or

 

iv)        was an owner of a sole proprietorship or partner of a partnership that was a vendor at the time the vendor engaged in practices prohibited by applicable federal or State law or regulation;

 

B)        For purposes of this subsection (a)(10), "applicable federal or State law or regulation" includes, but is not limited to, licensing or certification standards contained in State or federal law or regulations related to the Medical Assistance Program, any other licensing standards as they relate to the vendor's practice or business or any federal or State laws or regulations related to the Medical Assistance Program;

 

C)        For purposes of this subsection (a)(10), conviction or a plea of guilty to activities violative of applicable federal or State law or regulation shall be conclusive proof that those activities were engaged in;

 

11)         The vendor, a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an owner of a sole proprietorship that is a vendor, or a partner in a partnership that is a vendor has been convicted in this or any other State, or in any Federal Court, of any offense not related to the Medical Assistance Program, if the offense constitutes grounds for disciplinary action under the licensing Act applicable to that individual or vendor;

 

12)         The vendor, a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an owner of a sole proprietorship that is a vendor, or partner in a partnership that is a vendor has been convicted in this or any other state, or in any Federal Court, of:

 

A)        murder;

 

B)        a Class X felony under the Illinois Criminal Code of 1961;

 

C)        sexual misconduct that may subject recipients to an undue risk of harm;

 

D)        a criminal offense that may subject recipients to an undue risk of harm;

 

E)        a crime of fraud or dishonesty;

 

F)         a crime involving a controlled substance;

 

G)        a misdemeanor relating to fraud, theft, embezzlement or breach of fiduciary responsibility; or

 

H)        other financial misconduct related to a health care program.

 

13)         The direct or indirect ownership of the terminated, suspended or excluded vendor (including the ownership of a vendor that is a sole proprietorship, a partner's interest in a vendor that is a partnership, or ownership of 5% or more of the shares of stock or other evidences of ownership in a corporate vendor) has been transferred by an individual to the individual's spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin or relative by marriage.

 

b)         The Department may suspend a vendor's eligibility to participate in the Medical Assistance Program if the vendor is not in compliance with State income tax requirements, child support payments in accordance with Article X of the Illinois Public Aid Code, or educational loans guaranteed by the Illinois Student Assistance Commission.  The vendor may prevent suspension of eligibility by payment of past-due amounts in full or by entering into payment arrangements acceptable to the appropriate State agency.

 

c)         The Department may terminate, suspend or exclude vendors who pose a risk of fraud, waste, abuse or harm, as defined in Section 140.13, from participation in the Medical Assistance Program.

 

(Source:  Amended at 38 Ill. Reg. 15081, effective July 2, 2014)

 

Section 140.17  Suspension of a Vendor's Eligibility to Participate in the Medical Assistance Program

 

In actions based on Section 140.16 in which the Notice states an intent to terminate, the final administrative decision may result in suspension for a specific time, which shall not exceed one year from the time of the final administrative decision, rather than termination, when the Department determines that:

 

a)         the seriousness and extent of the violations do not warrant termination; and

 

b)         the vendor had no prior history of violations of the Medical Assistance Program; and

 

c)         the lesser sanction of suspension will be sufficient to remedy the problem created by the vendor's violations.

 

(Source:  Amended at 16 Ill. Reg. 17302, effective November 2, 1992)

 

Section 140.18  Effect of Termination, Suspension, Exclusion or Revocation on Persons Associated with Vendor

 

a)         Upon termination, suspension or exclusion of a vendor of goods or services from participation in the Medical Assistance Program, a person with management responsibility for such vendor during the time of any conduct that served as the basis for that vendor's termination, suspension or exclusion is barred from participation in the Medical Assistance Program.

 

b)         Upon termination, suspension or exclusion of a corporate vendor, the officers and persons owning, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in the vendor during the time of any conduct that served as the basis for that vendor's termination, suspension or exclusion are barred from participation in the Medical Assistance Program.

 

c)                  Upon termination, suspension or exclusion of a sole proprietorship or partnership, the owner or partners during the time of any conduct that served as the basis for that vendor's termination, suspension or exclusion are barred from participation in the Medical Assistance Program.

 

d)        Upon revocation of an alternate payee pursuant to Section 140.1005, the owners, officers, and individuals with management responsibility for the alternate payee during the time of any conduct that served as the basis for that alternate payee's revocation may be prohibited from participation as an owner, an officer, or an individual with management responsibility for an alternate payee in the Illinois Medical Assistance Program.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.19  Application to Participate or for Reinstatement Subsequent to Termination, Suspension, Exclusion or Barring

 

a)         A vendor that has been terminated, suspended or excluded from the Medical Assistance Program may not apply to participate for at least one year after the date of the final administrative decision terminating, suspending or excluding eligibility, except that, if a vendor has been terminated, suspended or excluded based on a conviction of a violation of Article VIIIA of the Public Aid Code or a conviction of a felony based on fraud or a willful misrepresentation related to subsection (a)(1), (2) or (3), the vendor shall be barred from participation for five years or for the length of the vendor's sentence for that conviction, whichever is longer.

 

1)         The Medical Assistance Program under Article V of the Public Aid Code;

 

2)         A federal or another state's medical assistance or health care program; or

 

3)         The provision of health care services.

 

b)         After one year, a vendor who has been terminated, suspended or excluded for any reason, other than for the reasons in subsections (a)(1) through (3), may apply for reinstatement to the Medical Assistance Program. If a vendor's application for reinstatement is denied by the Department, he or she shall be barred from again applying for reinstatement for one year after the date of the final administrative decision denying his or her application for reinstatement.

 

c)         A vendor whose termination, suspension or exclusion from participation in the Illinois Medical Assistance Program under Article V was based solely on an action by a governmental entity other than the Department may, upon reinstatement by that governmental entity or upon reversal of the termination, suspension or exclusion from participation in the Medical Assistance Program.  Upon proper application for rescission, the vendor may be deemed eligible by the Director if the vendor meets the requirements for eligibility under the Public Aid Code.

 

d)         At the end of a period of suspension, a vendor that has been suspended from the Medical Assistance Program shall be reinstated upon completion of the necessary enrollment forms and execution of a new vendor agreement unless it is determined that such vendor has not corrected the deficiencies upon which the suspension was based.  If the deficiencies have not been corrected, the vendor shall, after notice and hearing, be terminated. The notice in any termination action based on this Section shall notify the vendor of the deficiencies not corrected.

 

e)         An individual barred pursuant to Section 140.18 can apply to participate in the Medical Assistance Program.  If an individual's application is denied by the Department or if he or she is denied special permission under Section 140.32, he or she shall be barred from again applying for one year after the date of the final administrative decision denying his or her application or special permission.

 

f)         If a vendor has been terminated, suspended or excluded and reinstated to the Medical Assistance Program and the vendor is terminated, suspended or excluded a second or subsequent time from the Medical Assistance Program, the vendor shall be barred from participation for at least two years, except that, if a vendor has been terminated, suspended or excluded a second time based on a conviction of a violation of Article VIIIA of the Public Aid Code or a conviction of a felony based on fraud or a willful misrepresentation related to subsection (a)(1), (2) or (3), the vendor shall be barred from participation for life.

 

g)         At the end of two years, a vendor who has been terminated, suspended or excluded for any reason, other than for the reasons in subsections (a)(1) through (3), may apply for reinstatement to the Medical Assistance Program.  If a vendor's application for reinstatement is denied by the Department, he or she shall be barred from again applying for reinstatement for two years after the date of the final administrative decision denying his or her application for reinstatement.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.20  Submittal of Claims

 

a)         When claims for payment are submitted to the Department, providers shall:

 

1)         Use Department designated billing forms or electronic format for submittal of charges; and

 

2)         Certify that:

 

A)        They have personally rendered the services and provided the items for which charges are being made;

 

B)        Payment has not been received, or that only partial payment has been received;

 

C)        The charge made for each item constitutes the complete charge;

 

D)        They have not, and will not, accept additional payment for any item from any person or persons;

 

E)        They will not make additional charges to, nor accept additional payment from, any persons if the charges they present are reduced by the Department to conform to Department standards; and

 

F)         Starting June 1, 2019, in the case of providers of medical equipment, supplies, prosthetic devices and orthotic devices, the provider is accredited by a healthcare accrediting body approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department under Section 140.475(g). 

 

b)         Statement of Certification

 

1)         All billing statements shall contain a certification statement that must remain unaltered, and must be legibly signed and dated in ink by the provider, his or her designated alternate payee, or his or her authorized representative.  A rubber stamp or facsimile signature is not acceptable.

 

2)         An "authorized representative" may only be a trusted employee over whom the provider has direct supervision on a daily basis and who is personally responsible on a daily basis to the provider.  The representative must be specifically designated and must sign the provider's name and his or her own initials on each certification statement.

 

3)         An alternate payee must be specifically designated by the provider and must sign the provider's name and alternate payee's authorized representative's initials on each certification statement.

 

c)         Effective July 1, 2012, to be eligible for payment consideration, a provider's vendor-payment claim or bill, either as an initial or resubmitted claim following prior rejection, that can be processed without obtaining additional information from the provider of the service or from a third party, must be received by the Department, or its fiscal intermediary, no later than 180 days after the date on which medical goods or services were provided, with the following exceptions:

 

1)         The Department must receive a claim after disposition by Medicare or its fiscal intermediary no later than 24 months after the date on which medical goods or services were provided.

 

2)         In the case of a provider whose enrollment is in process by the Department, the 180-day period shall not begin until the date on the written notice from the Department that the provider enrollment is complete.

 

3)         In the case of errors attributable to the Department or any of its claims processing intermediaries that 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.

 

4)         In the case of a provider for whom the Department initiates the monthly billing process.

 

5)         For claims for 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.

 

6)         For claims for which the Department is not the primary payer, claims must be submitted to the Department within 180 days after the final adjudication by the primary payer.

 

A)        For purpose of this subsection (c)(6), a primary payer is a payer that can reasonably be expected to make payments within 120 days after the date of service; for example, other medical insurance or a group health plan, when the patient is the insured party.  Primary payer does not include payers who are not reasonably expected to pay within 120 days; for example, liability insurance and workers' compensation, when the patient is not the insured party.

 

B)        During the 180 day period beginning November 15, 2014, providers may submit claims and request a time override from the Department for claims with dates of service on and after July 1, 2012 not filed because of the provider's belief that it could file after final adjudication by an insurer when the patient was not the insured party.  A provider asking for such a time override shall also provide a copy of the request for time override to the Department's Bureau of Collections, with a written notification to the Bureau indicating the names and addresses of other parties, insurers or attorneys involved in attempting to recover, defend or settle possible damages to the patient that resulted in the services provided.  Failure to provide the required information to the Bureau shall result in a denial of the request for time override.

 

7)         In the case of long term care facilities, admission documents shall be submitted as provided in Section 140.513. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal.  Once an admission transaction has been completed, the Department will generate a monthly billing statement (remittance advice) for the services rendered to the admitted Medicaid eligible resident from date of admission through date of discharge.  Any disputes regarding payment for services provided from the date of admission through date of completion of the admission transaction must be submitted to the Department for Payment Review Request (HFS Form 3725) no later than 180 days after the date of completion of the admission transaction.  For any disputes regarding payment for services rendered after the date of completion of the admission transaction, the Payment Review Request must be submitted to the Department within 180 days after the:

 

A)        date of the remittance advice that initially shows the adjudication for the date or dates of service that are disputed;

 

B)        date of the remittance advice that rejects a previously adjudicated claim, if rejection is the basis for the disputed payment; or

 

C)        date of the remittance advice that adjusts a previously adjudicated claim, if the adjustment is the basis for the disputed payment.

 

8)         For hospital inpatient claims, the 180 days is measured from the date of discharge.

 

9)         Per Public Act 98-104, 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 payment, a claim must be received by the Department or its fiscal intermediary no later than one year after the date on which medical goods or services were provided.

 

d)         Claims that are not submitted and received in compliance with the foregoing requirements will not be eligible for payment under the Department's Medical Assistance Program, and the State shall have no liability for payment of the claim.

 

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)

 

Section 140.21  Reimbursement for QMB Eligible Medical Assistance Recipients and QMB Eligible Only Recipients and Individuals Who Are Entitled to Medicare Part A or Part B and Are Eligible for Some Form of Medicaid Benefits

 

a)         In order to be qualified to receive reimbursement for services provided to QMB (Qualified Medicare Beneficiary) eligible medical assistance recipients, QMB eligible only recipients (see 89 Ill. Adm. Code 120.72), or individuals who are entitled to Medicare Part A or Part B and are eligible for some form of Medicaid benefits, providers must be enrolled in the Medical Assistance Program.  Providers must also accept assignment of Medicare benefits for QMB eligible medical assistance recipients and individuals who are entitled to Medicare Part A or Part B and are eligible for some form of Medicaid benefits, when payment for services to such persons is sought from the Department.

 

b)         For Medicaid covered services, the Department will reimburse qualified providers who render services to QMB eligible medical assistance recipients, QMB eligible only recipients and individuals who are entitled to Medicare Part A or Part B and are eligible for some form of Medicaid benefits in accordance with Department standards for the service(s) provided, with the following exception: for drugs and medical supplies provided by a pharmacy or Durable Medical Equipment (DME) provider, and reimbursed by Medicare, the Department's liability for deductible and coinsurance amounts shall be at the full Medicare rate.  For individuals enrolled in the SeniorCare Program, the provisions in this subsection (b) will apply to services provided on or after October 16, 2002. 

 

c)         For services approved by Medicare but not covered by Medicaid, the maximum allowable rate payable to qualified providers who render services to QMB eligible medical assistance recipients and recipients who are QMB eligible only is 80 percent of full Medicare rate when determining the Department's liability for deductible and coinsurance amounts.

 

d)         Licensed and Medicare certified nursing facilities that enroll for the sole purpose of receiving payment for services to QMB eligible only residents of the facility, then disenroll, are not subject to the provisions found in Section 140.506 governing voluntary withdrawal from the Medical Assistance Program.

 

(Source:  Amended at 27 Ill. Reg. 4364, effective February 24, 2003)

 

Section 140.22  Magnetic Tape Billings (Repealed)

 

(Source:  Repealed at 25 Ill. Reg. 3897, effective March 1, 2001)

 

Section 140.23  Payment Of Claims

 

a)         The Department shall pay only for those services and supplies that:

 

1)         Meet the U.S. Department of Health, Education and Welfare's definition of medical service (42 U.S.C. 1396d);

 

2)         Can be paid by vendor payment; and

 

3)         Are specified in the individual rules governing particular types of medical services provided.

 

b)         Except as provided in subsection (d), the Department shall make payment only after services have been rendered.

 

c)         Payment shall be made only to a provider who:

 

1)         Participates in the Medical Assistance Program; and

 

2)         Except as provided in subsections (d) and (e), is the actual provider of service.

 

d)         The Department may contract with qualified practitioners, hospitals and all other dispensers of medical services for the provision and reimbursement as specified in the contract of any and all medical care or services on a prepaid capitation, volume purchase, ambulatory visit or per discharge basis.  Such contracts shall be based either on formally solicited competitive bid proposals or individually negotiated rates with providers willing to enter into special contractual arrangements with the State.  Payments shall be made in advance of services under prepaid capitation arrangements.  The Department shall not pay a provider for services provided to recipient enrolled in a HMO or other plan as specified above when the service is one which the HMO or plan has contracted to provide.

 

e)         The Department will make payment to a provider for services provided by a substitute physician when the substitute physician is performing the duties of a qualified attending physician, and all of the following conditions are met:

 

1)         The attending physician is ill, on vacation, or otherwise unavailable because of an emergency situation;

 

2)         The substitute physician is a Doctor of Medicine (M.D.) or Osteopathy (D.O.) who holds a license to practice medicine in all its branches;

 

3)         The substitute physician is not terminated, suspended, barred or otherwise excluded from participation or has not voluntarily withdrawn from the Medical Assistance Program as part of a settlement agreement; and

 

4)         The substitution does not exceed 14 days for a single incident and up to a maximum of 90 days per year for the attending physician. If the substitute period extends beyond the 14 days per single incident, the substitute physician must enroll with the Department.

 

(Source:  Amended at 47 Ill. Reg. 16385, effective November 3, 2023)

 

Section 140.24  Payment Procedures

 

a)         Payment of valid claims will be made by a State warrant (check) issued through the Office of the State Comptroller.

 

b)         All providers of medical services must designate a payee when enrolling in the Department's Medical Assistance Program.

 

1)         Providers enrolled as business entities are limited to one payee.  A business entity is defined as any firm, corporation, partnership, agency, institution or other legal organization organized for the purpose of providing medically related professional services.  A provider enrolled as a business entity may designate the corporate or partnership name as the payee.  The mailing address for the payee must be the provider's service address, the designated address of the provider's corporate or partnership office, or a designated address that will accept and forward the remittance advice to the business entity.

 

2)         Providers enrolled as individual practitioners are allowed to have more than one payee.  An individual practitioner is defined as an individual person licensed by an authorized State agency to provide medical services.  Payment may be mailed to an individual practitioner at one of the following addresses that will accept and forward the remittance advice to the individual practitioner:

 

A)        The provider's service address; or

 

B)        The provider's residence; or

 

C)        The provider's designated address; or

 

D)        The address of the provider's designated alternate payee pursuant to subsection (d) of this Section; or

 

E)        The address of the entity specified according to an arrangement under Section 140.27(c) or (d).

 

3)         A long term care facility and its corporate or partnership owner may request the facility's warrant be sent directly to the business office address of the corporate or partnership owner.  After approval is given, the warrant will be issued in the name of the facility or corporate name doing business under the facility name, but sent to the business office address of the corporate or partnership owner rather than the facility.

 

c)         Individual practitioners may request the Department to designate an alternate payee for the practitioner.  The Department may permit a request if the Department determines that the designation is consistent with the provision of medical services to eligible recipients.  The alternate payee must meet the registration conditions for, and be registered as an alternate payee pursuant to, 89 Ill. Adm. Code 140.1001.  Additionally, the individual practitioner must meet the following conditions:

 

1)         The individual practitioner must have a contractual/salary arrangement with a hospital or a hospital affiliate, as defined by the Hospital Licensing Act [210 ILCS 85], that requires fees to be turned over to the hospital or hospital affiliate; or

 

2)         The individual practitioner must have a contractual/salary arrangement with a professional school that requires fees to be turned over to the professional school.  A professional school is defined as a college or university offering a degree to qualify individuals for licensure to perform medical services; or

 

3)         The individual practitioner must have a contractual/salary arrangement with or be employed by a practitioner owned group practice that requires fees to be turned over to the practitioner owned group practice.  The practitioner owned group practice must be owned by three or more full‑time licensed individual practitioners who are eligible to participate in the Medical Assistance Program; or

 

4)         The individual practitioner must have a contractual/salary arrangement with a partnership that requires fees to be turned over to the partnership.  The partnership must be solely-owned by two or more practitioners who are eligible to participate in the Medical Assistance Program; or

 

5)         The individual practitioner must have a contractual/salary arrangement or be employed by a governmental entity that requires fees to be turned over to the governmental entity; or

 

6)         The individual practitioner must have a contractual/salary arrangement with a community mental health agency that requires fees to be turned over to the community mental health agency.  The community mental health agency must be certified by the Department of Human Services under 59 Ill. Adm. Code 132 and be enrolled as a provider in the Medical Assistance Program; or

 

7)         The individual practitioner must have a contractual/salary arrangement or be employed by a Federally Qualified Health Center, Rural Health Center or Encounter Rate Clinic that requires fees to be turned over to the center or clinic.  The center or clinic must be enrolled as a provider in the Medical Assistance Program; or

 

8)         The individual practitioner must have a contractual/salary arrangement with a corporation registered with the Illinois Secretary of State's Office to do business in the State of Illinois that requires fees to be turned over to the corporation; or

 

9)         The individual practitioner must have a contractual/salary arrangement as a condition of employment with an individual practitioner "employer" that requires fees to be turned over to the employer.  The employer must be eligible to participate in the Medical Assistance Program. An individual practitioner may designate an employer who is a physician licensed under the Medical Practice Act of 1987 [225 ILCS 60] if the practitioner is an advanced practice nurse licensed under the Nurse Practice Act [225 ILCS 65].

