|
and appropriate measures to make emergency rules known to the
|
persons who may be affected by them.
|
(c) An emergency rule may be effective for a period of not |
longer than
150 days, but the agency's authority to adopt an |
identical rule under Section
5-40 is not precluded. No |
emergency rule may be adopted more
than once in any 24 month |
period, except that this limitation on the number
of emergency |
rules that may be adopted in a 24 month period does not apply
|
to (i) emergency rules that make additions to and deletions |
from the Drug
Manual under Section 5-5.16 of the Illinois |
Public Aid Code or the
generic drug formulary under Section |
3.14 of the Illinois Food, Drug
and Cosmetic Act, (ii) |
emergency rules adopted by the Pollution Control
Board before |
July 1, 1997 to implement portions of the Livestock Management
|
Facilities Act, ; or (iii) emergency rules adopted by the |
Illinois Department of Public Health under subsections (a) |
through (i) of Section 2 of the Department of Public Health Act |
when necessary to protect the public's health. Two or more |
emergency rules having substantially the same
purpose and |
effect shall be deemed to be a single rule for purposes of this
|
Section.
|
(d) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 1999 budget, |
emergency rules to implement any
provision of Public Act 90-587 |
or 90-588
or any other budget initiative for fiscal year 1999 |
may be adopted in
accordance with this Section by the agency |
charged with administering that
provision or initiative, |
except that the 24-month limitation on the adoption
of |
emergency rules and the provisions of Sections 5-115 and 5-125 |
do not apply
to rules adopted under this subsection (d). The |
adoption of emergency rules
authorized by this subsection (d) |
shall be deemed to be necessary for the
public interest, |
safety, and welfare.
|
(e) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2000 budget, |
emergency rules to implement any
provision of this amendatory |
|
Act of the 91st General Assembly
or any other budget initiative |
for fiscal year 2000 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (e). The adoption of emergency rules
authorized by |
this subsection (e) shall be deemed to be necessary for the
|
public interest, safety, and welfare.
|
(f) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2001 budget, |
emergency rules to implement any
provision of this amendatory |
Act of the 91st General Assembly
or any other budget initiative |
for fiscal year 2001 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (f). The adoption of emergency rules
authorized by |
this subsection (f) shall be deemed to be necessary for the
|
public interest, safety, and welfare.
|
(g) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2002 budget, |
emergency rules to implement any
provision of this amendatory |
Act of the 92nd General Assembly
or any other budget initiative |
for fiscal year 2002 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (g). The adoption of emergency rules
authorized by |
this subsection (g) shall be deemed to be necessary for the
|
public interest, safety, and welfare.
|
(h) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2003 budget, |
emergency rules to implement any
provision of this amendatory |
|
Act of the 92nd General Assembly
or any other budget initiative |
for fiscal year 2003 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (h). The adoption of emergency rules
authorized by |
this subsection (h) shall be deemed to be necessary for the
|
public interest, safety, and welfare.
|
(i) In order to provide for the expeditious and timely |
implementation
of the State's fiscal year 2004 budget, |
emergency rules to implement any
provision of this amendatory |
Act of the 93rd General Assembly
or any other budget initiative |
for fiscal year 2004 may be adopted in
accordance with this |
Section by the agency charged with administering that
provision |
or initiative, except that the 24-month limitation on the |
adoption
of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply
to rules adopted under this |
subsection (i). The adoption of emergency rules
authorized by |
this subsection (i) shall be deemed to be necessary for the
|
public interest, safety, and welfare.
|
(j) In order to provide for the expeditious and timely |
implementation of the provisions of the State's fiscal year |
2005 budget as provided under the Fiscal Year 2005 Budget |
Implementation (Human Services) Act, emergency rules to |
implement any provision of the Fiscal Year 2005 Budget |
Implementation (Human Services) Act may be adopted in |
accordance with this Section by the agency charged with |
administering that provision, except that the 24-month |
limitation on the adoption of emergency rules and the |
provisions of Sections 5-115 and 5-125 do not apply to rules |
adopted under this subsection (j). The Department of Public Aid |
may also adopt rules under this subsection (j) necessary to |
administer the Illinois Public Aid Code and the Children's |
Health Insurance Program Act. The adoption of emergency rules |
authorized by this subsection (j) shall be deemed to be |
|
necessary for the public interest, safety, and welfare.
|
(k) In order to provide for the expeditious and timely |
implementation of the provisions of the State's fiscal year |
2006 budget, emergency rules to implement any provision of this |
amendatory Act of the 94th General Assembly or any other budget |
initiative for fiscal year 2006 may be adopted in accordance |
with this Section by the agency charged with administering that |
provision or initiative, except that the 24-month limitation on |
the adoption of emergency rules and the provisions of Sections |
5-115 and 5-125 do not apply to rules adopted under this |
subsection (k). The Department of Public Aid may also adopt |
rules under this subsection (k) necessary to administer the |
Illinois Public Aid Code, the Senior Citizens and Disabled |
Persons Property Tax Relief and Pharmaceutical Assistance Act, |
the Senior Citizens and Disabled Persons Prescription Drug |
Discount Program Act, and the Children's Health Insurance |
Program Act. The adoption of emergency rules authorized by this |
subsection (k) shall be deemed to be necessary for the public |
interest, safety, and welfare.
|
(Source: P.A. 92-10, eff. 6-11-01; 92-597, eff. 6-28-02; 93-20, |
eff. 6-20-03; 93-829, eff. 7-28-04; 93-841, eff. 7-30-04; |
revised 10-25-04.)