 

d)         The Department will not permit the designation of a payee or alternate payee that appoints, employs, or contracts with any person as an owner, officer, director, or individual with management or advisory responsibility who is terminated, suspended, or barred or has voluntarily withdrawn as a result of a settlement agreement, from any state or federal healthcare program.

 

e)         If a practitioner designates an alternate payee, the practitioner and the alternate payee shall be jointly and severally liable to the Department for payments made to the alternate payee.

 

(Source:  Amended at 38 Ill. Reg. 4330, effective January 29, 2014)

 

Section 140.25  Overpayment or Underpayment of Claims

 

a)         When the Department, the provider, or the designated alternate payee has determined that an overpayment has been made, the provider or the alternate payee shall reimburse the Department for the overpayment.  The Department shall recover overpayments made to or on behalf of a provider that result from improper billing practices.  Recovery may occur by setoff, crediting against future billings or requiring direct repayment to the Department.

 

b)         When a provider believes it has received an underpayment for services, it may request Department review.  The request must be received by the Department within 12 months after the date payment was authorized.  If the review reveals an underpayment was made, the Department shall pay the additional amount due.  If the review reveals an overpayment was made, the provider, or the designated alternate payee, shall refund the amount of the overpayment.

 

c)         When 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 payment, believes it has received an underpayment for services, it may submit an adjustment to void and re-bill the claim.  The request must be received within one year after the date payment was authorized.

 

d)         For underpayments, the Department will not adjust claims received beyond the applicable timeframes identified in subsections (b) and (c). The review procedures provided for in this Section may not be used to submit any new or corrected information that was required to be submitted by a specific date in order to qualify for a payment or payment adjustment.

 

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

 

Section 140.26  Payment to Factors Prohibited

 

a)         Payment for any care or service furnished to an individual by a provider will not be made to or through a factor, either directly or by virtue of a power of attorney given by the provider to the factor.  In addition, transfers by providers to a factor of any claims for reimbursement or receivables under the Medical Assistance Program, either by assignment, sale or otherwise is expressly prohibited.  This prohibition shall include, but not be limited to, the following:

 

1)         Transfer of such claims or receivables to a nonrelated entity, i.e., an organization in which the provider is neither an officer nor an owner, which has given the provider an unsecured loan,

 

2)         Transfer of accounts for such claims or receivables, or

 

3)         The use of such claims or receivables by a provider as collateral for a loan, except as allowed under Section 140.27 ("Assignment of Vendor Payments").

 

b)         For purposes of these Rules, "factor" shall mean an organization, i.e., collection agency or service bureau which, or an individual who, advances money to a provider for his accounts receivable which the provider has assigned or sold, or otherwise transferred, including transfer through the use of power of attorney, to this organization or individual.  The organization or individual receives an added fee receivable in return for the advanced money.

 

(Source:  Amended at 8 Ill. Reg. 22097, effective October 24, 1984)

 

Section 140.27  Assignment of Vendor Payments

 

a)         Except as provided in this Section, vendor payments and the right to receive such payments are absolutely inalienable by assignment, sale, attachment, garnishment or otherwise.

 

b)         A medical vendor may use his or her right to receive vendor payments as collateral for loans from banks, credit unions, and savings and loan associations chartered under or trust companies issued certificates of authority under Chapter 205 of the Illinois Compiled Statutes, provided that such arrangements:

 

1)         shall not require the Department to issue the payment directly to any person or entity other than the vendor; and

 

2)         shall not constitute any activities prohibited by the provisions of 42 U.S.C.A. 1396(a)(32) (1983) and Section 140.26 ("Payment to Factors Prohibited").

 

c)         A medical vendor or other vendor or service provider may assign, reassign, sell, pledge or grant a security interest in any such financial aid, vendor payment or money payments of grants he or she has a right to receive to the Illinois Health Facilities Authority in connection with any financing program undertaken by that Authority, or to the Illinois Development Finance Authority in connection with any financing program undertaken by that Authority.  Each Authority may utilize an agent or trustee accepting, accomplishing, effectuating or realizing upon any such assignment, reassignment, sale, pledge or grant on such Authority's behalf; and such arrangements may provide that the Department shall issue the payment directly to the Illinois Health Facilities Authority, Illinois Development Finance Authority or to any such agent or trustee.

 

d)         A medical vendor that is a governmental entity or is exempt from income reporting under Section 1.6041-3(c) of the federal income tax regulations [26 CFR 1.6041-3(c)] and that provides Healthy Kids Program services under Section 140.485(d) may assign its interest in payment from the Department to a local school district with which the provider has an arrangement to provide such services.  Under such assignment, with Department approval, payment will be made directly to the school district.

 

(Source:  Amended at 19 Ill. Reg. 13019, effective September 5, 1995)

 

Section 140.28  Record Requirements for Medical Providers

 

a)         Providers shall maintain in the regular course of business the following:

 

1)         Any and all business records that may indicate financial arrangements between the provider and other providers in the program or other entities, or that are necessary to determine compliance with federal and State requirements, including but not limited to:

 

A)        business ledgers of all transactions,

 

B)        records of all payments received, including cash,

 

C)        records of all payments made, including cash,

 

D)        corporate papers, including stock record books and minute books,

 

E)        records of all arrangements and payments related in any way to the leasing of real estate or personal property, including any equipment,

 

F)         records of all accounts receivable and payable; and

 

2)         Any and all professional records that relate to the quality of care given by the provider or that document the care for which payment is claimed, including but not limited to:

 

A)        medical records for applicants and recipients of public assistance. This rule does not require a provider to keep or make available medical records for persons who are not applicants or recipients and for whom no claim to the Department for payment is made.

 

B)        other professional records required to be maintained by applicable federal or State law or regulations.

 

b)         The business and professional records required to be maintained shall be kept in accordance with accepted business and accounting practice and shall be legible.  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 the records must be retained until the audit is completed and every exception resolved.  This provision is not to be construed as a statute of limitations.  However, the Department will not deny, suspend or terminate a provider pursuant to Sections 140.14 through 140.19 solely because the provider has failed to keep records for more than 3 years.

 

c)         All records required to be maintained shall be available for inspection, audit and copying (including photocopying) by authorized Department personnel during normal business hours.  Department personnel shall make all attempts to examine such records without interfering with the professional activities of the provider.

 

d)                 The provider's business and professional records for at least 12 previous calendar months shall be maintained and available for inspection by authorized Department personnel on the premises of the provider. Department personnel shall make requests in writing to inspect records more than 12 months old at least 2 days in advance of the date they must be produced.

 

e)         The provider is responsible to furnish records to the Department.  If records are maintained by a designated alternate payee or another entity, the provider remains responsible for obtaining those records and furnishing them to the Department.

 

(Source:  Amended at 38 Ill. Reg. 4330, effective January 29, 2014)

 

Section 140.30  Audits

 

a)         Effective July 1, 2012, whether pre-payment or post-payment, all services for which charges are made to the Department are subject to audit.  During a review audit, the provider shall furnish to the Department or to its authorized representative, pertinent information regarding claims for payment.  If records are maintained by a designated alternate payee, it is the provider's responsibility to obtain the records and furnish them to the Department.  Should an audit reveal that incorrect payments were made, or that the provider's records do not support the payments that were made, or should the provider or designated alternate payee fail to furnish records to support payments that were made, the provider or designated alternate payee shall make restitution.

 

b)         The Department's procedure for auditing providers may involve the use of sampling and extrapolation.  Under such a procedure, the Department selects a statistically valid sample of the cases for which the provider or designated alternate payee received payment for the audit period in question and audits the provider's records for those cases.  All incorrect payments determined by an audit of the cases in the sample are then totaled and extrapolated to the entire universe of cases for which the provider or designated alternate payee has been paid during the audit period.  The provider or designated alternate payee shall be required to pay the Department the entire extrapolated amount of incorrect payments calculated under this procedure after notice and opportunity for hearing pursuant to 89 Ill. Adm. Code 104.210.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.31  Emergency Services Audits

 

a)         All emergency services for which charges are made to the Department and are provided to a recipient who does not require admission as an inpatient are subject to audit.

 

b)         An emergency services audit shall be limited to a review of records related to services rendered within three years of the date the hospital is notified that the audit will be initiated.  The Department shall notify the hospital of an audit at least four calendar weeks before the audit occurs, unless the hospital and the Department agree to schedule the audit at an earlier date.  The hospital's business and professional records for at least 12 previous calendar months shall be maintained and available for inspection by authorized Department personnel on the premises of the hospital.  Department personnel shall make requests in writing to inspect records more than 12 months old at least two business days in advance of the date they must be produced.  These records required to be maintained shall be kept in accordance with accepted business and accounting practice and shall be legible.  Such records must be retained for a period of not less than three 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 the records must be retained until the audit is completed and every exception resolved by settlement or by the Director's final decision.

 

c)         All records required to be maintained shall be available for inspection by authorized Department personnel during normal business hours.  Department personnel shall make all attempts to examine such records without interfering with the professional activities of the hospital.  The hospital shall make legible copies of those records requested by the Department upon completion of its inspection, and tender said copied records to the Department within two weeks after such request is made unless this time is extended by mutual consent.  Additionally, if the hospital locates records that were unavailable during the audit, that data shall be submitted to the Department within 30 days after completion of the audit conducted on the hospital's premises, and that data shall be utilized in generating the audit findings. The determination that an emergency medical condition exists shall be based solely upon the review of the legible information contained in those medical records supplied by the hospital during the audit.

 

d)         Authorized Department personnel shall meet with the chief executive officer of the hospital, or a person designated by the chief executive officer, upon arrival at the hospital to conduct the audit and at the conclusion of the audit.  The purpose of the pre-audit meeting shall be to inform the hospital of the scope of the audit.  The purpose of the post-audit meeting shall be to provide an opportunity for the auditors to discuss their preliminary findings with the chief executive officer, or a person designated by the chief executive officer.  More detailed audit findings shall be provided in writing to the hospital within 120 days after the date on which the audit conducted on the hospital premises was completed.

 

e)         The final determination of whether an emergency room visit was for the alleviation of severe pain or for the immediate diagnosis and/or treatment of conditions or injuries which might result in disability or death if there is not immediate treatment shall be based upon the symptoms and condition of the recipient at the time the recipient is initially examined by the hospital's emergency department physician and not upon the final determination of the recipient's actual medical condition (see Sections 140.3 and 140.5 of this Part).

 

f)         When the purpose of the audit is to determine the appropriateness of the emergency services provided, any final determination that would result in a denial of or reduction in payment to the hospital shall be based on the opinion of a physician licensed to practice medicine in all of its branches who is board certified in emergency medicine or by the appropriate health care professionals under the supervision of the physician.

 

g)         The Department or its designated review agent in cases where the Department seeks to recover an extrapolated amount, shall use statistically valid sampling techniques when conducting audits as provided by Section 140.30 of this Part.

 

h)         This Section shall not apply to any audits initiated prior to July 1, 1992.

 

(Source:  Added at 16 Ill. Reg. 19879, effective December 7, 1992)

 

Section 140.32  Prohibition on Participation, and Special Permission for Participation

 

a)         Prohibition on Participation by Terminated, Suspended, Excluded or Barred Entities

 

1)         Upon being terminated, suspended, excluded or barred, and while the disability from Medical Assistance Program participation remains in effect, an entity:

 

A)        Cannot be a vendor, assume management responsibility for a vendor, own (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership of a corporate vendor, become an owner of a sole proprietorship that is a vendor, become a partner of a vendor or become an officer of a corporate vendor;

 

B)        Cannot be an employer of a vendor; a person with management responsibility for an employer of a vendor; an officer of an employer of a vendor; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in an employer of a vendor; an owner of a sole proprietorship that employs a vendor; or a partner of a partnership that employs a vendor;

 

C)        Cannot order goods or services from a vendor when payment for such goods or services will be made in whole or in part by the Department;

 

D)        Cannot render goods or services as an employee of a vendor or as an independent contractor with a vendor for which payment will be made in whole or in part by the Department;

 

E)        Cannot, directly or indirectly, serve as a technical or other advisor to a vendor;

 

F)         Cannot, directly or indirectly, be an incorporator or member of the board of directors of a vendor;

 

G)        Cannot, directly or indirectly, be an investor in a vendor; and

 

H)        Cannot own (directly or indirectly) a 5% or greater interest in any premises or equipment leased by a vendor.

 

2)         An individual who is terminated or barred from participation in the Medical Assistance Program cannot transfer the direct or indirect ownership of a vendor (including the ownership of a vendor that is a sole proprietorship, a partner's interest in a vendor that is a partnership, or ownership of 5% or more of the shares of stock or other evidences of ownership in a vendor) to the individual's spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage.

 

3)         Effective July 1, 2012, a person who owns, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor who owes a debt to the Department, if that vendor has not made payment arrangements acceptable to the Department, shall not transfer his or her ownership interest in that vendor, or vendor assets of any kind, to his or her spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin or relative by marriage.

 

4)         After the provision of written notice to the affected parties, the Department may deny payment for goods or services rendered or ordered by an entity that violates the provisions of subsection (a)(1)(A), (B), (C) or (D). The Department may also pursue the imposition of all criminal and civil penalties as may be available and necessary.

 

5)         Whenever an entity violates the provisions of subsection (a)(1)(E), (F), (G) or (H) the Department may refer the matter for filing of an appropriate civil suit by the Attorney General or the State's Attorney to recover all benefits obtained improperly as well as treble damages or $10,000.00 for each such violation whichever amount is greater, in accordance with Section 11-27 of the Public Aid Code.

 

b)         Special Permission for Continuation or Reinstatement of Medical Assistance Program Participation for Barred Entities

 

1)         Any entity barred pursuant to Section 140.18 may seek special permission to continue participation in the Medical Assistance Program or for reinstatement in the Program.

 

2)         Special permission shall be granted only if the entity seeking such action demonstrates to the Department that it had no part in, and no knowledge of, the conduct which led to the decision to terminate upon which the barring was based or that it had no part in, and notified the Department as soon as it gained knowledge of, the conduct.

 

3)         In deciding whether to authorize the continued participation by, or reinstatement of, an entity that meets the conditions of this subsection (b) the Director shall consider the following factors:

 

A)        Whether the entity requesting special permission demonstrates a fitness to participate in the Medical Assistance Program;

 

B)        The extent to which any legally enforceable debts owed to the Department by the applicant or an entity in which the applicant or his nominee held a substantial ownership interest have been paid;

 

C)        Any other circumstances reasonably related to the issue of whether the special permission should be granted.

 

4)         Any entity that seeks special permission to continue or reinstate benefits shall submit a written request to the Director.  Upon receipt of such a request, the Director or his designee shall review the request and any supporting documentation which accompanies it, and shall notify the entity of the decision within 60 days after receipt of the request, where practicable.  In reviewing the request, the Director may require the entity to appear before and cooperate with a peer review committee of the Department.

 

5)         An entity may request special permission only once.  An entity that has been denied special permission may not apply for readmission under Section 140.14 for one year after the final decision to deny special permission.  An entity that has been denied readmission under Section 140.14 or has an application under Section 140.14 pending with the Department may not apply for special permission.

 

6)         Whenever a barred entity is readmitted to the Medical Assistance Program pursuant to this Section, the Director may make the vendor's continued participation contingent upon compliance with specified restrictions, including, but not limited to:

 

A)        Limiting the participation by the entity as to the location, type, volume or category of goods or services to be provided;

 

B)        Requiring that the entity obtain continuing education, or additional licenses or authorizations; and

 

C)        Any other terms or conditions which may be appropriate or required under the circumstances.

 

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.33  Publication of List of Sanctioned Entities

 

a)         The Department shall publish a list of every entity that is currently terminated, suspended or barred from participation in the Medical Assistance Program and shall include every alternate payee that has been revoked, and every entity prohibited from participating with an alternate payee.  The list may also include entities that have voluntarily withdrawn from participation in the Medical Assistance Program as a result of a settlement agreement.  The list shall also include the period of suspension.  The list shall be supplemented with additions and deletions each month, if any.  The list shall be published on the Office of the Inspector General's (OIG) website at www.state.il.us/agency/oig.

 

b)         The Department shall, upon request, mail the list and supplements, without charge, to associations and societies of vendors in the Medical Assistance Program, including their affiliates and components.  Societies and associations of vendors and other entities that wish to receive the list are responsible for providing the Department with a current mailing address.

 

c)         An entity may file a request, in writing or via e-mail, for a list of any adverse actions against a particular entity that are not currently in effect.  Inquiries may be directed to the OIG at 404 North Fifth Street, Springfield, Illinois 62702, or at Oigwebmaster@illinois.gov. The Department shall respond to such a request within ten days after receiving it.

 

(Source:  Amended at 31 Ill. Reg. 2413, effective January 19, 2007)

 

Section 140.35  False Reporting and Other Fraudulent Activities

 

a)         Providers are subject to Section 12-13.1 of the Illinois Public Aid Code, pertaining to penalties for vendor fraud and kickbacks.

 

b)         Providers are also subject to Section 1909 (42 U.S.C. 1396h) of the Social Security Act that prohibits kickbacks, false reporting and other fraudulent activities, and provides for fines and imprisonment for persons who engage in such activities.

 

(Source:  Amended at 47 Ill. Reg. 3738, effective March 1, 2023)

 

Section 140.40  Prior Approval for Medical Services or Items

 

a)         The Department may impose prior approval requirements as specified by rule, to determine the essentialness of medical care provided in individual situations.  Such requirements shall be based on recommendations of technical and professional staff and advisory committees.

 

b)         In general, in order for prior approval to be granted, items and services must be:

 

1)         non-experimental,

 

2)         appropriate to the client's needs,

 

3)         necessary to avoid institutional care, and

 

4)         medically necessary to preserve health, alleviate sickness, or correct a handicapping condition.

 

c)         Providers are responsible for requesting prior approval for medical services or items.  Prior approval requests must include at a minimum:

 

1)         patient name,

 

2)         recipient number,

 

3)         patient age, address, and whether or not the patient resides in a group care facility,

 

4)         identification of the practitioner prescribing or ordering the item or service,

 

5)         diagnosis,

 

6)         description of item or service,

 

7)         treatment plan,

 

8)         how long the service or item will be needed, and

 

9)         purchase or rental cost.

 

d)         To the extent possible, the request should show how the item or service is expected to correct or help the condition, and why the requested treatment plan is better than any other plan commonly used to deal with similar diagnoses or conditions.  Anything unique to the medical condition or living arrangement affecting the choice of a recommended treatment plan or item should be explained.

 

e)         A written notice of disposition of the request for prior approval will be sent to the client within the time limits prescribed below.  If the notice of disposition is not sent within the applicable time limit, prior approval will be granted automatically.  Oral notification will be given only when a request for medical transportation is approved.

 

(Source:  Amended at 22 Ill. Reg. 19898, effective October 30, 1998)

 

Section 140.41  Prior Approval in Cases of Emergency

 

a)         In cases of emergency, the provider may request prior approval by telephoning the office that gives such approval.  "Emergency" is defined as a condition or situation which threatens the recipient's life or may cause permanent damage, or requires services which, in the opinion of the attending physician, are needed to relieve immediate pain and suffering. If a recipient's condition is so severe that his or her life is endangered and there is not enough time to seek approval by telephone or the service is needed during non-working hours, the service may be provided before obtaining prior approval.

 

b)         When emergency approval is obtained by telephone, or the service is provided before obtaining approval under the above circumstances, the provider must still submit a written request in order to receive approval to bill for the services provided.

 

Section 140.42  Limitation on Prior Approval

 

The Department will not give prior approval for an item or service if a less expensive item or service is appropriate to meet the client needs. The Department will not approve purchase of equipment if the client already has equipment which is adequate and sufficient to meet the client's needs. The Department will not approve the purchase of equipment if the Department already owns such equipment and will make it available for the client to use.

 

Section 140.43  Post Approval for Items or Services When Prior Approval Cannot Be Obtained

 

a)         Post approval may be requested for items or services provided during Department nonworking hours, or nonworking hours of its agents, whichever is applicable, or when a life threatening condition exists and there is no time to call for approval.

 

b)         To be eligible for approval consideration, the requirements for prior approval must be met and post approval requests must be received by the Department or its agents, whichever is applicable, no later than 90 days after the date services or goods are provided.  Exceptions to this requirement will be permitted only in the following circumstances:

 

1)         The Department or the Department of Human Services has received the patient's Medical Assistance application, but approval of the application has not been issued, as of the date of service.  In such a case, the post approval request must be received no later than 90 days after the date of the Department's Notice of Decision, approving the patient's application.

 

2)         The patient did not inform the provider of his/her eligibility for Medical Assistance.  In such a case, the post approval request must be received no later than six months after the date of service, but will be considered for payment only if there is attached to the request a copy of the provider's dated, private pay bill or collection correspondence, which was addressed and mailed to the patient each month following the date of service.

 

3)         A request for payment was submitted to a third party billing within six months following the date of service.  In such a case, a post approval request must be received by the Department no later than 90 days after the date of final adjudication by the third party.

 

(Source:  Amended at 28 Ill. Reg. 4958, effective March 3, 2004)

 

Section 140.44  Withholding of Payments Due to Fraud or Misrepresentation

 

a)         Effective July 1, 2012, payments on pending and subsequently submitted bills may be withheld, in whole or in part, to a provider or alternate payee, when there is credible evidence from State or federal law enforcement or federal oversight agencies or from the results of a preliminary Department audit that the circumstances giving rise to the need for a withholding of payments may involve fraud or willful misrepresentation under the Illinois Medical Assistance Program.  Payments may be withheld without first notifying the provider or alternate payee of its intention to withhold the payments.

 

b)         The Department must send notice of its withholding within 5 days after taking that action. The notice must set forth the general allegations as to the nature of the withholding, but need not disclose any specific information concerning the ongoing investigation. The notice must also state the following:

 

1)         The payments are being withheld in accordance with Section 12-4.25(K) of the Public Aid Code.

 

2)         The withholding is for a temporary period; the notice shall cite the circumstances under which withholding will be terminated.

 

3)         When appropriate, the type of claim for which withholding is effective.

 

4)         The provider or alternate payee has the right to submit written evidence for reconsideration of the withholding of payments by the Department.

 

5)         A written request may be made to the Department for full or partial release of withheld payments and the request may be made at any time after the Department first withholds the payments.

 

c)         All withholding of payment actions under this Section shall be temporary and shall not continue after any of the following:

 

1)         The Department or the prosecuting authorities determine that there is insufficient evidence of fraud or willful misrepresentation by the provider or alternate payee.

 

2)         Legal proceedings related to the provider's or alternate payee's alleged fraud, willful misrepresentation, or violations of Article V of the Illinois Public Aid Code or violations of 89 Ill. Adm. Code:  Chapter I are completed. If the Department commences an administrative proceeding that seeks the termination of the provider or revocation of the alternate payee, withholding will continue in conformance with 89 Ill. Adm. Code 104.272.

 

3)         The withholding of payments for a period of 3 years.

 

d)         The provider or alternate payee request for reconsideration of payment withholding, or request for full or partial release of payments withheld, must be in writing, set out the reasons for the request, and be sent to the Department's Office of Inspector General at 2200 Churchill Road, A-1, Springfield, Illinois 62702, or by e-mail to HFS.OIGWebmaster@illinois.gov.  The request may include documentation that the allegations of fraud or willful misrepresentation involving the Medical Assistance Program did not take place.

 

e)         Partial or full release of payments on pending and subsequently submitted bills may be granted, at the discretion of the Inspector General of the Department, when it is in the best interest of the recipients of medical assistance. This may include, but not be limited to, access to medical services for recipients or the potential movement of patients from long term care settings. 

 

(Source:  Amended at 42 Ill. Reg. 14383, effective July 23, 2018)

 

Section 140.45  Withholding of Payments Upon Provider Audit, Quality of Care Review, Credible Allegation of Fraud or Failure to Cooperate

 

a)         Effective July 1, 2012, the Department may withhold payments, in whole or in part, to a provider or alternate payee upon:

 

1)         initiation of an audit;

 

2)         quality of care review;

 

3)         investigation in which there is a credible allegation of fraud; or

 

4)         the provider or alternate payee is demonstrating a clear failure to cooperate with the Department, giving rise to the need for a withholding of payments.

 

b)         The Department may withhold payments without first notifying the provider or alternate payee of its intention to withhold payments.

 

c)         A provider or alternate payee may request a hearing or a reconsideration of payment withholding, and the Department must grant the request.

 

d)         The Department must send notice of its withholding of payments within five days after taking the action.  The notice shall:

 

1)         Set forth the general allegation as to the nature of the withholding action; however, the notice need not disclose any specific information concerning an ongoing investigation.

 

2)         State that payments are being withheld in accordance with Section 12‑4.25(K-5) of the Code.

 

3)         State that the withholding is for a temporary period, as specified in subsection (g), and cite the circumstances under which withholding will be terminated.

 

4)         Specify, when appropriate, which type or types of claims are withheld.

 

5)         Inform the provider or alternate payee of the right to request a hearing or a reconsideration of the withholding by the Department, including the ability to submit written evidence.

 

6)         Inform the provider or alternate payee that a written request may be made to the Department for a hearing or reconsideration for the full or partial release of withheld payments and that such requests may be made at any time after the Department first withholds payments.

 

e)         A provider or alternate payee may request reconsideration of payment withholding for the purpose of a full or partial release of payments withheld pursuant to Section 12-4.25(K-5) of the Code.  The provider or alternate payee shall submit a written request for reconsideration and the reasons for the reconsideration to the Department's Inspector General at:

 

Office of Inspector General

404 North Fifth Street

Springfield, Illinois 62706 

 

Or by e-mail to: HFS.OIGWebmaster@illinois.gov.

 

1)         The request may include documentation to contest a credible allegation of fraud or failure to cooperate with the Department.

 

2)         Partial or full release of payments on pending and subsequently submitted bills may be granted, at the discretion of the Inspector General, when it is in the best interest of Medical Assistance Program recipients.  Factors in this decision may include, but are not limited to, recipients' access to medical services or the potential transport of patients from long term care settings.

 

f)         A provider or alternate payee may request a hearing on the issue of a withholding of payments pursuant to Section 12-4.25(K-5) of the Code.  The only issue at hearing will be whether a partial or full release of funds is properly based on the following factors:

 

1)         Whether there is a credible allegation of fraud;

 

2)         Whether the provider or alternate payee demonstrated a clear failure to cooperate with the Department, giving rise to the need for a withholding of payments;

 

3)         Whether a release is in the best interest of the recipients of medical assistance based on access to medical services for recipients; and

 

4)         The potential movement of patients from long term care settings.

 

g)         All withholding of payment actions under this Section shall be temporary and shall not continue after either of the following:

 

1)         The Department determines that there is insufficient evidence of fraud, or the provider or alternate payee demonstrates clear cooperation with the Department, as determined by the Department, so that the circumstances do not give rise to the need for withholding of payments; or

 

2)         the withholding of payments has lasted for a period in excess of three years.

 

(Source:  Added at 37 Ill. Reg. 10282, effective June 27, 2013)

 

Section 140.55  Electronic Data Interchange Service

 

a)         Definitions

As used in this Section, unless the context requires otherwise:

 

1)         "Batch Mode" is any request other than a "real time mode" request. The Department will respond to a "batch mode" request within 24 hours.

 

2)         "Medical Provider" is a provider of medical services who is enrolled with the Department to render services under any healthcare program administered by the Department.

 

3)         "Real Time Mode" is a request for eligibility verification for a single individual, or a request for claims status for a specific claim from a trading partner, to which the Department will respond as immediately as possible.

 

4)         "Recipient" is an individual eligible to receive services through any healthcare program administered by the Department.

 

5)         "Subscriber" is a medical provider or the agent of a medical provider who executes a contract with a trading partner to participate in the EDI service.

 

6)         "Trading Partner" is an entity that has successfully completed the EDI trading partner application process and executed an agreement with the Department to utilize the Department's EDI service.

 

b)         Electronic Data Interchange (EDI) Service

A new Electronic Data Interchange process will offer a HIPAA compliant means for trading partners to verify recipient eligibility (real time and batch mode), submit medical claims (batch mode only) and check medical claim status (real time and batch mode).  This information will be made available to medical providers through Department approved trading partners.  Trading partners are responsible for marketing the EDI service to medical providers.  Direct access to the EDI service will be made available through Department prescribed methods.  Only Department approved trading partners and their subscribing medical providers are authorized to access information provided through the EDI service, except as may be approved through subsection (e)(4).

 

c)         Recipient Eligibility Verification (REV) System Contract Termination

The REV system (see Section 5-1.2 of the Public Aid Code) offered on-line Medicaid eligibility information and claims history information to subscribers through REV contractors.  All REV vendor contracts that have not been terminated are terminated effective June 30, 2013.  Any REV vendor who had a contract with the Department that has terminated must apply to become a trading partner under subsection (d).

 

d)         Eligibility Requirements for Trading Partners

In order to be qualified to participate in the service, a trading partner must:

 

1)         Submit a Department prescribed application to the Department and execute an agreement with the Department. The agreement will establish the amount of reimbursement the trading partner will pay to the Department for real time mode and batch mode requests.  The agreement will also provide that the provider or trading partner will execute a written contract with each subscriber prior to any exchange of data with that subscriber;

 

2)         Agree to access data through one or more high speed data transmission circuits determined by the Department to be compatible with current technology and operating needs.  Current compatible high speed data transmission circuits shall be identified as part of the information provided to applicants who request the application from the Department.  Updates to technology, operating needs or transmission circuits will be provided to existing trading partners via electronic communication at least 30 days before usage is required;

 

3)         Treat all information, including information relating to recipients and medical providers obtained under the agreement with the Department as confidential information pursuant to the Public Aid Code [305 ILCS 5] and federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (42 CFR 160, 162 and 164);

 

4)         Provide data to subscribers through a system designed to be flexible to meet each subscriber's needs as well as meeting the following specific requirements:

 

A)        Support various means of telecommunication that are commonly available for use by the subscriber; and

 

B)        Be compatible with the State of Illinois Department of Central Management Services' current electronic communication protocols;

 

5)         Certify that it is neither an individual nor an organization that:

 

A)        Furnishes statements or bills and receives payment in the name of medical providers; or

 

B)        Advances money to a medical provider for accounts receivable that the medical provider has assigned, sold or transferred to the individual or organization for an added fee or a deduction of the portion of the accounts receivable.

 

e)         Subscriber Contracts

The trading partner must agree that all contracts with subscribers provide that:

 

1)         Access to the system shall be restricted to the sole purpose of verification of medical assistance eligibility, submission of medical claims, and providing claims history information when a subscriber is requesting payment information for medical services rendered to a recipient;

 

2)         The subscriber indemnifies and holds harmless the State, its agents and employees from any and all claims by the subscriber or any recipient who is aggrieved by the actions of any party under the contract;

 

3)         The subscriber is an enrolled medical provider or the medical provider's agent;

 

4)         A third party who is not qualified as a subscriber may be granted access to the EDI service through a trading partner only with prior approval of the Department;

 

5)         All information, including information relating to recipients and providers obtained by the subscriber, through performance under contract with the contractor, is treated as confidential information pursuant to the Public Aid Code [305 ILCS 5] and federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (42 CFR 160, 162 and 164); and

 

6)         The subscriber will certify that neither it, nor any employees, partners, officers or shareholders of the subscriber, are currently barred, suspended or terminated from participation in the Medicaid or Medicare program, nor are any of the above currently under sanction for, or serving a sentence for, conviction of any Medicaid or Medicare program offenses.

 

f)         Charges for EDI Services

 

1)         Reimbursement rates for real time mode and batch mode requests from a trading partner will be established in the agreement between the trading partner and the Department.

 

2)         Charges to the subscribers are made in accordance with the fee schedule and provisions specified in the contract between the trading partner and subscriber.

 

(Source:  Amended at 38 Ill. Reg. 4330, effective January 29, 2014)

 

Section 140.71  Reimbursement for Medical Services Through the Use of a C-13 Invoice Voucher Advance Payment and Expedited Payments

 

a)         C-13 Invoice Voucher Advance Payments

 

1)         The C-13 invoice voucher, when used as an advanced payment, is an exception to the regular reimbursement process.  It may be issued only under extraordinary circumstances to qualified providers of medical assistance services.  C-13 advance payments will be made only to a hospital organized under the University of Illinois Hospital Act, subject to approval by the Director, or to qualified providers who meet the following requirements:

 

A)        are enrolled with the Department;

 

B)        have experienced an emergency which necessitates C-13 advance payments. Emergency in this instance is defined as a circumstance under which withholding of the advance payment would impose severe and irreparable harm to the clients served.  Circumstances which may create such emergencies include, but are not limited to, the following:

 

i)          agency system errors (either automated system or clerical) which have precluded payments, or which have caused erroneous payments such that the provider's ability to provide further services to clients is severely impaired; or

 

ii)         cash flow problems encountered by a provider or group of providers which are unrelated to agency technical system problems.  These situations include problems which are exclusively those of the providers or problems related to State cash flow which result in delayed payments and extensive financial problems to a provider, adversely impacting on the ability to promptly serve the clients;

 

C)        serve a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

 

i)          for long term care facilities, 80 percent or more of their residents must be eligible for public assistance;

 

ii)         for long term care facilities enrolled in the Exceptional Care Program, four or more residents receiving exceptional care;

 

iii)        for hospitals, the hospital must qualify as a disproportionate share hospital as described in 89 Ill. Adm. Code 148.120 or receive Medicaid Percentage Adjustment payments as described in 89 Ill. Adm. Code 148.122;

 

iv)        for practitioners and other medical providers, 50 percent or more of their patient revenue must be generated through Medicaid reimbursement;

 

v)         for sole source pharmacies in a community which are not within a 25-mile radius of another pharmacy, the provisions of this Section may be waived;

 

vi)        for government-owned facilities, this subsection (a)(1)(C) may be waived if the cash flow criterion under subsection (a)(1)(B)(ii) is met; and

 

vii)       for providers who have filed for Chapter 11 bankruptcy, this subsection (a)(1)(C) may be waived if the cash flow criterion under subsection (a)(1)(B)(ii) are met;

 

D)        sign an agreement with the Department which specifies the terms of advance payment and subsequent repayment.  The agreement will contain the following provisions:

 

i)          specific reasons for advanced payments;

 

ii)         specific amount agreed to be advanced;

 

iii)        specific date to begin recoupment; and

 

iv)        method of recoupment (percentage of payable amount of each Medicaid Management Information System (MMIS) voucher, specific amount per month, a warrant intercept, or a combination of the three recovery methods).

 

2)         Determination of amount of payment to be issued shall be based on anticipated future payments as determined by the Department.

 

3)         Approval Process

 

A)        In order to obtain C-13 advance payments, providers must submit their request in writing (telefacsimile and email requests are acceptable) to the appropriate Bureau Chief within the Division of Medical Programs.  The request must include:

 

i)          an explanation of the circumstances creating the need for the advance payments;

 

ii)         supportive documentation to substantiate the emergency nature of the request and risk of irreparable harm to the clients; and

 

iii)        specification of the amount of the advance required.

 

B)        An agreement will be issued to the provider for all approved requests. The agreement must be signed by the administrator, owner, chief executive officer or other authorized representative and be received by the Department prior to release of the warrant.

 

C)        C-13 advance payments shall be authorized for the provider following approval by the Administrator of the Division of Medical Programs or designee.  Once all requirements of this subsection (a)(3) are met, the Administrator will authorize payment within seven days.

 

4)         Recoupment

 

A)        Health care entities other than individual practitioners shall be required to sign an agreement stating that, should the entity be sold, the new owners will be made aware of the liability and will assume responsibility for repaying the debt to the Department according to the original agreement.

 

B)        All providers shall sign an agreement specifying the terms of recoupment.  An agreed percentage of the total payment to the provider for services rendered shall be deducted from future payments until the debt is repaid.  For providers who are properly certified, licensed or otherwise qualified under appropriate State and federal requirements, the recoupment period shall not exceed six months from the month in which payment is authorized.  For those providers enrolled but not in good standing (e.g., decertification termination hearing or other adverse action is pending), recoupment will be made from the next available payments owed the provider.

 

C)        In the event that the provider fails to comply with the recoupment terms of the agreement, the remaining balance of any advance payment shall be immediately recouped from claims being processed by the Department.  If such claims are insufficient for complete recovery, the remaining balance will become immediately due and payable by check to the Illinois Department of Public Aid.  Failure by the provider to remit such check will result in the Department pursuing other collection methods.

 

5)         Prior Agreements

The terms of any agreement signed between the provider and the Department prior to the adoption of this Section or prior to any amendment to this Section will remain in effect, notwithstanding the provisions of this Section.