|
Section 12. The Illinois Act on the Aging is amended by |
changing Section 4.02 as follows:
|
(20 ILCS 105/4.02) (from Ch. 23, par. 6104.02)
|
Sec. 4.02. The Department shall establish a program of |
services to
prevent unnecessary institutionalization of |
persons age 60 and older in
need of long term care or who are |
established as persons who suffer from
Alzheimer's disease or a |
related disorder under the Alzheimer's Disease
Assistance Act, |
thereby enabling them
to remain in their own homes or in other |
living arrangements. Such
preventive services, which may be |
coordinated with other programs for the
aged and monitored by |
area agencies on aging in cooperation with the
Department, may |
|
include, but are not limited to, any or all of the following:
|
(a) home health services;
|
(b) home nursing services;
|
(c) homemaker services;
|
(d) chore and housekeeping services;
|
(e) day care services;
|
(f) home-delivered meals;
|
(g) education in self-care;
|
(h) personal care services;
|
(i) adult day health services;
|
(j) habilitation services;
|
(k) respite care;
|
(k-5) community reintegration services;
|
(l) other nonmedical social services that may enable |
the person
to become self-supporting; or
|
(m) clearinghouse for information provided by senior |
citizen home owners
who want to rent rooms to or share |
living space with other senior citizens.
|
The Department shall establish eligibility standards for |
such
services taking into consideration the unique economic and |
social needs
of the target population for whom they are to be |
provided. Such eligibility
standards shall be based on the |
recipient's ability to pay for services;
provided, however, |
that in determining the amount and nature of services
for which |
a person may qualify, consideration shall not be given to the
|
value of cash, property or other assets held in the name of the |
person's
spouse pursuant to a written agreement dividing |
marital property into equal
but separate shares or pursuant to |
a transfer of the person's interest in a
home to his spouse, |
provided that the spouse's share of the marital
property is not |
made available to the person seeking such services.
|
Beginning July 1, 2002, the Department shall require as a |
condition of
eligibility that all financially eligible |
applicants and recipients apply
for medical assistance
under |
Article V of the Illinois Public Aid Code in accordance with |
rules
promulgated by the Department.
|
|
The Department shall, in conjunction with the Department of |
Public Aid,
seek appropriate amendments under Sections 1915 and |
1924 of the Social
Security Act. The purpose of the amendments |
shall be to extend eligibility
for home and community based |
services under Sections 1915 and 1924 of the
Social Security |
Act to persons who transfer to or for the benefit of a
spouse |
those amounts of income and resources allowed under Section |
1924 of
the Social Security Act. Subject to the approval of |
such amendments, the
Department shall extend the provisions of |
Section 5-4 of the Illinois
Public Aid Code to persons who, but |
for the provision of home or
community-based services, would |
require the level of care provided in an
institution, as is |
provided for in federal law. Those persons no longer
found to |
be eligible for receiving noninstitutional services due to |
changes
in the eligibility criteria shall be given 60 days |
notice prior to actual
termination. Those persons receiving |
notice of termination may contact the
Department and request |
the determination be appealed at any time during the
60 day |
notice period. With the exception of the lengthened notice and |
time
frame for the appeal request, the appeal process shall |
follow the normal
procedure. In addition, each person affected |
regardless of the
circumstances for discontinued eligibility |
shall be given notice and the
opportunity to purchase the |
necessary services through the Community Care
Program. If the |
individual does not elect to purchase services, the
Department |
shall advise the individual of alternative services. The target
|
population identified for the purposes of this Section are |
persons age 60
and older with an identified service need. |
Priority shall be given to those
who are at imminent risk of |
institutionalization. The services shall be
provided to |
eligible persons age 60 and older to the extent that the cost
|
of the services together with the other personal maintenance
|
expenses of the persons are reasonably related to the standards
|
established for care in a group facility appropriate to the |
person's
condition. These non-institutional services, pilot |
projects or
experimental facilities may be provided as part of |
|
or in addition to
those authorized by federal law or those |
funded and administered by the
Department of Human Services. |
The Departments of Human Services, Public Aid,
Public Health, |
Veterans' Affairs, and Commerce and Economic Opportunity and
|
other appropriate agencies of State, federal and local |
governments shall
cooperate with the Department on Aging in the |
establishment and development
of the non-institutional |
services. The Department shall require an annual
audit from all |
chore/housekeeping and homemaker vendors contracting with
the |
Department under this Section. The annual audit shall assure |
that each
audited vendor's procedures are in compliance with |
Department's financial
reporting guidelines requiring an |
administrative and employee wage and benefits cost split as |
defined in administrative rules
a 27% administrative cost split |
and a 73%
employee wages and benefits cost split. The audit is |
a public record under
the Freedom of Information Act. The |
Department shall execute, relative to
the nursing home |
prescreening project, written inter-agency
agreements with the |
Department of Human Services and the Department
of Public Aid, |
to effect the following: (1) intake procedures and common
|
eligibility criteria for those persons who are receiving |
non-institutional
services; and (2) the establishment and |
development of non-institutional
services in areas of the State |
where they are not currently available or are
undeveloped. On |
and after July 1, 1996, all nursing home prescreenings for
|
individuals 60 years of age or older shall be conducted by the |
Department.
|
The Department is authorized to establish a system of |
recipient copayment
for services provided under this Section, |
such copayment to be based upon
the recipient's ability to pay |
but in no case to exceed the actual cost of
the services |
provided. Additionally, any portion of a person's income which
|
is equal to or less than the federal poverty standard shall not |
be
considered by the Department in determining the copayment. |
The level of
such copayment shall be adjusted whenever |
necessary to reflect any change
in the officially designated |
|
federal poverty standard.