 

b)         Expedited Claims Payments

 

1)         Expedited claims payments are issued through the regular MMIS payment process and represent an acceleration of the regular payment schedule.  They may be issued only under extraordinary circumstances to qualified providers of medical assistance services.  Reimbursement through the expedited process will be made only to a hospital qualified and participating under the Long Term Acute Care Hospital Quality Improvement Transfer Program Act [210 ILCS 155], a hospital organized under the University of Illinois Hospital Act, subject to approval by the Director, or to qualified providers who meet the following requirements:

 

A)        are enrolled with the Department;

 

B)        have experienced an emergency which necessitates expedited payments. Emergency in this instance is defined as a circumstance under which withholding of the expedited payment would impose severe and irreparable harm to the clients served.  Circumstances which may create such emergencies include, but are not limited to, the following:

 

i)          agency system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the provider's ability to provide further services to the clients is severely impaired;

 

ii)         cash flow problems encountered by a provider or group of providers which are unrelated to Department technical system problems.  These situations include problems which are exclusively those of the providers (i.e., provider billing system problems) or problems related to State cash flow which result in delayed payments and extensive financial problems to a provider adversely impacting on the ability to serve the clients;

 

C)        serve a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

 

i)          for long term care facilities, 80 percent or more of their residents must be eligible for public assistance;

 

ii)         for long term care facilities enrolled in the Exceptional Care Program, four or more residents receiving exceptional care;

 

iii)        for hospitals, the hospitals must qualify as a disproportionate share hospital as described in 89 Ill. Adm. Code 148.120 or receive Medicaid Percentage Adjustment payments as described in 89 Ill. Adm. Code 148.122;

 

iv)        for practitioners and other medical providers, 50 percent or more of their patient revenue must be generated through Medicaid reimbursement;

 

v)         for sole source pharmacies in a community that are not within a 25-mile radius of another pharmacy, the provisions of this Section may be waived;

 

vi)        for government-owned facilities, this subsection (b)(1)(C) may be waived if the cash flow criteria under subsection (a)(1)(B)(ii) are met; and

 

vii)       for providers who have filed for Chapter 11 bankruptcy, subsection (b)(1)(C) may be waived if the cash flow criteria under subsection (b)(1)(B)(ii) are met.

 

2)         Reimbursement will be based upon the amount of claims determined payable and be made for a period specified by the Department.

 

3)         Approval Process 

 

A)        In order to qualify for expedited payments, providers must submit their request in writing (telefacsimile and email requests are acceptable) to the appropriate Bureau Chief within the Division of Medical Programs.  The request must include:

 

i)          an explanation of the need for the expedited payments; and

 

ii)         supportive documentation to substantiate the emergency nature of the request.

 

B)        Expedited payments shall be authorized for the provider following approval by the Administrator of the Division of Medical Programs or designee.

 

C)        The Department will periodically review the need for any continued expedited payments.

 

4)         Prior Agreements

The terms of any agreement signed between the provider and the Department prior to the adoption of this Section or prior to any amendment to this Section will remain in effect, notwithstanding the provisions of this Section.

 

(Source:  Amended at 38 Ill. Reg. 15081, effective July 2, 2014)

 

Section 140.72  Drug Manual (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 141 at 8 Ill. Reg. 16354)

 

Section 140.73  Drug Manual Updates (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 141 at 8 Ill. Reg. 16354)

 

Section 140.74  Resolution of Claims Related to Inaccurate or Updated Enrollment Information

 

a)         Payment shall be made for a medically necessary covered service when payment is initially denied due to inaccurate or updated enrollment information on the date of service when the provider:

 

1)         Submits documentation to the entity responsible for payment pursuant to subsection (c) that the provider verified the client's enrollment on the date of service by using the Recipient Eligibility Verification Program (REV), the Medical Electronic Data Interchange (MEDI), or any other electronic system that the Department designates for electronic enrollment verification; and

 

2)         Meets all other requirements for providing the medically necessary covered service on the date of service.

 

b)         In order to receive payment for the medically necessary covered service rendered, the provider must also meet the following:

 

1)         For services that required prior authorization, the provider must submit documentation to the entity responsible for payment pursuant to subsection (c) that the prior authorization request was approved by the previous entity to which the client was identified as being enrolled pursuant to subsection (a). For services that did not require prior authorization, the provider must provide proof that no prior authorization was required by the previous entity.

 

A)        The MCO responsible for payment pursuant to subsection (c) must accept the approved prior authorization made by the previous entity and may not impose any further prior authorization or similar requirements.

 

B)        For services that did not require prior authorization from the previous entity, the MCO responsible for payment pursuant to subsection (c) may not impose any further prior authorization or similar requirements.

 

2)         The provider must supply evidence of claim denial or rejection and supporting documentation of enrollment to the entity responsible for payment pursuant to subsection (c).

 

3)         The approved prior authorization request from the previous entity, or proof that no prior authorization was required by the previous entity, and initial or resubmitted claim must be received by the entity responsible for payment pursuant to subsection (c) within the appropriate timely filing period. The timely filing period shall begin on the date on the payment voucher/remittance advice that informs the provider that the claim is denied or rejected and extend for a period of 180 days.

 

c)         The MCO in which the client is enrolled on the date of service is responsible for payment.

 

d)         Payment by the responsible MCO will be made as follows:

 

1)         In-network managed care providers shall receive the payor's contracted rate that was in effect on the date of service.

 

2)         Out-of-network and fee-for-service providers shall receive, at a minimum, the fee-for-service rate, plus any add-ons, that was in effect on the date of service.

 

3)         A payment penalty reduction is not permissible.

 

e)         For the purposes of this Section, documentation may include, but is not limited to:

 

1)         REV eligibility batch file or screen print, MEDI eligibility batch file or screen print, or other eligibility statement from the electronic enrollment verification system designated by the Department and used to verify the client's eligibility on the date of service. For long term care providers, if the batch report or screen image is dated on or after the first day that the Department opens access to the enrollment verification system for purposes of verifying the client's eligibility for the covered service, it shall be accepted as the date of service verification.

 

2)         Previous entity's policy as contained in a provider manual, provider notice, provider contract, policy memorandum, or other entity-created document that indicates that no prior authorization was required for the services rendered, or the previous entity's prior authorization approval;

 

3)         Initial claim or resubmitted claim; and

 

4)         Payment voucher/remittance advice or explanation of benefits (EOB) that informs the provider that the previous entity denied or rejected the claim.

 

(Source:  Added at 41 Ill. Reg. 10950, effective August 9, 2017)

 

Section 140.75  Managed Care − Disputed Provider Claims Resolution Process

 

a)         The Department will maintain an electronic provider complaint portal through which a disputed claim between a provider and an MCO is documented, monitored, and resolved. A disputed claim is a determination made by an MCO that denies in whole or in part a claim for reimbursement to a provider for services rendered by the provider to an enrollee of the MCO with which the provider disagrees. 

 

b)         A provider or its billing agent may submit to the Department's provider complaint portal a disputed claim only after filing with the MCO's internal provider dispute resolution process, as described in this subsection (b).  Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy.

 

1)         The provider's submission to the portal must include the date the disputed claims were filed with the MCO's internal provider dispute resolution process and the corresponding MCO-provided tracking number.

 

2)         Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the provider complaint portal no sooner than 30 calendar days after submitting to the MCO's internal process and not later than 30 calendar days after the unsatisfactory resolution of the internal MCO process or 60 calendar days after submitting the dispute to the MCO internal process. 

 

c)         The Department, within 10 business days after a provider's disputed claims submission to the provider complaint portal, will present the disputed claims to the MCO for resolution. 

 

d)         The MCO, within 30 calendar days after receiving the disputed claims from the Department's provider complaint portal, will develop a written proposal to resolve the disputed claims, which shall be electronically transmitted to the provider and uploaded to the provider complaint portal, unless an extension is granted pursuant to subsection (e), resulting in an MCO having 60 calendar days to develop a written proposal. 

 

1)         In the event the MCO requires additional information from the provider to review the disputed claims, the MCO must request the additional information from the provider within 5 business days after receiving the disputed claims from the Department's provider complaint portal, unless the MCO requests an extension within this 5 business day timeframe and is granted an extension pursuant to subsection (e).  When an MCO is granted an extension, the MCO must request the additional information from the provider within 5 business days after receiving the extension.

 

2)         When additional information is requested from the provider by the MCO within the timeframes described in subsection (d)(1), the provider has 5 business days to respond with the requested information, unless the provider requests an extension within this 5 business day response timeframe and is granted an extension pursuant to subsection (e). When a provider is granted an extension, the provider must respond with the requested information within 5 business days after receiving the extension.  Failure to timely provide the information will result in the disputed claims being closed.

 

e)         During the disputed claims resolution process described in subsection (d), the MCO or the provider may request, through the provider complaint portal, that the Department authorize a single 30 calendar day extension.  The MCO or the provider may submit an extension request during the timeframes established in subsection (d).  An extension request, made by either the MCO or the provider, that occurs after the timelines in subsection (d) must be made no later than 7 calendar days prior to the end of the initial 30 calendar day period.  Approval of the extension is at the Department's discretion.  An approved extension adds 30 calendar days to the initial 30 calendar day period, for a total of 60 calendar days within which the MCO must develop a written proposal to address the disputed claims.

 

f)         A provider that disagrees with the MCO's written proposal or does not receive the MCO's written proposal within the required timeframe has 30 calendar days to request that the Department review the disputed claims and render a final decision.  

 

1)         Within 30 calendar days after a provider's request for Department review, both the MCO and the provider shall deliver all relevant information to the Department, including contact information for knowledgeable personnel. 

 

2)         Within 30 calendar days after the timeframe established in subsection (f)(1), the Department shall provide a written decision on the disputed claims that reflects, and is consistent with, applicable contract terms, written Department policies and procedures, and State and federal statute and regulations.

 

3)         The decision of the Department is final. Disputes between MCOs and providers presented to the Department for resolution are not contested cases and do not confer any right to an administrative hearing.

 

(Source:  Added at 44 Ill. Reg. 4616, effective March 3, 2020)

SUBPART C: PROVIDER ASSESSMENTS

 

Section 140.80  Hospital Provider Fund

 

a)         Purpose and Contents

 

1)         The Hospital Provider Fund (Fund) was created in the State Treasury on February 3, 2004 (see 305 ILCS 5/5A-8).  Interest earned by the Fund shall be credited to the Fund. The Fund shall not be used to replace any funds appropriated to the Medicaid program by the General Assembly.

 

2)         The Fund is created for the purpose of receiving and disbursing monies in accordance with this Section and Article 5A of the Code.

 

3)         The Fund shall consist of:

 

A)        All monies collected or received by the Department under subsection (b);

 

B)        All federal matching funds received by the Department as a result of expenditures made by the Department that are attributable to monies deposited in the Fund;

 

C)        Any interest or penalty levied in conjunction with the administration of the Fund;

 

D)        Monies transferred from another fund in the State treasury;

 

E)        All other monies received for the Fund from any other source, including interest earned on those monies.

 

b)         Provider Assessments

 

1)         Subject to Sections 5A-3, 5A-10 and 5A-15 of the Code, for State fiscal years 2009 through 2018, or as long as continued under Section 5A-16, 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, 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 5A-12-5 of the Code, with that increase only taking effect upon the date that a State share for those payments is required under federal law.  For the period of April through June 2015, the amount of $218.38 used to calculate the assessment under this subsection (b)(1) shall be increased by a uniform percentage to generate $20,250,000 in the aggregate for that period from all hospitals subject to the annual assessment under this Section.  For State fiscal years 2009 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 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 Department or its duly authorized agents and employees.  Subject to Sections 5A-3, 5A-10, and 5A-16 of the Code, for State fiscal years 2019 and 2020, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $197.19 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days. For State fiscal years 2019 and 2020, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 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. Notwithstanding any other provision in this Section, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.  Subject to Sections 5A-3 and 5A-10, and in accordance with federal approval and P.A. 101-0650, for the period of July 1, 2020 through December 31, 2020 and calendar years 2021 and 2022, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $221.50 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days, provided, however, for the period of July 1, 2020 through December 31, 2020, the assessment shall be equal to 50% of the annual amount and the amount of $221.50 shall be retroactively adjusted by a uniform percentage to generate an amount equal to 50% of the Assessment Adjustment as defined in subsection (l). For the period of July 1, 2020 through December 31, 2020 and calendar years 2021 and 2022, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 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. For a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State Fiscal Year 2020 on the basis of hypothetical data, the data that was the basis for the 2020 assessment shall be used to calculate the assessment under this subsection (b)(1).

 

2)         In addition to any other assessments imposed under this Section, effective July 1, 2016 and semiannually thereafter through June 2018, or as provided in Section 5A-16, in addition to any federally required State share as authorized under subsection (b)(1), the amount of $218.38 shall be increased by a uniform percentage to generate an amount equal to 75% of the ACA Assessment Adjustment, as defined in subsection (l)(1).

 

3)         Subject to Sections 5A-3, 5A-10, and 5A-15 of the Code for the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012, and for State fiscal years 2013 through 2018, 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, the multiplier 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 5A-12-5, with that increase only taking effect upon the date that a State share for those payments is required under federal law.  For the period of April through June 2015, the amount of .008766 used to calculate the assessment under this subsection (b)(3) shall be increased by a uniform percentage to generate $6,750,000 in the aggregate for that period from all hospitals subject to the annual assessment under this Section.  For the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012 and for State fiscal years 2013 through 2018, 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 that 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. 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.  Subject to Sections 5A-3, 5A-10, and 5A-16, for State fiscal years 2019 and 2020, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .01358 multiplied by the hospital's outpatient gross revenue. For State fiscal years 2019 and 2020, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 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. Notwithstanding any other provision in this Section, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.  Subject to Sections 5A-3 and 5A-10, for the period of July 1, 2020 through December 31, 2020 and calendar years 2021 and 2022, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .01525 multiplied by the hospital's outpatient gross revenue, provided however, for the period of July 1, 2020 through December 31, 2020, the assessment shall be equal to 50% of the annual amount and the amount of .01525 shall be retroactively adjusted by a uniform percentage to generate an amount equal to 50% of the Assessment Adjustment, as defined in subsection (1). For the period of July 1, 2020 through December 31, 2020 and calendar years 2021 and 2022, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to that data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's outpatient revenue data from any source available, including, but not limited to, records maintained by the hospital provider. The data may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. For a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State Fiscal Year 2020 on the basis of hypothetical data, the data that was the basis for the 2020 assessment shall be used to calculate the assessment under this subsection (b)(3).

 

c)         Payment of Assessment Due

 

1)         The inpatient assessment imposed by Section 5A-2 of the Code for State fiscal year 2009 through State fiscal year 2018, or as provided in Section 5A-16, shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 14^th State business day of each month.  No installment payments of an inpatient assessment shall be due and payable, however, until after the Comptroller has issued the payments required under Section 5A-12.2 of the Code.  Assessment payments postmarked on the due date will be considered as paid on time.

 

2)         Except as provided in Section 5A-4(a-5) of the Code, the outpatient assessment imposed by subsection (b)(3) for the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012 and for State fiscal year 2013 through State fiscal year 2018, or as provided in Section 5A-16, shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 14^th State business day of each month.

 

A)        No installment payment of an outpatient assessment imposed by subsection (b)(3) shall be due and payable, however, until after:

 

i)          the Department notifies the hospital provider, in writing, that the payment methodologies to hospitals required under Section 5A-12.4 of the Code have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services (CMMS), and the waiver under 42 CFR 433.68 for the assessment imposed by subsection (b) of this Section, if necessary, has been granted by CMMS; and

 

ii)         the Comptroller has issued the payments required under Section 5A-12.4 of the Code.

 

B)        Assessment payments postmarked on the due date will be considered as paid on time. Upon notification to the Department of approval of the payment methodologies required under Section 5A-12.4 of the Code and the waiver granted under 42 CFR 433.68, if necessary, all installments otherwise due under subsection (b)(3) of this Section prior to the date of notification shall be due and payable to the Department upon written direction from the Department and issuance by the Comptroller of the payments required under Section 5A-12.4 of the Code.

 

3)         The assessment imposed under P.A. 101-0650 and Section 5A-2 of the Code for State fiscal year 2019 and each subsequent State fiscal year shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 17^th State business day of each month.  The Department has discretion to establish a late date due to delays in payments being made to hospitals, as required by Section 5A-12.7 of the Code.

 

A)        No installment payment of an assessment imposed by P.A. 101-0650 and Section 5A-2 of the Code shall be due and payable, however, until after:

 

i)          The Department notifies the hospital provider, in writing, that the payment methodologies to hospitals required under Section 5A-12.6 or 5A-12.7 of the Code have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, and the waiver under 42 CFR 433.68 for the assessment imposed by P.A. 101-0650 and Section 5A-2 of the Code, if necessary, has been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services; and

 

ii)         The Comptroller and managed care organizations have issued the payments required under Section 5A-12.6 or 5A-12.7 of the Code.

 

B)        Upon notification to the Department of approval of the payment methodologies required under Section 5A-12.6 or 5A-12.7 of the Code and the waiver granted under 42 CFR 433.68, if necessary, all installments otherwise due under subsection (b)(3) prior to the date of notification shall be due and payable to the Department upon written direction from the Department and issuance by the Comptroller and managed care organizations of the payments required under Section 5A-12.6 or 5A-12.7 of the Code.

 

4)         Any assessment amount that is due and payable to the Department more frequently than once per calendar quarter shall be remitted to the Department by the hospital provider by means of electronic funds transfer.  The Department may provide for remittance by other means if the amount due is less than $10,000 or electronic funds transfer is unavailable for this purpose.

 

5)         All payments received by the Department shall be credited first to unpaid installment amounts (rather than to penalty or interest), beginning with the most delinquent installments.

 

d)         Notice Requirements, Penalty, and Maintenance of Records

 

1)         The Department shall send a notice of assessment to every hospital provider subject to an assessment under subsection (b), except that no notice shall be sent for the outpatient assessment imposed under subsection (b)(3) until the Department receives written notice that the payment methodologies to hospitals required under Section 5A-12.4 of the Code has been approved and the waiver under 42 CFR 433.68, if necessary, has been granted by CMMS.

 

2)         If a hospital provider conducts, operates, or maintains more than one hospital licensed by the Illinois Department of Public Health, a separate notice shall be sent for each hospital.

 

e)         Procedure for Partial Year Reporting/Operating Adjustments

 

1)         Cessation of business during the fiscal year in which the assessment is being paid.  If a hospital provider ceases to conduct, operate, or maintain a hospital for which the person is subject to assessment under subsection (b), the assessment for the State fiscal year in which the cessation occurs shall be adjusted by multiplying the assessment computed under subsection (d) 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 adjusted (to the extent not previously paid).

 

2)         Commencing of business during the fiscal year in which the assessment is being paid.  A hospital provider who commences conducting, operating, or maintaining a hospital for which the person is subject to assessment under subsection (b), upon notice by the Department, shall pay the assessment under subsection (d) as computed by the Department in installments on the due dates stated on the notices and on the regular installment due dates for the State fiscal year occurring after the due date of the initial assessment notice. For State fiscal years 2009 through 2018, in the case of a hospital provider that did not conduct, operate or maintain a hospital in 2005, the inpatient 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 Department.  For the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012, and for State fiscal years 2013 through 2018, in the case of a hospital provider that did not conduct, operate or maintain a hospital in 2009, the outpatient assessment imposed under subsection (b)(3) shall be computed on the basis of hypothetical gross outpatient revenue for the full calendar year as determined by the Department.  The assessment determination made by the Department is final.

 

3)                  Partial Calendar Year Operation Adjustment.  For a hospital provider that did not conduct, operate, or maintain a hospital throughout the entire calendar year reporting period, the assessment for the State fiscal year shall be annualized for the portion of the reporting period the hospital was operational (dividing the assessment due by the number of days the hospital was in operation and then multiplying the amount by 365).  Information reported by a prior provider from the same hospital during the calendar year shall be used in the annualization equation, if available.

 

4)         Notwithstanding any other provision in this Section, for State fiscal years 2019 through calendar year 2022, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in the year that is the basis of the calculation of the assessment under this Section, the assessment under subsection (b) for the 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, except that for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.

 

5)         Notwithstanding any other provision in this Section, for State fiscal years 2019 through calendar year 2022, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in the year that is the basis of the calculation of the assessment under this Section, the assessment under subsection (b) 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, except that for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.

 

6)         Change in Ownership and/or Operators.  The full quarterly installment must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment amount (including past due assessments and any interest or penalties that may have accrued against the amount) rests on the hospital provider currently operating or maintaining the hospital regardless if these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

 

f)         Penalties

 

1)         Any hospital that fails to pay the full amount of an installment when due shall be charged, unless waived by the Department for reasonable cause, a penalty equal to 5% of the amount of the installment not paid on or before the due date, plus 5% of the portion remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the installment amount not paid on or before the due date. Waiver due to reasonable cause may include but is not limited to:

 

A)        provider has not been delinquent on payment of an assessment due, within the last three calendar years from the time the delinquency occurs.

 

B)        provider can demonstrate to the Department's satisfaction that a payment was made prior to the due date.

 

C)        provider is a new owner/operator and the late payment occurred in the quarter in which the new owner/operator assumed control of the facility.

 

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent hospitals participating in the Medicaid Program. Payments may be withheld from the hospital until the entire assessment, including any interest and penalties, is satisfied or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached or if a hospital fails to comply with an agreement, the Department reserves the right to recover any outstanding provider assessment, interest and penalty by recouping the amount or a portion thereof from the hospital's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process. Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same hospital two times in a fiscal year may be cause for termination from the Medicaid Program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

 

3)         If the hospital does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system, within three months after the fee due date, the Department may begin legal action to recover the monies, including penalties and interest owed, plus court costs.

 

g)         Delayed Payment – Groups of Hospitals

The Department may establish delayed payment of assessments and/or waive the payment of interest and penalties for groups of hospitals such as disproportionate share hospitals or all other hospitals when:

 

1)         The State delays payments to hospitals due to problems related to State cash flow; or

 

2)         A cash flow bond pool's, or any other group financing plans', requests from providers for loans are in excess of its scheduled proceeds such that a significant number of hospitals will be unable to obtain a loan to pay the assessment.

 

h)         Delayed Payment – Individual Hospitals

In addition to the provisions of subsection (g), the Department may delay assessments for individual hospitals that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the calendar quarter following the quarter in which the assessment was to have been received by the Department as described in subsection (c). The request must be received by the Department prior to the due date of the assessment.

 

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions may be made only to qualified hospitals who meet all of the following requirements:

 

A)        The provider has experienced an emergency that necessitates institution of delayed payment provisions.  Emergency in this instance is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1) and (f)(2) would impose severe and irreparable harm to the clients served.  Circumstances that may create these emergencies include, but are not limited to, the following:

 

i)          Department system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the provider's ability to provide further services to clients is severely impaired;

 

ii)         Cash flow problems encountered by a provider that are unrelated to Department technical system problems and that result in extensive financial problems to a facility, adversely impacting on its ability to serve its clients.

 

B)        The provider serves a significant number of clients under the medical assistance program.  "Significant" in this instance means:

 

i)          A hospital that serves a significant number of clients under the medical assistance program; significant in this instance means that the hospital qualifies as a disproportionate share hospital (DSH) under 89 Ill. Adm. Code 148.120(a)(1) through 148.120(a)(2); or qualifies as a Medicare DSH hospital under the current federal guidelines.

 

ii)         A government-owned facility that meets the cash flow criterion under subsection (h)(1)(A)(ii).

 

iii)        A hospital that has filed for Chapter 11 bankruptcy and that meets the cash flow criterion under subsection (h)(1)(A)(ii).

 

C)        The provider must ensure that a delay of payment request, as defined under subsection (h)(3)(A), is received by the Department prior to the payment due date, and the request must include a Cash Position Statement that is based upon current assets, current liabilities and other data for a date that is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of assessment payments will be denied if any of the following criteria are met:

 

i)          The ratio of current assets divided by current liabilities is greater than 2.0.

 

ii)         Cash, short term investments and long term investments equal or exceed the total of accrued wages payable and the assessment payment.  Long term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation.

 

D)        The provider must show evidence of denial of an application to borrow assessment funds through a cash flow bond pool or financial institutions such as a commercial bank.  The denial must be 90 days old or less.

 

E)        The provider must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

 

i)          Specific reasons for institution of the delayed payment provisions;

 

ii)         Specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

 

iii)        The interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the provider as a result of institution of the delayed payment provisions;

 

iv)        A certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

 

v)         A certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

 

vi)        Other terms and conditions that may be required by the Department.

 

2)         A hospital that does not meet the above criteria may request a delayed payment schedule.  The Department may approve the request, notwithstanding the hospital not meeting the above criteria, upon a sufficient showing of financial difficulties and good cause by the hospital.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

 

3)         Approval Process

 

A)        In order to receive consideration for delayed payment provisions, providers must ensure their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Hospital and Provider Services.  The request must be received by the date designated by the Department.  Providers will be notified, in writing, as to the due dates for submitting delay of payment requests.  Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests, postmarked no later than the date of the telefax.  The request must include:

 

i)          An explanation of the circumstances creating the need for the delayed payment provisions;

 

ii)         Supportive documentation to substantiate the emergency nature of the request including a cash position statement as defined in subsection (h)(1)(C), a denial of application to borrow the assessment as defined in subsection (h)(1)(D) and an explanation of the risk of irreparable harm to the clients; and

 

iii)        Specification of the specific arrangements requested by the provider.

 

B)        The hospital shall be notified by the Department, in writing prior to the assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the provider for all approved requests.  The agreement must be signed by the administrator, owner, chief executive officer or other authorized representative and be received by the Department prior to the first scheduled payment date listed in that agreement.

 

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the provider's request for institution of delayed payment provisions.  In the event a provider's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject quarter unless the provider fails to meet all of the terms and conditions of the agreement. In the event the provider fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and the penalties shall be fully reinstated.

 

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the hospital meets the criteria in subsections (h)(1)(A) and (B).  Any waivers granted shall be expressly identified in the agreement described in subsection (h)(1)(E).

 

6)         Subsequent Delayed Payment Arrangements.  Once a provider has requested and received approval for delayed payment arrangements, the provider shall not receive approval for subsequent delayed payment arrangements until such time as the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delayed payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a provider that has not satisfied the terms and conditions of any current delayed payment agreement.

 

i)          Administration and Enforcement Provisions

The Department shall establish and maintain a listing of all hospital providers appearing in the licensing records of the Department of Public Health, which shall show each provider's name and principal place of business and the name and address of each hospital operated, conducted, or maintained by the provider in this State.  The Department shall administer and enforce Sections 5A-1, 2, 3, 4, 5, 7, 8, 10, 12, 15, and 16 of the Code and collect the assessments and penalty assessments imposed under P.A. 101-0650 and Sections 5A-2 and 4 of the Code.  The Department, its Director, and every hospital provider subject to assessment measured by occupied bed days shall have the following powers, duties and rights:

 

1)         The Department may initiate either administrative or judicial proceedings, or both, to enforce the provisions of Sections 5A-1, 2, 3, 4, 5, 7, 8, 10, 12, 15 and 16 of the Code.  Administrative enforcement proceedings initiated shall be governed by the Department's rules at 89 Ill. Adm. Code 104.200 through 104.330.  Judicial enforcement proceedings initiated 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 three 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 hospital provider before the expiration of this limitation period.

 

3)         Any unpaid assessment under P.A. 101-0650 and Section 5A-2 of the Code shall become a lien upon the assets of the hospital upon which it was assessed.  If any hospital provider, outside the usual course of its business, sells or transfers the major part of any one or more of the real property and improvements, the machinery and equipment, or the furniture or fixtures of any hospital that is subject to the provisions of Sections 5A-1, 2, 3, 4, 5, 7, 8, 10, 12, 15 and 16 of the Code, the seller or transferor shall pay the Department the amount of any assessment, assessment penalty, and interest (if any) due from it under P.A. 101-0650 and Sections 5A-2 and 4 of the Code 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 the asset shall be liable for the amount of the assessment, penalties 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, penalties, 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 the 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 P.A. 101-0650 and Sections 5A-2, 4 and 5 of the Code.

 

4)         Payments under Section 5A-4 of the Code are not subject to the Illinois Prompt Payment Act [30 ILCS 540].  Credits or refunds shall not bear interest.

 

5)         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 hospital provider.

 

j)          Exemptions

The following classes of providers are exempt from the assessment imposed under Section 5A-4 of the Code unless the exemption is adjudged to be unconstitutional or otherwise invalid:

 

1)         A hospital provider that is a State agency, a State university, or a county with a population of 3,000,000 or more.

 

2)         A hospital provider that is a county with a population of less than 3,000,000 or a township, municipality, hospital district, or any other local governmental unit.

 

k)         Nothing in Section 5A-4 of the Code shall be construed to prevent the Department from collecting all amounts due under this Section pursuant to an assessment imposed before February 3, 2004.

 

l)          Definitions

As used in this Section, unless the context requires otherwise:

 

1)         "ACA Assessment Adjustment" means:

 

A)        For the period of July 1, 2016 through December 31, 2016, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) of the Code to managed care organizations for hospital services due and payable in the month of April 2016 multiplied by 6.

 

B)        For the period of January 1, 2017 through June 30, 2017, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) to managed care organizations for hospital services due and payable in the month of October 2016 multiplied by 6, except that the amount calculated under this subsection (l)(1)(B) shall be adjusted, either positively or negatively, to account for the difference between the actual payments issued under Code Section 5A-12.5 for the period beginning July 1, 2016 through December 31, 2016 and the estimated payments due and payable in the month of April 2016 multiplied by 6 as described in subsection (l)(1)(A).

 

C)        For the period of July 1, 2017 through December 31, 2017, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) of the Code to managed care organizations for hospital services due and payable in the month of April 2017 multiplied by 6, except that the amount calculated under this subsection (l)(1)(C) shall be adjusted, either positively or negatively, to account for the difference between the actual payments issued under Code Section 5A-12.5 for the period beginning January 1, 2017 through June 30, 2017 and the estimated payments due and payable in the month of October 2016 multiplied by 6 as described in subsection (l)(1)(B).

 

D)        For the period of January 1, 2018 through June 30, 2018, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) of the Code to managed care organizations for hospital services due and payable in the month of October 2017 multiplied by 6, except that:

 

i)          the amount calculated under this subsection (l)(1)(D) shall be adjusted, either positively or negatively, to account for the difference between the actual payments issued under Code Section 5A-12.5 for the period of July 1, 2017 through December 31, 2017 and the estimated payments due and payable in the month of April 2017 multiplied by 6 as described in subsection (l)(1)(C); and

 

ii)         the amount calculated under this subsection (l)(1)(D) shall be adjusted to include the product of .19125 multiplied by the sum of the fee-for-service payments, if any, estimated to be paid to hospitals under Section 5A-12.5(b) of the Code.

 

2)         "Assessment Adjustment" means, for the period of July 1, 2020 through December 31, 2020, the product of .3853 multiplied by the total of the actual payments made under Section 5A-12.7(c) through (k) of P.A. 101-0650 attributable to that period, less the total of the assessment imposed under subsections (b)(1) and (b)(3) of this Section for the period. For each calendar quarter beginning on and after January 1, 2021, the product of .3853 multiplied by the total of the actual payments made under Section 5A-12.7(c) through (k) of P.A. 101-0650 attributable to the period, less the total of the assessment imposed under subsections (b)(1) and (b)(3) of this Section for that period.

 

3)         "CMMS" means the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.

 

4)         "Code" means the Illinois Public Aid Code [305 ILCS 5].

 

5)         "Department" means the Illinois Department of Healthcare and Family Services.

 

6)         "Fund" means the Hospital Provider Fund.

 

7)         "HCRIS" means the federal Centers for Medicare and Medicaid Services Healthcare Cost Report Information System.

 

8)         "Hospital" means an institution, place, building, or agency located in this State that is subject to licensure by the Illinois Department of Public Health under the Hospital Licensing Act, whether public or private and whether organized for profit or not-for-profit.

 

9)         "Hospital Provider" means a person licensed by the Department of Public Health to conduct, operate, or maintain a hospital, regardless of whether the person is a Medicaid provider.  For purposes of this definition, "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.

 

10)        "Inpatient Gross Revenue" means total inpatient gross revenue, as reported on the HCRIS Worksheet C, Part 1, Column 6, Line 101, less the sum of the following lines (including any subset lines of these lines):

 

A)        Line 34:  Skilled Nursing Facility.

 

B)        Line 35:  Other Nursing Facility.

 

C)        Line 35.01:  Intermediate Care Facility for the Mentally Retarded.

 

D)        Line 36:  Other Long Term Care.

 

E)        Line 45:  PBC Clinical Laboratory Services – Program Only.

 

F)         Line 60:  Clinic.

 

G)        Line 63:  Other Outpatient Services.

 

H)        Line 64:  Home Program Dialysis.

 

I)         Line 65:  Ambulance Services.

 

J)         Line 66:  Durable Medical Equipment – Rented.

 

K)        Line 67:  Durable Medical Equipment – Sold.

 

L)        Line 68:  Other Reimbursable.

 

11)        "Medicare Bed Days" means, for each hospital, the sum of the number of days that each bed was occupied by a patient who was covered by Title XVIII of the Social Security Act, excluding days attributable to the routine services provided to persons receiving skilled or intermediate long term care services. Medicare bed days shall be computed separately for each hospital operated or maintained by a hospital provider.

 

12)        "Medicare Gross Inpatient Revenue" means the sum of the following:

 

A)        The sum of the following lines from the HCRIS Worksheet D-4, Column 2 (excluding the Medicare gross revenue attributable to the routine services provided to patients in a psychiatric hospital, a rehabilitation hospital, a distinct part psychiatric unit, a distinct part rehabilitation unit or swing beds):

 

i)          Line 25:  Adults and Pediatrics.

 

ii)         Line 26:  Intensive Care Unit.

 

iii)        Line 27:  Coronary Care Unit.

 

iv)        Line 28:  Burn Intensive Care Unit.

 

v)         Line 29:  Surgical Intensive Care Unit.

 

vi)        Line 30:  Other Special Care Unit.

 

B)        From Worksheet D-4, Column 2, the amount from Line 103 less the sum of Lines 60, 63, 64, 66, 67 and 68 (and any subset lines of these lines).

 

C)        The amount from Worksheet D-6, Part 3, Column 3, Line 53.

 

13)        "Medicare Gross Outpatient Revenue" means the amount from the HCRIS Worksheet D, Part V, Line 101, Columns 5, 5.01, 5.02, 5.03 and 5.04 less the sum of Lines 45, 60, 63, 64, 65, 66 and 67 (and any subset lines of these lines).

 

14)        "Occupied Bed Days" means the sum of the number of days that each bed was occupied by a patient for all beds, excluding beds classified as long term care beds and assessed a licensed bed fee during calendar year 2001. Occupied bed days shall be computed separately for each hospital operated or maintained by a hospital provider.

 

15)        "Outpatient Gross Revenue" (prior to State fiscal year 2019 from Medicare 2552-96 cost reports) means, for each hospital, its total gross charges attributed to outpatient services as reported on the Medicare cost report at Worksheet C, Part I, Column 7, Line 101 less the sum of lines 45, 60, 63, 64, 65, 66, 67 and 68 (and any subset lines of these lines).

 

16)        "Outpatient Gross Revenue" (for State fiscal year 2019 and thereafter from Medicare 2552-10 cost reports) means, for each hospital, its total gross charges attributed to outpatient services as reported on the Medicare cost report at Worksheet C, Part I, Column 7, Line 200 less the sum of lines 61, 90, 94, 95, 96, 97, 99, 100, 101, 115, 116, and 117 (and any subset lines of these lines).

 

(Source:  Amended at 44 Ill. Reg. 19713, effective December 11, 2020)

 

Section 140.82  Developmentally Disabled Care Provider Fund

 

a)         Purpose and Contents

 

1)         The Developmentally Disabled Care Provider Fund was created in the State Treasury on July 1, 1992, July 14, 1993 and July 1, 1995 (see 305 ILCS 5/5C-7).  Interest earned by the Fund shall be credited to the Fund.  The Fund shall not be used to replace any funds appropriated to the Medicaid program by the General Assembly.

 

2)         The Fund is created for the purpose of receiving and disbursing monies in accordance with this Section and Sections 5C-2 and 7 of the Code.

 

3)         The Fund shall consist of:

 

A)        All monies collected or received by the Department under subsection (b);

 

B)        All federal matching funds received by the Department as a result of expenditures made by the Department that are attributable to monies deposited in the Fund;

 

C)        Any interest or penalty levied in conjunction with the administration of the Fund;

 

D)        All other monies received for the Fund from any other source, including interest earned thereon; and

 

E)        All monies transferred from the Medicaid Developmentally Disabled Provider Participation Fee Trust Fund.

 

b)         Provider Assessments

 

1)         Beginning on July 1, 1993, 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.  The revenue for each year will be reported on the Developmentally Disabled Care Provider Tax form to be filed by a date designated by the Department.  The Department reserves the right to audit the reported data. 

 

2)         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 in the same amount and upon the same conditions and requirements as imposed in Section 140.84 and a license fee is imposed in the same amount and upon the same conditions and requirements as imposed in Section 140.84.  Notwithstanding any provision of any other Act, the assessment and license fee imposed by this subsection (b)(2) 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.

 

c)         Payment of Assessment Due

 

1)         The assessment described in subsection (b) shall be due and payable in quarterly installments, each equaling one-fourth of the assessment for the year, on September 30, December 31, March 31, and May 31 of the year, modified to accommodate weekends and holidays.  Providers will be notified, in writing, of the due dates.  Assessment payments postmarked on the due date will be considered paid on time.

 

2)         All payments received by the Department shall be credited first to unpaid installment amounts (rather than to penalty or interest), beginning with the most delinquent installments.

 

d)         Reporting Requirements, Penalty, and Maintenance of Records

 

1)         After June 30 of each State fiscal year, and on or before September 30 of the succeeding State fiscal year, every developmentally disabled care provider subject to an assessment under subsection (b) shall file a report with the Department.  The report shall be on a form prepared by the Department.  The report shall include the adjusted gross developmentally disabled care revenue from the State fiscal year just ended and shall be utilized by the Department to calculate the assessment for the State fiscal year commencing on the preceding July 1.  If a developmentally disabled care provider operates or maintains more than one developmentally disabled care facility, a separate report shall be filed for each facility.  In the case of a developmentally disabled care provider existing as a corporation or legal entity other than an individual, the report filed by it shall be signed by its president, vice-president, secretary, or treasurer or by its properly authorized agent.

 

2)         If the developmentally disabled care provider fails to file its report for a State fiscal year on or before the due date of the report, there shall, unless waived by the Department for reasonable cause, be added to the assessment imposed in subsection (b) a penalty assessment equal to 25 percent of the assessment imposed for the year.

 

3)         Every developmentally disabled care provider subject to an assessment under subsection (b) shall keep records and books that will permit the determination of adjusted gross developmentally disabled care revenue on a State fiscal year basis.  All such books and records shall be maintained for a minimum of three years following the filing date of the assessment report 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.