|
The Department, or the Department's authorized |
representative, shall
recover the amount of moneys expended for |
services provided to or in
behalf of a person under this |
Section by a claim against the person's
estate or against the |
estate of the person's surviving spouse, but no
recovery may be |
had until after the death of the surviving spouse, if
any, and |
then only at such time when there is no surviving child who
is |
under age 21, blind, or permanently and totally disabled. This
|
paragraph, however, shall not bar recovery, at the death of the |
person, of
moneys for services provided to the person or in |
behalf of the person under
this Section to which the person was |
not entitled;
provided that such recovery shall not be enforced |
against any real estate while
it is occupied as a homestead by |
the surviving spouse or other dependent, if no
claims by other |
creditors have been filed against the estate, or, if such
|
claims have been filed, they remain dormant for failure of |
prosecution or
failure of the claimant to compel administration |
of the estate for the purpose
of payment. This paragraph shall |
not bar recovery from the estate of a spouse,
under Sections |
1915 and 1924 of the Social Security Act and Section 5-4 of the
|
Illinois Public Aid Code, who precedes a person receiving |
services under this
Section in death. All moneys for services
|
paid to or in behalf of the person under this Section shall be |
claimed for
recovery from the deceased spouse's estate. |
"Homestead", as used
in this paragraph, means the dwelling |
house and
contiguous real estate occupied by a surviving spouse
|
or relative, as defined by the rules and regulations of the |
Illinois Department
of Public Aid, regardless of the value of |
the property.
|
The Department shall develop procedures to enhance |
availability of
services on evenings, weekends, and on an |
emergency basis to meet the
respite needs of caregivers. |
Procedures shall be developed to permit the
utilization of |
services in successive blocks of 24 hours up to the monthly
|
maximum established by the Department. Workers providing these |
|
services
shall be appropriately trained.
|
Beginning on the effective date of this Amendatory Act of |
1991, no person
may perform chore/housekeeping and homemaker |
services under a program
authorized by this Section unless that |
person has been issued a certificate
of pre-service to do so by |
his or her employing agency. Information
gathered to effect |
such certification shall include (i) the person's name,
(ii) |
the date the person was hired by his or her current employer, |
and
(iii) the training, including dates and levels. Persons |
engaged in the
program authorized by this Section before the |
effective date of this
amendatory Act of 1991 shall be issued a |
certificate of all pre- and
in-service training from his or her |
employer upon submitting the necessary
information. The |
employing agency shall be required to retain records of
all |
staff pre- and in-service training, and shall provide such |
records to
the Department upon request and upon termination of |
the employer's contract
with the Department. In addition, the |
employing agency is responsible for
the issuance of |
certifications of in-service training completed to their
|
employees.
|
The Department is required to develop a system to ensure |
that persons
working as homemakers and chore housekeepers |
receive increases in their
wages when the federal minimum wage |
is increased by requiring vendors to
certify that they are |
meeting the federal minimum wage statute for homemakers
and |
chore housekeepers. An employer that cannot ensure that the |
minimum
wage increase is being given to homemakers and chore |
housekeepers
shall be denied any increase in reimbursement |
costs.
|
The Department on Aging and the Department of Human |
Services
shall cooperate in the development and submission of |
an annual report on
programs and services provided under this |
Section. Such joint report
shall be filed with the Governor and |
the General Assembly on or before
September 30 each year.
|
The requirement for reporting to the General Assembly shall |
be satisfied
by filing copies of the report with the Speaker, |
|
the Minority Leader and
the Clerk of the House of |
Representatives and the President, the Minority
Leader and the |
Secretary of the Senate and the Legislative Research Unit,
as |
required by Section 3.1 of the General Assembly Organization |
Act and
filing such additional copies with the State Government |
Report Distribution
Center for the General Assembly as is |
required under paragraph (t) of
Section 7 of the State Library |
Act.
|
Those persons previously found eligible for receiving |
non-institutional
services whose services were discontinued |
under the Emergency Budget Act of
Fiscal Year 1992, and who do |
not meet the eligibility standards in effect
on or after July |
1, 1992, shall remain ineligible on and after July 1,
1992. |
Those persons previously not required to cost-share and who |
were
required to cost-share effective March 1, 1992, shall |
continue to meet
cost-share requirements on and after July 1, |
1992. Beginning July 1, 1992,
all clients will be required to |
meet
eligibility, cost-share, and other requirements and will |
have services
discontinued or altered when they fail to meet |
these requirements.
|
(Source: P.A. 92-597, eff. 6-28-02; 93-85, eff. 1-1-04; 93-902, |
eff. 8-10-04.)
|
Section 15. The Children's Health Insurance Program Act is |
amended by changing Section 30 as follows:
|
(215 ILCS 106/30)
|
Sec. 30. Cost sharing.
|
(a) Children enrolled in a health benefits program pursuant |
to subdivision
(a)(2) of Section 25 and persons enrolled in a |
health benefits waiver program pursuant to Section 40 shall be |
subject to the following cost sharing
requirements:
|
(1) There shall be no co-payment required for well-baby |
or well-child
care, including age-appropriate |
immunizations as required under
federal law.
|
(2) Health insurance premiums for family members, |
|
either children or adults, in families whose household
|
income is above 150% of the federal poverty level shall be |
payable
monthly, subject to rules promulgated by the |
Department for grace periods and
advance payments, and |
shall be as follows:
|
(A) $15 per month for one family member
child.
|
(B) $25 per month for 2 family members
children.
|
(C) $30 per month for 3 family members
or more |
children. |
(D) $35 per month for 4 family members. |
(E) $40 per month for 5 or more family members.
|
(3) Co-payments for children or adults in families |
whose income is at or below
150% of the federal poverty |
level, at a minimum and to the extent permitted
under |
federal law, shall be $2 for all medical visits and |
prescriptions
provided under this Act.
|
(4) Co-payments for children or adults in families |
whose income is above 150%
of the federal poverty level, at |
a minimum and to the extent permitted under
federal law |
shall be as follows:
|
(A) $5 for medical visits.
|
(B) $3 for generic prescriptions and $5 for brand |
name
prescriptions.
|
(C) $25 for emergency room use for a non-emergency
|
situation as defined by the Department by rule.
|
(5) The maximum amount of out-of-pocket expenses for |
co-payments shall be
$100 per family per year.
|
(b) Individuals enrolled in a privately sponsored health |
insurance plan
pursuant to subdivision (a)(1) of Section 25 |
shall be subject to the cost
sharing provisions as stated in |
the privately sponsored health insurance plan.
|
(Source: P.A. 90-736, eff. 8-12-98; 91-266, eff. 7-23-99.)
|
Section 20. The Illinois Public Aid Code is amended by |
changing Sections 5-5.4, 5-5.12, 5-11, and 12-4.35 as follows:
|
|
(305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)
|
Sec. 5-5.4. Standards of Payment - Department of Public |
Aid.
The Department of Public Aid shall develop standards of |
payment of skilled
nursing and intermediate care services in |
facilities providing such services
under this Article which:
|
(1) Provide for the determination of a facility's payment
|
for skilled nursing and intermediate care services on a |
prospective basis.
The amount of the payment rate for all |
nursing facilities certified by the
Department of Public Health |
under the Nursing Home Care Act as Intermediate
Care for the |
Developmentally Disabled facilities, Long Term Care for Under |
Age
22 facilities, Skilled Nursing facilities, or Intermediate |
Care facilities
under the
medical assistance program shall be |
prospectively established annually on the
basis of historical, |
financial, and statistical data reflecting actual costs
from |
prior years, which shall be applied to the current rate year |
and updated
for inflation, except that the capital cost element |
for newly constructed
facilities shall be based upon projected |
budgets. The annually established
payment rate shall take |
effect on July 1 in 1984 and subsequent years. No rate
increase |
and no
update for inflation shall be provided on or after July |
1, 1994 and before
July 1, 2006
2005, unless specifically |
provided for in this
Section.
The changes made by this |
amendatory Act of the 93rd General Assembly extending the |
duration of the prohibition against a rate increase or update |
for inflation are effective retroactive to July 1, 2004.
|
For facilities licensed by the Department of Public Health |
under the Nursing
Home Care Act as Intermediate Care for the |
Developmentally Disabled facilities
or Long Term Care for Under |
Age 22 facilities, the rates taking effect on July
1, 1998 |
shall include an increase of 3%. For facilities licensed by the
|
Department of Public Health under the Nursing Home Care Act as |
Skilled Nursing
facilities or Intermediate Care facilities, |
the rates taking effect on July 1,
1998 shall include an |
increase of 3% plus $1.10 per resident-day, as defined by
the |
Department.
|
|
For facilities licensed by the Department of Public Health |
under the
Nursing Home Care Act as Intermediate Care for the |
Developmentally Disabled
facilities or Long Term Care for Under |
Age 22 facilities, the rates taking
effect on July 1, 1999 |
shall include an increase of 1.6% plus $3.00 per
resident-day, |
as defined by the Department. For facilities licensed by the
|
Department of Public Health under the Nursing Home Care Act as |
Skilled Nursing
facilities or Intermediate Care facilities, |
the rates taking effect on July 1,
1999 shall include an |
increase of 1.6% and, for services provided on or after
October |
1, 1999, shall be increased by $4.00 per resident-day, as |
defined by
the Department.
|
For facilities licensed by the Department of Public Health |
under the
Nursing Home Care Act as Intermediate Care for the |
Developmentally Disabled
facilities or Long Term Care for Under |
Age 22 facilities, the rates taking
effect on July 1, 2000 |
shall include an increase of 2.5% per resident-day,
as defined |
by the Department. For facilities licensed by the Department of
|
Public Health under the Nursing Home Care Act as Skilled |
Nursing facilities or
Intermediate Care facilities, the rates |
taking effect on July 1, 2000 shall
include an increase of 2.5% |
per resident-day, as defined by the Department.
|
For facilities licensed by the Department of Public Health |
under the
Nursing Home Care Act as skilled nursing facilities |
or intermediate care
facilities, a new payment methodology must |
be implemented for the nursing
component of the rate effective |
July 1, 2003. The Department of Public Aid
shall develop the |
new payment methodology using the Minimum Data Set
(MDS) as the |
instrument to collect information concerning nursing home
|
resident condition necessary to compute the rate. The |
Department of Public Aid
shall develop the new payment |
methodology to meet the unique needs of
Illinois nursing home |
residents while remaining subject to the appropriations
|
provided by the General Assembly.
A transition period from the |
payment methodology in effect on June 30, 2003
to the payment |
methodology in effect on July 1, 2003 shall be provided for a
|
|
period not exceeding 2 years after implementation of the new |
payment
methodology as follows:
|
(A) For a facility that would receive a lower
nursing |
component rate per patient day under the new system than |
the facility
received
effective on the date immediately |
preceding the date that the Department
implements the new |
payment methodology, the nursing component rate per |
patient
day for the facility
shall be held at
the level in |
effect on the date immediately preceding the date that the
|
Department implements the new payment methodology until a |
higher nursing
component rate of
reimbursement is achieved |
by that
facility.
|
(B) For a facility that would receive a higher nursing |
component rate per
patient day under the payment |
methodology in effect on July 1, 2003 than the
facility |
received effective on the date immediately preceding the |
date that the
Department implements the new payment |
methodology, the nursing component rate
per patient day for |
the facility shall be adjusted.
|
(C) Notwithstanding paragraphs (A) and (B), the |
nursing component rate per
patient day for the facility |
shall be adjusted subject to appropriations
provided by the |
General Assembly.
|
For facilities licensed by the Department of Public Health |
under the
Nursing Home Care Act as Intermediate Care for the |
Developmentally Disabled
facilities or Long Term Care for Under |
Age 22 facilities, the rates taking
effect on March 1, 2001 |
shall include a statewide increase of 7.85%, as
defined by the |
Department.
|
For facilities licensed by the Department of Public Health |
under the
Nursing Home Care Act as Intermediate Care for the |
Developmentally Disabled
facilities or Long Term Care for Under |
Age 22 facilities, the rates taking
effect on April 1, 2002 |
shall include a statewide increase of 2.0%, as
defined by the |
Department.