 

4)         Amended Assessment Reports.  With the exception of amended assessment reports filed in accordance with subsections (d)(5) or (6), an amended assessment report must be filed within 30 calendar days after the original report due date.  The amended report must be accompanied by a letter identifying the changes and the justification for the amended report.  The provider will be advised of any adjustments to the original annual assessment amount through a written notification from the Department.  Penalties may be applied to the amount underpaid due to a filing error.

 

5)         Submission of Financial Audit Statements.  All developmentally disabled care providers are required to submit a copy of all financial statements audited by an external, independent auditor to the Department within 30 days after the close of the externally performed financial audits.  If the provider's year end does not coincide with the June 30 ending date for the assessment report, the provider must submit all financial audits covering the tax report period. An amended assessment report must accompany the external financial audit statements if the data submitted on the initial tax report changes based upon the findings of the external financial audits and as indicated in the audited external financial statements.  Penalties may be applied to the amount underpaid due to a filing error.

 

6)         Reconsideration of Adjusted Tax.  If the Department, through an audit conducted by the Department or its agent within three years after the end of the fiscal year in which the assessment was due, changes the assessment liability of a developmentally disabled care provider, the developmentally disabled care provider may request a review or reconsideration of the adjusted assessment within 30 days after the Department's notification of the change in assessment liability.  Requests for reconsideration of the assessment adjustment shall not be considered if those requests are not postmarked on or before the end of the 30 day review period.  Penalties may be applied to the amount underpaid due to a filing error.

 

e)         Procedure for Partial Year Reporting/Operating Adjustments

 

1)         Cessation of business during the fiscal year in which the assessment is being paid.  For a developmentally disabled care provider who ceases to conduct, operate, or maintain a facility for which the person is subject to assessment under subsection (b), the assessment for the State fiscal year in which the cessation occurs shall be adjusted by multiplying the assessment computed under subsection (d) by a fraction, the numerator of which is the number of months in the year during which the provider conducts, operates, or maintains the facility and the denominator of which is 12.  The person shall file a final, amended report with the Department not more than 30 calendar days after the cessation, reflecting the adjustment, and shall pay with the final report the assessment for the year as so adjusted, to the extent not previously paid.

 

2)         Commencing of business during the fiscal year in which the assessment is being paid.  A developmentally disabled care provider who commences conducting, operating, or maintaining a facility for which the person is subject to assessment under subsection (b) shall file an initial return for the State fiscal year in which the commencement occurs within 30 calendar days thereafter and shall pay the assessment under subsection (d) as computed by the Department in equal installments on the due date of the initial assessment determination and on the regular installment due dates for the State fiscal year occurring after the due date of the initial assessment determination.  In determining the annual assessment amount for the provider the Department shall develop hypothetical annualized revenue projections based upon geographic location, facility size and patient case mix.  The assessment determination made by the Department is final.

 

3)         Partial Fiscal Year Operation Adjustment.  For a developmentally disabled care provider that did not conduct, operate, or maintain a facility throughout the entire fiscal year reporting period, the assessment for the following State fiscal year shall be annualized based on the provider's actual developmentally disabled care revenue for the portion of the reporting period the facility was operational (dividing adjusted developmentally disabled care revenue by the number of months the facility was in operation and then multiplying that amount by 12).  Developmentally disabled care revenue realized by a prior provider from the same facility during the fiscal year shall be used in the annualization equation, if available.

 

4)         Change in Ownership and/or Operators.  The full quarterly assessment must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment amount (including past due assessments and any interest or penalties that may have accrued against the amount) rests on the developmentally disabled care provider currently operating or maintaining the developmentally disabled care facility regardless if these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

 

f)         Penalties

 

1)         Any facility that fails to pay the full amount of an installment when due shall be charged, unless waived by the Department for reasonable cause, a penalty equal to five percent of the amount of the installment not paid on or before the due date, plus five percent of the portion thereof remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the installment amount not paid on or before the due date. Reasonable cause may include but is not limited to:

 

A)        a provider who has not been delinquent on payment of an assessment due within the last three calendar years from the time the delinquency occurs;

 

B)        a provider who can demonstrate to the Department's satisfaction that a payment was made prior to the due date; or

 

C)        that the provider is a new owner/operator and the late payment occurred in the quarter in which the new owner/operator assumed control of the facility.

 

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent facilities participating in the Medicaid Program. Payments may be withheld from the facility until the entire provider assessment, including any penalties, is satisfied, or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached, or if the facility fails to comply with an agreement the Department reserves the right to recover any outstanding provider assessment, interest and penalty by recouping the amount or a portion thereof from the provider's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process.  Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same facility two times in a fiscal year may be cause for termination from the Program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

 

3)         If the facility does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system, within three months of the assessment due date, the Department may begin legal action to recover the monies, including penalties and interest owed, plus court costs.

 

g)         Delayed Payment – Groups of Facilities

The Department may establish delayed payment of assessments and/or waive the payment of interest and penalties for groups of facilities when:

 

1)         the State delays payments to facilities due to problems related to State cash flow; or

 

2)         a cash flow bond pool's or any other group financing plans' requests from providers for loans are in excess of its scheduled proceeds such that a significant number of facilities will be unable to obtain a loan to pay the assessment.

 

h)         Delayed Payment – Individual Facilities

In addition to the provisions of subsection (g), the Department may delay assessments for individual facilities that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the calendar quarter following the quarter in which the assessment was to have been received by the Department as described in subsection (c). The request must be received by the Department prior to the date of the assessment.

 

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions shall be made only to qualified facilities who meet all of the following requirements:

 

A)        the facility has experienced an emergency which necessitates institution of delayed payment provisions.  Emergency in this instance is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1), (f)(2) and (f)(3) would impose severe and irreparable harm to the clients served.  Circumstances that may create such emergencies include, but are not limited to, the following:

 

i)          Department system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the facility's ability to provide further services to clients is severely impaired;

 

ii)         cash flow problems encountered by a facility that are unrelated to Department technical system problems and that result in extensive financial problems to a facility adversely impacting on its ability to serve its clients.

 

B)        the facility serves a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

 

i)          85 percent or more of their residents must be eligible for public assistance;

 

ii)         a government-owned facility, that meets the cash flow criteria under subsection (h)(1)(A)(ii).

 

iii)        a provider who has filed for Chapter 11 bankruptcy that meets the cash flow criterion under subsection (h)(1)(A)(ii).

 

C)        the facility must ensure that a delay of payment request, as defined in subsection (h)(3)(A), is received by the Department prior to the payment due date, and the request must include a Cash Position Statement that is based upon current assets, current liabilities and other data for a date that is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of assessment payments will be denied if any of the following criteria are met:

 

i)          the ratio of current assets divided by current liabilities is greater than 2.0;

 

ii)         cash, short-term investments and long-term investments equal or exceed the total of accrued wages payable and the assessment payment.  Long-term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation;

 

iii)        cash or other assets have been distributed during the previous 90 days to owners or related parties in an amount equal to or exceeding the assessment payment for dividends, salaries in excess of those allowable under Section 140.541 or payments for purchase of goods or services in excess of cost as defined in Section 140.537.

 

D)        the facility, with the exception of government owned facilities, must show evidence of denial of an application to borrow the assessment funds through a cash flow bond pool or financial institutions such as a commercial bank.  The denial must be 90 days old or less.

 

E)        the facility must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

 

i)          specific reasons for institution of the delayed payment provisions;

 

ii)         specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

 

iii)        the interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the facility as a result of institution of the delayed payment provisions;

 

iv)        a certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

 

v)         a certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

 

vi)        such other terms and conditions that may be required by the Department.

 

2)         A facility that does not meet the criteria listed in subsection (h)(1) may request a delayed payment schedule.  The Department may approve the request, notwithstanding the facility not meeting the above criteria, upon a sufficient showing of financial difficulties and good cause by the facility.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

 

3)         Approval Process

 

A)        In order to receive consideration for delayed payment provisions, facilities must ensure that their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Program and Reimbursement Analysis.  The request must be received by the due date designated by the Department.  Providers will be notified, in writing, of the due dates for submitting delay of payment requests. Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests postmarked no later than the date of the telefax.  The request must include:

 

i)          an explanation of the circumstances creating the need for the delayed payment provisions;

 

ii)         supportive documentation to substantiate the emergency nature of the request and risk of irreparable harm to the clients; and

 

iii)        specification of the specific arrangements requested by the facility

 

B)        The facility shall be notified by the Department, in writing prior to the assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the facility for all approved requests.  The agreement must be signed by the administrator, owner or other authorized representative and be received by the Department prior to the first scheduled payment date listed in such agreement.

 

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the facility's request for institution of delayed payment provisions.  In the event a facility's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject quarter unless the facility fails to meet all of the terms and conditions of the agreement.  In the event the facility fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and the penalties shall be fully reinstated.

 

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the facility meets the criteria in subsections (h)(1)(A) and (B).  Any such waivers granted shall be expressly identified in the agreement described in subsection (h)(1)(E).

 

6)         Subsequent Delayed Payment Arrangements.  Once a facility has requested and received approval for delayed payment arrangements, the facility shall not receive approval for subsequent delayed payment arrangements until the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delay of payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a facility that has not satisfied the terms and conditions of any current delayed payment agreement.

 

i)          Administration and Enforcement Provisions

The Department shall administer and enforce Section 5C-6 of the Public Aid Code and collect the assessments, interest, and penalty assessments imposed under the law, using procedures employed in its administration of the Code generally and, as it deems appropriate, in a manner similar to that in which the Department of Revenue administers and collects the retailers' occupation tax under the Retailers' Occupation Tax Act ("ROTA").

 

j)          Nothing in Section 5C of the Code shall be construed to prevent the Department from collecting all amounts due under this Section pursuant to an assessment imposed before July 1, 1995.

 

k)         Definitions

 

1)         "Adjusted gross developmentally disabled care revenue" 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, rental of facility space, or sheltered care revenue.  Adjusted gross developmentally disabled care revenue must be reported on an accrual basis for the tax reporting period.  All patient revenue accrued during the tax reporting period must be included even though reimbursement may occur after the tax reporting period.  Patient revenue must be reported on a basis that is consistent with methods used on the facility's last two cost reports.

 

2)         "Contractual Allowance" means the difference between charges at established rates and the amount estimated to be paid by third party payors or patients, as appropriate, pursuant to agreements/contracts with the developmentally disabled care provider; courtesy and policy discounts provided to employees, medical staff and clergy; and charity care, but "contractual allowance" does not mean any Provider Participation fees/taxes paid to the Department.

 

3)         "Department" means the Illinois Department of Healthcare and Family Services.

 

4)         "Developmentally disabled care facility" means an intermediate care facility for the mentally retarded 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.

 

5)         "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.

 

6)         "Facility" means all intermediate care facilities as defined under "developmentally disabled care facility" (see subsection (k)(4)).

 

7)         "Fund" means the Developmentally Disabled Care Provider Fund.

 

8)         "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 5.4h of the Code.

 

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

 

Section 140.84  Long Term Care Provider Fund

 

a)         Purpose and Contents

 

1)         The Long Term Care Provider Fund was created in the State Treasury on July 1, 1992, July 14, 1993 and July 1, 1995 (see Section 5B-8 of the Code).  Interest earned by the Fund shall be credited to the Fund.  The Fund shall not be used to replace any funds appropriated to the Medicaid program by the General Assembly.

 

2)         The Fund is created for the purpose of receiving and disbursing monies in accordance with this Section and Sections 5B-2 and 5B-8 of the Code.

 

3)         The Fund shall consist of:

 

A)        All monies collected or received by the Department under subsection (b);

 

B)        All federal matching funds received by the Department as a result of expenditures made from the Fund;

 

C)        Any interest or penalty levied in conjunction with the administration of the Fund;

 

D)        All other monies received for the Fund from any other source, including interest earned thereon; and

 

E)        All monies transferred from the Tobacco Products Tax Act [35 ILCS 143].

 

b)         License Fee and Provider Assessment

 

1)         Beginning on July 1, 1993, and ending on June 30, 2022, a nursing home license fee is imposed upon each nursing home provider in an amount equal to $1.50 for each licensed nursing bed day for the calendar quarter in which the payment is due. All nursing beds subject to licensure under the Nursing Home Care Act or the Hospital Licensing Act, with the exception of swing-beds, as defined in subsection (k)(11) will be used to calculate the licensed nursing bed days for each quarter.  This license fee shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider.  Changes in the number of licensed nursing beds will be reported to the Department quarterly, as described in subsection (d)(1). The Department reserves the right to audit the reported data.

 

2)         Beginning July 1, 2011 and ending on June 30, 2022, an assessment is imposed upon each long term care provider in an amount equal to $6.07 times the number of occupied bed days due and payable each month.  This assessment shall be construed as a tax, but shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider.

 

3)         Beginning July 1, 2022, an assessment is imposed upon each long-term care provider in an amount varying with the number of paid Medicaid resident days per annum in the facility with the following schedule of occupied bed tax amounts. This assessment is due and payable each month and shall be construed as a tax but shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider.

 

A)        The tax shall follow the schedule below and be rebased by the Department on an annual basis.

 

i)          0-5,000 paid Medicaid resident days per annum, $10.67.

 

ii)         5,001-15,000 paid Medicaid resident days per annum, $19.20.

 

iii)        15,001-35,000 paid Medicaid resident days per annum, $22.40.

 

iv)        35,001-55,000 paid Medicaid resident days per annum, $19.20.

 

v)         55,001-65,000 paid Medicaid resident days per annum, $13.86.

 

vi)        65,001+ paid Medicaid resident days per annum, $10.67.

 

vii)       Any non-profit nursing facilities without Medicaid-certified beds, $7 per occupied bed day.

 

B)        The Department shall publish each facility's rebased tax rate according to the schedule in this subsection 30 days prior to the beginning of the 6-month period beginning July 1, 2022 and thereafter 30 days prior to the beginning of each calendar year which shall incorporate the number of paid Medicaid days used to determine each facility's rebased tax rate.  The notice shall include the number of paid Medicaid days broken down by days paid by each Managed Care Organization, Fee for Service, and each contracted MMAI plan.  The notice shall also specify the dates of service used for the determination and the date on which the data was queried.  

 

C)        For each new calendar year and for the 6-month period beginning July 1, 2022, a facility's paid Medicaid resident days per annum shall be determined using the Department's Medicaid Management Information System to include Medicaid resident days for the year ending 9 months earlier. The Department will query the MMIS to make this determination as late as is reasonably possible subject to the publication deadline in subsection (b)(3)(B) and will adjust the number of paid Medicaid resident days per annum, if necessary, using the Department’s nursing home provider tax database to more accurately distinguish Medicare and Medicaid payment.  The number of paid Medicaid days shall also include hospice days and provisional days, if applicable.

 

4)         Appeals of Tax Rate Determinations

 

A)        Appeals of tax rate determinations shall be submitted in writing to the Department.  Appeals received within 30 days after tax rate notification shall, if upheld, be made effective as of the beginning of the tax year.  The effective date of all upheld appeals filed after the initial 30-day period shall be the first day of the month after the date the complete appeal was received.  Payments shall be made based on the Department's determination pending the results of the appeal.

 

B)        Appeals of tax rate determinations under this Section shall be submitted in writing to the Chief, Bureau of Long Term Care.  The Department shall rule on all appeals within 120 days after the date of appeal, except that if the Department requires additional information from the facility the period shall be extended until such time as the information is provided.  Appeals for any tax year must be filed before the close of the first quarter of the tax year.  Amounts owed as a result of an upheld appeal shall be applied as a credit towards future taxes owed and payable.

 

c)         Payment of License Fee and Assessment Due

 

1)         The license fee described in subsection (b) shall be due and payable in quarterly installments, on September 10, December 10, March 10, and June 10 of the year, modified to accommodate weekends and holidays.  Providers will be notified, in writing, of the quarterly due dates.  License fee payments postmarked on the due date will be considered as paid on time.

 

2)         The assessment described in subsection (b) shall be due and payable monthly, on the last State business day of the month for occupied bed days reported for the preceding third month prior to the month in which the tax is payable and due.  A facility that has its payments from the State delayed, due to problems related to State cash flow, may request an extension on the due date for payment pursuant to subsection (b) and shall pay each extended assessment payment within 30 days after each reimbursement for services by the Department.

 

A)        The Department shall provide for an electronic submission process for each long term care facility to report the number of occupied bed days of the long term care facility for the reporting period and other reasonable information the Department requires for the administration of its responsibilities. To the extent practicable, the Department shall coordinate the assessment reporting requirements with other reporting required of long term care facilities.

 

B)        Beginning July 1, 2013, a separate electronic submission shall be completed for each long term care facility in this State operated by a long term care provider.  The Department shall prepare an assessment, based on the reported occupied beds, and will bill the facility stating the amount due and payable each month and submit it to each long term care facility via an electronic process.  Each assessment payment shall be accompanied by a copy of the assessment bill sent to the long term care facility by the Department.

 

C)        The provider assessment imposed by this Section shall not be due and payable until after the Department notifies the long term care providers, in writing, that the payment methodologies to long term care providers required under Section 5-5.4 of the Public Aid Code have been approved and the waivers under 42 CFR 433.68, if necessary, have been granted by CMMS.

 

3)         All payments received by the Department shall be credited first to unpaid installment amounts (rather than to penalty or interest), beginning with the most delinquent installments.

 

4)         County nursing homes directed and maintained pursuant to Section 5-1005 of the Counties Code [55 ILCS 5] may meet their license fee or assessment obligation by the county government certifying to the Department that county expenditures have been obligated for the operation of the county nursing home in an amount at least equal to the amount of the license fee or assessment.  County governments wishing to provide such certification must:

 

A)        Sign a certification form certifying that the funds represent expenditures eligible for federal financial participation under Title XIX of the Social Security Act (42 U.S.C. 1396), and that these funds are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds;

 

B)        Submit the certification document to the Department once a year along with a copy of that portion of the county budget showing the funds appropriated for the operation of the county nursing home.  These documents must be submitted within 30 days after the final approval of the county budget;

 

C)        Submit the monthly claim form in the amount of the rate established by the Department minus any third party liability amount.  This amount will be reduced by an amount determined by the amount certified and the number of months remaining in the fiscal year, prior to payment because a certification statement was provided in lieu of an actual license fee or assessment payment; and

 

D)        Make records available upon request to the Department and/or the United States Department of Health and Human Services pertaining to the certification of county funds.

 

d)         Reporting Requirements, Penalty, and Maintenance of Records

 

1)         On or before the due dates described in subsection (c)(1), each nursing home provider subject to a license fee under subsection (b) shall file a report with the Department reflecting any changes in the number of licensed nursing beds occurring during the reporting quarter. The report shall be on a form prepared by the Department.  The changes will be reported quarterly and shall be submitted with the revised quarterly license fee payment.  For the purpose of calculating the license fee described in subsection (b), all changes in licensed nursing beds will be effective upon approval of the change by the Illinois Department of Public Health.  Documentation showing the change in licensed nursing beds, and the date the change was approved by the Illinois Department of Public Health, must be submitted to the Department of Healthcare and Family Services with the licensed nursing bed change form. 