This increase terminates on July 1, 2002;
beginning |
July 1, 2002 these rates are reduced to the level of the rates
|
|
in effect on March 31, 2002, as defined by the Department.
|
For facilities licensed by the Department of Public Health |
under the
Nursing Home Care Act as skilled nursing facilities |
or intermediate care
facilities, the rates taking effect on |
July 1, 2001 shall be computed using the most recent cost |
reports
on file with the Department of Public Aid no later than |
April 1, 2000,
updated for inflation to January 1, 2001. For |
rates effective July 1, 2001
only, rates shall be the greater |
of the rate computed for July 1, 2001
or the rate effective on |
June 30, 2001.
|
Notwithstanding any other provision of this Section, for |
facilities
licensed by the Department of Public Health under |
the Nursing Home Care Act
as skilled nursing facilities or |
intermediate care facilities, the Illinois
Department shall |
determine by rule the rates taking effect on July 1, 2002,
|
which shall be 5.9% less than the rates in effect on June 30, |
2002.
|
Notwithstanding any other provision of this Section, for |
facilities
licensed by the Department of Public Health under |
the Nursing Home Care Act as
skilled nursing
facilities or |
intermediate care facilities, if the payment methodologies |
required under Section 5A-12 and the waiver granted under 42 |
CFR 433.68 are approved by the United States Centers for |
Medicare and Medicaid Services, the rates taking effect on July |
1, 2004 shall be 3.0% greater than the rates in effect on June |
30, 2004. These rates shall take
effect only upon approval and
|
implementation of the payment methodologies required under |
Section 5A-12.
|
Notwithstanding any other provisions of this Section, for |
facilities licensed by the Department of Public Health under |
the Nursing Home Care Act as skilled nursing facilities or |
intermediate care facilities, the rates taking effect on |
January 1, 2005 shall be 3% more than the rates in effect on |
December 31, 2004.
|
For facilities
licensed
by the
Department of Public Health |
under the Nursing Home Care Act as Intermediate
Care for
the |
|
Developmentally Disabled facilities or as long-term care |
facilities for
residents under 22 years of age, the rates |
taking effect on July 1,
2003 shall
include a statewide |
increase of 4%, as defined by the Department.
|
Notwithstanding any other provision of this Section, for |
facilities licensed by the Department of Public Health under |
the Nursing Home Care Act as skilled nursing facilities or |
intermediate care facilities, effective January 1, 2005, |
facility rates shall be increased by the difference between (i) |
a facility's per diem property, liability, and malpractice |
insurance costs as reported in the cost report filed with the |
Department of Public Aid and used to establish rates effective |
July 1, 2001 and (ii) those same costs as reported in the |
facility's 2002 cost report. These costs shall be passed |
through to the facility without caps or limitations, except for |
adjustments required under normal auditing procedures.
|
Rates established effective each July 1 shall govern |
payment
for services rendered throughout that fiscal year, |
except that rates
established on July 1, 1996 shall be |
increased by 6.8% for services
provided on or after January 1, |
1997. Such rates will be based
upon the rates calculated for |
the year beginning July 1, 1990, and for
subsequent years |
thereafter until June 30, 2001 shall be based on the
facility |
cost reports
for the facility fiscal year ending at any point |
in time during the previous
calendar year, updated to the |
midpoint of the rate year. The cost report
shall be on file |
with the Department no later than April 1 of the current
rate |
year. Should the cost report not be on file by April 1, the |
Department
shall base the rate on the latest cost report filed |
by each skilled care
facility and intermediate care facility, |
updated to the midpoint of the
current rate year. In |
determining rates for services rendered on and after
July 1, |
1985, fixed time shall not be computed at less than zero. The
|
Department shall not make any alterations of regulations which |
would reduce
any component of the Medicaid rate to a level |
below what that component would
have been utilizing in the rate |
|
effective on July 1, 1984.
|
(2) Shall take into account the actual costs incurred by |
facilities
in providing services for recipients of skilled |
nursing and intermediate
care services under the medical |
assistance program.
|
(3) Shall take into account the medical and psycho-social
|
characteristics and needs of the patients.
|
(4) Shall take into account the actual costs incurred by |
facilities in
meeting licensing and certification standards |
imposed and prescribed by the
State of Illinois, any of its |
political subdivisions or municipalities and by
the U.S. |
Department of Health and Human Services pursuant to Title XIX |
of the
Social Security Act.
|
The Department of Public Aid shall develop precise |
standards for
payments to reimburse nursing facilities for any |
utilization of
appropriate rehabilitative personnel for the |
provision of rehabilitative
services which is authorized by |
federal regulations, including
reimbursement for services |
provided by qualified therapists or qualified
assistants, and |
which is in accordance with accepted professional
practices. |
Reimbursement also may be made for utilization of other
|
supportive personnel under appropriate supervision.
|
(Source: P.A. 92-10, eff. 6-11-01; 92-31, eff. 6-28-01; 92-597, |
eff. 6-28-02; 92-651, eff. 7-11-02; 92-848, eff. 1-1-03; 93-20, |
eff. 6-20-03; 93-649, eff. 1-8-04; 93-659, eff. 2-3-04; 93-841, |
eff. 7-30-04; 93-1087, eff. 2-28-05.)
|
(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
|
Sec. 5-5.12. Pharmacy payments.
|
(a) Every request submitted by a pharmacy for reimbursement |
under this
Article for prescription drugs provided to a |
recipient of aid under this
Article shall include the name of |
the prescriber or an acceptable
identification number as |
established by the Department.
|
(b) Pharmacies providing prescription drugs under
this |
Article shall be reimbursed at a rate which shall include
a |
|
professional dispensing fee as determined by the Illinois
|
Department, plus the current acquisition cost of the |
prescription
drug dispensed. The Illinois Department shall |
update its
information on the acquisition costs of all |
prescription drugs
no less frequently than every 30 days. |
However, the Illinois
Department may set the rate of |
reimbursement for the acquisition
cost, by rule, at a |
percentage of the current average wholesale
acquisition cost.
|
(c) (Blank).