 

2)         After December 31 of each year, and on or before March 31 of the succeeding year, every long term care provider subject to assessment under subsection (c)(2) shall file a report with the Department.  The report shall be in a form and manner prescribed by the Department and shall state the revenue received by the long term care provider, reported in such categories as may be required by the Department, and other reasonable information the Department requires for the administration of its responsibilities.

 

3)         If a provider operates or maintains more than one nursing home, a separate report shall be filed for each facility.  In the case of a provider existing as a corporation or legal entity other than an individual, the report filed by it shall be signed by its president, vice president, secretary or treasurer or by its properly authorized agent.

 

4)         If the provider fails to file its report for a State fiscal year on or before the due date of the report, there shall, unless waived by the Department for reasonable cause, be added to the license fee or assessment imposed in subsection (b) a penalty fee equal to 25% of the assessment or license fee imposed for the year.  After July 1, 2013, no penalty will be assessed if the Department has not established a process for the electronic submission of information as it pertains to the assessment.

 

5)         Every provider subject to a license fee or assessment under subsection (b) shall keep records and books that will permit the determination of licensed nursing bed days on a quarterly basis and occupied beds on a monthly basis.  All such books and records shall be maintained for a minimum of three years following the filing date of each report 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.

 

6)         Amended License Fee and Assessment Reports.  With the exception of amended license fee or assessment reports filed in accordance with this subsection (d)(6), an amended license fee report or monthly assessment report must be filed within 30 calendar days after the original report due date.  The amended report must be accompanied by a letter identifying the changes and the justification for the amended report.  The provider will be advised of any adjustments to the original annual license fee or assessment amount through a written notification from the Department.  Penalties may be applied to the amount underpaid due to a filing error.

 

7)         Reconsideration of Adjusted License Fee or Assessment.  If the Department, through an audit conducted by the Department or its agent within three years after the end of the fiscal year in which the license fee or assessment was due, changes the license fee or assessment liability of a provider, the provider may request a review or reconsideration of the adjusted license fee or assessment within 30 days after the Department's notification of the change in license fee or assessment liability. Requests for reconsideration of the license fee or assessment adjustment shall not be considered if those requests are not postmarked on or before the end of the 30 day review period.  Penalties may be applied to the amount underpaid due to a filing error.

 

8)         Effective January 1, 2023, all providers operating or maintaining a long-term care facility shall notify the Department of all individual owners and any individuals or organizations that are part of a limited liability company with ownership of that facility, and the percentage ownership of each owner.  This ownership reporting requirement does not include individual shareholders in a publicly held corporation.  Submission of the information as part of the Department's cost reporting requirements shall satisfy this request.

 

e)         Procedure for Partial Year Reporting/Operating Adjustments

 

1)         Cessation of business during the period in which the license fee or assessment is being paid and the closure date has been set.  A provider who ceases to conduct, operate, or maintain a facility for which the person is subject to the license fee or assessment imposed under subsection (b) of this Section, and for which the closure date for the facility has been set, shall file a final report with the Department on or before the due date for the period in which the closure is to occur. The report will reflect the adjusted number of days the facility is open during the reporting period and shall be submitted with the final quarterly license fee or monthly assessment payment. Example: A facility is set to close on September 24.  On or before the due date for the reporting quarter of July 1 through September 30, the facility will submit a final report reflecting 86 days of operation (July 1 through September 24) and the corresponding quarterly license fee payment.

 

2)         Cessation of business after the monthly or quarterly due date.  A provider who ceases to conduct, operate, or maintain a facility for which the person is subject to the license fee or assessment imposed under subsection (b), and for which closure occurs after the due date for the reporting period, but prior to the last day of the reporting period, shall file an amended final report with the Department within 30 days after the closure date.  The amended report will reflect the number of days the facility was operational during the reporting period and the revised license fee or assessment amount.  Upon verifying the data submitted on the amended report, the Department will issue a refund for the amount overpaid.  Example: On December 10 a facility pays the license fee for 92 days covering the reporting quarter of October 1 through December 31.  The facility closes on December 27.  An amended report reflecting 88 days, the actual number of days the facility was operational during the quarter (October 1 through December 27) must be filed with the Department.

 

3)         Cessation of business prior to the monthly or quarterly due date.  A provider who ceases to conduct, operate, or maintain a facility for which the person is subject to the license fee or assessment imposed under subsection (b), and for which closure occurs prior to the due date for the reporting period, shall file a final report with the Department within 30 days after the closure date. The final report will reflect the number of days the facility was operational during the reporting period and the corresponding final license fee and assessment amount.  Closure dates will be verified with the Department of Public Health, and if necessary adjustments will be made to the final license fee and assessment due. Example:  Facility closes on January 17.  On or before February 17, the facility must file a final report for the reporting quarter of January 1 through March 31.  The report would reflect 17 days of operation (January 1 through January 17) during the quarter and must be accompanied by the final license fee payment for the facility.

 

4)         Commencing of business during the fiscal year in which the license fee or assessment is being paid.  A provider who commences conducting, operating, or maintaining a facility for which the person is subject to the license fee or assessment imposed under subsection (b) shall file an initial report for the reporting period in which the commencement occurs within 30 calendar days thereafter and shall pay the license fee and assessment under subsection (c).  In determining the annual assessment amount for the provider, the Department shall develop hypothetical annualized occupied bed projections based upon geographic location and facility.  The assessment determination made by the Department is final.

 

5)         Change in Ownership and/or Operators.  The full monthly/quarterly assessment/license fee must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment/license fee amount (including past due assessment/license fees and any interest or penalties that may have accrued against the amount) rests on the provider currently operating or maintaining the nursing facility regardless if these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment/license fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment/license fee liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

 

6)         Upon request, the Department will share with a potential buyer of a facility information on outstanding assessments and penalties owed by that facility.

 

f)         Penalties

 

1)         Any provider that fails to pay the full amount of a license fee or assessment when due, or fails to report a change in licensed nursing beds approved by the Department of Public Health prior to the due date of the license fee or assessment, shall be charged, unless waived by the Department for reasonable cause, a penalty equal to five percent of the amount of the license fee or assessment not paid on or before the due date, plus five percent of the portion thereof remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the installment or assessment amount not paid on or before the due date. Reasonable cause may include but is not limited to:

 

A)        a provider who has not been delinquent on payment of a license fee or assessment due, within the last three calendar years from the time the delinquency occurs;

 

B)        a provider who can demonstrate to the Department's satisfaction that a payment was made prior to the due date; or

 

C)        that the provider is a new owner/operator and the late payment occurred in the reporting period in which the new owner/operator assumed control of the facility.

 

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent providers participating in the Medicaid Program.  Payments may be withheld from the provider until the entire license fee or assessment, including any penalties, is satisfied or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached, or if a provider fails to comply with an agreement, the Department reserves the right to recover any outstanding license fee, assessment, interest and penalty by recouping the amount or a portion thereof from the provider's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process. Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same provider two times in a fiscal year may be cause for termination from the Program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

 

3)         If the provider does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system, within three months after the license fee or assessment due date, the Department may begin legal action to recover the monies, including penalties and interest owed, plus court costs.

 

g)         Delayed Payment – Groups of Facilities

The Department may establish delayed payment of fees/assessment and/or waive the payment of interest and penalties for groups of facilities when:

 

1)         the State delays payments to facilities due to problems related to State cash flow; or

 

2)         a cash flow bond pool's or any other group financing plans' requests from providers for loans are in excess of its scheduled proceeds such that a significant number of facilities will be unable to obtain a loan to pay the license fee.

 

h)         Delayed Payment – Individual Facilities

In addition to the provisions of subsection (g), the Department may delay license fees or assessments for individual facilities that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the calendar period or month following the quarter in which the license fee or the assessment payment was to have been received by the Department as described in subsection (c). The Department may not deny a request for delay of payment of the assessment imposed in subsection (b) if the provider has not been paid due to problems related to State cash flow for services provided during the month in which the assessment is levied.  The request must be received by the Department prior to the due date of the assessment.

 

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions shall be made only to qualified facilities who meet all of the following requirements:

 

A)        the facility has experienced an emergency that necessitates institution of delayed payment provisions.  Emergency in this instance is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1), (f)(2) and (f)(3) would impose severe and irreparable harm to the clients served.  Circumstances which may create such emergencies include, but are not limited to, the following:

 

i)          Department system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the facility's ability to provide further services to clients is severely impaired;

 

ii)         cash flow problems encountered by a facility that are unrelated to Department technical system problems and which result in extensive financial problems to a facility adversely impacting on its ability to serve its clients.

 

B)        the facility serves a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

 

i)          85% or more of their residents must be eligible for public assistance;

 

ii)         a government-owned facility that meets the cash flow criterion under subsection (h)(1)(A)(ii);

 

iii)        a provider who has filed for Chapter 11 bankruptcy, which meets cash flow criterion under subsection (h)(1)(A)(ii).

 

C)        the facility must ensure that a delay of payment request, as defined under subsection (h)(3)(A), is received by the Department and the request must include a Cash Position Statement that is based upon current assets, current liabilities and other data for a date which is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of license fee or assessment payments will be denied if any of the following criteria are met:

 

i)          the ratio of current assets divided by current liabilities is greater than 2.0;

 

ii)         cash, short term investments and long term investments equal or exceed the total of accrued wages payable and the license fee payment.  Long term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation;

 

iii)        cash or other assets has been distributed during the previous 90 days to owners or related parties in an amount equal to or exceeding the license fee or assessment payment for dividends, salaries in excess of those allowable under Section 140.541 or payments for purchase of goods or services in excess of cost as defined in Section 140.537.

 

D)        the facility, with the exception of government owned facilities, must show evidence of denial of an application to borrow license fee or assessment funds through a cash flow bond pool or financial institutions such as a commercial bank.  The denial must be 90 days old or less.

 

E)        the facility must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

 

i)          specific reasons for institution of the delayed payment provisions;

 

ii)         specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

 

iii)        the interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the facility as a result of institution of the delayed payment provisions;

 

iv)        a certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

 

v)         a certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

 

vi)        other terms and conditions that may be required by the Department.

 

2)         A facility that does not meet the criteria in subsection (h)(1) may request a delayed payment schedule, prior to the due date.  The Department may approve the request, notwithstanding the facility not meeting the above criteria, upon a sufficient showing of financial difficulties and good cause by the facility.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

 

3)         Approval Process

 

A)        In order to receive consideration for delayed payment provisions, facilities must ensure their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Rate Development and Analysis.  The request must be received by the due date designated by the Department.  Providers will be notified, in writing, of the due dates for submitting delay of payment requests.  Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests, postmarked no later than the date of the telefax.  The request must include:

 

i)          an explanation of the circumstances creating the need for the delayed payment provisions;

 

ii)         supportive documentation to substantiate the emergency nature of the request including a cash position statement as defined in subsection (h)(1)(C); a denial of application to borrow the license fee or assessment as defined in subsection (h)(1)(D) and an explanation of the risk of irreparable harm to the clients; and

 

iii)        specification of the specific arrangements requested by the facility.

 

B)        The facility shall be notified by the Department, in writing prior to the license fee or assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the facility for all approved requests.  The agreement must be signed by the administrator, owner or other authorized representative and be received by the Department prior to the first scheduled payment date listed in such agreement.

 

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the facility's request for institution of delayed payment provisions.  In the event a facility's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject quarter or month as it pertains to assessment, unless the facility fails to meet all of the terms and conditions of the agreement.  In the event the facility fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and such penalties shall be fully reinstated.

 

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the facility meets the criteria in subsections (h)(1)(A) and (B).  Any such waivers granted shall be expressly identified in the agreement described in subsection (h)(1)(E).

 

6)         Subsequent Delayed Payment Arrangements.  Once a facility has requested and received approval for delayed payment arrangements, the facility shall not receive approval for subsequent delayed payment arrangements until such time as the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delay of payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a facility that has not satisfied the terms and conditions of any current delayed payment agreement.

 

i)          Administration and Enforcement Provisions

The Department shall administer and enforce Section 5B-7 of the Code, and collect the license fees, assessments, interest, and penalty fees imposed under the law, using procedures employed in its administration of this Code generally and, as it deems appropriate, in a manner similar to that in which the Department of Revenue administers and collects the retailers' occupation tax under ROTA.

 

j)          Nothing in Section 5B of the Code shall be construed to prevent the Department from collecting all amounts due under this Section pursuant to an assessment imposed before July 1, 1995.

 

k)         Definitions

As used in this Section, unless the context requires otherwise:

 

1)         "Department" means the Illinois Department of Healthcare and Family Services.

 

2)         "Fund" means the Long Term Care Provider Fund.

 

3)         "Hospital provider" means a person licensed by the Department of Public Health to conduct, operate, or maintain a hospital, regardless of whether the person is a Medicaid provider.  For purposes of this definition, "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.

 

4)         "Licensed nursing bed days" means, with respect to a nursing home provider, the sum for all nursing beds, with the exception of swing-beds, as described in subsection (k)(11), of the number of days during a calendar quarter on which each bed is covered by a license issued to that provider under the Nursing Home Care Act [210 ILCS 45] or the Hospital Licensing Act [210 ILCS 85].

 

5)         "Long term care facility" means 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 [210 ILCS 47], including a county nursing home directed and maintained under Section 5-1005 of the Counties Code, and 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 developmentally disabled within the meaning of Title XIX of the Social Security Act.

 

6)         "Long term care provider" means a person licensed by the Department of Public Health to operate and maintain a skilled nursing or intermediate long term care facility or a hospital provider that provides skilled or intermediate long term care services within the meaning of Title XVII or XIX of the Social Security Act.  For purposes of this definition, "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.

 

7)         "Nursing home" means a skilled nursing or intermediate long term care 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, including a county nursing home directed and maintained under Section 5-1005 of the Counties Code; and 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.  However, the term "nursing home" does not include a facility operated solely as an intermediate care facility for the mentally retarded within the meaning on Title XIX of the Social Security Act.

 

8)         "Nursing home provider" means a person licensed by the Department of Public Health to operate and maintain a skilled nursing or intermediate long term care facility which charges its residents, a third party payor, Medicaid, of Medicare for skilled nursing or intermediate long term care services; or 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.

 

9)         "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 primary payer. For a resident whose care is covered by the Medicare-Medicaid Alignment Initiative demonstration, Medicare Part A is considered the primary payer to the extent Medicare would have been the primary payer in the absence of the demonstration.

 

10)        "Person" means, in addition to natural persons, 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.

 

11)        "Swing-beds" means those beds for which a hospital provider has been granted an approval from the federal Centers for Medicare and Medicaid Services to provide post-hospital extended care services (42 CFR 409.30, October 1, 1991) and be reimbursed as a swing-bed hospital (42 CFR 413.114, October 1, 1991).

 

(Source:  Amended at 46 Ill. Reg. 19641, effective November 28, 2022)

 

Section 140.86  Supportive Living Facility Fund

 

a)         Purpose and Contents

 

1)         The Supportive Living Facility Fund was created in the State Treasury on July 1, 2014 (see 305 ILCS 5/5G-35).  Interest earned by the Fund shall be credited to the Fund.  The Fund shall not be used to replace any funds appropriated to the Medicaid program by the General Assembly.

 

2)         The Fund is created for the purpose of receiving and disbursing monies in accordance with this Section and Sections 5G-10 and 35 of the Code.

 

3)         The Fund shall consist of:

 

A)        All monies collected or received by the Department under subsection (b);

 

B)        All monies collected or received by the Department under subsection (j);

 

C)        All federal matching funds received by the Department as a result of expenditures made by the Department that are attributable to monies deposited in the Fund;

 

D)        Any interest or penalty levied in conjunction with the administration of the Fund;

 

E)        All monies transferred from another fund in the State Treasury; and

 

F)         All other monies received for the Fund from any other source, including interest earned on monies in the Fund.

 

b)         Provider Assessment

Beginning on July 1, 2014, an annual assessment is imposed upon each supportive living facility in an amount equal to $2.30 for each supportive living facility's care days.  This assessment shall not be billed or passed on to any resident of a supportive living facility.

 

c)         Payment of Assessment and Assessment Due

 

1)         The assessment described in subsection (b) of this Section shall be due and payable monthly, 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 its payments from the State delayed, due to problems related to State cash flow, may request an extension on the due date for payment pursuant to subsection (c) and shall pay the assessment within 30 days after reimbursement by the Department.

 

A)        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. To the extent practicable, the Department shall coordinate the assessment reporting requirements with other reporting required of supportive living facilities.

 

B)        The Department shall prepare an assessment, based on the reported care days, and will bill the facility stating the amount due and payable each month and submit it to each supportive living facility via an electronic process.  Each assessment payment shall be accompanied by a copy of the assessment bill sent to the supportive living facility by the Department.

 

C)        The provider assessment imposed by this Section shall not 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 the Public Aid Code have been approved and the waivers under 42 CFR 433.68, if necessary, have been granted by CMMS.

 

D)        The provider assessment imposed by this Section 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.

 

3)         All payments received by the Department shall be credited first to unpaid assessment payment amounts (rather than to penalty or interest), beginning with the most delinquent assessment payments.

 

d)         Reporting Requirements, Penalty, and Maintenance of Records

 

1)         Every supportive living facility subject to the assessment described in subsection (b) shall report the number of 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.

 

2)         If a provider operates or maintains more than one supportive living facility, a separate report shall be filed for each facility.  In the case of a provider existing as a corporation or legal entity other than an individual, the report filed by it shall be signed by its president, vice president, secretary or treasurer or by its properly authorized agent.

 

3)         If the provider fails to file its monthly report on or before the due date of the report, there shall, unless waived by the Department for reasonable cause, be added to the assessment imposed in subsection (b) a penalty fee equal to 25% of the assessment due.

 

4)         Every provider subject to a license fee or assessment under subsection (b) 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, be subject to inspection by the Department or its duly authorized agents and employees.

 

5)         Amended Assessment Reports.  With the exception of amended assessment reports filed in accordance with this subsection (d)(5), an amended monthly assessment report must be filed within 30 calendar days after the original report due date.  The amended report must be accompanied by a letter identifying the changes and the justification for the amended report.  The provider will be advised of any adjustments to the original assessment amount through a written notification from the Department.  Penalties may be applied to the amount underpaid due to a filing error.

 

6)         Reconsideration of Adjusted Assessment.  If the Department, through an audit conducted by the Department or its agent within three years after the end of the fiscal year in which the assessment was due, changes the assessment liability of a provider, the provider may request a review or reconsideration of the adjusted assessment within 30 days after the Department's notification of the change in assessment liability. Requests for reconsideration of the assessment adjustment shall not be considered if those requests are not postmarked on or before the end of the 30 day review period.  Penalties may be applied to the amount underpaid due to a filing error.

 

e)         Procedure for Partial Year Reporting/Operating Adjustments

 

1)         Cessation of Business Prior to the Monthly Due Date.  A provider who ceases to conduct, operate, or maintain a facility for which the provider is subject to the assessment imposed under subsection (b), and for which closure occurs prior to the due date for the assessment period, shall file a final report with the Department within 30 days after the closure date. The final report will reflect the number of days the facility was operational during the assessment period and the corresponding final assessment amount.  Closure dates will be verified with the Department of Public Health and, if necessary, adjustments will be made to the final assessment due. (Example:  Facility closes on January 17.  On or before February 17, the facility must file a final report for the reporting month of January 1 through January 31.  The report would reflect 17 days of operation (January 1 through January 17) during the month and must be accompanied by the final assessment payment for the facility.)