Reimbursement under this Article for |
prescription drugs shall be
limited to reimbursement for 4 |
brand-name prescription drugs per patient per
month. This |
subsection applies only if (i) the brand-name drug was not
|
prescribed for an acute or urgent condition, (ii) the |
brand-name drug was not
prescribed for Alzheimer's disease, |
arthritis, diabetes, HIV/AIDS, a mental
health condition, or |
respiratory disease, and (iii) a therapeutically
equivalent |
generic medication has been approved by the federal Food and |
Drug
Administration.
|
(d) The Department shall not impose requirements for prior |
approval
based on a preferred drug list for anti-retroviral, |
anti-hemophilic factor
concentrates,
or
any atypical |
antipsychotics, conventional antipsychotics,
or |
anticonvulsants used for the treatment of serious mental
|
illnesses
until 30 days after it has conducted a study of the |
impact of such
requirements on patient care and submitted a |
report to the Speaker of the
House of Representatives and the |
President of the Senate.
|
(Source: P.A. 92-597, eff. 6-28-02; 92-825, eff. 8-21-02; |
93-106, eff.
7-8-03.)
|
(305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
|
Sec. 5-11. Co-operative arrangements; contracts with other |
State
agencies, health care and rehabilitation organizations, |
and fiscal
intermediaries.
|
(a) The Illinois Department may enter into co-operative |
arrangements
with
State agencies responsible for administering |
|
or supervising the
administration of health services and |
vocational rehabilitation services to
the end that there may be |
maximum utilization of such services in the
provision of |
medical assistance.
|
The Illinois Department shall, not later than June 30, |
1993, enter into
one or more co-operative arrangements with the |
Department of Mental Health
and Developmental Disabilities |
providing that the Department of Mental
Health and |
Developmental Disabilities will be responsible for |
administering
or supervising all programs for services to |
persons in community care
facilities for persons with |
developmental disabilities, including but not
limited to |
intermediate care facilities, that are supported by State funds |
or
by funding under Title XIX of the federal Social Security |
Act. The
responsibilities of the Department of Mental Health |
and Developmental
Disabilities under these agreements are |
transferred to the Department of
Human Services as provided in |
the Department of Human Services Act.
|
The Department may also contract with such State health and
|
rehabilitation agencies and other public or private health care |
and
rehabilitation organizations to act for it in supplying |
designated medical
services to persons eligible therefor under |
this Article. Any contracts
with health services or health |
maintenance organizations shall be
restricted to organizations |
which have been certified as being in
compliance with standards |
promulgated pursuant to the laws of this State
governing the |
establishment and operation of health services or health
|
maintenance organizations. The Department shall renegotiate |
the contracts with health maintenance organizations and |
managed care community
networks that took effect August 1, |
2003, so as to produce $70,000,000 savings to the Department |
net of resulting increases to the fee-for-service program for |
State fiscal year 2006. The Department may also contract with |
insurance
companies or other corporate entities serving as |
fiscal intermediaries in
this State for the Federal Government |
in respect to Medicare payments under
Title XVIII of the |
|
Federal Social Security Act to act for the Department in
paying |
medical care suppliers. The provisions of Section 9 of "An Act |
in
relation to State finance", approved June 10, 1919, as |
amended,
notwithstanding, such contracts with State agencies, |
other health care and
rehabilitation organizations, or fiscal |
intermediaries may provide for
advance payments.
|
(b) For purposes of this subsection (b), "managed care |
community
network" means an entity, other than a health |
maintenance organization, that
is owned, operated, or governed |
by providers of health care services within
this State and that |
provides or arranges primary, secondary, and tertiary
managed |
health care services under contract with the Illinois |
Department
exclusively to persons participating in programs |
administered by the Illinois
Department.
|
The Illinois Department may certify managed care community
|
networks, including managed care community networks owned, |
operated, managed,
or
governed by State-funded medical |
schools, as risk-bearing entities eligible to
contract with the |
Illinois Department as Medicaid managed care
organizations. |
The Illinois Department may contract with those managed
care |
community networks to furnish health care services to or |
arrange those
services for individuals participating in |
programs administered by the Illinois
Department. The rates for |
those provider-sponsored organizations may be
determined on a |
prepaid, capitated basis. A managed care community
network may |
choose to contract with the Illinois Department to provide only
|
pediatric
health care services.