 

2)         Commencing of Business During the Month in Which the Assessment is Being Paid.  A provider who commences conducting, operating, or maintaining a facility for which the person is subject to the assessment imposed under subsection (b) shall file an initial report for the assessment period in which the commencement occurs within 30 calendar days after commencement and shall pay the assessment under subsection (c).

 

3)         Change in Ownership and/or Operators.  The full monthly assessment must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment amount (including past due assessment and any interest or penalties that may have accrued against the amount) rests on the provider currently operating or maintaining the nursing facility regardless of whether these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment/license fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment/license fee liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

 

4)         Upon request, the Department will share with a potential buyer of a facility information on outstanding assessments and penalties owed by that facility.

 

f)         Penalties

 

1)         Any provider that fails to pay the full amount of an assessment payment when due shall be charged, unless waived by the Department for reasonable cause, a penalty equal to one percent of the amount of the assessment payment not paid on or before the due date, plus one percent of the portion thereof remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the assessment amount not paid on or before the due date. Reasonable cause may include but is not limited to:

 

A)        a provider who has not been delinquent on payment of an assessment payment due within the last three calendar years from the time the delinquency occurs;

 

B)        a provider who can demonstrate to the Department's satisfaction that a payment was made prior to the due date; or

 

C)        that the provider is a new owner/operator and the late payment occurred in the assessment period in which the new owner/operator assumed control of the facility.

 

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent providers participating in the Medicaid Program.  Payments may be withheld from the provider until the entire assessment, including any penalties, is satisfied or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached, or if a provider fails to comply with an agreement, the Department reserves the right to recover any outstanding assessment, interest and penalty by recouping the amount or a portion thereof from the provider's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process. Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same provider two times in a fiscal year may be cause for termination from the program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

 

3)         If the provider does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system within three months after the license fee or assessment due date, the Department may initiate either administrative or judicial proceedings, or both, to enforce provisions of this Section. Administrative enforcement proceedings initiated under this subsection (f)(3) shall be governed by the Department's administrative rules. Judicial enforcement proceedings initiated under this subsection (f)(3) shall be governed by the rules of procedure applicable to the courts of this State.

 

4)         No proceedings for collection, refund, credit, or other adjustment of an assessment amount shall be issued more than three 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.

 

5)         Any unpaid assessment and/or penalties 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 the real property and improvements, the machinery and equipment, or the furniture or fixtures of any supportive living facility that is subject to the provisions of this Section, the seller or transferor shall pay the Department the amount of any assessment, penalty and interest (if any) due from it under this Section up to the date of the sale or transfer. If the seller or transferor fails to pay any assessment, penalty and interest (if any) due, the purchaser or transferee of the 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 the 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 Section. 

 

g)         Delayed Payment – Groups of Facilities

The Department may establish delayed payment of assessment and/or waive the payment of interest and penalties for groups of facilities when:

 

1)         the State delays payments to facilities due to problems related to State cash flow; or

 

2)         a cash flow bond pool's or any other group financing plans' requests from providers for loans are in excess of its scheduled proceeds such that a significant number of facilities will be unable to obtain a loan to pay the assessment.

 

h)         Delayed Payment – Individual Facilities

In addition to the provisions of subsection (g), the Department may delay assessments for individual facilities that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the month following the month the assessment payment was to have been received by the Department as described in subsection (c). The Department may not deny a request for delay of payment of the assessment imposed in subsection (b) if the provider has not been paid due to problems related to State cash flow for services provided during the month in which the assessment is levied.  The request must be received by the Department prior to the due date of the assessment.

 

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions shall be made only to qualified facilities who meet all of the following requirements:

 

A)        The facility has experienced an emergency that necessitates institution of delayed payment provisions.  Emergency, in this instance, is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1), (f)(2) and (f)(3) would impose severe and irreparable harm to the clients served.  Circumstances that may create these emergencies include, but are not limited to, the following:

 

i)          Department system errors (either automated system or clerical) that have precluded payments or that have caused erroneous payments such that the facility's ability to provide further services to clients is severely impaired;

 

ii)         cash flow problems encountered by a facility that are unrelated to Department technical system problems and that result in extensive financial problems for a facility, adversely impacting its ability to serve its clients.

 

B)        The facility serves a significant number of clients under the Medical Assistance Program.  Significant, in this instance, means:

 

i)          85% or more of the facility's residents are eligible for public assistance;

 

ii)         The facility is a government-owned facility that meets the cash flow criterion of subsection (h)(1)(A)(ii);

 

iii)        The facility is a provider who has filed for Chapter 11 bankruptcy, which meets the cash flow criterion of subsection (h)(1)(A)(ii).

 

C)        The facility must ensure that a delay of payment request, as defined under subsection (h)(3)(A), is received by the Department and the request must include a cash position statement that is based upon current assets, current liabilities and other data for a date that is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of license fee or assessment payments will be denied if any of the following criteria are met:

 

i)          the ratio of current assets divided by current liabilities is greater than 2.0;

 

ii)         cash, short term investments and long term investments equal or exceed the total of accrued wages payable and the license fee payment.  Long term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation;

 

iii)        cash or other assets have been distributed during the previous 90 days to owners or related parties in an amount equal to or exceeding the license fee or assessment payment for dividends, salaries in excess of those allowable under Section 140.541 or payments for purchase of goods or services in excess of cost as defined in Section 140.537.

 

D)        The facility, with the exception of government-owned facilities, must show evidence of denial of an application to borrow assessment funds through a cash flow bond pool or financial institution such as a commercial bank.  The denial must be 90 days old or less.

 

E)        The facility must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

 

i)          specific reasons for institution of the delayed payment provisions;

 

ii)         specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

 

iii)        the interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the facility as a result of institution of the delayed payment provisions;

 

iv)        a certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

 

v)         a certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

 

vi)        such other terms and conditions that may be required by the Department.

 

2)         A facility that does not meet the criteria of subsection (h)(1) may request, prior to the due date, a delayed payment schedule.  The Department may approve the request, notwithstanding the facility not meeting these criteria, upon a sufficient showing of financial difficulties and good cause by the facility.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

 

3)         Approval Process

 

A)        In order to receive consideration for delayed payment, facilities must ensure their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Hospital and Provider Services.  The request must be received by the due date designated by the Department.  Providers will be notified, in writing, of the due date for submitting delay of payment requests.  Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests, postmarked no later than the date of the telefax.  The request must include:

 

i)          an explanation of the circumstances creating the need for the delayed payment provisions;

 

ii)         supportive documentation to substantiate the emergency nature of the request, including a cash position statement as defined in subsection (h)(1)(C), a denial of application to borrow the license fee or assessment as defined in subsection (h)(1)(D), and an explanation of the risk of irreparable harm to the clients; and

 

iii)        specification of the specific arrangements requested by the facility.

 

B)        The facility shall be notified by the Department, in writing prior to the assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the facility for all approved requests.  The agreement must be signed by the administrator, owner or other authorized representative and be received by the Department prior to the first scheduled payment date listed in the agreement.

 

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the facility's request for institution of delayed payment provisions.  In the event a facility's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject month as it pertains to assessment, unless the facility fails to meet all of the terms and conditions of the agreement.  In the event the facility fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and penalties shall be fully reinstated.

 

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the facility meets the criteria in subsections (h)(1)(A) and (B).  Any waivers granted shall be expressly identified in the agreement.

 

6)         Subsequent Delayed Payment Arrangements.  Once a facility has requested and received approval for delayed payment arrangements, the facility shall not receive approval for subsequent delayed payment arrangements until the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delay of payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a facility that has not satisfied the terms and conditions of any current delayed payment agreement.

 

i)          Administration and Enforcement Provisions

The Department shall administer and enforce Section 5G-5 of the Code and collect the assessments, interest, and penalty fees imposed under the law, using procedures employed in its administration of the Code generally and, as it deems appropriate, in a manner similar to that in which the Department of Revenue administers and collects the retailers' occupation tax under the Retailers' Occupation Tax Act (ROTA).

 

j)          Certification Fee

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. The certification fee imposed by this subsection 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.

 

k)         Definitions

As used in this Section, unless the context requires otherwise:

 

1)         "Department" means the Illinois Department of Healthcare and Family Services.

 

2)         "Fund" means the Supportive Living Facility Fund.

 

3)         "Supportive Living Facility" means an enrolled supportive living site as described Section 5-5.01a of the Code that meets the participation requirements under 89 Ill. Adm. Code 146.215.

 

4)         "Care Days" means, with respect to a supportive living facility, the sum for all apartment units, the number of days during the month in which each apartment unit was occupied by a resident.

 

(Source:  Added at 38 Ill. Reg. 23623, effective December 2, 2014)

 

Section 140.88  Managed Care Organization Provider Assessment

 

a)         Definitions

 

1)         "Base Year" means the 12 month period from January 1, 2018 to December 31, 2018

 

2)         "Department" means the Department of Healthcare and Family Services.

 

3)         "Federal employee health benefit" means the program of health benefits plans, as defined in 5 U.S.C. 8901, available to federal employees under 5 U.S.C. 8901 to 8914.

 

4)         "Fund" means the Healthcare Provider Relief Fund.

 

5)         "Managed Care Organization" means an entity operating under a certificate of authority issued pursuant to the Health Maintenance Organization Act [215 ILCS 125] or as a Managed Care Community Network pursuant to Section 5-11 of the Public Aid Code [305 ILCS 5].

 

6)         "Medicaid Managed Care Organization" or "Medicaid MCO" means a Managed Care Organization under contract with the Department to provide services to recipients of benefits in the Medical Assistance Program under Article V of the Public Aid Code, the Children's Health Insurance Program Act [215 ILCS 106], and the Covering ALL KIDS Health Insurance Act [215 ILCS 170].  It does not include contracts the same entity or an affiliated entity maintains for other business.

 

7)         "Medicare" means the federal Medicare program established under Title XVIII of the Social Security Act.

 

8)         "Member months" means the aggregate total number of months all individuals are enrolled for coverage in an MCO during the base year. Member months are determined by the Department for Medicaid MCOs based on enrollment data in its Medicaid Management Information System and by the Department of Insurance for other MCOs based on required filings with the Department of Insurance.  Member months do not include months individuals are enrolled in a Limited Health Services Organization, including stand-alone dental or vision plans, a Medicare Advantage Plan, a Medicare Supplement Plan, a Medicaid-Medicare Alignment Initiative Plan pursuant to a Memorandum of Understanding between the Department and the federal Centers for Medicare and Medicaid Services or a Federal Employee Health Benefits Plan.

 

b)         For State Fiscal Years 2020 through 2021, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

 

1)         Tier 1 − $61.70 per member month;

 

2)         Tier 2 − $1.20 per member month; and

 

3)         Tier 3 − $2.40 per member month.

 

c)         For State Fiscal Year 2022, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

 

1)         Tier 1 − $69.40 per member month;

 

2)         Tier 2 − $1.20 per member month; and

 

3)         Tier 3 − $2.40 per member month.

 

d)         For State Fiscal Year 2023, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

 

1)         Tier 1 − $74.40 per member month;

 

2)         Tier 2 − $1.20 per member month; and

 

3)         Tier 3 − $2.40 per member month.

 

e)         For State Fiscal Years 2024 through 2025, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

 

1)         Tier 1 − $78.90 per member month;

 

2)         Tier 2 − $1.40 per member month; and

 

3)         Tier 3 − $2.40 per member month.

 

f)         The tiers are established as follows:

 

1)         Tier 1 includes the first 4,195,000 member months in a Medicaid MCO for the base year;

 

2)         Tier 2 includes member months over 4,195,000 in a Medicaid MCO during the base year; and

 

3)         Tier 3 includes member months during the base year in an MCO that is not a Medicaid MCO.

 

g)         The assessment payable for State FY 2020 shall be prorated and due and payable in monthly installments, each equaling one-eighth of the assessment for the year, on the first State business day of each month beginning November 1, 2019. The assessment payable for State FY 2021 through 2025 shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the first State business day of each month.

 

h)         The Department shall notify each MCO of its annual assessment and the installment due dates no later than 30 days prior to the first due date of each fiscal year, and the annual assessment and due dates for each subsequent year, at least 30 days prior to the start of each fiscal year.

 

i)          Proceeds from the assessment levied shall be deposited into the Fund, except for those proceeds upon a county provider as defined in 305 ILCS 5/15-1 , which shall be deposited directly into the County Provider Trust Fund [305 ILCS 5/5H-4].

 

j)          In the event of a merger, acquisition or any similar transaction involving entities subject to the assessment under this Section, the resultant entity shall be responsible for the full amount of the assessment for all entities involved in the transaction, with the member months allotted to tiers as they were prior to the transaction, and no member months shall change tiers as a result of any transaction.  An MCO that ceases doing business in the State during any fiscal year shall be liable only for the monthly installments due in months that it operated in the State.

 

k)         An MCO that is liable for the assessment under this Section shall keep accurate and complete records and pertinent documents as may be required by the Department, including but not limited to records of:  member months, premium revenue, and plans that provide coverage to individuals who are eligible for Medicare, Medicaid or a federal employee health benefits program.  Records required by the Department shall be retained for a period of 4 years after the assessment imposed under this Act to which the records apply is due, or as otherwise provided by law.  The Department or the Department of Insurance may audit all records necessary to ensure compliance with this Section and make adjustments to assessment amounts previously calculated based on the results of any such audit.

 

l)          If an MCO fails to make a payment due under this Section in a timely fashion, it shall pay an additional penalty of 5% of the amount of the installment not paid on or before the due date, or any grace period granted, plus 5% of the portion remaining unpaid on the last day of each 30-day period thereafter.  The Department is authorized to grant grace periods of up to 30 days upon request of an MCO for good cause due to financial or other difficulties, as determined by the Department.  If an MCO fails to make a payment within 60 days after the due date, the Department shall additionally impose a contractual sanction allowed against a Medicaid MCO and may terminate any such contract.

 

m)        For an MCO which is first doing business in the State after 2018, the base year data on which the MCO will be assessed shall be the first year in which the data was available to the Department to calculate the assessment.

 

(Source:  Amended at 47 Ill. Reg. 18024, effective November 21, 2023)

 

Section 140.94  Medicaid Developmentally Disabled Provider Participation Fee Trust Fund/Medicaid Long Term Care Provider Participation Fee Trust Fund (Repealed)

 

(Source:  Repealed at 42 Ill. Reg. 14383, effective July 23, 2018)

 

Section 140.95  Hospital Services Trust Fund (Repealed)

 

(Source:  Repealed at 42 Ill. Reg. 14383, effective July 23, 2018)

 

Section 140.96  General Requirements (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.30 at 13 Ill. Reg. 9497)

 

Section 140.97  Special Requirements (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.40 at 13 Ill. Reg. 9497)

 

Section 140.98  Covered Hospital Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.50 at 13 Ill. Reg. 9497)

 

Section 140.99  Hospital Services Not Covered (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.60 at 13 Ill. Reg. 9497)

 

Section 140.100  Limitation On Hospital Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.70 at 13 Ill. Reg. 9497)

 

Section 140.101  Transplants (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.80 at 13 Ill. Reg. 9497)

 

Section 140.102  Heart Transplants (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.90 at 13 Ill. Reg. 9497)

 

Section 140.103  Liver Transplants (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.100 at 13 Ill. Reg. 9497)

 

Section 140.104  Bone Marrow Transplants (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.110 at 13 Ill. Reg. 9497)

 

Section 140.110  Disproportionate Share Hospital Adjustments (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.120 at 13 Ill. Reg. 12118)

 

Section 140.116  Payment for Inpatient Services for GA (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.130 at 13 Ill. Reg. 9497)

 

Section 140.117  Hospital Outpatient and Clinic Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.140 at 13 Ill. Reg. 9497)

 

Section 140.200  Payment for Hospital Services During Fiscal Year 1982 (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.150 at 13 Ill. Reg. 9497)

 

Section 140.201  Payment for Hospital Services After June 30, 1982 (Repealed)

 

(Source:  Repealed at 9 Ill. Reg. 9564, effective June 5, 1985)

 

Section 140.202  Payment for Hospital Services During Fiscal Year 1983 (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.160 at 13 Ill. Reg. 9497)

 

Section 140.203  Limits on Length of Stay by Diagnosis (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.170 at 13 Ill. Reg. 9497)

 

Section 140.300  Payment for Pre-operative Days and Services Which Can Be Performed in an Outpatient Setting (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.180 at 13 Ill. Reg. 9497)

 

Section 140.350  Copayments (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.190 at 13 Ill. Reg. 9497)

 

Section 140.360  Payment Methodology (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.200 at 13 Ill. Reg. 9497)

 

Section 140.361  Non-Participating Hospitals (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.210 at 13 Ill. Reg. 9497)

 

Section 140.362  Pre July 1, 1989 Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.220 at 13 Ill. Reg. 9497)

 

Section 140.363  Post June 30, 1989 Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.230 at 13 Ill. Reg. 9497)

 

Section 140.364  Prepayment Review (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.240 at 13 Ill. Reg. 9497)

 

Section 140.365  Base Year Costs (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.250 at 13 Ill. Reg. 9497)

 

Section 140.366  Restructuring Adjustment (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.260 at 13 Ill. Reg. 9497)

 

Section 140.367  Inflation Adjustment (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.270 at 13 Ill. Reg. 9497)

 

Section 140.368  Volume Adjustment (Repealed)

 

(Source:  Peremptory repealer at 8 Ill. Reg. 18151, effective September 18, 1984)

 

Section 140.369  Groupings (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.280 at 13 Ill. Reg. 9497)

 

Section 140.370  Rate Calculation (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.290 at 13 Ill. Reg. 9497)

 

Section 140.371  Payment (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.300 at 13 Ill. Reg. 9497)

 

Section 140.372  Review Procedure (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.310 at 13 Ill. Reg. 9497)

 

Section 140.373  Utilization (Repealed)

 

(Source:  Repealed at 13 Ill. Reg. 3351, effective March 6, 1989)

 

Section 140.374  Alternatives (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.320 at 13 Ill. Reg. 9497)

 

Section 140.375  Exemptions (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.330 at 13 Ill. Reg. 9497)

 

Section 140.376  Utilization, Case-Mix and Discretionary Funds (Repealed)

 

(Source:  Repealed at 13 Ill. Reg. 3351, effective March 6, 1989)

 

Section 140.390  Subacute Alcoholism and Substance Abuse Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.340 at 13 Ill. Reg. 9497)

 

Section 140.391  Definitions (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.350 at 13 Ill. Reg. 9497)

 

Section 140.392  Types of Subacute Alcoholism and Substance Abuse Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.360 at 13 Ill. Reg. 9497)

 

Section 140.394  Payment for Subacute Alcoholism and Substance Abuse Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.370 at 13 Ill. Reg. 9497)

 

Section 140.396  Rate Appeals for Subacute Alcoholism and Substance Abuse Services (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.380 at 13 Ill. Reg. 9497)

 

Section 140.398  Hearings (Recodified)

 

(Source:  Recodified to 89 Ill. Adm. Code 148.390 at 13 Ill. Reg. 9497)

SUBPART D: PAYMENT FOR NON-INSTITUTIONAL SERVICES