The
Illinois Department shall |
by rule adopt the criteria, standards, and procedures
by
which |
a managed care community network may be permitted to contract |
with
the Illinois Department and shall consult with the |
Department of Insurance in
adopting these rules.
|
A county provider as defined in Section 15-1 of this Code |
may
contract with the Illinois Department to provide primary, |
secondary, or
tertiary managed health care services as a |
managed care
community network without the need to establish a |
separate entity and shall
be deemed a managed care community |
|
network for purposes of this Code
only to the extent it |
provides services to participating individuals. A county
|
provider is entitled to contract with the Illinois Department |
with respect to
any contracting region located in whole or in |
part within the county. A
county provider is not required to |
accept enrollees who do not reside within
the county.
|
In order
to (i) accelerate and facilitate the development |
of integrated health care in
contracting areas outside counties |
with populations in excess of 3,000,000 and
counties adjacent |
to those counties and (ii) maintain and sustain the high
|
quality of education and residency programs coordinated and |
associated with
local area hospitals, the Illinois Department |
may develop and implement a
demonstration program from managed |
care community networks owned, operated,
managed, or
governed |
by State-funded medical schools. The Illinois Department shall
|
prescribe by rule the criteria, standards, and procedures for |
effecting this
demonstration program.
|
A managed care community network that
contracts with the |
Illinois Department to furnish health care services to or
|
arrange those services for enrollees participating in programs |
administered by
the Illinois Department shall do all of the |
following:
|
(1) Provide that any provider affiliated with the |
managed care community
network may also provide services on |
a
fee-for-service basis to Illinois Department clients not |
enrolled in such
managed care entities.
|
(2) Provide client education services as determined |
and approved by the
Illinois Department, including but not |
limited to (i) education regarding
appropriate utilization |
of health care services in a managed care system, (ii)
|
written disclosure of treatment policies and restrictions |
or limitations on
health services, including, but not |
limited to, physical services, clinical
laboratory tests, |
hospital and surgical procedures, prescription drugs and
|
biologics, and radiological examinations, and (iii) |
written notice that the
enrollee may receive from another |
|
provider those covered services that are not
provided by |
the managed care community network.
|
(3) Provide that enrollees within the system may choose |
the site for
provision of services and the panel of health |
care providers.
|
(4) Not discriminate in enrollment or disenrollment |
practices among
recipients of medical services or |
enrollees based on health status.
|
(5) Provide a quality assurance and utilization review |
program that
meets
the requirements established by the |
Illinois Department in rules that
incorporate those |
standards set forth in the Health Maintenance Organization
|
Act.
|
(6) Issue a managed care community network
|
identification card to each enrollee upon enrollment. The |
card
must contain all of the following:
|
(A) The enrollee's health plan.
|
(B) The name and telephone number of the enrollee's |
primary care
physician or the site for receiving |
primary care services.
|
(C) A telephone number to be used to confirm |
eligibility for benefits
and authorization for |
services that is available 24 hours per day, 7 days per
|
week.
|
(7) Ensure that every primary care physician and |
pharmacy in the managed
care community network meets the |
standards
established by the Illinois Department for |
accessibility and quality of care.
The Illinois Department |
shall arrange for and oversee an evaluation of the
|
standards established under this paragraph (7) and may |
recommend any necessary
changes to these standards.
|
(8) Provide a procedure for handling complaints that
|
meets the
requirements established by the Illinois |
Department in rules that incorporate
those standards set |
forth in the Health Maintenance Organization Act.
|
(9) Maintain, retain, and make available to the |
|
Illinois Department
records, data, and information, in a |
uniform manner determined by the Illinois
Department, |
sufficient for the Illinois Department to monitor |
utilization,
accessibility, and quality of care.
|
(10) Provide that the pharmacy formulary used by the |
managed care
community
network and its contract providers |
be no
more restrictive than the Illinois Department's |
pharmaceutical program on the
effective date of this |
amendatory Act of 1998 and as amended after that date.
|
The Illinois Department shall contract with an entity or |
entities to provide
external peer-based quality assurance |
review for the managed health care
programs administered by the |
Illinois Department. The entity shall be
representative of |
Illinois physicians licensed to practice medicine in all its
|
branches and have statewide geographic representation in all |
specialities of
medical care that are provided in managed |
health care programs administered by
the Illinois Department. |
The entity may not be a third party payer and shall
maintain |
offices in locations around the State in order to provide |
service and
continuing medical education to physician |
participants within those managed
health care programs |
administered by the Illinois Department. The review
process |
shall be developed and conducted by Illinois physicians |
licensed to
practice medicine in all its branches. In |
consultation with the entity, the
Illinois Department may |
contract with other entities for professional
peer-based |
quality assurance review of individual
categories of services |
other than services provided, supervised, or coordinated
by |
physicians licensed to practice medicine in all its branches. |
The Illinois
Department shall establish, by rule, criteria to |
avoid conflicts of interest in
the conduct of quality assurance |
activities consistent with professional
peer-review standards. |
All quality assurance activities shall be coordinated
by the |
Illinois Department.
|
Each managed care community network must demonstrate its |
ability to
bear the financial risk of serving individuals under |
|
this program.
The Illinois Department shall by rule adopt |
standards for assessing the
solvency and financial soundness of |
each managed care community network.
Any solvency and financial |
standards adopted for managed care community
networks
shall be |
no more restrictive than the solvency and financial standards |
adopted
under
Section 1856(a) of the Social Security Act for |
provider-sponsored
organizations under Part C of Title XVIII of |
the Social Security Act.
|
The Illinois
Department may implement the amendatory |
changes to this
Code made by this amendatory Act of 1998 |
through the use of emergency
rules in accordance with Section |
5-45 of the Illinois Administrative Procedure
Act. For purposes |
of that Act, the adoption of rules to implement these
changes |
is deemed an emergency and necessary for the public interest,
|
safety, and welfare.
|
(c) Not later than June 30, 1996, the Illinois Department |
shall
enter into one or more cooperative arrangements with the |
Department of Public
Health for the purpose of developing a |
single survey for
nursing facilities, including but not limited |
to facilities funded under Title
XVIII or Title XIX of the |
federal Social Security Act or both, which shall be
|
administered and conducted solely by the Department of Public |
Health.
The Departments shall test the single survey process on |
a pilot basis, with
both the Departments of Public Aid and |
Public Health represented on the
consolidated survey team. The |
pilot will sunset June 30, 1997. After June 30,
1997, unless |
otherwise determined by the Governor, a single survey shall be
|
implemented by the Department of Public Health which would not |
preclude staff
from the Department of Public Aid from going |
on-site to nursing facilities to
perform necessary audits and |
reviews which shall not replicate the single State
agency |
survey required by this Act. This Section shall not apply to |
community
or intermediate care facilities for persons with |
developmental disabilities.
|
(d) Nothing in this Code in any way limits or otherwise |
impairs the
authority or power of the Illinois Department to |
|
enter into a negotiated
contract pursuant to this Section with |
a managed care community network or
a health maintenance |
organization, as defined in the Health Maintenance
|
Organization Act, that provides for
termination or nonrenewal |
of the contract without cause, upon notice as
provided in the |
contract, and without a hearing.
|
(Source: P.A. 92-370, eff. 8-15-01.)
|
(305 ILCS 5/12-4.35)
|
Sec. 12-4.35. Medical services for certain noncitizens.
|
(a) Notwithstanding
Subject to specific appropriation for |
this purpose, and notwithstanding
Section 1-11 of this Code or |
Section 20(a) of the Children's Health Insurance
Program Act, |
the Department of Public Aid may provide medical services to
|
noncitizens who have not yet attained 19 years of age and who |
are not eligible
for medical assistance under Article V of this |
Code or under the Children's
Health Insurance Program created |
by the Children's Health Insurance Program Act
due to their not |
meeting the otherwise applicable provisions of Section 1-11
of |
this Code or Section 20(a) of the Children's Health Insurance |
Program Act.
The medical services available, standards for |
eligibility, and other conditions
of participation under this |
Section shall be established by rule by the
Department; |
however, any such rule shall be at least as restrictive as the
|
rules for medical assistance under Article V of this Code or |
the Children's
Health Insurance Program created by the |
Children's Health Insurance Program
Act.
|
(b) The Department is authorized to take any action, |
including without
limitation cessation of enrollment, |
reduction of available medical services,
and changing |
standards for eligibility, that is deemed necessary by the
|
Department during a State fiscal year to assure that payments |
under this
Section do not exceed available funds
the amounts |
appropriated for this purpose.
|
(c) Continued
In the event that the appropriation in any |
fiscal year for the
Children's Health Insurance Program created |
|
by the Children's Health Insurance
Program Act is determined by |
the Department to be insufficient to continue
enrollment of |
otherwise eligible children under that Program during that |
fiscal
year, the Department is authorized to use funds |
appropriated for the purposes
of this Section to fund that |
Program and to take any other action necessary to
continue the |
operation of that Program. Furthermore, continued enrollment |
of
individuals into the program created under this Section in |
any fiscal year is
contingent upon continued enrollment of |
individuals into the Children's Health
Insurance Program |
during that fiscal year.
|
(d) (Blank).
The General Assembly finds that the adoption |
of rules to meet the
purposes of subsections (a), (b), and (c) |
is an emergency and necessary for
the public interest, safety, |
and welfare. The Department may adopt such rules
through the |
use of emergency rulemaking in accordance with Section 5-45 of |
the
Illinois Administrative Procedure Act, except that the |
limitation on the number
of emergency rules that may be adopted |
in a 24-month period shall not apply.
|
(Source: P.A. 90-588, eff. 7-1-98.)
|
Section 25. The All-Inclusive Care for the Elderly Act is |
amended by changing Sections 10 and 15 as follows:
|
(320 ILCS 40/10) (from Ch. 23, par. 6910)
|
Sec. 10. Services for eligible persons. Within the context |
of the
PACE program established under this Act, the Illinois |
Department of Public
Aid may include any or all of the services |
in Article 5 of the Illinois
Public Aid Code.
|
An eligible person may elect to receive services from the |
PACE program.
If such an election is made, the eligible person |
shall not remain eligible
for payment through the regular |
Medicare or Medicaid program. All services
and programs |
provided through the PACE program shall be provided in
|
accordance with this Act. An eligible person may elect to |
disenroll from
the PACE program at any time.
|
|
For purposes of this Act, "eligible person" means a frail |
elderly
individual who voluntarily enrolls in the PACE program, |
whose income and
resources do not exceed limits established by |
the Illinois Department of
Public Aid and for whom a licensed |
physician certifies that such a program
provides an appropriate |
alternative to institutionalized care. The term
"frail |
elderly" means an individual who meets the age and functional |
eligibility
requirements, as established by the Illinois |
Department of Public Aid and
the Department on Aging for |
nursing home care, and who is 65 years of age
or older.
|
(Source: P.A. 87-411.)
|
(320 ILCS 40/15) (from Ch. 23, par. 6915)
|
Sec. 15. Program implementation.
|
(a) Upon receipt of federal approval
waivers, the Illinois |
Department of Public
Aid shall implement the PACE program |
pursuant to the provisions of the approved Title XIX State plan
|
as a demonstration program to provide
the services set forth in |
Section 10 to eligible persons, as defined in
Section 10, for a |
period of 3 years. After the 3 year demonstration, the
General |
Assembly shall reexamine the PACE program and determine if the
|
program should be implemented on a permanent basis.
|
(b) Using a risk-based financing model, the nonprofit |
organization providing
the PACE program shall assume |
responsibility for all costs generated by
the PACE program |
participants, and it shall create and maintain a risk
reserve |
fund that will cover any cost overages for any participant. The
|
PACE program is responsible for the entire range of services in |
the
consolidated service model, including hospital and nursing |
home care,
according to participant need as determined by a |
multidisciplinary team.
The nonprofit organization providing |
the PACE program is responsible for
the full financial risk at |
the conclusion of the demonstration period
and when permanent |
waivers from the federal Health Care Financing
Administration |
are granted. Specific arrangements of the risk-based
financing |
model shall be adopted and negotiated by the federal Centers |